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NI2 > Traumatic Brain Injury > Flashcards

Traumatic Brain Injury Flashcards

1
Q

What is TBI?

A

Brain injury caused by an impact to the head resulting in an acceleration or deceleration of the brain within the skullll

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2
Q

What are the two main types of TBI?

A

Focal & diffuse

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3
Q

What are the characteristics of focal TBI?

A
  • Produce contusions & haematomas
  • Subsequent deficits based on location, size & progression
  • Commonly in frontal lobes & anterior & inferior temporal regions
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4
Q

What are the characteristics of diffuse TBI?

A
  • Result of stretch & shearing to axons
  • Most commonly in BG, cerebellum, corpus callosum & midbrain
  • Higher mortality & morbidity than focal
  • More likely paediatrics than adults
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5
Q

What does initial medical management of TBI involve?

A
  • Check GCS score at scene
  • Preventing hypoxia & hypotension & treating any operable intracranial lesions (as primary brain injury cannot be reversed)
  • Patient may require intubation, sedation & paralysis, intravenous fluids
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6
Q

What values are MAP and CPP maintained above in the management of primary TBI?

A

MAP > 90mmHg

CPP > 70mmHg

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7
Q

When is surgery considered for TBI?

A

If SDH >5mm or ICH >20ml with a mid-line shift

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8
Q

What are TBI outcomes inversely proportional to?

A

Percentage of time ICP >20mmHg

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9
Q

What are the common causes of TBI?

A
  • Falls (28%)
  • MVA (20%)
  • Struck by/against events (19%)
  • Assaults (11%)
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10
Q

What are the rates of falls?

A
  • Highest for children 0-4 years & adults 75+ years
  • Risk increases with age, women > men
  • 2/3 of those who fall will fall again within 6 months
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11
Q

What are the common primary motor impairments in TBI?

A
  • Loss of strength
  • Loss of dexterity
  • Loss of sensation
  • Spasticity
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12
Q

What are the common non-motor impairments in TBI?

A

Language:

  • Receptive/expressive aphasia
  • Commonly have both at the same time

Perceptual-cognitive:

  • Information processing
  • Attention
  • Memory

Behavioural:

  • Lability (uncontrolled emotions)
  • Disinhibition (no social filter)
  • Apathy (difficulty initiating/finishing anything, looks like laziness)
  • Decreased planning
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13
Q

What are the characteristics of expressive aphasia?

A
  • Inability to express language
  • Comprehension preserved, expression affected
  • Little impact on motor training
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14
Q

What are the characteristics of receptive aphasia?

A
  • Inability to understand language
  • Comprehension, reading and writing affected
  • May have significant impact on motor training
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15
Q

What are the strategies for training patients with aphasia?

A
  • Liaise with speech pathologist
  • Establish some form of communication
  • Don’t exclude the patient or finish the patient’s
    sentences during conversation
  • Keep sentences short & simple
  • Provide time for the patient to answer
  • Use eye contact, gestures and demonstrations
  • Don’t shout
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16
Q

What are the characteristics of loss of information processing?

A
  • Slowness in response to cognitive demands

- Reduced ability to perform two tasks at once

17
Q

What are the characteristics of loss of attention?

A
  • Sustained
  • Selective
  • Spatial
18
Q

What are the types of loss of memory?

A
  • Short term memory loss

- Post-traumatic amnesia (PTA)

19
Q

What did Madigan et al 2000 find regarding loss of information processing in TBI patients

A
  • Compared TBI patients with control
  • Provided subjects with 2 serial addition tasks (one auditory, one visual)
  • Greater time required to complete auditory tasks for both groups
  • TBI patients were slower than controls in both conditions
  • At preferred speed TBI patients had greater accuracy
  • CIs: Give patients time to process instructions &
    complete the task, provide written/verbal instructions & photos/diagrams
20
Q

What are the strategies for motor training when a patient has loss of information processing?

A
  • Give patients time (slow down)
  • Ensure patient is on task
  • Provide written information
  • Increase arousal before completing more
    difficult cognitive tasks
21
Q

What is the impact of loss of attention on motor training?

A
  • Mental fatigue after several repetitions
  • Distracted after several repetitions
  • Inability to attend to stimuli on one side of the
    body or the environment
22
Q

What did Whyte et al 1994 find regarding loss of attention in TBI?

A
  • 4 TBI patients
  • Video taped patients completing 3 tasks with varying degrees of structure over 3 sessions
  • Deliberate, random distractions implemented
    throughout task
  • Measured time on/off task
  • All patients improved
  • The more structured the task, the greater the
    time spent on task
  • The greater the complexity the less time spent on
    task
  • The greater the number of distractions the less
    time spent on task
23
Q

What are the clinical implications of the study by Whyte et al 1994 regarding loss of attention?

A
  • Attention and time on task improves with practice, so can be trained

To increase motor practice:

  • Increase structure of the task
  • Reduce complexity of the task
  • Reduce distractions
24
Q

What did Robertson et al 1996 find regarding loss of attention in TBI?

A
  • Trained patients with left neglect under 5
    conditions (control, PROM exercises left hand, visual anchor to left, auditory anchor to left, AROM left fingers and knee)
  • Greatest improvement on the letter cancellation
    test was under the AROM condition
  • Some improvement with the visual and auditory
    anchor
  • No change with PROM
  • CIS: Train active movements ASAP
25
Q

What are the strategies for motor training for patients with loss of spatial attention?

A
  • Increase awareness and arousal
  • Encourage visual scanning
  • Encourage searching
  • Encourage active movements of the affected side
  • Use markers to anchor vision
  • Use rehearsal and self cueing
26
Q

What are the strategies for motor training for patients with loss of selective & sustained attention?

A
  • Reorient the patient often
  • Use feedback and visual cues
  • Increase the structure of training
  • Minimise distractions
  • Set goals to sustain attention
27
Q

What did Wilson et al 2001 find regarding short term memory loss?

A
  • Patients with difficulty remembering ADLs randomly allocated to pager system for 7 weeks
  • Significant improvement in remembering ADLs
    at end of 7 weeks with use of pager
  • 75% of the first group retained improvement
    after they stopped using the pager
  • CIs: Devices that alert patients to complete practice
    may be a useful adjunct to therapy
28
Q

What are the strategies for motor training patients with short term memory loss?

A
  • Simplify information
  • Reduce the amount of information
  • Reduce distractions
  • Ensure understanding
  • Link new information with already known information
  • Encourage questions
  • Label the environment
  • Use reminders
  • Use internal mnemonic strategies
29
Q

What are the types of memory?

A

Declarative:

  • Data based memory (factual)
  • Affected in PTA, e.g. won’t remember therapist from the day before

Procedural:

  • Rule based memory
  • Related to skill learning
  • Intact in PTA, e.g. will remember skills learnt the day before
30
Q

What are the strategies for motor training patients with PTA?

A
  • As for short term memory loss plus
  • Keep the structure of practice the same (i.e. same order of exercises)
  • Use trickery and bribery
  • Reorient the patient continually to the task
  • Keep instructions short
31
Q

What is the impact of behavioural impairments on physio?

A
  • Reduces the amount of practice achieved
  • Decreases the retention of learnt skills
  • Creates stress for staff and family
32
Q

What did Eames & Wood 1985 find regarding behavioural modification in disinhibition?

A
  • TBI patients > 1 year post injury with severe
    disinhibition resulting in unacceptable behaviour (e.g. walking around naked)
  • Implemented behavioural modification & tokens to extinguish inappropriate behaviours
  • Reduced supervision for 66% of patients & 50% continued to improve after cessation of intervention
33
Q

What did Burke et al 1991 find regarding TBI patients with behavioural impairments?

A
  • TBI patients were provided with written check-
    lists for problem solving, planning or apathy
  • Resulted in a progressive reduction in the
    prompting required to complete the task & increase in the number of tasks completed
34
Q

What are the clinical implications of the studies regarding behavioural impairments?

A
  • Behavioural impairments can be successfully
    treated by combining rehabilitation &
    behavioural modification
  • Providing structured written information may
    reduce prompting required and increase the amount of practice performed
35
Q

What are the interventions for behavioural impairments?

A
  • Positive reinforcement
  • Extinction
  • Fogging and broken record (repeating instructions)
  • Time out on the spot
  • Non-contingent reinforcement (telling them they’re great all the time)
  • Token systems
  • Contracts
  • Checklists
  • Graph results
  • Train what patient wants to do
  • Provide structure and direction
  • Complete home visits & set goals
36
Q

What are the outcome measures used for perceptual-cognitive & behavioural impairments?

A

Performed by OT or neuropsych
- Westmead PTA scale
- Rivermead Behavioural Memory test
- Rivermead Perceptual Assessment Battery
- Behavioural Inattention test
- Recording number of inappropriate behaviours
per session

NI2 (12 decks)

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