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DPT 620: Neuro > Traumatic Brain Injury and Concussion > Flashcards

Traumatic Brain Injury and Concussion Flashcards

1
Q

is there a higher incidence of TBIs in males or females?

A

males

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2
Q

there is an increased incidence of TBIs in males to females by __:___ ratio

A

2:1

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3
Q

t/f: a lower socioeconomic status is associated with a higher rate of injury

A

true

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4
Q

what is the lifetime cost for an individual with TBI?

A

$4 million

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5
Q

what is the annual cost of all TBIs in the US?

A

$60 billion

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6
Q

what are the 4 types of TBIs?

A

1) closed head injuries
2) severe acceleration injuries
3) blast injuries
4) open head injuries and penetrating brain injuries

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7
Q

what are closed head injuries?

A

external forces hitting the head or the head hitting an object hard enough to cause brain movt

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8
Q

what are the 2 subtypes of closed head injuries?

A

w/ or w/o skull fx

coup and contracoup

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9
Q

what is a coup injury?

A

injury at the site of impact

“impact” lesion

contusion resulting directly from the impact

on the side of the impact

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10
Q

what is a contracoup injury?

A

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

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11
Q

what does severe acceleration/deceleration of the head w/o impact result in?

A

axonal shear

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12
Q

what are open head injuries and penetrating brain injuries?

A

objects cause direct cellular and vascular damage; including damaging the blood supply to the brain

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13
Q

the severity of TBI may range from ____ to _____

A

mild, severe

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14
Q

what is a mild TBI?

A

a brief change in mental status or consciousness

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15
Q

what is a severe TBI?

A

an extended period of unconsciousness or memory loss after injury

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16
Q

what is primary injury in TBI?

A

brain damage from external forces that may cause brain tissue to make direct contact w/object, rapid acceleration/deceleration or blast/explosion

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17
Q

what are common areas of focal (primary injury) in TBIs?

A

anterior temporal poles

frontal poles

lateral and inferior temporal corticies

orbital frontal corticies

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18
Q

what is secondary injury in TBI?

A

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

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19
Q

how long does it take for secondary processes to progress?

A

hours to days

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20
Q

what things cause secondary processes progress over hours to days?

A

glutamate neurotoxicity

influx of excitatory NTs

free radical release

inflammation

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21
Q

t/f: the rigid structure of the skull can prevent pressure release in TBIs

A

true

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22
Q

what can cause elevated ICP?

A

swelling

abnormal brain fluid dynamics

hematoma (epidural, subdural, intracerebral)

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23
Q

what is normal ICP?

A

5-15 mmHg

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24
Q

if ICP is high enough, what may result?

A

emergency management like decompression

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25
Q

what is excitotoxicity?

A

excessive activation of neuronal amino acid receptors that are tocic to the cell and inhibit typical neurotransmission

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26
Q

what is a principle excitatory NT in the brain affected by TBI?

A

glutamate

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27
Q

what is the typical role of glutamate?

A

open ion channels

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28
Q

what is the result of too much glutamate following TBI?

A

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

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29
Q

what is oxidative stress?

A

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)

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30
Q

mobilization of pts post TBI is often very dependent on what?

A

VS response (ICP monitoring)

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31
Q

what is apoptosis?

A

after a brain injury, many regional neurons will undergo programmed necrotic cell death

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32
Q

the apoptotic cell % reaches up to ____% of all cells in the peri-infarct area (like the penumbra)

A

26

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33
Q

t/f: the peri-infarct area is an area of vulnerability that we can activate/stimulate

A

true

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34
Q

what are the 2 areas of the brain that can be affected by TBI causing disorders of consciousness?

A

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

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35
Q

what areas of the cerebrum can be damaged in TBI causing disorders of consciousness?

A

basal forebrain

hypothalamic/thalamic activating areas

entire cerebral cortex

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36
Q

what are areas of the BS can be damaged in TBI causing disorder of consciousness?

A

the reticular formation and/or axons of the reticular activating system

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37
Q

when the systems of consciousness (cerebrum and reticular areas) are activated, what happens?

A

arousal

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38
Q

when the systems of consciousness (cerebrum and reticular areas) are depressed or damaged, what happens?

A

sleep or coma

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39
Q

coma occurs when there is a lesion to…

A

upper BS reticular formation

BL regions of cerebral cortex (specifically the anterior cingulate cortex)

BL lesions of thalamus (specifically the intralaminar thalamic nuclei)

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40
Q

what area of the cerebral cortex specifically can cause coma when damaged?

A

the anterior cingulate cortex

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41
Q

what area of the thalamus specifically can cause coma when damaged?

A

the intralaminar thalamic nuclei

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42
Q

the intralaminar thalamic nuclei are essential for what?

A

arousal, awareness, thinking, and motor behavior

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43
Q

what are the minimally conscious states?

A

lethargy

obtunded

stupor

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44
Q

what is confusion?

A

progressive disordientation, forgetfulness, difficulty following commands, and restless/agitated state

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45
Q

what is lethargy?

A

A+Ox3, sluggish, sleep frequently, but awakens to voice/gentle shaking

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46
Q

what is obtunded?

A

extreme drowsiness, minimally responsive, barely follows commands, requires vigorous stimulation to awaken, stays awake for mere minutes

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47
Q

what is stupor?

A

min movt, responds in groans and moans, awakens briefly only w/repeated stimulation

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48
Q

what is coma?

A

doesn’t respond to verbal stimuli, doesn’t speak, decorticate/decerebrate/no response to pain

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49
Q

what is unresponsive wakefulness syndrome (vegetative state)?

A

appear awake

may have eyes open but no meaningful responses coming forth

automatic and reflexive responses only

not aware or interactive w/environment

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50
Q

what is a minimally conscious state?

A

minimal/inconsistent awareness

follows simple commands but not consistently

show some purposeful movt but relatively inconsistent

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51
Q

what are the closed head injuries?

A

concussion

contusion

coup lesion

contracoup lesion

axonal shearing

hematomas

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52
Q

what is a concussion?

A

trauma that induces an alteration in mental status (physical/cognitive abilities) that may/may not involve a loss of consciousness

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53
Q

what is a contusion?

A

“bruising” or small vessel hemorrhages of the surface of the brain resulting from impact

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54
Q

t/f: accleration/deceleration forces associated with coup and contracoup injuries results in further vessel damage, occlusion and edema

A

true

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55
Q

axonal shearing occurs from what forces?

A

hyperflexion/extension or rotation

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56
Q

what is axonal shearing?

A

diffuse axonal injury or death can disconnect the BS activating centers from the modulation of the cerebral hemispheres

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57
Q

what are the areas most susceptible to shear?

A

corpus callosum

basal ganglia

superior cerebellar peduncles

periventricular white matter

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58
Q

what structures of the brain are less susceptible to axonal shearing?

A

midbrain structures

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59
Q

what are hematomas?

A

vascular hemmorrhage resulting from impact

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60
Q

what are the 2 types of hematomas that can result from TBI?

A

epidural hematoma

subdural hematoma

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61
Q

what is an epidural hematoma?

A

typically a rupture of the middle meningeal artery resulting from severe MVA or blow to the side of the head

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62
Q

what are the typical characteristics of an epidural hematoma?

A

period of unconsiousness, followed by an alert/lucid period, followed by a rapid decline as the blood continues to leak and the hematoma enlargens

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63
Q

which hematoma usually results in death within hours?

A

epidural hematoma

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64
Q

which type of hematoma causes damage to the arterial system?

A

epidural hematoma

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65
Q

which hematoma is much more dangerous?

A

epidural hematoma

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66
Q

what is a subdural hematoma?

A

acute venous hemmorhage resulting in hematoma bw the dura and the arachnoid

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67
Q

which type of hematoma cuases blood to leak from the venous system accumulating slowly over hours to weeks?

A

subdural hematoma

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68
Q

t/f: subdural hematoma is very common post fall w/a blow to the head

A

true

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69
Q

describe the onset of symptoms of a subdural hematoma?

A

slow, insidious, and fluctuant

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70
Q

t/f: subdural hematoma can cause changes like a cognitive decline bw sessions

A

true

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71
Q

in what population is a blast injury common?

A

military populations

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72
Q

what is a blast injury?

A

when a solid/liquid explosive material explodes and turns into a gas

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73
Q

what is the mechanism of a blast injury?

A

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

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74
Q

t/f: blast injury can cause stress and shear injuries

A

true

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75
Q

what is an example of a blast injury result?

A

rupture of the tympanic membrane and lung and GI injuries

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76
Q

t/f: the exact mechanism of blast injuries is known and set

A

false, it is unknown and variable

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77
Q

what is the suspected mechanism of injury for blast injury?

A

axonal shearing and shearing of vascular structures

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78
Q

what are the 2 types of penetrating object injuries?

A

high velocity penetrating injuries

low velocity penetrating injuries

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79
Q

what is a high velocity penetrating injury?

A

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

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80
Q

what is a low velocity penetrating injury?

A

foreign objects such as sticks and sharp toys cause direct damage to the tissues they contact

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81
Q

what are some consequences of TBI (secondary injury/sequelae)?

A

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

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82
Q

how does electrolyte imbalance lead to secondary death?

A

through necrosis and apoptosis

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83
Q

what are the autonomic sequelae of TBI (autonomic dysregulation)?

A

changes in pulse and RR or regularity

temp elevations

BP changes

excessive sweating, salivation, tearing, and sebum secretion

dilated pupils

vomiting

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84
Q

if autonomic dysregulation is severe, what can it lead to?

A

sympathetic storming

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85
Q

what often causes autonomic dysregulation in athletes?

A

exercise intolerance

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86
Q

what is post-traumatic amnesia (PTA)?

A

time lapsed bw the accident and the point at which the fxns concerned w/memory have been restored

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87
Q

the duration of PTA is an indicator of what?

A

severity of injury

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88
Q

when PTA is longer, are the outcomes more or less favorable?

A

less

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89
Q

when PTA is shorter, are the outcomes more or less favorable?

A

more

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90
Q

what are the two types of amnesia that result from TBI?

A

retrograde amnesia

anterograde amnesia

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91
Q

what is retrograde amnesia?

A

a partial/total loss of the ability to recall events that have occured during the period immediately preceding brain injury

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92
Q

t/f: the duration of retrograde amnesia may progressively decrease

A

true

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93
Q

how does the duration of retrograde amnesia progressively decrease?

A

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

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94
Q

what is anterograde amnesia?

A

inability to form new memories

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95
Q

t/f: the capacity for anterograde memory is frequently the last fxn to return after recovery from loss of consciousness

A

true

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96
Q

what are the key principles of the examination of brain injury?

A

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

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97
Q

what is the multifactorial phenomenon?

A

multiple body systems are involved (multiple areas of assessment)

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98
Q

where are post TBI pts treated?

A

across the continuum of care:

ICU, acute care, acute rehab, outpatient, homecare, etc

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99
Q

what aspect of TBI is often the most disabiling?

A

the cognitive and behavioral limitations

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100
Q

what tends to be the most challenging aspect of care for TBI pts?

A

the cognitive and behavioral limitations

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101
Q

what are general concerns of acute care for moderate to severe TBI?

A

medical stability

neurologic and neurochemical stability

behavioral stability

physical assessment and mobilization

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102
Q

t/f: medical stability in moderate to severe TBI is often fluctuant

A

true

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103
Q

what is a key part of medical stability in moderate to severe TBI?

A

prevention of secondary sequelae

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104
Q

what is key to neurologic and neurochemical stability?

A

adequate brain rest, particularly in acute care

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105
Q

t/f: behavioral stability is often fluctuant and unpredictable in TBI recovery

A

true

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106
Q

what is one of the most challenging components of the exam and intervention of moderate to severe TBI?

A

the behavioral stability component

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107
Q

t/f: early mobilization in moderate to severe TBI is critical

A

true

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108
Q

what is involved in pt/family education in moderate to severe TBI?

A

positioning, stimulation, and arousal strategies

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109
Q

what is involved in emergency medial management?

A

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

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110
Q

what is involved in medical stability in acute care of TBIs?

A

prevention of the complications associated w/TBIs as previously outlines

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111
Q

what meds can prevent complications of TBI?

A

sedating meds

antispasticity meds

mood stabilizers

amantadinen

beta blockers

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112
Q

what sedating meds can prevent complications of TBI?

A

glutamate receptor antagonists

calcium antagonists

cyclosporine

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113
Q

what antispasticity meds can prevent complications of TBI?

A

tizanidine

SSRIs

anxiolytics

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114
Q

what is a mood stabilizer used to prevent complications of TBI?

A

carbamazepine

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115
Q

what is a dopamine agonist that is considered effective in improving cognitive fxn related to arousal, memory, and aggression in moderate to severe TBIs?

A

amantadine

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116
Q

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

A

true

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117
Q

why does beta blocker therapy increase survival and increase long term fxnal outcomes compared to controls?

A

bc of the autonomic stability it can establish

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118
Q

what is the goal of external ventricular draining (EVD)?

A

monitoring ICP

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119
Q

what is ICP?

A

pressure around the brain

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120
Q

what is cerebral perfusion pressure (CPP)?

A

pressure at which the brain is perfused

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121
Q

what is normal CPP?

A

60-80 mmHg

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122
Q

what is normal ICP?

A

5-15 mmHg

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123
Q

CPP<50 mmHg indicates what?

A

cerebral ischemia and tissue death (cardiogenic shock, stroke)

124
Q

what are the indications for EVD?

A

hydrocephalus

SAH

TBI

stroke w/hemorrhagic conversion

any other process impeding CSF flow

125
Q

what vitals should be monitored in TBI pts?

A

BP, HR, ICP, and CPP

126
Q

for pts age 50-69, SBP should be …

A

greater than or equal to 100 mmHg

127
Q

for pts age 15-49, or over 70, SBP should be…

A

greater than or equal to 110 mmHg

128
Q

pts w/o invasive monitoring maintain SBP of…

A

120 mmHg

129
Q

HR >100 bpm may indicate what?

A

paroxysmal sympathetic hyperactivity (sympathetic storming)

130
Q

what things do we want to examine in early stage TBI?

A

arousal, attention, and cognition

integumentary integrity

sensory integrity

motor fxn

ROM

reflex integrity

ventilation and respiration/gas exchange

131
Q

t/f: screens should emphasize precautions during interventions and ID any red flags that will require referrals

A

true

132
Q

what should be involved in the system review?

A

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

133
Q

what are the neuromuscular impairments in TBI?

A

paresis

impaired coordination

abnormal tone

abnormal postural control

impaired somatosensation

134
Q

what are the cognitive impairments in TBI?

A

attention

arousal

concentration

memory

learning

executive fxning (including response inhibition)

disorders of consciousness

135
Q

what are the neurobehavioral impairments in TBI?

A

disinhibition

apathy

agitation

emotional lability

136
Q

what are the communication impairments in TBI?

A

nonaphasic (tangential oral and written communication, word retrieval difficulties)

137
Q

what is tangential communication?

A

frequently drifting off topic

138
Q

what is dysautonomia?

A

elevated sympathetic NS

increased HR, RR, and BP

diaphoresis

hyperthermia

“sympathetic storming”

139
Q

t/f: post-traumatic seizures can result from TBI

A

true

140
Q

what is the Glascow coma scale (GCS)?

A

a popular and widely utilized tool in classification and prognosis of TBI

141
Q

what is the GCS of a pt in a vegetative state?

A

0-3

142
Q

what is the prognosis of a GCS of 0-3?

A

death

143
Q

what is the GCS of a pt with severe TBI?

A

3-8

144
Q

what is the prognosis of a GCS of 3-8?

A

permanent physical and cognitive deficits

145
Q

what is the GCS of a pt with moderate TBI?

A

9-12

146
Q

what is the prognosis of a GCS of 9-12?

A

most have permanent physical, cognitive, and behavioral deficits

147
Q

would a mild, moderate, or severe TBI arrive to the ED awake, but confused and inappropriate?

A

moderate TBI

148
Q

would a mild, moderate, or severe TBI have a loss of consciousness in <20 minutes?

A

mild TBI

149
Q

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?

A

mild TBI

150
Q

t/f: we as PTs often don’t give the GCS, but have to interpret it

A

true

151
Q

what scale assesses a person’s level of consciousness after injury or monitors changes in consciousness over time?

A

GCS

152
Q

what is the cutoff score for mild brain injury on the GCS?

A

13-15

153
Q

what is the cutoff score for moderate brain injury on the GCS?

A

9-12

154
Q

what is the cutoff score for coma, severe brain injury on the GCS?

A

<8

155
Q

what does a low GCS mean?

A

severity of brain injury and predictive of death and potential recovery

156
Q

t/f: there are adequate correlations bw GCS scores and specific measures of pathology in subdural hematoma and blunt force TBI

A

true

157
Q

what is the best predictor of outcome from TBI?

A

the score and length (duration) of unconsciousness as measured by the GCS

158
Q

GCS scores <5 are indicative of what?

A

50% mortality rate, significantly higher rate than those with GSC >5

159
Q

GCS scores less than or equal to 3 had a higher or lower mortality rate than those >3?

A

higher

160
Q

GCS-eye opening and GCS-verbal scores of 1 had _ probability of mortality than pts with scores >1

A

higher

161
Q

what GCS score showed higher probility of mortality?

A

GCS-E=1
GCS-V=1
GCS-M=3 or less

162
Q

what is the purpose of the JFK Coma Recovery Scale (CRS-R)?

A

to assist w/differential dx, prognostic assessment, and treatment planning in pts with disorders of consciousness

163
Q

the JFK CRS is designed to asses pts at what Rancho level?

A

1-4 (ceiling effect)

164
Q

if structural imaging is normal, do they likely have mild, moderate, or severe TBI?

A

mild TBI

165
Q

if structural imaging is normal or abnormal, do they likely have mild, moderate, or severe TBI?

A

moderate or severe TBI

166
Q

if the loss of consciousness is <30 minutes, do they likely have mild, moderate, or severe TBI?

A

mild TBI

167
Q

if the loss of consciousness is 30 minutes-24 hours, do they likely have mild, moderate, or severe TBI?

A

moderate TBI

168
Q

if the loss of consciousness is >24 hours, do they likely have mild, moderate, or severe TBI?

A

severe TBI

169
Q

if the alteration of consciousness/mental state lasts a moment to 24 hours, do they likely have a mild, moderate, or severe TBI?

A

mild

170
Q

if the alteration of consciousness/mental state lasts >24 hours, do they likely have a mild, moderate, or severe TBI?

A

moderate or severe TBI

171
Q

if the PTA lasts 0-1 days, do they likely have a mild, moderate, or severe TBI?

A

mild TBI

172
Q

if the PTA lasts >1 and <7 days, do they likely have a mild, moderate, or severe TBI?

A

moderate TBI

173
Q

if the PTA lasts >7 days, do they likely have a mild, moderate, or severe TBI?

A

severe TBI

174
Q

if the Ranchos # is higher than 8, what does this mean?

A

they have higher cognitive fxning

175
Q

when is the coma recovery revised used?

A

for lower cognitive fxning (Ranchos 1-4 pts)

176
Q

what is a vegetative state (minimal wakefulness state)?

A

persistent state characterized by reduced responsiveness associated with wakefulness possibly exhibiting eye opening, sucking, yawning, and localized motor responses

177
Q

what are the characteristics of someone in a vegetative state with severe disability?

A

consciousness

may require 24 hr dependence bc of cognitive, behavioral, or physical disabilities, including dysarthria and dysphagia

178
Q

what are the characteristics of someone in a vegetative state with moderate disability?

A

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

179
Q

what are the characteristics of someone in a vegetative state with a good recovery?

A

reintegration into normal social life

able to return to work

may be mild persisting sequelae

180
Q

what is the purpose of the Ranchos Los Amigos Levels of Cognitive Function (LOCF)?

A

to ID patterns of recovery and common language for recovery for people w/brain injury

181
Q

what does the Ranchos LOCF describe?

A

the behavioral characteristics and cognitive deficits associated with brain injury

182
Q

what scale helps providers understand and focus on the person’s abilities in treatment planning?

A

Ranchos LOCF

183
Q

what is RLOCF level 1?

A

no response

184
Q

what is RLOCF level 2?

A

generalized response

185
Q

what is RLOCF level 3?

A

localized response

186
Q

what is RLOCF level 4?

A

confused and agitated

187
Q

what is RLOCF level 5?

A

confused and inappropriate

188
Q

what is RLOCF level 6?

A

confused and appropriate

189
Q

what is RLOCF level 7?

A

automatic and appropriate

190
Q

what is RLOCF level 8?

A

purposeful and appropriate

191
Q

which RLOCF is often very challenging?

A

RLOCF level 4

192
Q

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)

A

true

193
Q

t/f: when there is a greater change in RLOCF score, pts return to work more

A

true

194
Q

is the lesion area or size more important to prognosis of TBI?

A

lesion area

195
Q

what lesion areas are predictive of poorer outcomes than lesions in other areas?

A

frontal and frontotemporal lesion

196
Q

what brain lesions result in poorer outcomes than other lesions?

A

BS lesions

197
Q

involvement of what structures is associated with non-recovery from persistent vegetative state?

A

corpus callosum and dorsolateral BS

198
Q

what personal factors are prognostic indicators?

A

age, pre-injury education level and work hx

199
Q

adults older than ___ have significantly longer PTA and worse fxnal outcomes at any severity of TBI

A

40

200
Q

when do we make the decision to screen vs full exam?

A

if we see deficits, assess them

when we know the lesion location-full CN assessment

201
Q

why do we test CNs in TBIs?

A

bc we need to know what CNs will be affected as it will directly affect our interventions

202
Q

what are the 2 biggest drivers for the decision on screening vs exam?

A

clinical presentation and lesion location

203
Q

how do CNs affect treatment of TBIs?

A

safety risk

vision

hearing

homeostasis

swallowing

ability to maintain BP and respiration

204
Q

what are the general goals of acute management of TBIs?

A

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

205
Q

what is involved in TBI management during the early stages?

A

exam of consciousness

integumentary integrity

sensation

motor fxns

ROM

reflex integrity

ventilation/respiration

early mobilization

cognitive/behavioral recovery

206
Q

describe the best environment for TBI recovery?

A

closed environment, free of distractions

structured

ample time for response

207
Q

what is included in motor fxn management?

A

tone abnormalities including decorticate and decerebrate posturing

spastic hypertonia

208
Q

how early should we be mobilizing after a mild TBI?

A

after 24 hours

209
Q

what are the interventions and goals in the acute stage of TBIs?

A

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

210
Q

what is involved in secondary impairment risk reduction in acute stage TBI?

A

skin integrity maintenance

proper positioning in bed and WC

211
Q

t/f: pts with generalized responses are not appropriate for therapy

A

FALSE

212
Q

describe the sensory stimulation of acute TBI care

A

structured and consistent

213
Q

what is included in caregiver training, safety, and education?

A

clear and realistic family education about their prognosis

reflexive vs purposeful movt

ROM and positioning education

214
Q

t/f: early mobilization post-TBI can assist in short LOS

A

true

215
Q

what is the biggest benefit of early mobilization post TBI?

A

increased likelihood of home d/c

216
Q

what are the benefits of early mobilization post TBI?

A

shorter LOS

increased likelihood of home d/c

improved outcomes

217
Q

what are contraindications to early mobilization post TBI?

A

unstable spine

increased ICP

218
Q

what are the precautions to early mobilization post TBI?

A

autonomic irregularity

WBing restrictions

CV status

integumentary

closely monitor VSs

219
Q

how can we be progressive and systematic in early mobilizations?

A

adjusting EOB, tilt table, standing frame, body weight support systems

220
Q

what are possible barriers to active recovery in moderate to severe TBIs?

A

disorientation

confusion

physical aggression

memory deficits

limited attention

221
Q

what are the tests for balance post TBI during active rehab?

A

Berg balance

FGA vs DGI

clinical test of sensory interaction and balance

COMMUNITY BALANCE AND MOBILITY SCALE

222
Q

what is the community balance and mobility scale?

A

very specific to TBI populations

high level test that goes through reintroduction to the community for higher level TBI populations

223
Q

what are the tests for behavior in active rehab post TBI?

A

AGITATED BEHAVIOR SCALE (inpatient only)

224
Q

in what setting would the agitated behavior scale be used?

A

inpatient only

225
Q

what are the tests for attention and cognition in active rehab post TBI?

A

MOSS ATTENTION RATING SCALE

COMA RECOVERY SCALE REVISED

RANCHO LEVELS OF COGNITIVE FXN

226
Q

what are the test for fxnal status in active rehab post TBI?

A

6MWT
10MWT

observation task/gait analysis

COMMUNITY INTEGRATION QUESTIONNAIRE

dizziness handicap inventory

227
Q

what is the Moss Attention Rating Scale?

A

test of attention and cognition completed based on 2 dates following 3 days of observation

228
Q

what is the agitated behavior scale?

A

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

229
Q

what are the subscales of the agitated behavior scale?

A

disinhibition, aggression, and lability

230
Q

what is the predictive value of the agitated behavior scale?

A

agitation was significantly associated with longer rehab needs

231
Q

an agitation behavior scale score of 21 or less indicates what?

A

within normal limits

232
Q

an agitation behavior scale score of 22-28 indicates what?

A

mild agitation

233
Q

an agitation behavior scale score of 29-35 indicates what?

A

moderate agitation

234
Q

an agitation behavior scale score of >35 indicates what?

A

severe agitation

235
Q

what test is important to use when seeing signs of agitation (Rancho level 4)?

A

agitation behavior scale

236
Q

if you get an abnormal agitation behavior scale score, what is done?

A

serially done

237
Q

once you get a normal agitation behavior scale score, so you have to test anymore?

A

probably not

238
Q

what are the parts of the community integration questionnaire?

A

home integration

social integration

integration into productive activities

239
Q

what is the community balance and mobility scale?

A

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

240
Q

what is a highly validated outpatient score for integration of a high functioning pt into the community?

A

the community balance and mobility score

241
Q

what are the general goals of active rehab?

A

(same as acute management)

move towards community reintegration

increase independence w/self care

return to social participation

compensation vs recovery

242
Q

what are the RCA 1-3 disorders of consciousness?

A

coma, UWS, MCS

243
Q

what does the FIM measure?

A

the level of disability and how much assistance is required to carry out ADLs

244
Q

t/f: the FIM scale is based on what the pt contributes

A

true

245
Q

what items are included in the FIM?

A

eating, grooming, bathing, upper/lower body dressing, toileting, B/B management, stairs, cognitive comprehension, expression, social interaction, problem-solving, memory

246
Q

what pts is the FIM an appropriate measure for?

A

pts with acute post brain injury

247
Q

what are the physical impairments of TBI?

A

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)

248
Q

t/f: TBI impairments vary by structural damage and severity

A

true

249
Q

what are the cognitive impairments in TBI?

A

alterness

fatigue

sleep dysfxn

executive fxn (cognition, memory, attention)

memory

pre-morbid education

250
Q

what are the behavioral impairments in TBI?

A

impulsivity

confabulation

disinhibition

aggression

motivation

anxiety

depression

PTSD

251
Q

what is the optimal time frame to start mobilizing a pt post TBI?

A

within 2-7 days

252
Q

when there is a traumatic onset and d/c home, what are the goals?

A

biological and mobility goals

253
Q

when we are d/c home, what are the goals?

A

social and mobility goals

254
Q

when our aim is long term adjustment, what are the goals?

A

psychological and mobility goals

255
Q

what are the 3 treatment considerations?

A

cognitive

physical

behavioral

256
Q

what are the treatment principles?

A

integratation of physical rehab strategies w/cognitive and behavioral components

257
Q

what practice schedule is recommended initially in TBI care?

A

distributed practice with ample rest breaks for physical and cognitive fatigue

258
Q

what practice schedule can we progress to after distributed practice for TBI care for improved learning?

A

random practice

259
Q

t/f: most often, TBI rehab is a combo of compensatory and restorative interventions

A

true

260
Q

what are compensatory interventions?

A

using alternative strategies to compensate for lost ability

261
Q

what are restorative interventions?

A

aims to restore normal use of the affected body parts

262
Q

research in TBI rehab supports the need for what in interventions?

A

tasks specificity

263
Q

what neuroplastic principles are key in rx of TBI?

A

specific functional goals (specificity matters)

meaningful to the pts (salience matters)

challenging (intensity matters)

264
Q

t/f: the neuroplastic principles do not apply to TBI recovery

A

false, they are key to recovery in TBI

265
Q

treatment in RLOCF focuses on what things?

A

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

266
Q

what are rx focus for pts in UWS or coma?

A

bimodal or multimodal stimulation

to improve arousal with noxious stimuli, strategic environment, cues, and family members

267
Q

what are the charactersitics of RLOCF level 1?

A

not responding

unpurposeful

268
Q

what are the characteristics of RLOCF level 2?

A

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

269
Q

what are the characteristics of RLOCF level 3?

A

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

270
Q

at what RLOCF may pts verbalize sounds?

A

level 3

271
Q

at what RLOCF may pts start to verbalize using words?

A

level 4

272
Q

what RLOCF are pts more physically functional but more agitatated and cognitively impaired?

A

level 4

273
Q

what RLOCF is marked by restlessness and agitation?

A

level 4

274
Q

what is a big concern with RLOCF level 4 pts?

A

their unpredictable behavior and safety risk

275
Q

what are some impairments in RLCOF level 4 pts?

A

impaired attention, balance, mobility which worsens with dual tasks

276
Q

what are some considerations for pts in RLOCF level 4?

A

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

277
Q

what may agitation be a sign of?

A

lost attention (similar to form fatigue)

278
Q

how do we qualify agitation?

A

the agitation behavior scale

timing of agitation and the amount of redirect required

restlessness

279
Q

what are the treatent goals for RLOCF level 4?

A

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

280
Q

how do we improve motor fxn and mobility in RLOCF level 4 rehab?

A

exercise, fxnal training, proprioceptive exercises, kinesthetic stimulation

281
Q

how can we decrease agitation and confusion?

A

sensory regulation to decrease overstimulation

limit changes to the environment and staff

familiar activities

redirection if showing agitation

282
Q

t/f: there is good evidence for serial casting

A

false

283
Q

what is the purpose of serial casting?

A

to maintain or improve ROM

284
Q

how does serial casting work?

A

by stretching into a position os lost range, casting for 2-5 days then further stretching and casting again

285
Q

what is a precaution to be aware of with serial casting?

A

skin integrity

286
Q

which RLOCF has more mobility but continued cognitive declines w/limited attention span and follows only simple commands?

A

RCLOF level 5-6

287
Q

will RLOCF 5-6 require assistance with activity?

A

yes

288
Q

will RLOCF 5-6 be impulse?

A

yes

289
Q

what should be incorporated into interventions during RLOCF level 5-6?

A

repetitions with frequent rest periods

290
Q

research support what kind of interventions for RLOCF 5-6?

A

task-specific interventions

291
Q

t/f: task specific interventions can be combined with cognitive didactic tasks

A

true

292
Q

what RLOCF level is less agitated, and more confused?

A

5-6

293
Q

for goals of walking function and balance in RLOCF level 5-6, what should we consider for application of interventions?

A

HIIT and specific walking intensities, strength training,>70% of 1RM, circuit training, cycling, and virtual reality

294
Q

t/f: ther ex is used in RLOCF 5-6 for tone reduction

A

true

295
Q

what interventions are used for RLOCF 5-6?

A

fxnal mobility training, neurodevelopmental, e-stim, cardiorespiratory endurance

296
Q

would we consider using CIMT in RLOCF level 5-6?

A

sure

297
Q

should we incorporate cognitive reorientation strategies into ambulation training in RLOCF level 5-6 interventions?

A

yes

298
Q

which RLOCF level shows automatic and concrete thinking, is appropriate, slow processing, impulsive, and overestimates abilities?

A

level 7-8

299
Q

is supervision required at RLOCF level 7-8?

A

sometimes

300
Q

do pts in RLOCF level 7-8 become quickly frustrated?

A

yes

301
Q

t/f: we should consider occupational based cognitive rehab in RLOCF level 7-8

A

true

302
Q

what what level of RLOCF must goals align with life roles and address return to school or work?

A

level 7-8

303
Q

what are some treatment strategies in RLOCF level 7-8?

A

exercise

locomotor CPG for gait and balance

task specific practice at high intensity

multidiscipline approach

304
Q

what interventions may be involved in RLOCF level 7-8?

A

neurodevelopmental techniques for tone and functional mobility

motor learning strategies for subtask and whole task reps

dual task training

balance training

305
Q

what are the behavioral management considerations for confusion and agitation?

A

consistency

low expectation for carryover bw sessions

model calm behavior

expect over-confidence

be flexible and have options

safety is paramount

306
Q

as pts progress through levels of coma recovery, pts also progress through what?

A

Rancho LOCF

DPT 620: Neuro (10 decks)

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