Test 3: Moderate TBI Flashcards
what is a moderate TBI
middle GCS
moderate to high medical needs
some LOC
PTA at least 1 day and less than 7
marked confusion- Rancho level indicates
what is a mild TBI
concussion
no LOC
<1 day PTA
no injury on image
GCS for moderate TBI
9-12
PTA for moderate TBI and score on O-log
1-7 days PTA
O-log score <25/30 for at least 1 day but less than 7
or
GOAT score of <75 for 1-7 days
LOC for those with moderate TBI
30 min to 24 hours
rancho levels IV-VI and meaning
IV = confused/agitated
V = confused/inappropriate
VI = confused/appropriate
describe characteristics of pts with Rancho level IV (confused/agitated)
heightened activity
bizarre behavior
unable to cooperate directly with treatment
incoherent/inappropriate verbalization
lack of short and long term recall
may confabulate- create story that makes sense for them; not intentionally lying
limited ability to learn
describe characteristics of pts with rancho level V (confused/inappropriate)
can consistently respond to commands
random response to complex commands
has attention to environment but lacks focused attention to task
confabulatory/inappropriate verbalization
impaired memory
inappropriate use of objects
can perform old tasks but trouble with performing new ones
**Like IV but without violence; more confusion and “why” than hostility
describe characteristics of pts with rancho level VI (confused/appropriate)
can demonstrate goal behavior but need external input or direction
shows carry over for learned task
follow simple directions consistently
past memories are showing up more in depth than recent memories
may have wrong answer to questions, but is appropriate in answer
things to consider when taking history/doing pt interview with moderate TBI pt
Behavior, arousal, consciousness limit
pts not good historians - often confused and confabulate
medical status not as dynamic as severe TBU but still consult RN
cognitive screens/scales used for cognition with moderate TBI (if appropriate to test)
coma recovery scale (CRS)
moss attention rating scale (MARS)
rancho levels of consciousness scale
describe MARS
measurs attention related behaviors after TBI
22 items
5 point rating scale
selective vs divided attention
selective = requires pt to attend to a singular particular task (i.e. digit span task)
divided attention = examined by requiring pt to attend to 2 tasks simultaneously
basic cognitive functions vs advanced
basic = attention, memory, and language
advanced = abstract thinking, problem solving, judgement, and reasoning
how does attention require cognitive demand
difficulty paying attention = increases cognitive demand
leads to cognitive fatigue
fatigue leads to agitation and irritability
how does executive function allow us to behave appropriately and pragmatically
poor judgement = poor choices
decreased filter for what is appropriate = say inappropriate things
presents as misbehavior
recommended measure for looking at affect/behavior changes in moderate TBI pts
agitated behavior scale
describe the agitated behavior scale
measures behavior aspects of agitation during acute phase from TBI
measures aggression, disinhibition, and lability
can also be used with dementia
14 items scored 1-4 (1 is not present behavior, 4 is extremely present)
min score = 14, max = 56
lower scores better
scoring scale for agitated behavior scale
</= 21 - WNL
22-28 = mild agitation
29-35 = moderate agitation
36 or over = severe agitation
outcome measures used for general neurological injury
6 MWT
10 MWT
Berg Balance Scale
Functional Gait Assessment
Activities Specific Balance Confidence Scale
5 time STS
outcome measures recommended for inpatient rehab TBI pts
FAM+FIM
Barthel index
Disability rating scale
outcome measures recommended for outpatient rehab TBI pts
high level mobility assessment
community balance and mobility scale
quality of life after brain injury
interpretation of berg balance scale
45-56 = independent
<45 = fall risk (for stroke and older adults)
ceiling effect possible
describe the berg balance scale
14 item
geriatric adult or neuro pt to assess fall risk
15-20 min to administer
0-4 pt scoring; 0 is lowest, 4 is highest level of function
describe the Functional Assessment Measure (FAM + FIM)
12 items added to FIM; enhances utility for brain injury population
rated on same 7 pt scale as FIM
increased time to administer
what are the 12 items added to FIM to create FIM+FAM
swallowing
car transfer
community access
readign
writing
speech intelligibility
emotional status
adjustable to limitations
employability
orientation
attention
safety judgement
describe the barthel index
assesses ability of individual with neuromuscular or musculoskeletal disorder to care for him/her self
inpatient rehab
activity domain - caring for yourself
not specific to TBI/stroke
evaluation of independence; measures changes in disability over time
score measures functional independence; higher score = better function
describe the disability rating scale
tracks recovery of individual from coma to community
measures general functional changes ove rcourse of recovery for mod-severe TBI
30 pt scale
observer rated
evaluates 8 areas of functioning and 4 categories
-consciousness
-cognitive ability
-dependence on others
-employability
high score = higher level of disability (29 highest, 0 min)
outcome measures for gait
setting doesnt matter; outcome measures for gait are same no matter the setting
diagnosis does not matter
TUG
6MWT
10 MWT
Dynamic gait index
gait outcome measure for TBI pt
high level mobility assessment (HiMAT)
community balance and mobility scales
describe the HiMAT outcome measure
assesses high level performance in TBI
may use orthoses
must be able to ambulate 20 m independently w/o AD
used in outpatient
activity ICF domain
13 items performed at max speed (running, skipping, hopping, etc)
total scores from 0-54 (each item 0-4)
higher scores = better performance
normative values for HiMAT 18-25 years old
males: 50-54
females: 44-54
describe the community balance and mobility scale
detects high level balance and mobility deficits based on tasks that are commonly encountered in community environments
similar to HiMAT but not specific to TBI
allowed to wear orthotic
cant use ambulation aids
13 challenging tasks with 6 tasks performed on both sides
scoring for community balance and mobility scale
items scored from 0-5 and reflect progressing difficulty
0 = complete inability to perform
5 = most successful completion of item possible
max score of 96
high score = high function
intervention considerations for PTs with moderate TBI pt
distribute practice with frequent rest (mental fatigue leads to irritability, lowered attention, etc)
self efficacy and executive function
dual task performance for community reintegration
aerobic conditioning (helps with deconditioning associated with prolonged stay in ICU/acute care)
where to start with return to mobility for moderate TBI pts
upright interventions
good for BP management, WBing, strength, building against gravity, prevention of contractures, and progression toward function
for more alert pts: standing frame, BW support, or sabina lift
examples of task oriented training
crossing street
doing laundry
folding towels
cooking a meal
taking the bus
playing the guitar
when is behavior management most often used
rancho IV TBU
cant participate in new learning and pt is easily agitated
reorientation is primary focus
ways to manage behavior in pts
work on familiar activities (no new learning; dont overstimulate)
coregulation of ANS (use your ANS to regulate theirs; open posture, calm voice, low stimulation)
do no escalate with them
consistent time/schedule; team effort
nonviolent crisis intervention training
what is a behavior modification plan
uses behavioral modification techniques such as positive reinforcement with an accompanied point or reward system
developed with pt based on percieved goals for behavioral modificaiton
must have capacity to learn (Rancho V and VI)
describe management of cognitive/executive function as an intervention
focus of SLP and OT
PT needs to reinforce
use outcome measures (MMSE, MOCA, SLUMS)
work on prioritization of tasks
reinforce appropriate vs inappropriate behavior
promote safety
start simple then ass complex as they emerge through rancho stages (usually applicable to rancho VI and beyond)
for PT, incorporate cognitive thought into mobility exercises (i.e. self reflection or mental walkthroughs)
neuroprotective benefits of ecercises - pros
aerobic conditioning for cognitive benefit
neuroprotective benefits of exercises - cons
TBI pts have decreased ability to perform aerobic exercise due to deconditioning due to prolonged ICU/acute care stays
