TBI Flashcards
Diffuse axonal injury
Extensive and widespread damage due to shearing forces (usually rotational) from rapid acceleration/deceleration
Contusion
Bruising on the brain resultant from a direct impact to the head
Hematomas: Epidural, subdural, and intracerebral
- Epidural: Blood between the dura and skull, resultant from skull fxs that cause a rapid increase in ICP
- Subdural: Bleeding between dural and subarachnoid, resultant from blunt trauma without fx
- Intracerebral: Frontal/temporal lobes
Normal ICP + increased ICP
- Normal: 0-10 mm HG
- Increased: >20 mm HG
Sxs of increased ICP
- HA
- Papilledema
- Vomiting
- Drowsiness
- Altered consciousness
CPP equation
CPP = MAP - ICP
Normal CPP + abnormal CPP
- Normal >70 mm HG
- Ischemic <4–50 mm HG
Glasgow Coma Scale
- Eye response (4)
- Verbal response (5)
- Motor response (6)
GCS Severity
Mild 13-15
Moderate 9-12
Severe 3-8
Coma
- Unarousable unconsciousness
- No periods of wakefulness or eye opening to stimulations
Vegetative state
- Lack of awareness but preserved capacity for arousal (spontaneous or stim-induced)
1. No evidence of awareness of self or environment
2. No evidence of purposeful or voluntary behavioral response to stim
3. No language
4. Bowel and bladder incontinence
5. Variable preservation of cranial nerve and spinal reflexes
6. Sufficient preservation of autonomic function
7. Intermittent wakefulness manifested by the presence of sleep wake cycles
Minimally conscious state
- Reproducible awareness of self or environment by one of the following:
1. Simple command following
2. Gestural or verbal yes/no responses
3. Intelligible verbalization
4. Purposeful behavior (movement or affective)
PTA Stages of Recovery
Mild 5-60 minutes Moderate 1-24 hours Severe 1-7 days Very Severe 1-4 weeks Extremely severe >4 weeks
I: No response
- Complete absence of observable behavior to stim
II: Generalized response
- Reaction to external stimuli in non-specific, inconsistent, and non-purposeful manner with stereotypical responses
III: Localized response
- Responds specifically and inconsistently with delays to stim
IV: Confused/gitated
- Alert and in heightened state of activity, restless, agitated
- Absent STM
- Lack of deficit awareness
V: Confused/inappropriate/non-agitated
- Alert and non-agitated
- Not oriented to person, place, or time
- Absence of goal-directed, problem solving, self-monitoring behavior
- Appropriate responses to simple commands with external cueing (inappropriate/non-purposeful without cueing)
VII: Automatic/appropriate
- Performs daily routine automamtically
- Carryover of new learning
- Initiates social interactions but judgement is impaired, overestimates abilities
VIII: Purposeful/appropriate (SBA)
- Consistently oriented to person, place, and time
- Aware of impairments but difficulty taking corrective action when completing tasks
- Difficulty with abstract reasoning, stress tolerance, and judgement
IX: Purposeful/appropriate (SBA on request)
- Independently shifts between tasks for 2 hours
- Requires some assist to adjust to life’s demands
- Emotional/behavioral issues possible
X: Purposeful/appropriate (Mod I)
- Goal-directed behavior, able to handle multiple tasks independently but may continue to have decreased attention and require increased time to complete tasks
Onset of spasticity
Occurs 3 days post-injury
Pharmacological Management: Baclonfen, Dizepam (Valium), Dantrolene, Botox
- Baclofen: GABA receptor agonist, orally or intrathecally
- Diazepam (Valium): Benzo, used to treat anxiety
- Dantrolene: Muscle relaxant
- Botox: Injected for localized effects lasting 3-4 months
Serial casting
- Joint is immobilized for 7-10 days
- Stretching is performed after removal of cast
- Apply new cast at endrange
- *Effective for improving PROM but not spasticity or function
Dynamic splinting
Be careful of pressure points and skin integrity
Coma is caused by:
- Diffuse B hemispheric damage and/or failure of the ascending reticular activating system
- Unilateral hemisphere lesion does not cause coma
- Brainstem infarction or hemorrhage commonly causes coma, as well as drug and metabolic disease
Self-efficacy
Rehab should address patient’s self-efficacy beliefs in addition to their cog/phys impairments
**Shows a strong relationship with life satisfaction post-TBI
Rehab of executive function
Required in regaining independence
- Ask patient to predict their performance prior to beginning the task
- Ask patients to provide post-task feedback about performance
- Use systematic cueing strategy to maximize patient recognition of errors and improve ability to generate solutions
Balance and dual-task performance
Balance more strongly related to falls hx then measures of attention or dual-task performance
**Motor slowing utilized as a compensatory strategy
Guidelines for cardiorespiratory and endurance training
- 60-90% of age predicted max HR
- 20-40 min per session
- 3-4x per week
Acute care highly recommended outcome measures
- ABS
- CRS
- Moss Attention Rating Scale
- Rancho Levels of Cognitive Functioning
ABS cut-off scores
Within normal limits: <21
Mild agitation: 22-28
Moderate agitation: 29-35
Severe agitation: >35
Moss Attention Rating Scale
- Observational tool used to measure attention-related behaviors after TBI
Observation of 22 items reflecting both good and impaired attention - Each item scored from 1 (definitely false) - 5 (definitely true)
**No cut-off scores
Recommended outcome measures for moderate-severely dependent in ambulation
- Functional Assessment Measure
- FIM
Recommended outcome measures for mildly dependent to independent in ambulation
- 6MWT
- 10MWT
- Balance Error Scoring System
- Community Mobility and Balance Scale
- HiMAT
- Functional Assessment Measure
Community Mobility and Balance Scale
- Used to assess high level balance and mobility in the community
- Allowed to wear orthotic but may not use AD
- 13 tasks with total score of 96 (most able)
- *No cut-off scores
Disability Rating Scale
- Used to monitor recovery from coma to community in people with moderate to severe TBI
- Scores range from 0 (without disability) - 29 (vegetative state)
- *No cut-off scores
Functional Assessment Measure
- Consists of 12 items that are added onto 18-item FIM test
- Scored 0 (TOTAL) - 7 (IND)
- Cut-off score: <65 identifies individuals at risk for long term unemployment
HiMAT
- Scale used to assess high level balance and mobility performance
- 13 items, scored 0-4
- Orthotics are permitted, must be able to ambulate independently over 20 meters without AD
Patient Health Questionnaire
- Self-report questionnaire to assess depressive symptoms over previous two-week period
- Scoring from 0 (not at all) - 3 ( nearly every day)
- 9 items with maximum score of 27
- *Cut-off score: >12 suggests possible major depressive disorder
Quality of Life After Brain Injury
- Health-related quality of life questionnaire
- 37 items
- Scored 0 (worst possible QOL) - 100 (best possible QOL)
- *No cut-off scores
