TBI: pathology, classification, exam, outcomes measures Flashcards
What is the #1 cause of TBIs
Unintentional falls
Caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain.
Traumatic brain injury
Mild– a brief change in mental status or consciousness
Severe– an extended period of unconsciousness or amnesia after the injury
Type of TBIs caused by direct contact
Concussion
contusion (coup/contrecoup)
hematoma (epidural, intracerebral, subarachnoid)
Type of TBIs caused by penetrating injury
invasive injury to neuronal and vasculature tissue
Type of TBIs caused by acceleration/deceleration
concussion
hematoma (subdural)
diffuse axonal injury
Type of TBIs caused by blast injury
Diffuse axonal injury
Type of TBIs caused by heart attack, near drowning (acquired brain injuries)
anoxia (the absence of oxygen)
hypoxia (inadequate oxygen to tissues)
contusion
Swollen brain tissue where there is vascular and tissue damage
- can be a response to the brain moving around in the skull (same side = coup; opposite side from contact = contrecoup)
- identified on CT; appears as hemorrhagic lesion
- differentiated from hematoma in that blood is intermixed with brain tissue
Hematoma
Damage to major blood vessels in the head or heavy bleeding into or around the brain
- epidural: bleeding between skull and dura
- Subdural: bleeding between dura and arachnoid
- subarachnoid/intracerebellar: bleeding within the brain
Diffuse axonal injuries
Torsion or shearing of long axons
- greater likelihood of disruption of white matter tracts: corpus callosum, internal capsule, brainstem, cerebellar peduncles
- axonal injury not always diffuse
- interruptions of axonal transport and axonal swellings
- not identified on CT and sometimes on MRI
Blast injuries
Primary: occur following high order over-pressurization shock wave moving through the body, affects gas-filled organs such as lungs, GI tract, middle ear, etc.
Secondary: caused by bomb fragments and other objects propelled by an explosion resulting in penetrating injuries
Tertiary: result from the blast wind throwing the victim and include bone fractures and amputation
Quaternary: include injuries not included in the first three (burns, crush injuries, and respiratory injuries)
What are the typical intracranial pressure values?
10-15 mm Hg in supine
-10 mm Hg in standing
Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) - Intracranial Pressure (IP)
What can result from excess intracranial pressure?
papilledema, herniation, brain tissue damage, stroke, etc.
Signs: decreased pulse rate, change in consciousness, agitation, coma
What is Cushing’s Triad?
Three primary signs that often indicate increased intracranial pressure: increased Systolic BP decreased pulse decreased respiration *opposite of shock symptoms*
Glasgow Coma Scale: eye opening response scoring
Spontaneous: open before stimulus- 4 pts
To verbal stimuli (spoken or shouted request)- 3 pts
to pressure (finger tip stimulus)- 2 pts
No opening at any time, no interfering factor- 1 pt
Non-testable: closed by local factor- NT
Glasgow Coma Scale: verbal response scoring
Oriented: correctly gives names/place/date- 5 pts
Confused conversation, but coherent- 4 pts
Words: intelligible but inappropriate- 3 pts
Sounds: incomprehensible, moans/groans- 2 pts
No response, no interfering factor- 1 pt
non-testable: closed by local factor- NT
Glasgow Coma Scale: motor response
Obeys commands for movement- 6 pts
Purposeful movements to stimulus- 5 pts
Withdraws in response to pain- 4 pts
Flexion response to pain (decorticate)- 3 pts
Extension response to pain (decerebrate)- 2 pts
No response, no interfering factor- 1 pt
Non-testable: closed by local factor- NT
Abnormal flexion response to stimulus
slow stereotyped arm across chest forearm rotates thumb clenched leg extends
Normal flexion response to stimulus
rapid
variable
arm away from body
Head injury classification via GCS
3-8–severe
9-12– moderate
13-15– mild
classification of TBI severity: loss of consciousness (LOC)
0-30 min– mild
> 30 min and < 24 hrs– moderate
> 24 hrs– severe
classification of TBI severity: alteration of consciousness/ mental state (AOC)
up to 24 hrs– mild
> 24 hrs; severity based on other criteria– moderate or severe
classification of TBI severity: post-traumatic amnesia (PTA)
0-1 day– mild
>1 day and < 7 days– moderate
> 7 days– severe
classification of TBI severity: Glasgow Coma Scale (best available scores in first 24 hrs)
13-15– mild
9-12– moderate
< 9– severe
Coma
unconscious and no sleep wake cycles; may have reflexive movement
Persistent Vegetative state
unconscious, but have sleep wake cycles;
withdraws to noxious stimuli;
occasional non-purposeful movement;
brief orientation to sound or an object
Minimally conscious state
partially conscious
localize noxious stimulus and sound
inconsistent following commands
Stupor
general unresponsiveness
require repeated stimuli
obtunded
reduced alertness
slow to respond to stimuli
Delirium
disoriented
fearful and misinterpret stimuli
Ranchos Los Amigos Scale for cognitive function
L1: no response (total assist): unconscious/comatose; no reaction to stimuli
L2: generalized response (total assist): reaction inconsistent/without purpose
L3: localized response (total assist): more specific reaction, i.e. may turn head in direction of voice
L4: confused/agitated (max assist): active; bizarre behavior; may react in hostile manner secondary to confusion
L5: confused, inappropriate non-agitated (max assist): less agitated/more consistent but still confused/inappropriate
L6: confused, appropriate (mod assist): context-appropriate, goal-directed responses, requires direction
L7: automatic, appropriate (min assist for ADLs): follow routine, but judgement/problem-solving impaired
L8: purposeful, appropriate (stand by assist): oriented, independent with familiar tasks, may need assistance to manage routines and planning of daily personal, household, community, work and leisure activities
L9: purposeful, appropriate (stand by assist on request): independent with tasks for longer period, may still request assistance for routines
L10: purposeful, appropriate (Mod. independent): able to handle multiple tasks simultaneously, accurately estimates abilities and independently adjusts to tasks demands
Differential diagnosis for mild TBI vs. concussion
mTBI requires traumatically induced physiological disruption of brain function, as manifest by at least on of the following:
- any period of loss of consciousness
- any loss of memory for events immediately before or after accident
- any alteration in mental state at the time of the accident
- focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following;
- loss of consciousness of approx. 30 min or less
- after 30 min an initial GCS of 13-15
- post-traumatic amnesia not greater than 24 hr.
Concussion
recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness (LOC). (American Academy of neurology)
Sports Related Concussion
- may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
- typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously.
- in some cases, signs and symptoms evolve over a number of minutes to hours.
- acute and clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury
Signs and symptoms of concussion/mTBI
Thinking/remembering: difficulty thinking clearly, feeling slowed down, difficulty concentrating, difficulty remembering new info
Physical: headache, fuzzy/blurry vision, nausea/vomiting (early), dizziness, sensitivity to noise or light, balance issues, feeling tired, having no energy
Emotional/mood: irritability, sadness, more emotional, nervousness or anxiety
Sleep: sleeping more than usual, sleeping less than usual, trouble falling asleep
what is the problem with the ImPACT test?
inconsistent results
has high error rates
can be easily misled by neurological factors unrelated to concussion
Components of the Sports Concussion Assessment Tool (SCAT5)
Immediate/on-field assessment: -red flags -observable signs -memory assessment -GCS -cervical spine assessment Off-Field assessment
Components of the Vestibular/Ocular-motor screening (VOMS) for concussion/mTBI
Smooth pursuits Saccades Convergence Visual motion sensitivity VOR Score for headaches, dizziness, nausea, fogginess on 1-10 scale
Components of Cervical Exam for concussion/mTBI
ROM
Pain with palpation/isometric contraction
Components of visual exam for concussion/mTBI
Extra-ocular movements (smooth pursuit, saccades, convergence)
VOR
Dynamic visual acuity (Head movements @ 2 Hz. > 3 line change = + test)
Components of post-traumatic vertigo (BPPV) exam for concussion/mTBI
Canal testing: posterior, anterior, lateral, multiple canal involvement
Components of balance exam for concussion/mTBI
Balance Error Scoring System (BESS):
-recommended for sideline screening
-very similar to mCTSIB but may be better for higher level patient/athlete
Sensory Organization Testing via Modified Clinical Test of Sensory Integration and Balance (mCTSIB):
-good psychometric properties
-better for wide range or non-athlete patient
What is the prognosis for a concussion/mTBI?
-neuropsychological deficits are present during the first 2-weeks after mTBI
-less agreement on when deficits resolve (> 6mo)
-young children may not be able to report symptoms: look for behavior changes, excess crying, vomiting, loss of new skills
Older adults:
-brain atrophy may result in more severe injury due to coup/contre-coup action.
-symptoms of mTBI often attributed to other co-morbidities (stroke, syncope, seizure, dehydration, dementia, etc)
-on average, experience higher morbidity and mortality, slower recovery, and worse functional, cognitive and psychosocial outcomes than younger individuals.
Age-related issues for a concussion/mTBI
-young children may not be able to report symptoms: look for behavior changes, excess crying, vomiting, loss of new skills
Older adults:
-brain atrophy may result in more severe injury due to coup/contre-coup action.
-symptoms of mTBI often attributed to other co-morbidities (stroke, syncope, seizure, dehydration, dementia, etc)
-on average, experience higher morbidity and mortality, slower recovery, and worse functional, cognitive and psychosocial outcomes than younger individuals.
Who is involved in intervention/management of mTBIs
neuropsychologist physician (PCP, Sports Med, Neuro, Ortho, Psych, PM & R) PT OT Behavior Neuro-optometry Athletic Trainer
Active Rehab principles for mTBI
Rest 24-48 hrs post-concussion
start light activity as tolerable after that period; adolescent athletes that rested 5 days had slower recovery
for post-concussive syndrome:
-graded cardiovascular exercise
-treatment of symptoms: cervical/headache, vestibular, ocular motor
Questions to guide the examination for mTBI
PIP: -usually participation restriction or activity limitation -may be impairment (dizziness, headache, balance, visual deficits, sensitivity to sensory stimulation, feeling mentally slow or foggy) Non PIP: -arousal -cognition Precautions/contraindications: -elevated ICP -seizure disorder -autonomic abnormalities: HR, RR, BP
sympathetic storming
uncontrolled activation of the sympathetic nervous system
clinical presentation:
- temperature of 38.5* C (101.3 F)
- hypertension
- HR > or = 130 bpm
- Respiratory rate > or = 40 breaths per minute
- agitation
- diaphoresis
- dystonia
Review of integumentary system
ask about: skin integrity
burns or lacerations (blast injuries/MVA)
sites of prolonged pressure
review of cardiopulmonary system
ask about: lung function and fatigue pneumothorax physical fatigue cognitive fatigue -changes to auto-regulatory center may impact physiological function
review of musculoskeletal system
ask about: joint motion and injury
heterotopic ossification (calcium deposits in joint)
fractures or amputation
AROM w/ overpressure
-presence of ho or contracture will impact movement
-management: NSAIDS, biphosphonates, radiation therapy
review of neuromuscular system
ask about: seizures, vision, dizziness, balance, swallowing, cognition, sleep, changes in neurologic impairments -seizure disorders -cranial nerve integrity -cognitive impairment -concussion -undiagnosed change in neurologic status Cranial nerve test, VOMS, & BESS -mechanism may suggest cranial nerve impairment (particularly CN VIII); postural control systems may be impaired
review of neuromuscular system
ask about: emotional stability
- mood swings
- anxiety
- depression
- temper/outbursts
Questions to determine immediate referral
headaches that worsen presence of seizures focal neuro signs (numbness, weakness) drowsy/can't be aroused repeated vomiting slurred speech can't recognizer people/places increasing confusion/irritability neck pain unusual behavior change change in state of consciousness
Common patient-identified problems
difficulty…
swallowing
orienting to environment
looking
common impairments related to difficulty swallowing
difficulty... with lip closure (drooling)-- CN VII chewing-- CN V moving bolus posteriorly-- CN VII (retention of food between cheeks and gums); CN XII (retention of food in mouth) initiating swallow-- CN IX and X
simple orientation is spontaneous recall of…
date, time, city, kind of place, name of hospital, event, deficits
higher level orientation with cognitive process…
able to repeat address of an unknown person
count backwards from 20
state months in reverse order
estimate 30 seconds without clock
atypical orientation response…
required logical cueing (that was yesterday so today msut be...) requires options (is it this or that?) requires phonemic cueing (it's Frrr...) inaccurate despite cueing inappropriate response unable to respond
Pursuit eye movements
able to smoothly follow a target 3 ft away across midline in both horizontal and vertical direction at a speed of 1 foot per second
atypical response:
jerky, requires saccadic correction, induce dizziness or HA
Saccades
able to move accurately and quickly between two targets that are both 30 degrees from midline
Atypical:
over/undershoot requiring a correction, induce dizziness or HA
convergence
able to keep a target in focus when bringing a target from arms length to 6 cm from the nose with both eyes moving medially
insufficiency:
asymmetry in medial eye movement (outward deviation of one eye), blurriness, dizziness or HA
Vestibulo-ocular reflex
able to stabilize vision with head movement of at least 20 degrees at a speed of rotation at 180/minute (3/second)
impaired:
saccadic correction, blurriness, dizziness or HA
Common impairments that interfere with activities
coordination perception somatosensation force generation flexibility
Coma recovery scale- revised
measures arousal
23 items, 6 subscales addressing auditory, visual, motor, oromotor, communication and arousal functions.
lowest item on each subscale = reflexive activity
highest item on each = cognitively-mediated behaviors
Moss Attention Rating Scale (MARS)
Measures attention
22 items, scored on 5-point Likert scale
Agitated Behavior Scale
measures agitation 1 = absent 2 = present to a slight degree 3 = present to a moderate degree 4 = present to an extreme degree
Cognitive TUG
dual task TUG, requiring the person to count backward by threes from a randomly selected number between 20-100 while completing the movement task
TBI EDGE: Activity level measures
functional assessment measure: adds cognitive items to FIM
Disability rating scale: responsiveness and ADLs
Community balance and mobility scale: standing and walking item
6-minute walk test
10-meter walk test
Berg Balance Scale
Functional assessment measure (FAM)
12 items added to the 18 items of the FIM:
swallowing, car transfer, community access, reading, writing, speech intelligibility, emotional status, adjustability to limitations, employability, orientation, attention, safety judgement
Disability Rating Scale
evaluates 8 areas of function in 4 categories
- consciousness
- cognitive ability
- dependence on others
- employability
Community Balance and Mobility Scale (CB&M)
Detects high level balance and mobility deficits based on tasks commonly encountered in community environments
TBI EDGE: participation level measures
Community integration questionnaire: quantifies independence with independence in the community
Dizziness Handicap Inventory: quantifies dizziness symptoms with activities
Quality of Life after Brain Injury
Community Integration Questionnaire
3 domains:
home integration
social integration
Dizziness Handicap inventory
3 domains: functional emotional physical question examples: does looking up increase your pain? because of your problem, do you feel frustrated? does walking down
Quality of Life after Brain Injury
comprehensive questionnaire with 37 items covering six dimensions of HRQoL after TBI
Domains include cognition, self, daily life & autonomy, social relationships, emotions, physical problems
