TBI: Therapeutic Approaches Flashcards
Acute goals for moderate-severe TBI pts
- Increase physical function and level of alertness
- Reduce risk of secondary impairments
- Improve motor control
- Manage effects of tone (positioning)
- Improve postural control
- Increase tolerance to activities & positions
- Improve/maintain joint integrity & mobility
- Educate family/caregivers on dx, interventions, goals, outcomes
- Coordinate care among all team members
General overview of levels of cognitive functioning I-III
- These individuals have disorders of consciousness (phases of waking up)
- No to limited movement
- Total assist
1. Appears asleep
2. Generalized response; nonspecific, chewing response common
3. Localized response; pain withdrawal, inconsistent following commands, give time
Prevention for LOCF I-III
- Positioning: reduce risk of contractures, DVTs, pressure sores
- Managing spasticity: PROM, positioning, splinting, serial casting, WB (using tilt table)
Restoration for LOCF I-III
- Increasing level of arousal via upright positioning (will change brainstem functioning)
- Increases activation within reticular formation -> increased responsiveness
- Check medical activity orders first**
- Sensory stimulation (rubbing arm, face)
Upright positioning for pts with disorders of consciousness I-III (mostly)
- Dependent on medical stability, comorbidities, activity orders, precautions
- Adjusting head of bed/adjusting bed to chair -> monitor vitals
- Tilt table -> early weight bearing, improved circulation, decreases DVT risk, spasticity, and orthostasis, increases kidney function, ankle ROM, respiration, preserves bone density and provides pressure relief (monitor vitals)
- Mechanical transfer to chair
- May require compression stockings/abdominal binders for hemodynamic reasons
Sensorimotor stimulation for LOCF I-III
- Auditory, tactile, visual, olfactory, gustatory, kinesthetic
- Should be presented in a graded manner -> start 1 at a time then add additional forms or intensity until arousal is achieved
- Document stimuli including intensity as well as type and duration of response
For patients emerging from minimally conscious state
- Focus on increasing level of awareness of self and environment
- Encourage eye and or head tracking to familiarize yourself with visual/auditory stimuli
- Encourage reaching, grasping, or placing objects
Instructions for therapists, family friends of pts with LOCF levels I-III
- Explain to therapist what you are going to do
- Talk in normal tone of voice, one person at a time
- Keep comments and questions short and simple
- Tell the person who you are, where they are, why they’re there, and what day it is
- Keep the room calm and quiet
- Bring favorite belongings and pictures of family/friends
- Encourage them in familiar activities ie. Listening to favorite music, talking about family and friends, reading out loud, watching TV
General overview of levels of cognitive functioning IV-VI
- Individuals are conscious but are confused
- Very limited ability to learn or demonstrate carryover
- Activities usually not goal-oriented
- Mod to Max assist
Motor learning considerations for LOCF IV-VI
- Explicit/declarative memory: long term memory concerned with recollection of facts and events. Requires effort
- Implicit/procedural memory: long term memory concerned with performance of tasks and skills. Unconscious, automatic (used in these stages)
- Can leverage implicit learning capabilities to facilitate motor learning ie. Provide basketball to an activity for individual who used to play
Environmental considerations for LOCF IV-VI
- Performance of certain activity may be improved when performed in relevant environment
- Training for brushing teeth more likely to be effective when done in the bathroom vs. bed
- Complex environments may increase distractibility
Behavior modifications for LOCF IV-VI
- Should communicate with other team members to address
- Consistency is key due to impaired learning and cognition
- Simple cues work best ie. That is inappropriate or that is not safe
- Can use positive reinforcement as motivation
General overview for levels of cognitive functioning VII-X
- Performance becomes more automatic
- New learning occurring
- Behavior is corrected with assistance
- Min assist to modified independent for basic tasks
Common motor deficits following TBI include
- Loss of selective or isolated control
- Weakness/impaired force production
- Altered tone
- Poor timing and sequencing
- Loss of coordination
Biggest difference in physical therapy approach with TBI patients
Must incorporate considerations for changes in mood, cognition, personality, communication etc.
Gait training for LOCF VII-X
- Treadmill, overground, body weight supported
- Moderate to high intensity training
Virtual reality for LOCF VII-X
- Immersive intervention, able to stimulate functional environments
- May improve motivation and compliance
Endurance/aerobic training for LOCF VII-X
Improved neuroplasticity, reduces risk of secondary health complications related to inactivity
Dual-task training for LOCF VII-X
Addresses cognitive/attention deficits combined with mobility training
Task-specific training for LOCF VII-X
Treatment focused on function
Practical considerations prior to and during when working with TBI pts
- Have they eaten/will they be hungry
- Do they need to use the bathroom
- Is pain reasonably well-controlled
- Are they sensitive to lights/sounds
- Is a private room necessary
- Do they have double vision, is a patch necessary
Use of patient restraints when working with TBI patients
- More commonly seen at LOCF states III-V
- Prevent harm to oneself
- Prevent harm to other patients
- Prevent harm to caregivers/staff
- Prevent serious disruption to environment
Non-contact restraints
- Try to use these if able/appropriate
- Safety net beds
- 1-1 staff supervision
Less-restrictive devices for patient restraint
- Posey vest (rare)
- Safety mittens
- Bed alarms
Restrictive restraints
- Only used in most serious situations
- 2 and 4 corner restraints
Amount of severe TBI survivors have mod-severe disability
57%
Emotional and cognitive issues present at 3-4 years after injury in
30-90% of individuals
Persistent motor impairments occur in
25% of survivors
Communication/language barriers persist in
25% of survivors
Need for assistive device to walk following insult occurs in
70% of survivors
Return to work occurs in
20-36% of survivors
