Traumatic Brain Injury Flashcards
What is TBI?
Brain injury caused by an impact to the head resulting in an acceleration or deceleration of the brain within the skullll
What are the two main types of TBI?
Focal & diffuse
What are the characteristics of focal TBI?
- Produce contusions & haematomas
- Subsequent deficits based on location, size & progression
- Commonly in frontal lobes & anterior & inferior temporal regions
What are the characteristics of diffuse TBI?
- Result of stretch & shearing to axons
- Most commonly in BG, cerebellum, corpus callosum & midbrain
- Higher mortality & morbidity than focal
- More likely paediatrics than adults
What does initial medical management of TBI involve?
- 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
What values are MAP and CPP maintained above in the management of primary TBI?
MAP > 90mmHg
CPP > 70mmHg
When is surgery considered for TBI?
If SDH >5mm or ICH >20ml with a mid-line shift
What are TBI outcomes inversely proportional to?
Percentage of time ICP >20mmHg
What are the common causes of TBI?
- Falls (28%)
- MVA (20%)
- Struck by/against events (19%)
- Assaults (11%)
What are the rates of falls?
- 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
What are the common primary motor impairments in TBI?
- Loss of strength
- Loss of dexterity
- Loss of sensation
- Spasticity
What are the common non-motor impairments in TBI?
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
What are the characteristics of expressive aphasia?
- Inability to express language
- Comprehension preserved, expression affected
- Little impact on motor training
What are the characteristics of receptive aphasia?
- Inability to understand language
- Comprehension, reading and writing affected
- May have significant impact on motor training
What are the strategies for training patients with aphasia?
- 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
What are the characteristics of loss of information processing?
- Slowness in response to cognitive demands
- Reduced ability to perform two tasks at once
What are the characteristics of loss of attention?
- Sustained
- Selective
- Spatial
What are the types of loss of memory?
- Short term memory loss
- Post-traumatic amnesia (PTA)
What did Madigan et al 2000 find regarding loss of information processing in TBI patients
- 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
What are the strategies for motor training when a patient has loss of information processing?
- Give patients time (slow down)
- Ensure patient is on task
- Provide written information
- Increase arousal before completing more
difficult cognitive tasks
What is the impact of loss of attention on motor training?
- Mental fatigue after several repetitions
- Distracted after several repetitions
- Inability to attend to stimuli on one side of the
body or the environment
What did Whyte et al 1994 find regarding loss of attention in TBI?
- 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
What are the clinical implications of the study by Whyte et al 1994 regarding loss of attention?
- 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
What did Robertson et al 1996 find regarding loss of attention in TBI?
- 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
What are the strategies for motor training for patients with loss of spatial attention?
- 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
What are the strategies for motor training for patients with loss of selective & sustained attention?
- Reorient the patient often
- Use feedback and visual cues
- Increase the structure of training
- Minimise distractions
- Set goals to sustain attention
What did Wilson et al 2001 find regarding short term memory loss?
- 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
What are the strategies for motor training patients with short term memory loss?
- 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
What are the types of memory?
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
What are the strategies for motor training patients with PTA?
- 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
What is the impact of behavioural impairments on physio?
- Reduces the amount of practice achieved
- Decreases the retention of learnt skills
- Creates stress for staff and family
What did Eames & Wood 1985 find regarding behavioural modification in disinhibition?
- 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
What did Burke et al 1991 find regarding TBI patients with behavioural impairments?
- 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
What are the clinical implications of the studies regarding behavioural impairments?
- 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
What are the interventions for behavioural impairments?
- 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
What are the outcome measures used for perceptual-cognitive & behavioural impairments?
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
