TBI Flashcards
Relationship between ICP and CPP
CPP = MAP - ICP
MAP = (1/3 SBP) + (2/3 DBP)
As ICP goes up, CPP goes down (less blood going into brain!)
Goal ICP
Avoid ICP >20mmHg
Goal CPP
CPP = blood going into brain
Goal CPP ~60mmHg
After brain injury, __, __, or __ trigger the metabolic cascade. Recall, the impact itself causes [neurotransmitter] to rush out, yielding an imbalance. That imbalance causes ___ to rush into the cell which sends the ion pump into overdrive. This takes energy (aka ___) - so the __ in the cell get overworked, there is an increased need for glucose (to feed the energy cycle), the system is having trouble keeping up and this ultimately leads to cell death.
Elevated __ can perpetuate this cycle.
Medically, we want to slow/stop this cycle!
After brain injury, ISCHEMIA or HYPOXIA, or IMPACT DEPOLARIZATION trigger the metabolic cascade (= a microscopic chemical rxn causing tissue damage).
Recall, the impact itself causes GLUTAMATE to rush out, yielding an imbalance. That imbalance causes Ca2+ to rush into the cell which sends the ion pump into overdrive. This takes energy (aka ATP) - so the MITOCHONDRIA in the cell get overworked, there is an increased need for glucose (to feed the energy cycle), the system is having trouble keeping up and this ultimately leads to cell death.
Elevated ICP can perpetuate this cycle.
Medically, we want to slow/stop this cycle!
Lab values and vitals to watch post brain injury
Na+ (can sometimes trend too high) BUN Creatinine Acidosis Thalamic storming
Sympathetic storming (AKA paroxysmal autonomic instability and dystonia = PAID) can occur [how long?] post injury and involves an increase in ___ nervous system activity. Episodes are [provoked / often unprovoked] . Signs and symptoms include … Pts are at risk for secondary impairments resulting from decreased ___ . Medical mgmt?
Sympathetic storming (AKA paroxysmal autonomic instability and dystonia = PAID) can occur WEEKS post injury and involves an increase in SYMPATHETIC nervous system activity. Episodes are OFTEN UNPROVOKED. Brain goes into “overdrive,” often due to some brainstem damage, anoxic injuries, and more severe DAI. Signs and symptoms include POSTURING, TACHYCARDIA, TACHYPNEA, DIAPHORESIS, and INCREASED BP. Pts are at risk for secondary impairments resulting from decreased CEREBRAL OXYGENATION. MDs try to medically manage this with medications.
With acute brain injury, our goals are survival!
“ABCs”
Manage the __ and __ to prevent secondary injury
With acute brain injury, our goals are survival!
“ABCs”
Manage the ICP and CPP to prevent secondary injury
Glasgow Coma Scale Used with [acute / subacute / chronic] injuries Looks at what 3 areas of function? High score = [more/less] functional? Min score? Max score? Cutoffs?
Glasgow Coma Scale
Used with ACUTE injuries, used in field & ICU
Looks at EYE RESPONSE, VERBAL RESPONSE, and MOTOR RESPONSE
High score = MORE functional
Min score of 3 (that’s BAD!) -> max 15
Mild = 13-15; Moderate = 8-13; Severe = 3-8
=<8 = coma, 3 = unresponsive
(<5 on day 3 post anoxic injury assoc. with poor prognosis)
Limitation: does require verbal response (ie an injury specifically to speech/language centers may score particularly low even if they’re otherwise doing OK)
The FOUR Score is an alternative to the Glasgow Coma Scale that it looks at what 4 areas? What specific condition can it better recognize?
FOUR Score = looks at eye fxn, motor fxn, brainstem reflexes (pupil & corneal), and respiration pattern.
Can recognize Locked In Syndrome
The Ranchos Los Amigos scale is used throughout TBI course and describes behaviors demonstrated at each level.
Describe behaviors at each level.
High or low - which is better functioning?
The Ranchos Los Amigos scale is used throughout TBI course and describes behaviors demonstrated at each level. Can fluctuate between phases at any given time!
Level I = no response = coma
Level II = generalized response to external stim, non-specific, non-purposeful response to stimulus (e.g. lip smacking), often stereotypic and limited
Level III = localized response, responds specifically and inconsistently to stimuli with delays, but FOLLOWS SIMPLE COMMANDS
Level IV = confused and agitated, scared, overreact to stimuli, focused on basic needs; difficulty following directions and engaging; therapeutically, avoid eye contact if need to de-escalate, be overly calm! Safety is first goal. Hard for families at this stage.
Level V = confused, inappropriate, non-agitated; short attention span, needs step by step instructions for basic tasks, overwhelmed by stimuli, confabulate, perseverate; therapeutically, reorient regularly, short/simple instructions, frequent rest breaks, write down answers to frequently asked questions, reminisce on fun past experiences/family
Level VI= confused, appropriate, can follow a schedule w/assist, oriented to date/year, pays attention in non-distracting environment, aware of physical problems more so than cognitive/safety issues; reorient, repeat directions, encourage ownership of ADLs/therapy, use written material/references
Level VII = automatic, appropriate responses (follow what people tell them to do, almost robotic, but non planning/purposeful, not super flexible)
Level VIII = purposeful, appropriate response
(have also added a level IX and X! But I - VIII are most common)
Level IX = purposeful appropriate (standby assist on request)
Level X = purposeful appropriate (modified independent)
How do we classify “disorders of Consciousness” on the RLA scale? What are the 4 “stages” of DOC?
DOC = RLA levels I-III DOC ranges from: Brain Death = no brain activity Coma = eyes closed, no response Vegetative state = signs of response Minimally Conscious State = signs of purposeful response
A coma is a state of unarousable responsiveness in which they eyes [are open/ stay continuously closed].
- Response to stim?
- Sleep/wake cycles?
- Type of motor activity we see?
- What aspect of the brain injury causes this?
Generally, coma is [permanent / temporary, individual will progress to either vegetative of minimally conscious state].
Emergence from a coma in ____-___ wks predicts a more favorable outcome
A coma is a state of unarousable responsiveness in which they eyes stay CONTINUOUSLY CLOSED. NO understandable response to stimuli. NO sleep/wake cycles. REFLEXIVE activity only.
What aspect of brain injury causes coma?
- Most likely caused by the DAI in brainstem, midbrain
- May also be extensive B FRONTAL WHITE MATTER involvement
- Swelling -> herniation
- Medullary lesions may also cause coma, but short duration
Generally this is temporary! Individual will progress to either vegetative of minimally conscious state. Emergence from a coma in 2-4 wks predicts a more favorable outcome
A vegetative state is also known as “unresponsive wakefulness.” This individual has no signs of conscious awareness of [self / environment / both].
- Eyes are [open / closed]
- Reflexes?
- Sleep/wake cycles?
- Command following?
- Autonomic functions are [intact /disrupted]
Starting to have sleep wake cycles but NOT following commands. Autonomic system is intact for basic functions.
“Persistent” vegetative state = ___ [amt of time], vs “permanent” vegetative state = [amt of time.]
A vegetative state is also known as “unresponsive wakefulness.” This individual has no signs of conscious awareness of SELF OR ENVIRONMENT.
- Eyes are OPEN
- Reflexes INTACT
- Sleep/wake cycles are PRESENT (or at least emerging)
- NO command following
- Autonomic functions are INTACT for basic functions.
“Persistent” vegetative state = 1 MONTH
“Permanent” vegetative state = 12 MONTHS. Likelihood of emerging from this at this stage is slim.
A minimally conscious state is a condition of severely altered consciousness in which minimal, but definite behavioral evidence of self or environmental awareness is demonstrated. Inconsistent responses, but may include following commands, verbalization, yes/no responses, movement in response to environment (not reflexive)
In MCS, half of these patients have ___ lesions and 42% have grade [I / II / III] DAI. More sparing of cortical connections compared to those in a coma or vegetative state.
A minimally conscious state is a condition of severely altered consciousness in which minimal, but definite behavioral evidence of self or environmental awareness is demonstrated. Inconsistent responses, but may include following commands, verbalization, yes/no responses, movement in response to environment (not reflexive)
In MCS, half of these patients have thalamic lesions and 42% have grade II DAI. More sparing of cortical connections compared to those in a coma or vegetative state.
Prognostic indicators post brain injury…
Younger age/gender (women tend to do better than men)
GCS
Length of post traumatic amnesia (how long it takes for them to start establishing new injuries)
Traumatic injuries tend to do better than vascular/anoxic (because traumatic tends to be more focal)
Higher education level/pre-injury IQ
Early use of neurostimulants (e.g. ritalin)
Presence of pre-injury psych issues or substance abuse
Coma Recovery Scale - Revised (CRS-R):
23 items on __ subscales - what are they? It takes ~25 mins.
What do we use it for?
6 subscales, higher score is better: Auditory, visual, motor function, Oral motor, communication, and arousal
Used to detail which areas are still difficult for pt, used for prognosticating and treatment planning. Can indicate emergence from vegetative -> minimally conscious state -> emerging from minimally conscious state
When to use the DOCs scale vs CRS-R? How long does each take?
CRS-R is a little broader, takes ~25 mins, no training required - give a good 20-30 sec to get the desired response! Takes a bit!
DOCs scale is used in TBI to detect more subtle changes in observable indicators of neurobehavioral functioning. Requires training, takes ~45 mins
Emergence from a minimally conscious state is marked by the return of reliable and consistent interactive __ or ____.
Emergence from a minimally conscious state is marked by the return of reliable and consistent interactive COMMUNICATION or FUNCTIONAL OBJECT USE.
Meds to help with arousal = ___. Examples?
Stimulants help w/arousal. Examples include:
Amantadine
Ritalin
Provigil
___ can be used to help with seizures, but it has both sedating side effects and levels need to be monitored to avoid toxicity.
DILANTIN can be used to help with seizures, but it has both sedating side effects and levels need to be monitored to avoid toxicity.
Motor deficits post TBI may arise from problems with central control, including impaired:
- __ and control/___ production
- Intra/interlimb ___
- ___ (from cerebellar damage)
Additionally, motor deficits could stem from motor ___ problems (i.e. praxis) or from ___ injury!
Motor deficits post TBI may arise from problems with central control, including impaired:
- TIMING and control/FORCE production
- Intra/interlimb COORDINATION
- ATAXIA (from cerebellar damage)
Additionally, motor deficits could stem from motor PLANNING problems (i.e. praxis) or from PERIPHERAL NERVE injury!
Changes in muscle tone post TBI
Hypertonic: may have tonal influence (flexor or extensor pattern) or spasticity (veolicty dependent resistance to movement)
Hypotonic: more common early and with diffuse injuries (eg. anoxia, sometimes w/Cerebellar lesions)
Posturing:
Decorticate posturing: BLEs extended, UEs flexed
Decerebrate (worse prognostically): extended UEs and LEs
During a period of post-traumatic amnesia, someone is not forming new ___. This includes a period of coma, if present. Retrograde amnesia is the period of time prior to the ___ that the person cannot remember.
During a period of post-traumatic amnesia, someone is not forming new MEMORIES. This includes a period of coma, if present. Retrograde amnesia is the period of time prior to the TRAUMA that the person cannot remember.
Duration of post traumatic amnesia vs severity of brain injury... Very mild = < \_\_\_ minutes Mild = \_\_-\_\_ mins Moderate = \_\_\_-\_\_ hrs Severe = \_\_ -\_\_\_ days Very severe = \_\_\_ -\_\_\_ weeks Extremely severe = >\_\_\_ weeks
Longer periods of post traumatic amnesia = [better / worse/ no change in] prognosis.
Duration of post traumatic amnesia vs severity of brain injury... Very mild = < 5 minutes Mild = 5-60 mins Moderate = 1-24 hrs Severe = 1-7 days Very severe = 1-4 weeks Extremely severe = >4 weeks
Longer periods of post traumatic amnesia = WORSE prognosis
Describe the Moss Attention Rating Scale
Helps to quantify attention based on behavior. Good to use with rehab (highly recommended!) and acute (well recommended). Some items have better function with a higher score, whereas some have a better function with a lower score, so hard to look at score overall .
Agitated behavior scale can be useful in which RLA stages?
High score = [more/less agitated ]
Score of <=21 = ___
22-28 = ___
29-35 = ___
>35 = ___
Agitated behavior scale can be useful in/around RLA IV (confused and agitated)
High score = MORE AGITATED
Score of <=21 = WNL
22-28 = MILD agitation
29-35 = MODERATE agitation
>35 = SEVERE agitation
Frontal lobe dysfunctions / associated behaviors are often characterized by which area of the frontal lobe was damaged:
- Orbitofrontal = ____
- Dorsolateral = ___
- Medial = ___
Frontal lobe dysfunctions / associated behaviors are often characterized by which area of the frontal lobe was damaged:
- Orbitofrontal = DISINHIBITION
- Dorsolateral = DYSEXECUTIVE SYNDROME (problem solving, multitasking, planning)
- Medial = APATHETIC
Frontal lobe dysfunctions can be tied to specific areas of damage.
Disinhibition = ___ damage
Dysexecutive syndrome = ___ damage
Apathy = ___ damage
Frontal lobe dysfunctions can be tied to specific areas of damage.
Disinhibition = ORBITOFRONTAL damage
Dysexecutive syndrome = DORSOLATERAL damage
Apathy = MEDIAL damage
Prefrontal cortex damage differs a bit by hemisphere.
[right / left] frontal damage is associated with depressive affect and decreased engagement, facial expressions, and spontaneous speech.
[right / left] frontal damage is associated with greater irritability, agitation, and increased speech.
Prefrontal cortex damage differs a bit by hemisphere.
LEFT frontal damage is associated with depressive affect and decreased engagement, facial expressions, and spontaneous speech.
RIGHT frontal damage is associated with greater irritability, agitation, and increased speech.
Orbitofrontal cortex describes the inferior prefrontal cortex. It has connections to the __ and __ regions of the brain. Primary behavioral changes include ___, emotional ___, decreased ___, impaired ___/distractability, and perseveration .
Orbitofrontal cortex describes the inferior prefrontal cortex. It has connections to the AMYGDALA (emotion) and TEMPORAL (speech/hearing) regions of the brain. Primary behavioral changes include DISINHIBITION, emotional LABILITY, decreased JUDGEMENT, impaired ATTENTION/ DISTRACTIBILITY, and PERSEVERATION . Also can be lacking self-control, denial of deficits, impulsive, restless/hyperactive - kind of look like teenagers!
Heterotopic ossification involves ___ growth in extra-articular areas following some sort of insult, such as ___ trauma, ___, ___ injury, or severe ___. The etiology and pathogenesis are unknown. Incidence is __-__% following trauma. Peak occurrence is __-__ weeks post injury. Most common sites include__, __, and __. Signs/symptoms include localized __, __, and __ in the joint. Work-up includes labs to assess for elevated serum __ __ and [imaging.]
Heterotopic ossification involves BONE growth in extra-articular areas following some sort of insult, such as MUSCULOSKELETAL trauma, SCI, BRAIN injury, or severe BURNS. The etiology and pathogenesis are unknown. Incidence is 3-47% (WIDE range!) following trauma. Peak occurrence is 4-12 weeks post injury. Most common sites include ELBOW, HIP, and PECTORALIS. Hard end feel on ROM! Signs/symptoms include localized SWELLING, PAIN, and ELEVATED TEMPERATURE in the joint. Work-up includes labs to assess for elevated serum ALKALINE PHOSPHATASE and POSITIVE BONE SCAN (doesn’t always show up on XR).
Heterotopic Ossification…
PT intervention?
Medical management?
Surgical management?
Heterotopic Ossification…
PT intervention? Maintain motion as able
Medical management? NSAIDs, disodium etidronate (Didronel) to prevent HO formation
Surgical management? Can resect HO after the bone is “mature” and has stopped growing, typically is postponed until 14-18 months after onset! Recent evidence suggests surgery done sooner may be as effective
Disability rating scale in TBI
- Measures at what stage of severity?
- It is [highly / less] sensitive to small change
- Scores 0-30
- Higher score = [more / less] involved (30 = ___; >=22 is ____; good recovery = <= ___
- Predictive of ___
Disability rating scale in TBI - Measures from COMA TO COMMUNITY level - It is LESS sensitive to small change - Scores 0-30 - Higher score = MORE involved 30 = Dead 29-22 = Vegetative state 21-8 = Severe Disability 5-3 = Moderate Disability 3-0 = Good recovery - Predictive of EMPLOYABILITY (highly correlated with GCS) - MDs use this to determine disability benefits
Functional Independence Measure
- Areas assessed?
- Scoring?
Functional Assessment Measure (FIM+FAM) is specifically for [what population?]
- Adds on [#] items to the FIM = [#] items total
- Areas assessed?
Functional Independence Measure 18 items (13 motor, 5 cognitive/ADLs) 18 -126 (highest level of independence = higher score)
Functional Assessment Measure (FIM+FAM) is specifically for brain injury!
12 items intended to add to the 18 items on the FIM = 30 items total, with the extra items specific to brain injury
Self care, sphincter ctrl, mobility, locomotion, self care, cognitive
EACH item is scored 1-7:
1 = total assist/2 person asst
2 = maxA
3 = ModA (>50% asst)
4 = MinA ("touching" really more of a CTG)
5 = Supervision/cues
5 exception = ModI but only short distance (locomotion) or 4-6 stairs (instead of full flight of ~12)
6 = ModI (assistive device, AFOs, etc)
7 = totally independent
Modified Ashworth Scale 0 = 1 = 1+ = 2 = 3 = 4 =
0 = NO increase in tone, normal 1 = SLIGHT Increase in tone, w/"catch and release" or by minimal resistance at the END RANGE of motion when moved into flex/ext 1+ = SLIGHT increase in tone, with CATCH then MIN resistance through remainder (less than half) of the ROM 2 = MARKED increase in tone through most of ROM, but still easily moved 3 = CONSIDERABLE increase in tone, passive movement is difficult 4 = Affected part is RIGID in flexion or extension
Benefit of stretching in neuro populations?
- LIMITED evidence exists showing stretching has a SMALL immediate effect on joint mobility in neuro pops.
- High quality evidence exists showing stretching has “little or no short or long term effect on joint mobility, pain, spasticity, or activity limitation”
STretching may help short term to get someone into a splint or to be able to do an activity, but stretching alone isn’t gonna cut it.
Alternatives? Standing frames, walking - WEIGHT BEARING activity
Serial Casting in neuro pops.
- Why does it work?
- When is it indicated?
- Contraindications/ considerations
Serial Casting in neuro pops.
- Why does it work?
- ->Gives prolonged stretch; neurophysiological effects
- When is it indicated?
- -> “hint of range loss” as tone is increasing - use this EARLY ON (weeks/months following injury)
- -> 2-4 wks post injury may be a critical window
- With TBI, consider w/GCS <12
- Contraindications/ considerations
- -> Chronicity of contracture (>6 months)
- -> Skin/ sensory/ circulation issues
- -> Behavioral issues
- -> Plan for cast removal (either acutely or when ready)
- –> option: bivalve the cast so you can basically have it be a “splint” rather than a true cast
BUT: there’s little empirical data to support it, though it did help reduce PF contractures (early on, prior to pt initiating WB)
Orthoses in TBI
- Purposes
- UE:
- LE:
Orthoses in TBI
- Purposes
Positioning or prolonged stretch, fxn, gait
- UE: WHOs (wrist hand orthosis aka ‘cock up splint’), elbow dynamic splints, antispasticity splints (aka ball splint, helps to hold hand open not fisted)
- LE: KAFO or knee immobilizer, AFO: articulating vs solid vs Floor Reaction AFO
Can be pre-fab and provide stretching/prolonged positioning - easy to adjust, easy to remove; but only level 4 (weak) evidence
Wheelchair seating/positioning in TBI
- Goals?
- Specific to brain injury, might need specific modifications and custom chairs e.g. …
Overall: you want them to be functional!
Wheelchair seating/positioning in TBI
- Goals?
Postural alignment, comfort, deformity management, pressure distribution/relief, appearance
- Specific to brain injury, might need specific modifications and custom chairs e.g. … may need head control or use of a tilt chair; management of abnormal tone or fixed deformities; meeting caregivers needs (cleaning it, taking apart/fixing), propulsion can be challenging!
Overall: you want them to be FUNCTIONAL!
Outcome measures for seated balance in TBI?
Describe scoring, subscales
Trunk impairment scale! Scored 0-23 Three subscales: - Static Sitting balance - Dynamic sitting balance - Coordination
Each subscale has between 3-10 items
DGI vs FGA?
FGA was a revised version of the DGI, eliminated 1 item from DGI and added walking backward, tandem walking, and eyes closed
DGI max = 24
FGA max = 30
Not validated in BI, but can be useful
HI MAT
# items
Things tested?
13 items with wide range of high level activities
walking and running jumping & balance Stairs hopping skipping bounding
Causes of fatigue in individuals post TBI
Present in __-__%!
Causes of fatigue in individuals post TBI
- Disrupted sleep-wake cycles
- Difficulty maintaining arousal
- Depression
- Neuroendocrine disorders
Fatigue is present in 13-80%!
Headache management and brain injury
PTs can help w/headache monitoring, agg/ease factors
Biofeedback can help as can exercise
Participation measures post brain injury…
Participation measures post brain injury…
CIQ = Community Integration questionnaire; how person is able to return to social/ community roles
CHART = Craig Handicap Assessment and Reporting Technique. Used w/BI and other populations (including SCI, BI). Comprehensive measure. Looks more at physical limitations .
MPAI = MayoPortland - combined measure. Measures post-hospital participation in BI. Subscales = ability, adjustment, and participation
PART O = combines CIQ and CHART. Objective measure of participation. Looks at long term outcomes post BI, social and societal functioning, and physical limitations
Post BI, driving is a [high/low] level IADL.
HIGH level skill!
Needs emotional regulation, divided attention, physical abilities, and high level vision. 80% of BI survivors return to driving (many AMA!). Needs OT eval for return to driving
Return to work post BI?
~66% of all BI return to work at 1 year, 72% at 2 yrs
- Severe injuries (PTA >7 days): 37% return to work after 2 years
May need vocational counseling to transition
Aging and brain injury…
- How does age at injury and severity of physical limitation affect outcomes/mortality?
- Moderate and severe BI survivors are at greater risk of developing __ and __
Aging and brain injury…
- MORE ADVANCED AGE AT INJURY and GREATER PHYSICAL ISSUES yield shorter lifespan, poorer outcomes (less mobile, may throw a clot -> stroke, may die sooner)
- Moderate and severe BI survivors are at greater risk of developing PD and DEMENTIA
Recommend periodic “tune ups” with PT/OT!
