Traumatic Brain Injury Flashcards
What is the purpose of the Balance Error Scoring System (BESS)
Objective measure of assessing static postural stability (designed for the mild head injury population to assist in return to sports play decision)
Describe the Balance Error Scoring System (BESS)
6 condition each tested barefoot, eyes closed for 20 seconds each:
Double leg stance (feet together)
Single leg stance (non-dominant foot)
Tandem stance (non-dominant foot in back)
Score of 0-60 (lower scores indicate better balance and less errors)
What is the Purpose of the Cog-Log and O
Measures general cognitive abilities in a cursory way, designed to be used as a companion to the Orientation-Log (O-Log)
Describe the Cog-Log and O
The Cog-Log includes the 3 most difficult orientation items from the O-Log, and 7 additional items that test other cognitive ability
1. (O-Log) Name of facility
2. (O-Log) Date
3. (O-Log) Time of day
4. Repeat an address
5. Counting backwards from 20-1
6. Reciting the months of the year in reverse order
7. Estimating the passage of 30 seconds
8. Repeat a motor sequence (fist-edge-palm)
9. Raising finger to “red” and do nothing to “green”
10. Address recall
Score 0 to 30
What is the purpose of the “Community Balance and Mobility Scale,” and what area does it assess?
Used to detect “high level” balance and mobility deficits based on tasks that are commonly encountered in community environments.
Describe the Community Balance and Mobility Scale.
A performance measure of 13 challenging tasks with 6 tasks performed on both sides
Score the 1st trial for each item
Item scores range from 0 to 5 and reflect progressive task difficulty
A score of “0” = complete inability to perform the task
A score of “5” = the most successful completion of the item possible
All tasks performed without ambulation aides
Patients are permitted to wear an orthotic
What is the purpose of the Disorders and Consciousness Scale (DOCS)?
The DOCS is a bed side test measuring neurobehavioral functioning during coma recovery. It was developed to detect subtle changes in observable indicators of neurobehavioral functioning
Describe the DOCS.
23 items
The rating scale describes levels of neurobehavioral integrity and a level is assigned to responses to test stimuli. The rating scale points are as follows:
0 = No Response
1 = Generalized Response
2 = Localized Response
The rating scale defines transition from low to middle to high neurobehavioral functioning within the continuum of altered consciousness
What is the purpose of the Dizziness Handicap Inventory?
This is a 25-item self-assessment inventory designed to evaluate the self-perceived handicapping effects imposed by dizziness
Describe the Dizziness Handicap Inventory
25 items
Self-report questionnaire
Quantifies the impact of dizziness on daily life by measuring self-perceived handicap
Three Domains: Functional (9 Qu, 36 pnts), Emotional (9Qu, 36 pnts), and Physical (7Qu, 28 pnts)
Maximum score of 100 – Minimum score of 0. The higher the score, the greater the perceived handicap due to dizziness
Answers are graded 0 (no), 2 (sometimes), and 4 (yes)
What is the Purpose of the Disability Rating Scale (DRS)?
The Disability Rating Scale (DRS) was developed and tested with older juvenile and adult individuals with moderate and severe traumatic brain injury (TBI) in an inpatient rehabilitation setting. One advantage of the DRS is its ability to track an individual from coma to community.
Describe the Disability Rating Scale (DRS).
Items in this scale address all three World Health Organization categories: impairment, disability and handicap (WHO,1980).
The DRS rating must be reliable, i.e., obtained while the individual is not under the influence of anesthesia, other mind-altering drugs, recent seizure, or recovering from surgical anesthesia.
The scale is intended to measure accurately general functional changes over the course of recovery.
Describe the Functional Assessment Measure (FAM).
The FAM consists of 12 items is typically added to the 18 items of the FIM. The total 30 item scale combination is referred to as the FIM+FAM.
The 12 +18 Dimensions assessed include:
Swallowing, Car transfer, Community access, Reading, Writing, Speech intelligibility, Emotional status, Adjustability to limitations, Employability, Orientation, Attention, Safety judgment
What is the Purpose of the Global Fatigue Index (GFI)?
To measure Fatigue
Describe the GFI
GFI is derived from 15 items to measure fatigue across 4 dimensions
What is the Purpose of the Quality of Life (QOL) After Brain Injury assessment?
A health-related QOL instrument for survivors of TBI, which includes the person’s subjective perspective
Describe the QOL After Brain Injury assessment.
37-item scale with six subscales
• Responses to each item were scored 1 (‘Not at all’) to 5 (‘Very’), and the sum of all items was converted arithmetically to a percentage scale, with 0 representing the lowest possible HRQoL on the questionnaire and 100 the best possible HRQoL
T/F: A BESS score of 0 represents complete instability.
False: Score of 0-60 (lower scores indicate better balance and less errors)
The DOCS measure neurobehavioral integrity and a level is assigned to responses to test stimuli. What rating would you give to a localized response to test stimuli?
2 = Localized response
T/F: The higher the score on the Disability Rating Scale (DRS), the more debilitating the injury.
True: The maximum score a patient can obtain on the DRS is 29 (extreme vegetative state). A person without disability would score zero.
TBI
Bump, blow or jolt to head disrupting normal brain functions
Ranges from mild to severe
Most common causes TBI
MVA, Falls, Acts of Violence, Sports
Factors predicting outcomes from TBI
Premorbid characteristics:
Intellect, Level of education, Memory
Open versus Closed injuries
Open: penetrating wounds, skull fractures, meninges compromised
Close: Impact but no skull fracture, brain tissue damaged, dura remains intact
Subtypes of closed injuries
Concussion, contusion, hematomas, locked-in syndrome, acquired brain injuries
Concussion
Momentary loss of consciousness (may or may not lose) & reflexes
Concussion symptoms
Dizziness, disorientation, blurred vision, difficulty concentration, sleep pattern altered, nausea, headache, loss of balance
Retrograde vs. post-traumatic amnesia
Retro: Loss of memory of events before injury
Post: Unable to remember or learn new information
Coup versus Contrecoup Lesion
Coup: Contusion same side as impact
Contre: Surface hemorrhages in opposite side of trauma (from deceleration)
Hematoma
3rd category of closed head injuries
Epidural Hematoma
B/N dura mater & skull
3 results: Unconsciousness, alert, deteriorate
Subdural Hematoma
Rupture to cortical bridging veins, between dura & arachnoid
Blood leaks slowly over hours/weeks
Seen in elderly after falls, similar symptoms to CVA
Locked-in Syndrome
Paralysis of all voluntary muscles except eye movements, individual remains conscious but can’t move
Acronym to Improve Patients’ Functional Capabilities
REWARDING R-Rehab E-Education is a MUST W-Who A-Able to address cognitive & motor components R-Real and creative activities D-Discharge I-Introduce more difficult activities as patients progress N-Not every patient will be the same! G-Get input
Acquired Brain Injuries
Causes: airway obstruct, drowning, MI, CVA, toxins
Cognitive, communication, memory, attention & concentration, reasoning, abstract thinking, psychosocial behavior & information processing
Increased Intracranial Pressure
occurs within hours or several months later
Compresses brain tissue, decrease perfusion to brain tissue or herniations
Activities that inc. ICP
Cervical flexion, percussion & vibration, coughing
S & S of ICP
Decreased responsiveness, impaired consciousness, severe HA, vomiting, irritability, papilledema (optic disc swelling)
Anoxic Injuries
Brain demands 20%
Most common cause: Cardiac Arrest
Most vulnerable areas: hippocampus, cerebellum, BG
Hypothesized as reason for prevalence of amnesia and movement disorders
Anoxic Injuries
Seizure
Temporary brain dysfunction, characterized by excessive hypersynchronous corticol neuron discharge
Events triggering seizures
Stress, poor nutrition, electrolyte imbalance, missed medications, flickering lights infection, fever, worry, and fear
Glasgow Coma Scale
Pupillary response, motor activity, ability to verbalize
Scores range from 3-15
Higher equal less damage
Scores 3-4 don’t usually survive
Mild TBI (Glasgow Number)
13 or higher, loss of consciousness
Moderate TBI (Glasgow Number)
Have permanent physical, cognitive, & behavioral deficits
GCS of 9-12, Confused, unable to answer questions
Severe TBI (Glasgow Glasgow Number)
3-8, Indicates individual is in a coma
Neuronal Damage- Clinical Manifestations are varied
Decreased level of consciousness, cognitive impairments, motor disorders, sensory problems, communication deficits, behavioral changes, associated problems
Arousal
Awareness
Primitive state of being awake or alert
Conscious of internal & external environmental stimuli
Consciousness
Coma
State of being aware
State of decreased level of awareness; usually not >3 weeks
Vegetative state
Persistent vegetative state
Return of brainstem reflexes, sleep-wake cycles, but remain unconscious
A vegetative state for a year or longer
Stupor
Obtundity
Condition of general unresponsiveness
Occurs in individuals who sleep a great deal of time
Delirium
Clouding of consciousness
Characterized by disorientation, fear, and misperception of sensory stimuli
State of being confused, distracted and having poor memory
What causes Decerebrate Rigidity?
Neuroaxis in the midbrain is severed
What is the abnormal posture that is described as decerebrate rigidity?
LE and UE Extension
What causes Decorticate Rigidity?
Dysfunction above the red nucleus between the Basal Ganglia and the thalamus
What is the abnormal posture that is described as Decorticate rigidity?
LE extension and UE Flexion
What are some Cognitive Deficits of TBI?
Disorientation, Poor attention span, loss of memory, affected ability to learn
What are some Motor Deficits of TBI?
Abnormal postures, muscle weakness, tonic reflexes, ataxia, and incoordination
What are some sensory deficits of TBI?
Loss of smell, tactile and kinesthetic loss, visual and perceptual deficits
What are some Communication Deficits of TBI?
decreased awareness of environment, may need to explore other means of communication
What are some Behavioral Deficits of TBI?
changes in personality and temperaments, apathy, irritability, aggression
When should PT begin for a TBI patient?
as soon as the patient is medically stable
What are some goals of intervention for TBI patients?
- Increase level of arousal
- Prevent development of secondary impairment
- Improve patient function
- Provide education to patient and family
What is the better position for TBI patients and why?
Side-lying and semiprone because it decreases impact of tonic labyrinthine reflexes
Heterotropic Ossification: what is it? how is it diagnosed? and what is the common denominator?
Definition: Abnormal bone formation in soft tissue and muscle surrounding joints
Dx: Bone Scan
Denominator: Prolonged immobilization
What is the theory behind reflex inhibiting postures?
Abnormal tone from the tonic reflexes could be reversed by positioning a patient in the opposite pattern
What are the types of sensory stimulation?
Auditory, Olfactory, Tactile, Kinesthetic, and oral stimuli
What test can you use for cognitive functioning? Describe its levels.
- Ranchos Los Amigos
- Level I: No response
- Level X: alert, oriented, and independent
What are some primary problems during inpatient rehab?
- Decrease ROM
- potential for contractures
- increase muscle tone and abnormal posturing
- decreased awareness and responsiveness
- decreased endurance
- decreased sensory awareness
- There’s many more in the PPT
What do patients with TBI have exaggerated responses to?
- Auditory stimulation in gym
- Lighting
- Noise level
- Number of individuals present
Physical and Cognitive Components of a Task into Treatment
Disorientation Attention Deficits Memory Deficits Problem solving deficits Behavioral deficits Aggressive behaviors
What is more challenging component of treatment for TBI
Cognitive deficits are more challenging to treat than physical components
Motor Deficits and Interventions
Weight shifting Ball Exercises Bolster Tilt Boards Lighting can be changed
Discharge Planning
Discharge destination Adaptive Equipment Home Health care services Type of supervision Environmental modifications community re-entry outpatient rehab
In the Cog-Log test, what score would you apply if the pt answers a question right without cueing?
3…
3 if the spontaneous response is correct; 2 if the correct response requires cueing; 1 if a correct response reques multiple choice; 0 if a correct response is not obtained
What does a score of 0 represent on the DRS?
A score of 0 represents that the patient has no disability.
How is the FIM+FAM scored?
Tasks are rated on a 7 point ordinal scale that ranges from total assistance (or complete dependence) to complete independence
Scores are generally rated at admission and discharge
Functional Index Measure
Designed to be used by ANY health care professionals
“Type and amount of assistance required for a person with a disability to perform basic life activities”
2 Populations for FIM
Adults 18-64 with stroke, TBI, SCI, MS, orthopedic conditions, elderly going through inpatient rehab
Children 6mon-7yrs with brain injury, burns, multiple diagnosis
Normative Values/Scoring for FIM
7pt scale
Max score is 126 = functional independence
Lowest score 18 =complete functional dependencies
Collected within 72 hrs of admission
Type of Scale for FIM
Ordinal Scale
Coma Recovery Scale Revised
23 items that comprise 6 subscales addressing auditory, visual, motor, communication, and arousal functions
Moss Attention Rating Scale (MARS)
observational tool used to measure attention-related behaviors after TBI
Mainly performed by OT or neuropsychologists
Rancho Levels of Cognitive Function (LCFS)
assess cognitive functioning in post-coma patients. Scale generates classification of the patient in 1 of 8 levels from 1=no response to 8=purposeful-appropriate
Agitated Behavioral Scale
Primary purpose is to allow serial assessment of agitation by treatment professionals who want objective feedback about course of pt’s agitation
Most widely used outcome measure for rehab hospitals
FIM
It is the gold standard for assessing ADLs
Tonic Labyrinthine Reflex (TLR)
In supine position, body and extremities are held in extension
In prone position, body and extremities are held in flexion
Asymmetrical Tonic Neck Reflex (ATNR)
Turn to head to 1 side: Arm & Leg on the same side straighten or extend while the arm & leg on the opposite side bend or flex
Symmetrical Tonic Reflex (STR)
Head flexes: UEs flex & LEs extend
Head extends: UEs extend & LEs flex
Orpington Prognostic Scale
Patients 18-64, the earlier used after stroke the better
Mild to mod: 5.2
Dynamic Gait Index
20 Feet
Scored out of 24
19/24 or less related to increase falls
Berg Balance
Total score 56
41-56 = Low fall risk 21-40 = medium 0-20 = high
