TBI - Rancho I-VI Flashcards
What are the goals of TBI rehabilitation?
1) record and track recovery
2) optimize recovery
3) provide optimal environment to maximize rehab
4) provide support and education to family
5) design therapy to maximize neuroplastic changes and guide recovery
6) guide discharge
Describe the typical course of rehabilitation
ICU –> acute care –> long term care or outpatient –> possible re-entry or exercise programs
When should you start rehabilitation for a TBI?
- dependent on patient and 2 markers
1) normalization of ICP (<20mmHg)
2) hemodynamic stability
What are the neuromuscular impairments from a TBI?
1) impaired motor control
2) impaired coordination
3) hemiparesis
4) hypertonicity
5) somatosensory impairment
6) impaired postural control
What are the behavioral impairments from a TBI?
1) easily frustrated
2) agitation
3) mental inflexibility
4) impulsivity
5) disinhibition
6) emotional lability
7) irritability
What are the possible cognitive impairments from a TBI?
1) arousal/disorder of consciousness
2) attention
3) concentration
4) memory
5) learning
6) executive functions
What are the 3 stages of arousal/disorder of consciousness?
1) coma
2) UWS
3) MCS
What are the 5 executive functions affected with cognitive impairments?
1) planning
2) cognitive flexibility
3) initiation and self generation
4) response inhibition
5) serial ordering and sequencing
What is post traumatic amnesia?
patient is unable to form new memories
What must the patient be able to identify to be out of PTA? how many days in a row must he correctly do this?
- specifics of date, time, place, and situation consistently
- 2-3 days in a row
What are other non-categorized impairments from TBI?
- communication and language (not usually aphasia)
- cranial nerve involvement
- visual deficits
- perception deficits
- dysphagia
What medications are used for tone?
baclofen, diazepam, dantrolene
What medications are usually prescribed for seizure control in TBI?
anti- epilpetics: depakote, keppra, dilantin, cerebyx
What medications are usually prescribed for attention impairments from TBI?
neurostimulants and dopamine
What medications are usually prescribed for arousal impairments from TBI?
- amantadine (4-16wks after dx)
- methylphenidate
- other neurostimulants
What medications are usually prescribed for depression following TBI?
nontricyclic meds are most effective
What are some typical activity limitations following TBI?
ambulation, basic mobility, ADLs
What are some typical participation limitations following TBI?
return to employment, family role, community/social role
What levels on ranchos are considered low level patients?
1 - 3
What can be seen in the early stages of recovery based on the cognitive recovery pyramid?
wakefullness –> awareness, arousal, attention, purpose –> perception and recognition of info –> speed of info processing
What are some things to acknowledge/look for when doing an acute care chart review?
- ventilator
- ICP monitoring
- WB restrictions
- ROM restrictions
- cardiac precautions
- open wounds or surgical sites
- external fixators
- dysautonomia
- presence of other tubing
What are the rehab goals for ranchos levels 1-3?
- constantly assessing level of consciousness and tracking progress
- increase arousal
- improve tolerance to upright
- reduce risk of secondary impairments
- improve or retain ROM
- educate
What can be determined based on levels of consciousness in an acute care patient?
prognosis, treatment, education
What impacts a patients ability to respond to stimuli and commands?
- limited motor functions
- communication impairments
- sedating medications
- impaired sensation
- impaired cognition
What requirements place someone in Coma Ranchos level I?
- unresponsive to ANY stimuli
- arousal system not functioning
- eyes closed, often ventilator dependent
- no auditory, visual, cognitive, or communication function
What requirements place someone in Unresponsive Wakefulness Rancho level II?
- awake but NOT aware
- basic brainstem functions only
- minimal communication with cortex (spontaneous eye opening and restoration of sleep wake cycles)
What must you differentiate ranchos level II from?
locked in syndrome
What movement responses may be seen in Rancho Level II?
- may startle to visual or auditory stimuli
- not able to follow commands or communicate
- reflexive smiling/crying/yawning
- withdraw/posture to noxious stimuli
What requirements place someone in a minimally conscious state Rancho level III?
- awake and partially aware
- inconsistent cognitively mediated behaviors; different from reflexes
- needs to complete certain tasks routinely
What tasks must a rancho level III be able to do 1 or more of sustainably?
- follow simple commands
- gesture or verbal yes/no
- intelligible verbalization
- movement or emotional behavior that occur in relation to relevant stimuli
What would signal emergence from a minimally conscience state (level III)?
one or both reliable and consistently:
1) accurate yes/no responses to 6/6 situational questions on 2 consecutive exams
2) functional use of at least 2 different objects
Why would being able to functionally use objects signal emergence from MCS ? (how it relates to brain function?)
motor strip of the frontal lobe is able to send the signal from the brain –> communicate with basal ganglia –> brainstem –> CST –> muscles
What is the gold standard for assessing levels of consciousness?
coma recovery scale revised
What items are included coma recovery scale revised?
auditory, visual, motor, oromotor, communication, arousal
What is the coma recovery scale used to determine?
coma, VS, MCS, or emergence
What does the disorders of consciousness scale test for?
social knowledge, taste/swallowing, olfactory, proprioception, tactile sensation, auditory and visual function
What is the sensory modality rehab techniques (SMART) for?
treatment tool for patients in VS or MCS with a sensory component and behavioral observation
What does the western neurosensory stimulation profile used to assess?
arousal/attention, expressive communication, response to auditory visual tactile and olfactory stimulation
What is the goal of multi-modal sensory stimulation programs?
To increase arousal and attention
What is multi-modal sensory stumulation?
engage cortical function by including lots of stimulation in different ways. Make sure to balance stimulation and rest and monitor pt response
What is Familiar Auditory Stimulation Training (FAST)?
5 min storytelling by relatives that involve autobiographical events
- has show improvement in CRS and increased activation of language areas
What are the benefits of music therapy in MCS?
- behavioral improvement
- improved BP in MCS
- greater activation of auditory network and physical response
Is multi-modal more effective in MCS or VS/UWS?
MCS
What are the benefits of early mobilizations?
- shorter length of stay
- increase chance of D/c to home
- decreased secondary complications
- improved outcomes
What are the contraindications for early mobilization?
- unstable spine
- increasing ICP
What are the precautions for early mobilization?
- WBing restrictions
- skin/joint integrity
- autonomic instability
- CV status
What are examples of positions for early mobility?
- sitting on side of the bed
- sitting in wheelchair
- tilt table
- standing frame
What is the goal of early mobility?
- increase alertness with stimulation in different positions/environment
- improve level of consciousness
- improve GI motility, ROM, CV response
What secondary impairments should we be aiming to prevent with early mobility?
contractures, pressure sores, pneumonia, DVT
What are the proper parameters for wheelchair positioning?
- need manual wheelchair
- weight shift every 30 min for 2 min
What are the proper positioning and parameters for bed?
- hip/knees should be slightly flexed
- turn every 2 hours
What are the benefits of serial casting?
- help improve PROM
- used in various neuro conditions including pediatrics
What does the evidence state about serial casting?
- it has a positive effect on PROM but not on spasticity or functional abilities
What are the 4 layers of family education and support?
1) maintain open communication
2) involve them in POC and decisions
3) educate on current evidence when appropriate
4) provide realistic and consistent messages
What approach does the coma recovery scale revised take in terms of arranging tasks?
- a top down approach
- cognitively mediated processes to reflexive
True or False: The coma recovery scale can be used to determine emergence
true
What are some environmental factors to consider when assessing with the coma recovery scale?
- distraction free environment
- Patient positioning (best in a wheelchair so they stay awake)
- be cautiously optimistic when dealing with all staff and family members
- timing, patients tend to score better in the morning
What are the main considerations when assessing LOC with the coma recovery scale?
- only ask for motor behaviors within patients ability level and wait for a response
- reassess frequently
- look for consistency
What is the behavior correlated with Ranchos Level IV?
Confused-agitated
What kind of behavior would you expect to see in a ranchos IV patient?
non-purposeful behavior that is bizarre relevant to the environment
How is memory affected in ranchos level IV patients?
short term and long term are both impaired
What is a ranchos level IV patient driven by?
Confusion
True or False: you need multiple people to manage a ranchos level IV patient
false
What are the two main behavioral and cognitive concerns when examining a ranchos IV patient?
- ability to sustain attention
- distractability
What are some of the main challenges presented in a ranchos level IV patient?
- amnesia
- confusion
- decreased attention
- distracted
- uncooperative
- agitation
- aggressive
- impaired insight into deficits
What is the ideal environment for avoiding any agitation with a patient?
- closed
- freedom of movement
- low distraction
- dim light
- one family member at a time
How should consistency be included to avoid agitation from patients?
- address inappropriate behaviors in a consistent manner
- follow a consistent schedule
- expect no carry over of non-automatic tasks
- re-orient frequently
How should activity selection be used to decrease agitation in patients?
- change activities frequently
- choose functional tasks near patient level
- allow rest time and shorter treatment sessions
- do not force patient to do things!!
How can we model calm behavior to promote skillful patient interaction and decrease agitation?
- be in control of our motions
- use a calm slow tone
- get on patient level
How can we model our communication to promote skillful patient interaction and decrease agitation?
- be clear and concise
- be mindful of our nonverbal communication
- start with simple questions/commands
What items can be used for patient safety when agitated?
- helmet
- locked unit
- posey mitt
What are the general safety guidelines for PTs when dealing with an agitated patient?
- look out for signs of increasing agitation
- get help when needed
- maintain access route out of room
- be aware of clothing/jewelry
what is the behavior modification program built on?
- positive reinforcement and re-direction
What is always considered first choice for medical management?
behavioral interventions
What is always considered last for medical management?
restraints
When should you use medications for medical management?
At times required to maintain safety of patient, family, or staff
When should you use ativan for a patient?
in times of severe agitation
What SOM can be used during a ranchos level IV patient to measure aggression/agitation?
Agitated Behavior Scale
What is the most important thing to remember when setting rehab goals for a ranchos level IV?
- new learning is NOT possible at this level
- formerly learned skills can be practiced and regained at this level
What are some examples of appropriate goals for a ranchos IV patient?
- improve endurance
- improve activity tolerance
- improve attention to task
- family education and support
- prevent agitation
- help patient learn to control behavior
Identify 3 strategies for managing agitation
- stay calm
- get patient moving
- vary exercises frequently
What characteristic name fits with a ranchos Level V?
Confused-Inappropriate
What are some characteristics of ranchos level V?
- can follow simple commands
- extremely distractible
- inappropriate and confabulatory speech
- severely impaired memory
- can’t learn new info
- poor safety awareness
How would a patient in ranchos level V react to a complex task and environment?
- the patients response would be non-purposeful and random
- a structured environment would allow socialization on an automatic level for short periods
What characteristic name fits with a ranchos Level VI?
Confused-appropriate
What are some main characteristics of a patient in ranchos level VI?
- goal directed behavior
- recognizes basic needs
- shows carryover of re-learned tasks
- follows simple commands consistently
- able to follow a structured schedule
- poor insight into deficits
What memory problems would you expect to see in a patient in Ranchos Level VI?
- long term memory better than short
ex: Date may be wrong but person is giving a recent date
What are the treatment goals for patients in ranchos level V and VI?
- increase safety and independence with mobility and ADLs
- improve postural control, balance, and gait
- improve strength
- improve endurance
- education
What testing may be introduced during ranches level V and VI?
- formalized testing to determine more focal injury deficits
T/F: A patient in ranchos Levels V & VI are still confused and unable to learn new tasks
True
Why does a person in ranchos level V and VI need strict supervision during treatment?
They have poor insight into their deficits and poor safety awareness
What should you consider when choosing a treatment environment for ranchos level V & VI?
- work in meaningful environments
- reduce distractions
- start with short sessions and add breaks
- limit task complexity
- saliency
- create a routine
Give 3 examples of intervention examples for ranchos Level V & VI
- ball toss while standing
- STS transfer while reaching for colored targets
- adding cognitive load to exercises such as walking or stairs
What are the 5 communication strategies for treating a ranchos level V & VI?
- repeat info as needed
- use a memory planner
- avoid too many questions
- explain what is going to happen between activities
- allow time for processing and response
Which SOM would you use to measure attention and cognition in a ranchos level V & VI patient?
Moss Attention Rating Scale
What levels is the moss attention rating scale valid for?
Ranchos LOCF IV or higher
What are two secondary SOMs that can be used to measure attention and cognition in a ranchos level V and VI patient?
- orientation log
- galveston orientation and amnesia test
What is the orientation log used for?
- logging improvement in memory
What SOM is used to measure balance in a ranchos level V & VI?
Berg Balance Scale
