TBI Plan of Care Across the Continuum Flashcards
1
Q
What is the pathophysiology of a mild TBI?
A
the imbalance between the microvascular supply and metabolic demand
- longitudinal alterations in cognitive activity while reducing exposure to symptom aggravating stimuli
2
Q
What are the current guidelines for treatment of an acute mTBI?
A
limiting physical and cognitive activity while reducing exposure to symptoms aggravating stimuli
3
Q
Intervention/Plan of care for mTBI:
A
rest, avoid activities that have high risk for another concussion
- gradually resume normal activity based on tolerance
** this is patient specific NOT a protocol
4
Q
Management of mTBI:
A
- reduce/avoid provoking stimulus
- adjust environmental overuse, muscular, visual, vestibular issues through education/training
- used a time method for reading (increase by 5 mins each time)
- reduce environment if patient reports symptoms
- assess if patient is ready for physical activity
5
Q
Education tips for mTBI/concussion: AVOID
A
- avoid another blow/jolt to head
- avoid computer games/phone use/other cognitive activities
6
Q
Education tips for mTBI/concussion: ASK
A
- ask when it is safe to drive a car/ride a bike/play
- ask when to use heavy equipment
- when you can go back to work
7
Q
Education tips for mTBI/concussion: TAKE
A
- take medications the doctor has approved
8
Q
Education tips for mTBI/concussion: LISTEN
A
- listen to symptoms and reduce/rest when they increase
9
Q
How long should you rest when you first get injured with a concussion?
A
24-48 hours depending on severity
10
Q
When is the greatest risk for being diagnosed with another concussion?
A
the first 10 days after a concussion
11
Q
Who is at greatest risk for concussions?
A
- football and rugby players highest risk
- soccer and basketball the 2nd highest
- young girls/women
12
Q
An athlete who has a history of ______ or more concussions is at a greater risk for being diagnosed with another.
A
one
13
Q
Signs of mTBI
A
- ocular (reading, visual deficits)
- vestibular (cervical/ocular deficits, walking, turning head, driving car)
- posture (LOB, dynamic balance)
14
Q
Symptoms of mTBI
A
- attention (unable to perform work/school related activities, difficulty focusing, fatigue, memory loss)
- emotion (irritability, depression, sleep problems, less engaged in activities)
- environment (emotion, attention, sleep, noise/light/screen time problems)
15
Q
VOR function
A
keeps our eye gaze stabile while the c spine is rotating and or making vertical movements
- deficits include dizziness, inability to read, vertigo, unsteadiness, eye fatigue
16
Q
Vestibular postural system (VSR)
A
assists in postural stability and body orientation in space and in assisting postural tone
17
Q
Method of for testing VOR
A
dynamic visual acuity and the VOMS exams
18
Q
VOR: how it works
A
CN III, IV, VI (efferent nerves)
- when head turns L the eyes turn R to maintain focus
- when head turns R the eyes turn L to maintain focus
- when head turns the eyes move in opposite rotational directions of the neck because the semicircular canals are rotated in the opposite rotational direction
19
Q
What causes a delay/disruption in VOR transmission in TBIs?
A
when there a TBI, there may be primary damage to the VOR/CNs which causes synaptic disruptions and/or neurometabolic deficits that ca delay/disrupt transmission
20
Q
What is the oculomotor system connected through to formulate the VOR?
A
it is connected through the medial longitudinal fasiculus (MLF) with many oculuomotor, vestibular nuclei and the semicircular canal to formulate the VOR
21
Q
Memory loss in TBI
A
- short term/working memory is used to maintain short term information which is then used for higher level planning and processing
- fMRI evidence shows that disruption of excitation and inhibition input of the prefrontal cortex causes working memory disturbances inn mTBI
22
Q
Memory: hippocampus and amygdala
A
hippocampus = short term memory
amygdala = controls primitive emotional responses
- amygdala involvement can alter the hippocampus function by putting an emotional priority on certain memories
23
Q
What are the hippocampus and the amygdala connected to?
A
they are connected to the lower frontal lobes by the uniciate fasciculus
24
Q
Unicate fasiculus
A
fiber tract of axons that is VERY vulnerable to injury (twisting of brain tissue with a concussion)
25
Examination for a concussion
- musculoskeletal (c spine)
- neuromuscular
- communication/cognition
- integumentary
- cardiopulmonary
- Hx
- MOI
- social/school/work
- symptoms
26
Exam: visual ocular
- VOMS
- reading activities
- driving
- ask about symptoms (dizziness, vomiting, headache, fatigue, visual changes, uneasy feelings)
27
Exam: balance
- BESS
- computerized posturography
- sway balance systems (Bertec, APDM)
28
Exam: coordination/reaction time
- ruler drop test
- cerebellar exams (assessing speed/accuracy)
29
Exam: endurance
- buffalo concussion treadmill stress test
- assessment of HR, RPE, symptoms
30
Exam: gait and quick movements
DGI or FGA
31
Buffalo Concussion Stress Test
- patient has HR monitor
- RPE scale and symptoms severity scale (VAS) used
- walk on treadmill at brisk pace
- incline and speed increased gradually over time
- HR, RPE, VAS recorded at each min
- test stops when patient is exhausted, dizzy, nauseous, or gets a headache
32
The buffalo concussion test is stopped when:
- VAS score increases 3+ points
- RPE is 17+
- patient appears faint or has stopped communicating
33
Clinical S/S of vestibular ocular system impairments
- VOR deficits
- problems with ocular movements
- problems with gaze stability
- decreased postural control
34
otoliths
peripheral input = linear acceleration
central integration = cerebellum & vestibular nuclei
motor outputs = VOR, extraocular muscles, gaze stability
35
semicircular canals
peripheral input = rotational/angular acceleration
central integration = vestibular nuclei
motor outputs = vestibular spinal reflex, VOR, vestibulocollic reflex
36
Just turning head
working semicircular canals
37
Just walking forward
working otoliths
38
Walking with head turns
working BOTH semicircular canals and otoliths
* vestibulocollic reflex (stable head while moving body)
39
Ocular system training for mTBI
TREAT THE SYMPTOMS
- visual exercises/saccades done seated, standing, varying speed
- smooth pursuit done in all directions, seated, standing
- target training done seated, standing, varying speed
40
What is the most important aspect of training the vestibular ocular system?
continuously progress exercise to make it harder
ex: VOR with just eyes, then move head, then do it standing, they add trunk rotation, add unstable surface, then you can do VOR cancellation exericises
41
VOR cancellation exercises
allows the body to work as a unit, requires a higher level of cognitive processing/coordination
- actively trying to actively cancel out the sensation of movement from the vestibular system
42
Examples of VOR program exercises
- walking with visual activity (finding objects with saccades, vertical and horizontal eye movements)
- walking with head turns (keep gaze stable on objects)
- changing speeds while walking (change speed of head turns)
43
Examples of postural control exercises
- static (eyes open/closed, stable surface, change foot position)
- dynamic (SLS, unstable surface, reaching out of BOS, catching small objects, figure 8 walking with head turns)
44
Examples of balance activities with ocular and vestibular systems
- ball activities for hand eye coordination
- bouncing ball and catching off wall
- rapid ball toss
- changing foot positions and engaging in activities above
- changing cervical positions and engaging in ball activities
45
Graded aerobis exercise
- studies have show temperature and cardiac autoregulation are altered after a TBI
- start off with low levels (walking or bike)
- measure HR to reach target HR
- STOP if patient has dizziness or headaches
- continue if patient feels good, to submax HR (70-80% of THR)
46
Why do patients feel headaches and dizziness after a TBI during exericse?
the blood is not circulating correctly and the reduced cerebral blood profusion may cause headaches/dizziness
47
Brock string exercises
used during treatment of convergence insufficiency and binocular vision (convergence and vergence)
- helps develops skills of convergence
- helps disrupt suppression of one of the eyes
48
Caveats about mTBIs
- premature exercise can be detrimental to recovery
- excessive intense exercise may be detrimental to recovery
- younger adults/kids are more prone to these events
* ANS may not respond to increase cardiopulmonary demands
** always watch for symptoms and blunting of HR/BP
49
When do you go back to school/work/play after a TBI?
- gradual introduction back to activity
- add more distractions slowly (light/noise/etc)
- higher level activities may take longer to habituate
50
Primary damage in TBIs (seconds to minutes)
1. diffuse axonal injuries = axonal swelling
2. membrane mechanoporation = Ca++ accumulation excitotoxicity
3. acute ischemia = cellular acidosis
51
Secondary damage in TBIs (hours to days)
apoptosis
activation of microglia
secondary axotomy
demyelination
secondary ischemia
52
Neurodegeneration in TBIs (months to years)
can happen in brain cortex, hippocampus, amygdala, thalamus
- beta amyloid accumulation
- TDP 43 inclussions
- Tau neurofibrillary tangles
- inhibition of neurogenisis and gliogenisis
53
S/S brain injury: emotional
lability
anxiety
frustration
impulsivity
agitation
54
S/S brain injury: cognitive
memory disturbances
judgement
cognitive fatigue
55
S/S brain injury: sensory
decreased tolerance to sensory stimulation (light, noise, physical)
56
S/S brain injury: motor
coordination problems
decreased speed
deceased accuracy
problems with motor learning
57
Why is working memory affected with brain injuries?
many areas (prefrontal cortex, broca/wenicke, parietal lobe, occipital lobe) can get injured which can reduce the ability to process and store information in the hippocampus
58
Assessment of moderate-severe TBI: glasgow coma scale
1. arousability - awakens to voice, voice & tactile, voice & gentle push
2. sustains level of eyes open/tracking/semi awake/alert
3. how long eyes are open/tracking/alert
4. follows commands - 1, 2, 3 steps?
5. environment - tolerates noise/light?, movement stimulation
6. social engagement
7. procedural learning
8. irritability
59
Orientation/Behavior exams for TBIs
orientation (self, place, time, family, long term vs short term memory)
arousability (verbal, tactile, visual, pain)
attention/directions (time, follows 1/2 steps, dual task, emotional disruptions)
environment (light/noise/visual sensitivity)
behaviors (aggression, preservations, distractions, judgment/safety)
60
Neuro exam for TBIs
muscular performance (synergy, ataxia/incoordination, motor planning, weakness, speed/accuracy)
tone (hypertonicity, rigidity, spasticity, typotonicity, DTR)
cranial nerves (visual, vestibular, dysphagia)
sensation (proprioception, somatosensory, perceptual)
61
Posture & functional exam for TBIs
static balance (postural alignment, righting response, protective response, safety)
dynamic balance (change COM, obtains erect posture, postural adaptations)
transfers (follow directions, remembers procedures, impulsivity, safety, level of assistance, type of transfer)
Sit to stand (judgement, impulsivity, level of assistance)
gait (assistive device, orthotic, swing phase initiation, stance phase stability, level of assistance, distance)
62
Motor control with a head injury
selective motor control
- can they move joints without synergy or ataxia?
- can they adjust or plan movements?
63
Interventions should be? movement ideas
- task based
- attention
- relation to personal/functional goals
- wide ranging motor performance
64
Interventions should be? environment ideas
- decrease noise/light
- reduce distractions
- include rest breaks
- reduce complexity
65
Interventions should be? individual ideas
- decrease irritability
- decrease or increase cognitive load
- clearly identified support verbalized or written
66
Task based activities
use body weight, task, or environment to induce muscular changes and appropriate muscular firing
- keep activities relevant to everyday tasks
ex: folding/matching clothes, make bed, match shoes
ex: play games with balls, baskets, doors to include pushing, pulling, lifting
** cognitive overload is important!
67
Gait dynamics
sensory input to the central rhythm generator drives motor pattern
(sensory to interneurons to motor neurons)
68
Why is using the parallel bars important for TBI patients?
- provides feedback to the patient
- physical barriers and reminders to the patient
- allows for safety on the side and behind with the wheelchair
- allows for advancement of task based activities
69
Why do we do task based activites?
- engage entire nervous system
- follows normal activation brain patterns
* the brain encodes actions and tasks that are observed in the environment and planned in the brain
70
How does the brain encode motor activity?
1. posterior cortex provides sensory information to the frontal cortex
2. prefrontal cortex plans movement
3. premotor cortex organizes movement sequences
4. motor cortex produces specific movements
(posterior cortex sends goals --> prefrontal cortex plans --> premotor cortex sequences --> motor cortex executes actions)
71
Neurodevelopment treatment (NDT) priorities
1. handling of the core, head, and trunk alignment
2. lower limb alignment and connection to trunk
3. motor learning w/ task
4. dual tasking
72
Aerobic activities in TBI
- beneficial in reducing cognitive fatigue
- decreased irritability
- enhances neuroplasticity and neuroprotection (BDNF)
- reduces depression
- enhances self worth
supervised 12 weeks 3x/wk 30 mins @ 70-80% THR
73
How does aerobic exercise assist brain function?
the brain requires ~15% of total cardiac output and consumes ~20% of total O2 at rest
precise control of nutrient supply and byproducts is important in brain function due to its high energy consumption and lack of energy stores
74
When is aerobic exercise best?
aerobic exercise implementation at the acute phase is the best to support neuroplasticity
75
Neuroplasticity features in TBI: days
- increased cell death
- increased recruitment of neuro and glial cells to damaged area
- decreased corticial inhibitory pathways
- increased utilization of additional neuronal networks
- increased neural metabolic dysfunction
76
Neuroplasticity features in TBI: weeks
- increased neural metabolic stabilization
- increased synaptogenesis
- increased axonal sprouting
77
Neuroplasticity features in TBI: years
- decreased brain plasticity
78
Sequencing activities for the patient
with a TBI you need to make the simple tasks explicit, you need to reteach/plan it for them
- number the activity
- provide a picture of the activity
- provide a memory book so they can write down information to remember and practice recall
- provide a calendar to keep them orientated
79
Behavioral changes in TBI
irritability/physical outbursts/aggression are common in 29-71% of TBIs
- irritability comes from environmental distraction
- inability to express oneself
- communication breakdown
- can't meet expectations or unable to reach goals
80
Irritability with TBIs
irritability is the most permanent post TBI personality change
- patients that show irritability need breaks
- limit distractions
81
Healthy vs TBI brain:
healthy = able to ignore distractions and use brain longer, able to communicate clearly, higher level of thinking & organization
TBI = has trouble ignoring distractions which creates irritability, can't express frustration correctly, can't use brain for long periods
82
How do you reduce irritability as a PT?
- ask other disciplines to attend to the environmental stimulation
- keep calm
- keep emotions in check
- know their triggers (light, noise, visual)
- let patient rest
- establish cues before hand if patient needs help communicating (hand signals)
- go to private room, dim lights, set boundaries
83
What causes irritability in TBIs?
patients had delayed response times due to damaged myeline from TBI which causes them to become irritable because they don't understand or there are too many distractions/thoughts at one time
84
Clinician strategies to prevent agitation
- speak in soothing manner
- be patient
- keep calm, emotions in check
- reorient if needed
- change the environment (quiet area)
- have a plan for outbursts
- move patient or irritant if you notice changes in patient
- one or two step directions
- show patients what you want them to do
85
Person strategies to prevent agitation
- identify factors that create stress (people, electronics)
- practice breathing, communication methods
- relax
- time out/rest periods
- medications to relax
- practice communicating anger
86
Other strategies to prevent agitation
- educate staff on how to approach TBI
- use social greetings (speak soft, clear, direct)
- explain what you are going to do before you do it
- approach from the front
- do not crowd patient
- avoid sudden grabbing or touching patient
- formally end interaction ("all done")
- provide patient with a choice
- positive reinforcement
- give ample time to process information and formulate responses
87
Orientation in TBIs
patients lose awareness so anxiety increases
- it may feel like they are walking around a new place with no idea where anything is
* we need to reorient the patients!
- make room map
- practice finding things (way finding)
88
Way finding
navigation through unknown areas, methods of using memory, vestibular, vision, velocity, and mobility (everything is in constant integration)
*spatial cognition (moving our head in space gives us code to find out where we are in space)
