Traumatic Brain Injury and Concussion Flashcards
is there a higher incidence of TBIs in males or females?
males
there is an increased incidence of TBIs in males to females by __:___ ratio
2:1
t/f: a lower socioeconomic status is associated with a higher rate of injury
true
what is the lifetime cost for an individual with TBI?
$4 million
what is the annual cost of all TBIs in the US?
$60 billion
what are the 4 types of TBIs?
1) closed head injuries
2) severe acceleration injuries
3) blast injuries
4) open head injuries and penetrating brain injuries
what are closed head injuries?
external forces hitting the head or the head hitting an object hard enough to cause brain movt
what are the 2 subtypes of closed head injuries?
w/ or w/o skull fx
coup and contracoup
what is a coup injury?
injury at the site of impact
“impact” lesion
contusion resulting directly from the impact
on the side of the impact
what is a contracoup injury?
injuries distant from the site of impact
“rebound” lesion
surface hemmorrhage sustained on the opposite side of the brain from the impact, resulting from the deceleration forces
what does severe acceleration/deceleration of the head w/o impact result in?
axonal shear
what are open head injuries and penetrating brain injuries?
objects cause direct cellular and vascular damage; including damaging the blood supply to the brain
the severity of TBI may range from ____ to _____
mild, severe
what is a mild TBI?
a brief change in mental status or consciousness
what is a severe TBI?
an extended period of unconsciousness or memory loss after injury
what is primary injury in TBI?
brain damage from external forces that may cause brain tissue to make direct contact w/object, rapid acceleration/deceleration or blast/explosion
what are common areas of focal (primary injury) in TBIs?
anterior temporal poles
frontal poles
lateral and inferior temporal corticies
orbital frontal corticies
what is secondary injury in TBI?
cell death occuring as a result of cellular changes
the cascade of biochemical, cellular, or molecular changes
what happens as a result of brain inflammation/chemical changes
secondary processes due to hypoxemia, hypotension, ischemia, edema, and elevated ICP
how long does it take for secondary processes to progress?
hours to days
what things cause secondary processes progress over hours to days?
glutamate neurotoxicity
influx of excitatory NTs
free radical release
inflammation
t/f: the rigid structure of the skull can prevent pressure release in TBIs
true
what can cause elevated ICP?
swelling
abnormal brain fluid dynamics
hematoma (epidural, subdural, intracerebral)
what is normal ICP?
5-15 mmHg
if ICP is high enough, what may result?
emergency management like decompression
what is excitotoxicity?
excessive activation of neuronal amino acid receptors that are tocic to the cell and inhibit typical neurotransmission
what is a principle excitatory NT in the brain affected by TBI?
glutamate
what is the typical role of glutamate?
open ion channels
what is the result of too much glutamate following TBI?
too much Ca+ influx–>neuronal Ca+ overload–>membrane depolarization–>more ATP needed–>stimulates release of multiple enzymes–>neuronal self-digestion by protein breakdown, free radical formation, and lipid perioxidation
what is oxidative stress?
blood supply has been diminished while demand for blood/glucose has been increased leading to less ATP and production of reactive oxygen species damaging cell structures (lipids, membranes, proteins, DNA)
mobilization of pts post TBI is often very dependent on what?
VS response (ICP monitoring)
what is apoptosis?
after a brain injury, many regional neurons will undergo programmed necrotic cell death
the apoptotic cell % reaches up to ____% of all cells in the peri-infarct area (like the penumbra)
26
t/f: the peri-infarct area is an area of vulnerability that we can activate/stimulate
true
what are the 2 areas of the brain that can be affected by TBI causing disorders of consciousness?
1) damage to the cerebrum including basal forebrain, hypothalamic/thalamic activating areas, and fxn of the entire cerebral cortex
2) damage to the BS affecting the reticular formation and/or axons of the reticular activating system
what areas of the cerebrum can be damaged in TBI causing disorders of consciousness?
basal forebrain
hypothalamic/thalamic activating areas
entire cerebral cortex
what are areas of the BS can be damaged in TBI causing disorder of consciousness?
the reticular formation and/or axons of the reticular activating system
when the systems of consciousness (cerebrum and reticular areas) are activated, what happens?
arousal
when the systems of consciousness (cerebrum and reticular areas) are depressed or damaged, what happens?
sleep or coma
coma occurs when there is a lesion to…
upper BS reticular formation
BL regions of cerebral cortex (specifically the anterior cingulate cortex)
BL lesions of thalamus (specifically the intralaminar thalamic nuclei)
what area of the cerebral cortex specifically can cause coma when damaged?
the anterior cingulate cortex
what area of the thalamus specifically can cause coma when damaged?
the intralaminar thalamic nuclei
the intralaminar thalamic nuclei are essential for what?
arousal, awareness, thinking, and motor behavior
what are the minimally conscious states?
lethargy
obtunded
stupor
what is confusion?
progressive disordientation, forgetfulness, difficulty following commands, and restless/agitated state
what is lethargy?
A+Ox3, sluggish, sleep frequently, but awakens to voice/gentle shaking
what is obtunded?
extreme drowsiness, minimally responsive, barely follows commands, requires vigorous stimulation to awaken, stays awake for mere minutes
what is stupor?
min movt, responds in groans and moans, awakens briefly only w/repeated stimulation
what is coma?
doesn’t respond to verbal stimuli, doesn’t speak, decorticate/decerebrate/no response to pain
what is unresponsive wakefulness syndrome (vegetative state)?
appear awake
may have eyes open but no meaningful responses coming forth
automatic and reflexive responses only
not aware or interactive w/environment
what is a minimally conscious state?
minimal/inconsistent awareness
follows simple commands but not consistently
show some purposeful movt but relatively inconsistent
what are the closed head injuries?
concussion
contusion
coup lesion
contracoup lesion
axonal shearing
hematomas
what is a concussion?
trauma that induces an alteration in mental status (physical/cognitive abilities) that may/may not involve a loss of consciousness
what is a contusion?
“bruising” or small vessel hemorrhages of the surface of the brain resulting from impact
t/f: accleration/deceleration forces associated with coup and contracoup injuries results in further vessel damage, occlusion and edema
true
axonal shearing occurs from what forces?
hyperflexion/extension or rotation
what is axonal shearing?
diffuse axonal injury or death can disconnect the BS activating centers from the modulation of the cerebral hemispheres
what are the areas most susceptible to shear?
corpus callosum
basal ganglia
superior cerebellar peduncles
periventricular white matter
what structures of the brain are less susceptible to axonal shearing?
midbrain structures
what are hematomas?
vascular hemmorrhage resulting from impact
what are the 2 types of hematomas that can result from TBI?
epidural hematoma
subdural hematoma
what is an epidural hematoma?
typically a rupture of the middle meningeal artery resulting from severe MVA or blow to the side of the head
what are the typical characteristics of an epidural hematoma?
period of unconsiousness, followed by an alert/lucid period, followed by a rapid decline as the blood continues to leak and the hematoma enlargens
which hematoma usually results in death within hours?
epidural hematoma
which type of hematoma causes damage to the arterial system?
epidural hematoma
which hematoma is much more dangerous?
epidural hematoma
what is a subdural hematoma?
acute venous hemmorhage resulting in hematoma bw the dura and the arachnoid
which type of hematoma cuases blood to leak from the venous system accumulating slowly over hours to weeks?
subdural hematoma
t/f: subdural hematoma is very common post fall w/a blow to the head
true
describe the onset of symptoms of a subdural hematoma?
slow, insidious, and fluctuant
t/f: subdural hematoma can cause changes like a cognitive decline bw sessions
true
in what population is a blast injury common?
military populations
what is a blast injury?
when a solid/liquid explosive material explodes and turns into a gas
what is the mechanism of a blast injury?
when a solid/liquid explosive material explodes and turns into a gas
gas expands and forms a high pressure wave (overpressure wave) that travels at supersonic speed
pressure then drops, creating a relative vacuum (blast overpressure wave) that results in a reversal of airflow followed by a second overpressure wave
t/f: blast injury can cause stress and shear injuries
true
what is an example of a blast injury result?
rupture of the tympanic membrane and lung and GI injuries
t/f: the exact mechanism of blast injuries is known and set
false, it is unknown and variable
what is the suspected mechanism of injury for blast injury?
axonal shearing and shearing of vascular structures
what are the 2 types of penetrating object injuries?
high velocity penetrating injuries
low velocity penetrating injuries
what is a high velocity penetrating injury?
bullets/shrapnel from explosives cause primary tissue damage on contact, as well as additional damage remote from the areas of impact as a result of shock waves
what is a low velocity penetrating injury?
foreign objects such as sticks and sharp toys cause direct damage to the tissues they contact
what are some consequences of TBI (secondary injury/sequelae)?
increased ICP
acute hydrocephalus
cerebral hypoxia/ischemia
intracranial hemorrhage –>hypoxia, metabolic byproducts
infections (open head injury)
electrolyte imbalances–> secondary death (necrosis, apoptosis)
seizures from pressure and scarring
how does electrolyte imbalance lead to secondary death?
through necrosis and apoptosis
what are the autonomic sequelae of TBI (autonomic dysregulation)?
changes in pulse and RR or regularity
temp elevations
BP changes
excessive sweating, salivation, tearing, and sebum secretion
dilated pupils
vomiting
if autonomic dysregulation is severe, what can it lead to?
sympathetic storming
what often causes autonomic dysregulation in athletes?
exercise intolerance
what is post-traumatic amnesia (PTA)?
time lapsed bw the accident and the point at which the fxns concerned w/memory have been restored
the duration of PTA is an indicator of what?
severity of injury
when PTA is longer, are the outcomes more or less favorable?
less
when PTA is shorter, are the outcomes more or less favorable?
more
what are the two types of amnesia that result from TBI?
retrograde amnesia
anterograde amnesia
what is retrograde amnesia?
a partial/total loss of the ability to recall events that have occured during the period immediately preceding brain injury
t/f: the duration of retrograde amnesia may progressively decrease
true
how does the duration of retrograde amnesia progressively decrease?
forgetting a week b4 the injury-> forgetting a few days b4 the injury–>forgetting a few hours before the injury–>eventually re-establishing all memory
what is anterograde amnesia?
inability to form new memories
t/f: the capacity for anterograde memory is frequently the last fxn to return after recovery from loss of consciousness
true
what are the key principles of the examination of brain injury?
multifactorial phenomenon
pts post TBI are treated across the continuum of care
successful treatment requires a strong interdisciplinary team
PT interventions primarily address physical limitations
what is the multifactorial phenomenon?
multiple body systems are involved (multiple areas of assessment)
where are post TBI pts treated?
across the continuum of care:
ICU, acute care, acute rehab, outpatient, homecare, etc
what aspect of TBI is often the most disabiling?
the cognitive and behavioral limitations
what tends to be the most challenging aspect of care for TBI pts?
the cognitive and behavioral limitations
what are general concerns of acute care for moderate to severe TBI?
medical stability
neurologic and neurochemical stability
behavioral stability
physical assessment and mobilization
t/f: medical stability in moderate to severe TBI is often fluctuant
true
what is a key part of medical stability in moderate to severe TBI?
prevention of secondary sequelae
what is key to neurologic and neurochemical stability?
adequate brain rest, particularly in acute care
t/f: behavioral stability is often fluctuant and unpredictable in TBI recovery
true
what is one of the most challenging components of the exam and intervention of moderate to severe TBI?
the behavioral stability component
t/f: early mobilization in moderate to severe TBI is critical
true
what is involved in pt/family education in moderate to severe TBI?
positioning, stimulation, and arousal strategies
what is involved in emergency medial management?
surgical decompression and evacuation of intracranial hematomas
ICP monitoring to prevent diffuse cerebral ischemia
MAP monitoring
mechanical ventilation
prevention measures (DVT and pressure sores)
nutrition/feeding interventions (PEG tube)
VP shunt, fx fixation, debridement of penetrating injury/gunshot wound/foreign bodies
CN repair
intrathecal baclofen pump placement for spasticity
what is involved in medical stability in acute care of TBIs?
prevention of the complications associated w/TBIs as previously outlines
what meds can prevent complications of TBI?
sedating meds
antispasticity meds
mood stabilizers
amantadinen
beta blockers
what sedating meds can prevent complications of TBI?
glutamate receptor antagonists
calcium antagonists
cyclosporine
what antispasticity meds can prevent complications of TBI?
tizanidine
SSRIs
anxiolytics
what is a mood stabilizer used to prevent complications of TBI?
carbamazepine
what is a dopamine agonist that is considered effective in improving cognitive fxn related to arousal, memory, and aggression in moderate to severe TBIs?
amantadine
t/f: early and continuous beta blocker therapy is found to lead to increased survival and significantly better long-term fxnal outcomes compared to controls bc of the autonomic stability that it can establish
true
why does beta blocker therapy increase survival and increase long term fxnal outcomes compared to controls?
bc of the autonomic stability it can establish
what is the goal of external ventricular draining (EVD)?
monitoring ICP
what is ICP?
pressure around the brain
what is cerebral perfusion pressure (CPP)?
pressure at which the brain is perfused
what is normal CPP?
60-80 mmHg
what is normal ICP?
5-15 mmHg
CPP<50 mmHg indicates what?
cerebral ischemia and tissue death (cardiogenic shock, stroke)
what are the indications for EVD?
hydrocephalus
SAH
TBI
stroke w/hemorrhagic conversion
any other process impeding CSF flow
what vitals should be monitored in TBI pts?
BP, HR, ICP, and CPP
for pts age 50-69, SBP should be …
greater than or equal to 100 mmHg
for pts age 15-49, or over 70, SBP should be…
greater than or equal to 110 mmHg
pts w/o invasive monitoring maintain SBP of…
120 mmHg
HR >100 bpm may indicate what?
paroxysmal sympathetic hyperactivity (sympathetic storming)
what things do we want to examine in early stage TBI?
arousal, attention, and cognition
integumentary integrity
sensory integrity
motor fxn
ROM
reflex integrity
ventilation and respiration/gas exchange
t/f: screens should emphasize precautions during interventions and ID any red flags that will require referrals
true
what should be involved in the system review?
circulatory and respiratory screen
integ screen
MSK screen
autonomic NS screen
limbic stare screen
cognitive screen
language screen including oral motor and swallowing risk
neurobehavioral risk screen
what are the neuromuscular impairments in TBI?
paresis
impaired coordination
abnormal tone
abnormal postural control
impaired somatosensation
what are the cognitive impairments in TBI?
attention
arousal
concentration
memory
learning
executive fxning (including response inhibition)
disorders of consciousness
what are the neurobehavioral impairments in TBI?
disinhibition
apathy
agitation
emotional lability
what are the communication impairments in TBI?
nonaphasic (tangential oral and written communication, word retrieval difficulties)
what is tangential communication?
frequently drifting off topic
what is dysautonomia?
elevated sympathetic NS
increased HR, RR, and BP
diaphoresis
hyperthermia
“sympathetic storming”
t/f: post-traumatic seizures can result from TBI
true
what is the Glascow coma scale (GCS)?
a popular and widely utilized tool in classification and prognosis of TBI
what is the GCS of a pt in a vegetative state?
0-3
what is the prognosis of a GCS of 0-3?
death
what is the GCS of a pt with severe TBI?
3-8
what is the prognosis of a GCS of 3-8?
permanent physical and cognitive deficits
what is the GCS of a pt with moderate TBI?
9-12
what is the prognosis of a GCS of 9-12?
most have permanent physical, cognitive, and behavioral deficits
would a mild, moderate, or severe TBI arrive to the ED awake, but confused and inappropriate?
moderate TBI
would a mild, moderate, or severe TBI have a loss of consciousness in <20 minutes?
mild TBI
would a mild, moderate, or severe TBI arrive to the ED awake, but dazed, confused, and appropriate with a headache, fatigue, and normal CT scans?
mild TBI
t/f: we as PTs often don’t give the GCS, but have to interpret it
true
what scale assesses a person’s level of consciousness after injury or monitors changes in consciousness over time?
GCS
what is the cutoff score for mild brain injury on the GCS?
13-15
what is the cutoff score for moderate brain injury on the GCS?
9-12
what is the cutoff score for coma, severe brain injury on the GCS?
<8
what does a low GCS mean?
severity of brain injury and predictive of death and potential recovery
t/f: there are adequate correlations bw GCS scores and specific measures of pathology in subdural hematoma and blunt force TBI
true
what is the best predictor of outcome from TBI?
the score and length (duration) of unconsciousness as measured by the GCS
GCS scores <5 are indicative of what?
50% mortality rate, significantly higher rate than those with GSC >5
GCS scores less than or equal to 3 had a higher or lower mortality rate than those >3?
higher
GCS-eye opening and GCS-verbal scores of 1 had _ probability of mortality than pts with scores >1
higher
what GCS score showed higher probility of mortality?
GCS-E=1
GCS-V=1
GCS-M=3 or less
what is the purpose of the JFK Coma Recovery Scale (CRS-R)?
to assist w/differential dx, prognostic assessment, and treatment planning in pts with disorders of consciousness
the JFK CRS is designed to asses pts at what Rancho level?
1-4 (ceiling effect)
if structural imaging is normal, do they likely have mild, moderate, or severe TBI?
mild TBI
if structural imaging is normal or abnormal, do they likely have mild, moderate, or severe TBI?
moderate or severe TBI
if the loss of consciousness is <30 minutes, do they likely have mild, moderate, or severe TBI?
mild TBI
if the loss of consciousness is 30 minutes-24 hours, do they likely have mild, moderate, or severe TBI?
moderate TBI
if the loss of consciousness is >24 hours, do they likely have mild, moderate, or severe TBI?
severe TBI
if the alteration of consciousness/mental state lasts a moment to 24 hours, do they likely have a mild, moderate, or severe TBI?
mild
if the alteration of consciousness/mental state lasts >24 hours, do they likely have a mild, moderate, or severe TBI?
moderate or severe TBI
if the PTA lasts 0-1 days, do they likely have a mild, moderate, or severe TBI?
mild TBI
if the PTA lasts >1 and <7 days, do they likely have a mild, moderate, or severe TBI?
moderate TBI
if the PTA lasts >7 days, do they likely have a mild, moderate, or severe TBI?
severe TBI
if the Ranchos # is higher than 8, what does this mean?
they have higher cognitive fxning
when is the coma recovery revised used?
for lower cognitive fxning (Ranchos 1-4 pts)
what is a vegetative state (minimal wakefulness state)?
persistent state characterized by reduced responsiveness associated with wakefulness possibly exhibiting eye opening, sucking, yawning, and localized motor responses
what are the characteristics of someone in a vegetative state with severe disability?
consciousness
may require 24 hr dependence bc of cognitive, behavioral, or physical disabilities, including dysarthria and dysphagia
what are the characteristics of someone in a vegetative state with moderate disability?
independence in ADL and home.community activities, but with disability
may have memory or personality changes, hemiparesis, dysphagia, ataxia, acquired epilepsy, or major CN deficits
what are the characteristics of someone in a vegetative state with a good recovery?
reintegration into normal social life
able to return to work
may be mild persisting sequelae
what is the purpose of the Ranchos Los Amigos Levels of Cognitive Function (LOCF)?
to ID patterns of recovery and common language for recovery for people w/brain injury
what does the Ranchos LOCF describe?
the behavioral characteristics and cognitive deficits associated with brain injury
what scale helps providers understand and focus on the person’s abilities in treatment planning?
Ranchos LOCF
what is RLOCF level 1?
no response
what is RLOCF level 2?
generalized response
what is RLOCF level 3?
localized response
what is RLOCF level 4?
confused and agitated
what is RLOCF level 5?
confused and inappropriate
what is RLOCF level 6?
confused and appropriate
what is RLOCF level 7?
automatic and appropriate
what is RLOCF level 8?
purposeful and appropriate
which RLOCF is often very challenging?
RLOCF level 4
t/f: the RLOCF has an excellent ability to discriminate bw most severely involved group categories of vocational readiness (return to work, vocational training, supported work)
true
t/f: when there is a greater change in RLOCF score, pts return to work more
true
is the lesion area or size more important to prognosis of TBI?
lesion area
what lesion areas are predictive of poorer outcomes than lesions in other areas?
frontal and frontotemporal lesion
what brain lesions result in poorer outcomes than other lesions?
BS lesions
involvement of what structures is associated with non-recovery from persistent vegetative state?
corpus callosum and dorsolateral BS
what personal factors are prognostic indicators?
age, pre-injury education level and work hx
adults older than ___ have significantly longer PTA and worse fxnal outcomes at any severity of TBI
40
when do we make the decision to screen vs full exam?
if we see deficits, assess them
when we know the lesion location-full CN assessment
why do we test CNs in TBIs?
bc we need to know what CNs will be affected as it will directly affect our interventions
what are the 2 biggest drivers for the decision on screening vs exam?
clinical presentation and lesion location
how do CNs affect treatment of TBIs?
safety risk
vision
hearing
homeostasis
swallowing
ability to maintain BP and respiration
what are the general goals of acute management of TBIs?
increase physical fitness and alterness
reduce secondary complications
management of tone
improve motor control
maximize tolerance to activity
family/caregiver education
coordinate care w/all team members
what is involved in TBI management during the early stages?
exam of consciousness
integumentary integrity
sensation
motor fxns
ROM
reflex integrity
ventilation/respiration
early mobilization
cognitive/behavioral recovery
describe the best environment for TBI recovery?
closed environment, free of distractions
structured
ample time for response
what is included in motor fxn management?
tone abnormalities including decorticate and decerebrate posturing
spastic hypertonia
how early should we be mobilizing after a mild TBI?
after 24 hours
what are the interventions and goals in the acute stage of TBIs?
secondary impairment risk reduction
motor fxn improvement
maintain/improve jt integrity
increase level of arousal
improve tolerance to upright activities
sensory stimulation
caregiver training, safety, and education
what is involved in secondary impairment risk reduction in acute stage TBI?
skin integrity maintenance
proper positioning in bed and WC
t/f: pts with generalized responses are not appropriate for therapy
FALSE
describe the sensory stimulation of acute TBI care
structured and consistent
what is included in caregiver training, safety, and education?
clear and realistic family education about their prognosis
reflexive vs purposeful movt
ROM and positioning education
t/f: early mobilization post-TBI can assist in short LOS
true
what is the biggest benefit of early mobilization post TBI?
increased likelihood of home d/c
what are the benefits of early mobilization post TBI?
shorter LOS
increased likelihood of home d/c
improved outcomes
what are contraindications to early mobilization post TBI?
unstable spine
increased ICP
what are the precautions to early mobilization post TBI?
autonomic irregularity
WBing restrictions
CV status
integumentary
closely monitor VSs
how can we be progressive and systematic in early mobilizations?
adjusting EOB, tilt table, standing frame, body weight support systems
what are possible barriers to active recovery in moderate to severe TBIs?
disorientation
confusion
physical aggression
memory deficits
limited attention
what are the tests for balance post TBI during active rehab?
Berg balance
FGA vs DGI
clinical test of sensory interaction and balance
COMMUNITY BALANCE AND MOBILITY SCALE
what is the community balance and mobility scale?
very specific to TBI populations
high level test that goes through reintroduction to the community for higher level TBI populations
what are the tests for behavior in active rehab post TBI?
AGITATED BEHAVIOR SCALE (inpatient only)
in what setting would the agitated behavior scale be used?
inpatient only
what are the tests for attention and cognition in active rehab post TBI?
MOSS ATTENTION RATING SCALE
COMA RECOVERY SCALE REVISED
RANCHO LEVELS OF COGNITIVE FXN
what are the test for fxnal status in active rehab post TBI?
6MWT
10MWT
observation task/gait analysis
COMMUNITY INTEGRATION QUESTIONNAIRE
dizziness handicap inventory
what is the Moss Attention Rating Scale?
test of attention and cognition completed based on 2 dates following 3 days of observation
what is the agitated behavior scale?
measures behavioral aspects of agitation during the acute phase of recovery from acquired brain injury using a 14 item instrument
score 14-56
item rated 1-4
what are the subscales of the agitated behavior scale?
disinhibition, aggression, and lability
what is the predictive value of the agitated behavior scale?
agitation was significantly associated with longer rehab needs
an agitation behavior scale score of 21 or less indicates what?
within normal limits
an agitation behavior scale score of 22-28 indicates what?
mild agitation
an agitation behavior scale score of 29-35 indicates what?
moderate agitation
an agitation behavior scale score of >35 indicates what?
severe agitation
what test is important to use when seeing signs of agitation (Rancho level 4)?
agitation behavior scale
if you get an abnormal agitation behavior scale score, what is done?
serially done
once you get a normal agitation behavior scale score, so you have to test anymore?
probably not
what are the parts of the community integration questionnaire?
home integration
social integration
integration into productive activities
what is the community balance and mobility scale?
a test of 13 higher complexity balance activities with extensive tester/testing instructions that examines performance in L vs R extremities with a total score of 96
what is a highly validated outpatient score for integration of a high functioning pt into the community?
the community balance and mobility score
what are the general goals of active rehab?
(same as acute management)
move towards community reintegration
increase independence w/self care
return to social participation
compensation vs recovery
what are the RCA 1-3 disorders of consciousness?
coma, UWS, MCS
what does the FIM measure?
the level of disability and how much assistance is required to carry out ADLs
t/f: the FIM scale is based on what the pt contributes
true
what items are included in the FIM?
eating, grooming, bathing, upper/lower body dressing, toileting, B/B management, stairs, cognitive comprehension, expression, social interaction, problem-solving, memory
what pts is the FIM an appropriate measure for?
pts with acute post brain injury
what are the physical impairments of TBI?
motor fxn and planning (limb, trunk, oral motor)
sensory system and processing (vision, vestibular, perceptual, pain, ANS)
speech and language
postural control (anticipatory, reactive, voluntary)
t/f: TBI impairments vary by structural damage and severity
true
what are the cognitive impairments in TBI?
alterness
fatigue
sleep dysfxn
executive fxn (cognition, memory, attention)
memory
pre-morbid education
what are the behavioral impairments in TBI?
impulsivity
confabulation
disinhibition
aggression
motivation
anxiety
depression
PTSD
what is the optimal time frame to start mobilizing a pt post TBI?
within 2-7 days
when there is a traumatic onset and d/c home, what are the goals?
biological and mobility goals
when we are d/c home, what are the goals?
social and mobility goals
when our aim is long term adjustment, what are the goals?
psychological and mobility goals
what are the 3 treatment considerations?
cognitive
physical
behavioral
what are the treatment principles?
integratation of physical rehab strategies w/cognitive and behavioral components
what practice schedule is recommended initially in TBI care?
distributed practice with ample rest breaks for physical and cognitive fatigue
what practice schedule can we progress to after distributed practice for TBI care for improved learning?
random practice
t/f: most often, TBI rehab is a combo of compensatory and restorative interventions
true
what are compensatory interventions?
using alternative strategies to compensate for lost ability
what are restorative interventions?
aims to restore normal use of the affected body parts
research in TBI rehab supports the need for what in interventions?
tasks specificity
what neuroplastic principles are key in rx of TBI?
specific functional goals (specificity matters)
meaningful to the pts (salience matters)
challenging (intensity matters)
t/f: the neuroplastic principles do not apply to TBI recovery
false, they are key to recovery in TBI
treatment in RLOCF focuses on what things?
prevention of immobilization and disuse complications with positioning, ROM, and mobilization
maintenance of respiratory fxn including pulmonary hygiene
early mobilization
for pts in UWS or coma: bimodal or multimodal stimulation, improve arousal
what are rx focus for pts in UWS or coma?
bimodal or multimodal stimulation
to improve arousal with noxious stimuli, strategic environment, cues, and family members
what are the charactersitics of RLOCF level 1?
not responding
unpurposeful
what are the characteristics of RLOCF level 2?
awake but not following commands
unable to localize or attend to voice
minimal responses
delayed and inconsistent
no verbal and nonverbal responses
poor attention
fatigue
what are the characteristics of RLOCF level 3?
minimal conscious state
staring in direction of sound and reaching may be present
slow and inconsistent responses
following verbal commands
starting to recognize objects
still slow to decreased arousal
localizes pain and pulls away
at what RLOCF may pts verbalize sounds?
level 3
at what RLOCF may pts start to verbalize using words?
level 4
what RLOCF are pts more physically functional but more agitatated and cognitively impaired?
level 4
what RLOCF is marked by restlessness and agitation?
level 4
what is a big concern with RLOCF level 4 pts?
their unpredictable behavior and safety risk
what are some impairments in RLCOF level 4 pts?
impaired attention, balance, mobility which worsens with dual tasks
what are some considerations for pts in RLOCF level 4?
consider the length of time at your eval, the environmental distractions, and level of difficulty of tasks
discussion and questions should be kept short and simple
the room should be quiet with minimal stimulations
provide closed ended questions
don’t laugh at behaviors
may have to redirect and move to a different activity
stay a distance away if you know the patient is violent or don’t know them enough to know if they are or are not
family education on behaviors
what may agitation be a sign of?
lost attention (similar to form fatigue)
how do we qualify agitation?
the agitation behavior scale
timing of agitation and the amount of redirect required
restlessness
what are the treatent goals for RLOCF level 4?
educate family on behaviors
improve motor fxn and mobility
orthostasis
risk of secondary impairments
postural control improvement
sensory regulation to decrease overstimulation
limit environmental changes
familiar activities
how do we improve motor fxn and mobility in RLOCF level 4 rehab?
exercise, fxnal training, proprioceptive exercises, kinesthetic stimulation
how can we decrease agitation and confusion?
sensory regulation to decrease overstimulation
limit changes to the environment and staff
familiar activities
redirection if showing agitation
t/f: there is good evidence for serial casting
false
what is the purpose of serial casting?
to maintain or improve ROM
how does serial casting work?
by stretching into a position os lost range, casting for 2-5 days then further stretching and casting again
what is a precaution to be aware of with serial casting?
skin integrity
which RLOCF has more mobility but continued cognitive declines w/limited attention span and follows only simple commands?
RCLOF level 5-6
will RLOCF 5-6 require assistance with activity?
yes
will RLOCF 5-6 be impulse?
yes
what should be incorporated into interventions during RLOCF level 5-6?
repetitions with frequent rest periods
research support what kind of interventions for RLOCF 5-6?
task-specific interventions
t/f: task specific interventions can be combined with cognitive didactic tasks
true
what RLOCF level is less agitated, and more confused?
5-6
for goals of walking function and balance in RLOCF level 5-6, what should we consider for application of interventions?
HIIT and specific walking intensities, strength training,>70% of 1RM, circuit training, cycling, and virtual reality
t/f: ther ex is used in RLOCF 5-6 for tone reduction
true
what interventions are used for RLOCF 5-6?
fxnal mobility training, neurodevelopmental, e-stim, cardiorespiratory endurance
would we consider using CIMT in RLOCF level 5-6?
sure
should we incorporate cognitive reorientation strategies into ambulation training in RLOCF level 5-6 interventions?
yes
which RLOCF level shows automatic and concrete thinking, is appropriate, slow processing, impulsive, and overestimates abilities?
level 7-8
is supervision required at RLOCF level 7-8?
sometimes
do pts in RLOCF level 7-8 become quickly frustrated?
yes
t/f: we should consider occupational based cognitive rehab in RLOCF level 7-8
true
what what level of RLOCF must goals align with life roles and address return to school or work?
level 7-8
what are some treatment strategies in RLOCF level 7-8?
exercise
locomotor CPG for gait and balance
task specific practice at high intensity
multidiscipline approach
what interventions may be involved in RLOCF level 7-8?
neurodevelopmental techniques for tone and functional mobility
motor learning strategies for subtask and whole task reps
dual task training
balance training
what are the behavioral management considerations for confusion and agitation?
consistency
low expectation for carryover bw sessions
model calm behavior
expect over-confidence
be flexible and have options
safety is paramount
as pts progress through levels of coma recovery, pts also progress through what?
Rancho LOCF
