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
what is excitotoxicity?
excessive activation of neuronal amino acid receptors that are tocic to the cell and inhibit typical neurotransmission
26
what is a principle excitatory NT in the brain affected by TBI?
glutamate
27
what is the typical role of glutamate?
open ion channels
28
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
29
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)
30
mobilization of pts post TBI is often very dependent on what?
VS response (ICP monitoring)
31
what is apoptosis?
after a brain injury, many regional neurons will undergo programmed necrotic cell death
32
the apoptotic cell % reaches up to ____% of all cells in the peri-infarct area (like the penumbra)
26
33
t/f: the peri-infarct area is an area of vulnerability that we can activate/stimulate
true
34
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
35
what areas of the cerebrum can be damaged in TBI causing disorders of consciousness?
basal forebrain hypothalamic/thalamic activating areas entire cerebral cortex
36
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
37
when the systems of consciousness (cerebrum and reticular areas) are activated, what happens?
arousal
38
when the systems of consciousness (cerebrum and reticular areas) are depressed or damaged, what happens?
sleep or coma
39
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)
40
what area of the cerebral cortex specifically can cause coma when damaged?
the anterior cingulate cortex
41
what area of the thalamus specifically can cause coma when damaged?
the intralaminar thalamic nuclei
42
the intralaminar thalamic nuclei are essential for what?
arousal, awareness, thinking, and motor behavior
43
what are the minimally conscious states?
lethargy obtunded stupor
44
what is confusion?
progressive disordientation, forgetfulness, difficulty following commands, and restless/agitated state
45
what is lethargy?
A+Ox3, sluggish, sleep frequently, but awakens to voice/gentle shaking
46
what is obtunded?
extreme drowsiness, minimally responsive, barely follows commands, requires vigorous stimulation to awaken, stays awake for mere minutes
47
what is stupor?
min movt, responds in groans and moans, awakens briefly only w/repeated stimulation
48
what is coma?
doesn't respond to verbal stimuli, doesn't speak, decorticate/decerebrate/no response to pain
49
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
50
what is a minimally conscious state?
minimal/inconsistent awareness follows simple commands but not consistently show some purposeful movt but relatively inconsistent
51
what are the closed head injuries?
concussion contusion coup lesion contracoup lesion axonal shearing hematomas
52
what is a concussion?
trauma that induces an alteration in mental status (physical/cognitive abilities) that may/may not involve a loss of consciousness
53
what is a contusion?
"bruising" or small vessel hemorrhages of the surface of the brain resulting from impact
54
t/f: accleration/deceleration forces associated with coup and contracoup injuries results in further vessel damage, occlusion and edema
true
55
axonal shearing occurs from what forces?
hyperflexion/extension or rotation
56
what is axonal shearing?
diffuse axonal injury or death can disconnect the BS activating centers from the modulation of the cerebral hemispheres
57
what are the areas most susceptible to shear?
corpus callosum basal ganglia superior cerebellar peduncles periventricular white matter
58
what structures of the brain are less susceptible to axonal shearing?
midbrain structures
59
what are hematomas?
vascular hemmorrhage resulting from impact
60
what are the 2 types of hematomas that can result from TBI?
epidural hematoma subdural hematoma
61
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
62
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
63
which hematoma usually results in death within hours?
epidural hematoma
64
which type of hematoma causes damage to the arterial system?
epidural hematoma
65
which hematoma is much more dangerous?
epidural hematoma
66
what is a subdural hematoma?
acute venous hemmorhage resulting in hematoma bw the dura and the arachnoid
67
which type of hematoma cuases blood to leak from the venous system accumulating slowly over hours to weeks?
subdural hematoma
68
t/f: subdural hematoma is very common post fall w/a blow to the head
true
69
describe the onset of symptoms of a subdural hematoma?
slow, insidious, and fluctuant
70
t/f: subdural hematoma can cause changes like a cognitive decline bw sessions
true
71
in what population is a blast injury common?
military populations
72
what is a blast injury?
when a solid/liquid explosive material explodes and turns into a gas
73
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
74
t/f: blast injury can cause stress and shear injuries
true
75
what is an example of a blast injury result?
rupture of the tympanic membrane and lung and GI injuries
76
t/f: the exact mechanism of blast injuries is known and set
false, it is unknown and variable
77
what is the suspected mechanism of injury for blast injury?
axonal shearing and shearing of vascular structures
78
what are the 2 types of penetrating object injuries?
high velocity penetrating injuries low velocity penetrating injuries
79
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
80
what is a low velocity penetrating injury?
foreign objects such as sticks and sharp toys cause direct damage to the tissues they contact
81
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
82
how does electrolyte imbalance lead to secondary death?
through necrosis and apoptosis
83
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
84
if autonomic dysregulation is severe, what can it lead to?
sympathetic storming
85
what often causes autonomic dysregulation in athletes?
exercise intolerance
86
what is post-traumatic amnesia (PTA)?
time lapsed bw the accident and the point at which the fxns concerned w/memory have been restored
87
the duration of PTA is an indicator of what?
severity of injury
88
when PTA is longer, are the outcomes more or less favorable?
less
89
when PTA is shorter, are the outcomes more or less favorable?
more
90
what are the two types of amnesia that result from TBI?
retrograde amnesia anterograde amnesia
91
what is retrograde amnesia?
a partial/total loss of the ability to recall events that have occured during the period immediately preceding brain injury
92
t/f: the duration of retrograde amnesia may progressively decrease
true
93
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
94
what is anterograde amnesia?
inability to form new memories
95
t/f: the capacity for anterograde memory is frequently the last fxn to return after recovery from loss of consciousness
true
96
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
97
what is the multifactorial phenomenon?
multiple body systems are involved (multiple areas of assessment)
98
where are post TBI pts treated?
across the continuum of care: ICU, acute care, acute rehab, outpatient, homecare, etc
99
what aspect of TBI is often the most disabiling?
the cognitive and behavioral limitations
100
what tends to be the most challenging aspect of care for TBI pts?
the cognitive and behavioral limitations
101
what are general concerns of acute care for moderate to severe TBI?
medical stability neurologic and neurochemical stability behavioral stability physical assessment and mobilization
102
t/f: medical stability in moderate to severe TBI is often fluctuant
true
103
what is a key part of medical stability in moderate to severe TBI?
prevention of secondary sequelae
104
what is key to neurologic and neurochemical stability?
adequate brain rest, particularly in acute care
105
t/f: behavioral stability is often fluctuant and unpredictable in TBI recovery
true
106
what is one of the most challenging components of the exam and intervention of moderate to severe TBI?
the behavioral stability component
107
t/f: early mobilization in moderate to severe TBI is critical
true
108
what is involved in pt/family education in moderate to severe TBI?
positioning, stimulation, and arousal strategies
109
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
110
what is involved in medical stability in acute care of TBIs?
prevention of the complications associated w/TBIs as previously outlines
111
what meds can prevent complications of TBI?
sedating meds antispasticity meds mood stabilizers amantadinen beta blockers
112
what sedating meds can prevent complications of TBI?
glutamate receptor antagonists calcium antagonists cyclosporine
113
what antispasticity meds can prevent complications of TBI?
tizanidine SSRIs anxiolytics
114
what is a mood stabilizer used to prevent complications of TBI?
carbamazepine
115
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
116
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
117
why does beta blocker therapy increase survival and increase long term fxnal outcomes compared to controls?
bc of the autonomic stability it can establish
118
what is the goal of external ventricular draining (EVD)?
monitoring ICP
119
what is ICP?
pressure around the brain
120
what is cerebral perfusion pressure (CPP)?
pressure at which the brain is perfused
121
what is normal CPP?
60-80 mmHg
122
what is normal ICP?
5-15 mmHg
123
CPP<50 mmHg indicates what?
cerebral ischemia and tissue death (cardiogenic shock, stroke)
124
what are the indications for EVD?
hydrocephalus SAH TBI stroke w/hemorrhagic conversion any other process impeding CSF flow
125
what vitals should be monitored in TBI pts?
BP, HR, ICP, and CPP
126
for pts age 50-69, SBP should be ...
greater than or equal to 100 mmHg
127
for pts age 15-49, or over 70, SBP should be...
greater than or equal to 110 mmHg
128
pts w/o invasive monitoring maintain SBP of...
120 mmHg
129
HR >100 bpm may indicate what?
paroxysmal sympathetic hyperactivity (sympathetic storming)
130
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
131
t/f: screens should emphasize precautions during interventions and ID any red flags that will require referrals
true
132
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
133
what are the neuromuscular impairments in TBI?
paresis impaired coordination abnormal tone abnormal postural control impaired somatosensation
134
what are the cognitive impairments in TBI?
attention arousal concentration memory learning executive fxning (including response inhibition) disorders of consciousness
135
what are the neurobehavioral impairments in TBI?
disinhibition apathy agitation emotional lability
136
what are the communication impairments in TBI?
nonaphasic (tangential oral and written communication, word retrieval difficulties)
137
what is tangential communication?
frequently drifting off topic
138
what is dysautonomia?
elevated sympathetic NS increased HR, RR, and BP diaphoresis hyperthermia "sympathetic storming"
139
t/f: post-traumatic seizures can result from TBI
true
140
what is the Glascow coma scale (GCS)?
a popular and widely utilized tool in classification and prognosis of TBI
141
what is the GCS of a pt in a vegetative state?
0-3
142
what is the prognosis of a GCS of 0-3?
death
143
what is the GCS of a pt with severe TBI?
3-8
144
what is the prognosis of a GCS of 3-8?
permanent physical and cognitive deficits
145
what is the GCS of a pt with moderate TBI?
9-12
146
what is the prognosis of a GCS of 9-12?
most have permanent physical, cognitive, and behavioral deficits
147
would a mild, moderate, or severe TBI arrive to the ED awake, but confused and inappropriate?
moderate TBI
148
would a mild, moderate, or severe TBI have a loss of consciousness in <20 minutes?
mild TBI
149
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
150
t/f: we as PTs often don't give the GCS, but have to interpret it
true
151
what scale assesses a person's level of consciousness after injury or monitors changes in consciousness over time?
GCS
152
what is the cutoff score for mild brain injury on the GCS?
13-15
153
what is the cutoff score for moderate brain injury on the GCS?
9-12
154
what is the cutoff score for coma, severe brain injury on the GCS?
<8
155
what does a low GCS mean?
severity of brain injury and predictive of death and potential recovery
156
t/f: there are adequate correlations bw GCS scores and specific measures of pathology in subdural hematoma and blunt force TBI
true
157
what is the best predictor of outcome from TBI?
the score and length (duration) of unconsciousness as measured by the GCS
158
GCS scores <5 are indicative of what?
50% mortality rate, significantly higher rate than those with GSC >5
159
GCS scores less than or equal to 3 had a higher or lower mortality rate than those >3?
higher
160
GCS-eye opening and GCS-verbal scores of 1 had _ probability of mortality than pts with scores >1
higher
161
what GCS score showed higher probility of mortality?
GCS-E=1 GCS-V=1 GCS-M=3 or less
162
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
163
the JFK CRS is designed to asses pts at what Rancho level?
1-4 (ceiling effect)
164
if structural imaging is normal, do they likely have mild, moderate, or severe TBI?
mild TBI
165
if structural imaging is normal or abnormal, do they likely have mild, moderate, or severe TBI?
moderate or severe TBI
166
if the loss of consciousness is <30 minutes, do they likely have mild, moderate, or severe TBI?
mild TBI
167
if the loss of consciousness is 30 minutes-24 hours, do they likely have mild, moderate, or severe TBI?
moderate TBI
168
if the loss of consciousness is >24 hours, do they likely have mild, moderate, or severe TBI?
severe TBI
169
if the alteration of consciousness/mental state lasts a moment to 24 hours, do they likely have a mild, moderate, or severe TBI?
mild
170
if the alteration of consciousness/mental state lasts >24 hours, do they likely have a mild, moderate, or severe TBI?
moderate or severe TBI
171
if the PTA lasts 0-1 days, do they likely have a mild, moderate, or severe TBI?
mild TBI
172
if the PTA lasts >1 and <7 days, do they likely have a mild, moderate, or severe TBI?
moderate TBI
173
if the PTA lasts >7 days, do they likely have a mild, moderate, or severe TBI?
severe TBI
174
if the Ranchos # is higher than 8, what does this mean?
they have higher cognitive fxning
175
when is the coma recovery revised used?
for lower cognitive fxning (Ranchos 1-4 pts)
176
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
177
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
178
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
179
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
180
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
181
what does the Ranchos LOCF describe?
the behavioral characteristics and cognitive deficits associated with brain injury
182
what scale helps providers understand and focus on the person's abilities in treatment planning?
Ranchos LOCF
183
what is RLOCF level 1?
no response
184
what is RLOCF level 2?
generalized response
185
what is RLOCF level 3?
localized response
186
what is RLOCF level 4?
confused and agitated
187
what is RLOCF level 5?
confused and inappropriate
188
what is RLOCF level 6?
confused and appropriate
189
what is RLOCF level 7?
automatic and appropriate
190
what is RLOCF level 8?
purposeful and appropriate
191
which RLOCF is often very challenging?
RLOCF level 4
192
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
193
t/f: when there is a greater change in RLOCF score, pts return to work more
true
194
is the lesion area or size more important to prognosis of TBI?
lesion area
195
what lesion areas are predictive of poorer outcomes than lesions in other areas?
frontal and frontotemporal lesion
196
what brain lesions result in poorer outcomes than other lesions?
BS lesions
197
involvement of what structures is associated with non-recovery from persistent vegetative state?
corpus callosum and dorsolateral BS
198
what personal factors are prognostic indicators?
age, pre-injury education level and work hx
199
adults older than ___ have significantly longer PTA and worse fxnal outcomes at any severity of TBI
40
200
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
201
why do we test CNs in TBIs?
bc we need to know what CNs will be affected as it will directly affect our interventions
202
what are the 2 biggest drivers for the decision on screening vs exam?
clinical presentation and lesion location
203
how do CNs affect treatment of TBIs?
safety risk vision hearing homeostasis swallowing ability to maintain BP and respiration
204
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
205
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
206
describe the best environment for TBI recovery?
closed environment, free of distractions structured ample time for response
207
what is included in motor fxn management?
tone abnormalities including decorticate and decerebrate posturing spastic hypertonia
208
how early should we be mobilizing after a mild TBI?
after 24 hours
209
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
210
what is involved in secondary impairment risk reduction in acute stage TBI?
skin integrity maintenance proper positioning in bed and WC
211
t/f: pts with generalized responses are not appropriate for therapy
FALSE
212
describe the sensory stimulation of acute TBI care
structured and consistent
213
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
214
t/f: early mobilization post-TBI can assist in short LOS
true
215
what is the biggest benefit of early mobilization post TBI?
increased likelihood of home d/c
216
what are the benefits of early mobilization post TBI?
shorter LOS increased likelihood of home d/c improved outcomes
217
what are contraindications to early mobilization post TBI?
unstable spine increased ICP
218
what are the precautions to early mobilization post TBI?
autonomic irregularity WBing restrictions CV status integumentary closely monitor VSs
219
how can we be progressive and systematic in early mobilizations?
adjusting EOB, tilt table, standing frame, body weight support systems
220
what are possible barriers to active recovery in moderate to severe TBIs?
disorientation confusion physical aggression memory deficits limited attention
221
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
222
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
223
what are the tests for behavior in active rehab post TBI?
AGITATED BEHAVIOR SCALE (inpatient only)
224
in what setting would the agitated behavior scale be used?
inpatient only
225
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
226
what are the test for fxnal status in active rehab post TBI?
6MWT 10MWT observation task/gait analysis COMMUNITY INTEGRATION QUESTIONNAIRE dizziness handicap inventory
227
what is the Moss Attention Rating Scale?
test of attention and cognition completed based on 2 dates following 3 days of observation
228
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
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what are the subscales of the agitated behavior scale?
disinhibition, aggression, and lability
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what is the predictive value of the agitated behavior scale?
agitation was significantly associated with longer rehab needs
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an agitation behavior scale score of 21 or less indicates what?
within normal limits
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an agitation behavior scale score of 22-28 indicates what?
mild agitation
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an agitation behavior scale score of 29-35 indicates what?
moderate agitation
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an agitation behavior scale score of >35 indicates what?
severe agitation
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what test is important to use when seeing signs of agitation (Rancho level 4)?
agitation behavior scale
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if you get an abnormal agitation behavior scale score, what is done?
serially done
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once you get a normal agitation behavior scale score, so you have to test anymore?
probably not
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what are the parts of the community integration questionnaire?
home integration social integration integration into productive activities
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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
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what is a highly validated outpatient score for integration of a high functioning pt into the community?
the community balance and mobility score
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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
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what are the RCA 1-3 disorders of consciousness?
coma, UWS, MCS
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what does the FIM measure?
the level of disability and how much assistance is required to carry out ADLs
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t/f: the FIM scale is based on what the pt contributes
true
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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
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what pts is the FIM an appropriate measure for?
pts with acute post brain injury
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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)
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t/f: TBI impairments vary by structural damage and severity
true
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what are the cognitive impairments in TBI?
alterness fatigue sleep dysfxn executive fxn (cognition, memory, attention) memory pre-morbid education
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what are the behavioral impairments in TBI?
impulsivity confabulation disinhibition aggression motivation anxiety depression PTSD
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what is the optimal time frame to start mobilizing a pt post TBI?
within 2-7 days
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when there is a traumatic onset and d/c home, what are the goals?
biological and mobility goals
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when we are d/c home, what are the goals?
social and mobility goals
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when our aim is long term adjustment, what are the goals?
psychological and mobility goals
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what are the 3 treatment considerations?
cognitive physical behavioral
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what are the treatment principles?
integratation of physical rehab strategies w/cognitive and behavioral components
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what practice schedule is recommended initially in TBI care?
distributed practice with ample rest breaks for physical and cognitive fatigue
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what practice schedule can we progress to after distributed practice for TBI care for improved learning?
random practice
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t/f: most often, TBI rehab is a combo of compensatory and restorative interventions
true
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what are compensatory interventions?
using alternative strategies to compensate for lost ability
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what are restorative interventions?
aims to restore normal use of the affected body parts
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research in TBI rehab supports the need for what in interventions?
tasks specificity
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what neuroplastic principles are key in rx of TBI?
specific functional goals (specificity matters) meaningful to the pts (salience matters) challenging (intensity matters)
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t/f: the neuroplastic principles do not apply to TBI recovery
false, they are key to recovery in TBI
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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
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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
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what are the charactersitics of RLOCF level 1?
not responding unpurposeful
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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
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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
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at what RLOCF may pts verbalize sounds?
level 3
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at what RLOCF may pts start to verbalize using words?
level 4
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what RLOCF are pts more physically functional but more agitatated and cognitively impaired?
level 4
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what RLOCF is marked by restlessness and agitation?
level 4
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what is a big concern with RLOCF level 4 pts?
their unpredictable behavior and safety risk
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what are some impairments in RLCOF level 4 pts?
impaired attention, balance, mobility which worsens with dual tasks
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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
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what may agitation be a sign of?
lost attention (similar to form fatigue)
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how do we qualify agitation?
the agitation behavior scale timing of agitation and the amount of redirect required restlessness
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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
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how do we improve motor fxn and mobility in RLOCF level 4 rehab?
exercise, fxnal training, proprioceptive exercises, kinesthetic stimulation
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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
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t/f: there is good evidence for serial casting
false
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what is the purpose of serial casting?
to maintain or improve ROM
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how does serial casting work?
by stretching into a position os lost range, casting for 2-5 days then further stretching and casting again
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what is a precaution to be aware of with serial casting?
skin integrity
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which RLOCF has more mobility but continued cognitive declines w/limited attention span and follows only simple commands?
RCLOF level 5-6
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will RLOCF 5-6 require assistance with activity?
yes
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will RLOCF 5-6 be impulse?
yes
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what should be incorporated into interventions during RLOCF level 5-6?
repetitions with frequent rest periods
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research support what kind of interventions for RLOCF 5-6?
task-specific interventions
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t/f: task specific interventions can be combined with cognitive didactic tasks
true
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what RLOCF level is less agitated, and more confused?
5-6
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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
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t/f: ther ex is used in RLOCF 5-6 for tone reduction
true
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what interventions are used for RLOCF 5-6?
fxnal mobility training, neurodevelopmental, e-stim, cardiorespiratory endurance
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would we consider using CIMT in RLOCF level 5-6?
sure
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should we incorporate cognitive reorientation strategies into ambulation training in RLOCF level 5-6 interventions?
yes
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which RLOCF level shows automatic and concrete thinking, is appropriate, slow processing, impulsive, and overestimates abilities?
level 7-8
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is supervision required at RLOCF level 7-8?
sometimes
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do pts in RLOCF level 7-8 become quickly frustrated?
yes
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t/f: we should consider occupational based cognitive rehab in RLOCF level 7-8
true
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what what level of RLOCF must goals align with life roles and address return to school or work?
level 7-8
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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
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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
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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
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as pts progress through levels of coma recovery, pts also progress through what?
Rancho LOCF