Week 6 - ABI/TBI and balance Flashcards
Who is more at risk for falls and why?
Older people are more at risk due to:
- impaired vision
- dizziness
and other de-stabilizing health problems.
Where are the most common areas for fractures or injuries?
- 90% are hips and wrist fractures
- 60% are head injuries
what condition is the most in danger when falling?
Osteoporosis
why is Osteoporosis called the silent disease?
- bones may become weak with no symptoms
- may not be aware until they have a strain, bump, or fall that causes a bone to break
How common is a second fall after a one resulting in head injuries?
1/3 of older adults end up back I’m the ER within 90 days
what effects does ageing have on our bodies?
- Loss of muscle bulk (mass starts to deteriorate unless we stay active)
- Loss of agility
- losses of muscles in tib anterior
- Spinal degenerative disc disease (limiting flexibility and may cause pain)
- Diminished vision such as cataracts and glaucoma
- reaction time and reflexes
- possible chronic medical conditions
Cataracts vs Glaucoma
Cataracts
- eye condition where cloudy or opacity blocks light entry
Glaucoma
- Group of eye conditions that gradually steal sight without warning
- often without symptoms
- damage to optic nerve
Why might glasses not help improve vision for falls and how could you fix this?
- glasses might be bifocals or trifocals
- when they look through the bottom half, depth perception may be altered
- making it easier to lose balance
- to prevent, practice keeping eyes forward and head down to look
Altered reaction time vs reflexes
Altered Reaction:
- Ageing slows reaction time
- makes it harder to regain balance following a sudden shift of weight.
Altered Reflexes:
- May result in a fall
- As people age, reflexes go down
how might taking medication for a chronic medical condition increase the risk of falls?
some may also increase the risk of falls related to side effects such as:
- dizziness
- confusion
- disorientation
- slowed reflexes
What are the three types of falls?
Physiological (anticipated):
- Most in-hospital falls
- occur in patients who have risk factors for falls identified in advance, such as altered mental status, abnormal gait, frequent toileting needs, or high-risk medications.
- close supervision with attempts to address the patient’s risk factors.
Physiological (unanticipated):
- occur in a person who is otherwise at low fall risk, because of an event whose timing could not be anticipated
- seizure, stroke, or syncopal episode
- post-fall care with injury prevention strategies.
Accidental:
- low-risk people due to an environmental hazard
- Improving environmental safety will help reduce fall risk in these people and for all health providers.
How can we improve balance?
- whole body muscle strength (lower limbs and core exs)
- max vision correction
- practice daily balance exercises that are challenging enough, and work on dynamic trunk control, sitting and standing, dynamic balance
- correct abnormal posture
- correct abnormal movement patterns
- strengthen self efficacy in balance control –> this leads to reduced fear of falling, increase walking speed, improve physical function, and improved QOL
4 types of balance strategies
- ankle
- hip
- suspensory
- stepping
when can balance exercises be done?
every day or as many days as you like and as often as you like
when should older adults do balance training?
- 3 or more days a week
- strength/flex/balance exs from a standardized program demonstrated to reduce falls
what are the 3 things that can be used synonymously with balance?
- postural control
- postural stability
- equilibrium
what is needed to have good balance?
- ability to maintain one’s line of gravity within a base of support
- maintain equilibrium - all acting forces are cancelled by each other resulting in a stable balanced system
how much do healthy subjects rely on somatosensory, vestibular, and vision ON FIRM SURFACE?
- 70% on somatosensory
- 20% Vestibular
- 10% on Vision
how much do healthy subjects rely on somatosensory, vestibular, and vision ON UNSTBALE SURFACES?
- 60% vestibular
- 30% Vision
- 10% somatosensory
how is the somatosensory system important for balance?
- Proprioceptive information from spino-cerebellar pathways, processed unconsciously in the cerebellum
- required to control postural balance.
what is the time delay for Proprioceptive information?
- monosynaptic pathways that can process information as quickly as 40–50 ms and hence the major contributor for postural control in normal conditions.
What is the function of the Vestibular System?
Measures head rotation and head acceleration through semicircular canals and otolith organs (utricle and saccule)
what are the three generates compensatory responses to head motion?
Postural responses (Vestibulo-Spinal Reflex): keep the body upright and prevent falls when unexpectedly knocked off balance.
Ocular-motor responses (Vestibulo-Ocular Reflex): allows the eyes to remain steadily focused while the head is in motion.
Visceral responses (Vestibulo-Colic Reflex): help keep the head and neck centered, steady, and upright on the shoulders.
in relation to balance, what is the Visual System dependent on?
- characteristics of the visual environment
- the support surface
- including the size of the base of support and its rigidity
what is the time delay for the visual system information?
has longer time delays as long as 150-200 ms
what systems can adapt to composite for visual disorders?
- peripheral
- vestibular
- somatosensory perception
- cerebellar processing
help compensate for their visual information deficit and to provide good postural control.
what is internal and external Pertubation-based Balance Therapy (PBT)?
Internal: Patient perturbs their own balance
External: Other forces are applied to a patient to perturn their balance
what is Treadmill-based PBT?
- applied by therapists are the most feasible forms of PBT.
- constructs a safe environment with a harness and handrails, and is highly task-specific for fall prevention (eg, provoking slips or trips through unexpected accelerations)
- Improves control of step reactions
how frequent is Treadmill-based PBT done?
2-3 training sessions a week
What is a Acquired Brain Injury (ABI)?
- Damage to the brain, which occurs after birth
and is not related to a congenital or a
degenerative disease. - may be temporary or permanent
- cause partial, functional disability or psychosocial
maladjustment
what are two ways a Acquired Brain Injury (ABI) can happen?
Traumatic Brain Injury - TBI (e.g. car accident or fall)
Non-traumatic (e.g. Tumor or stroke)
what deficits can a severe injury cause?
- thought
- behaviour
- motivation
- personal traits
- talents
- movement
- cognition
- social skills
What are the mechanisms of injury?
- We have to know that brain tissue is contained within boney skull
-Any head movement that suddenly halted or any direct blow produces displacement and distortion of tissue
What can determine an injury?
- Nature
- Direction and magnitude of forces determine degree of primary and secondary damage
Where are the two sites where an ABI can occur?
Coup injury
Contrecoup injury
What are the types of focal - local injury
Cerebral contusions (of gray matter)
Lacerations
Hematomas
What is a cerebral contusion?
Damage under point of impact
Results in underlying hemorrhage
Mild → severe
What is a laceration?
Internal bony irregularities of skull abrade brain surface
What is a hematoma?
- Tearing of vascular structures causes swelling or mass of blood
-Occupy space and compress brain tissue; in severe cases can cause additional brain damage, shift or herniation
What are the 3 types of a hematoma?
- Epidural → blood collects between skull and dura mater (outer layer of meninges that protect the brain)
- Subdural → blood pools between dura mater and arachnoid mater (middle layer of meninges)
-Intracerebral → blood accumulates within the brain tissue itself
What is a cerebral herniation?
Brain tissue, blood, and csf shift from normal position inside the skull
Serious medical emergency, and fatal
How does a cerebral herniation present?
- Decreased level of consciousness → leads to coma
- Progressive motor dysfunction
- Vegetative disturbances
- Abnormal posturing
What is a diffuse brain injury?
- Rotational and shaking forces on brain
- Widely scattered shearing of axons within myelin sheaths
-This results in severe widespread degeneration of white matter, microscopic structural disruption
Clinical picture in a DAI?
Coma
Abnormal extensor posturing of limbs
Autonomic dysfunction
What is a coma in a DAI?
Different from sleep as person can not wake up
Not the same as brain death
Person is alive, but can not respond in a normal way to environment
Can persist in vegetative state for weeks → months
If regains consciousness, widespread functional impairment: attention, endurance, coordination, speed, judgement, insight
What is pathological posturing?
Sign of severe damage to brain
Rigidity is present
How in response can pathological posturing occur to noxious stimuli from external / internal sources?
Abscess
Hematoma
Hydrocephalus
Raises intracranial pressure
DAI
Tumor
Hemorrhage
Encephalitis
Lead poisoning
Meningitis
Abnormal posturing
Decorticate
Decerebrate
What is decorticate?
Rigid with bent arms turned in toward the body, clenched fists held on to chest, and legs are held straight in extension
What is decerebrate posturing?
Rigid with arms and legs held in extension, toes are pointed downward and head and neck are arched
What is a coma emergence?
Gradual process of regaining consciousness after a coma
What would pt experience in a coma emergence?
Significant agitation, anxiousness and aggression during time after coming out of coma
This would be due to pt inability to process the immediate sensory information with their environment
Pt may overreact in presence of relatively minor requests or task
Pt may demonstrate periods of tactile defensive behaviour → minimize manual cues
How should the treatment sessions be after coma emergence?
Quiet dark room
Coma emergence treatment?
Pt progressively mobilized through use of tilt table / standing frame activities
Pt may begin on sitting schedule to gradually increase sitting time
Vital signs monitored for orthostatic changes and adverse physiological responses to positional changes → fluctuations in bp and diaphoresis (excessive sweating)
Requires 2pA initially for transfer, positioning, and standing activities
Things to keep in mind post craniotomy?
Require helmet use when out of bed
When mobilized without helmet, care should be taken not to put excessive pressure over affected area
What are the secondary brain damage, results from initial injury?
- Raised intracranial pressure
- Arterial hypoxia and brain ischemia
- Cerebral edema
- Arterial hypotension
- Impaired salt and water balance
- Intracranial infection
- Hydrocephalus
What do clinicians use as recovery scales for ABI?
Glasgow coma scale
Ranchos los amigos scale
How many levels for Ranchos Los Amigos scale?
8
What is the Glasgow coma scale?
Eye Opening response
Verbal response
Motor response
What are the factors in an ABI recovery
Age
Size of lesion
Extent of diffuse injury
Premorbid skills, intelligence, behavior
Generic inheritance
Neural plasticity
Nutritional history
Environment
Early medical management, rehab, fam involvement
Availability of support services
ABI management
-Team approach is key
-Medical management: primary injuries, traumatic: address other injuries
-Early treatment: positioning, skin care, rom, pulmonary hygiene
What are the clinical consequences of a diffuse ABI?
Coma, persistent vegetative state
Confusion and cognitive stages
Mixed sensory and motor deficits
What are the clinical consequences of a local ABI?
Frontal lobe: confusion, impaired judgement, insight, safety; behavioural problems
Other brain areas: mixed sensory, motor and language deficits
What are the treatment considerations of a diffuse ABI?
Treatment and activity should be related to cognitive status
Emphasize movement, functional activities; deemphasize component deficits
What are the treatment considerations of a local ABI?
Behavioural focus, safety training
Sensory integration, compensation, function
What do PT like to focus on for TBI rehab and why?
Vestibular rehab
Why? → address pt dizziness and balance problems
What are some management considerations that PTs should keep in mind when treating?
Behav management
Motor learning
Motivation
Attention
Memory
Motor control
Family education
What are some of cognitive- behavioral issues and tips?
Impulsivity:
-Stay aware at all times
-Give patients 1 command at a time
Decreased initiative:
-Give patients choices
Emotional lability:
-Reassure patients this is not unusual; carry on
Decreased memory
-Use memory aids; ++repetition
Decreased attention
-Use memory aids; ++repetition
Decreased problem solving
-Provide choices, cues and prompting
Decreased abstract thinking
-Keep interactions concrete
Cognitive - communication issues
-Provide feedback; encourage turn taking
Agitation
-Recognize triggers, sign
-Use voice, distractions to de-escalate situations
Integration of cognitive and neuromuscular interventions
Cognitive impairments may be substantial
Sleep disorders may be interfered with treatment
Give time for problem solving; process slowly, needs more time to perform task
Diminished attention span → need ongoing redirection to the task
Appropriate time and cue to make the skill easier
Poor judgment can create a dangerous situation if left unsupervised
Gait interventions; pt performed necessary speed changes needed during an emergency situation like a fire drill
Reinforce safety strategies during sessions, turning on light when going to bathroom at night, hanging on to railing on stairs, brakes on wheelchair
The agitated patient
Be aware of the sensory experiences of pt
Pt biome anxious and aggressive when they can not process immediate sensory info with the environment
Pt may overreact in presence of minor requests or tasks
Treatment of agitated pt
Assess environment
Strategize deliver proper sensory experiences
Sessions to prevent sensory overload
Quiet areas are good to reduce distractions
Reducing volume of the voice is more calming
Multiple shorter sessions are more preferred
Time outs can be implemented when undesired behaviour is unable to be redirected
Be careful with bernal and manual cues during mobility
What communication disorders would you see in ABI issues and tips?
Aphasia: wernicke’s or broca’s
- for wernicke’s: gestures and write it out
- for broca’s simple, clear sentences
Apraxia: Hard to coordinate movement of speech muscles. Hard to get message out. Often accompanies aphasia
- Encourage breath control, pauses
- Ensure understanding ; clarifying words
Dysarthria: Speech muscles are damaged, paralyzed or weakened. Often accompanies aphasia
- Encourage breath control, pauses
- Ensure understanding ; clarifying words
Dysphasia: Partial loss of ability to produce and understand spoken language
- Use tools / diagrams ; pen / paper, dichotomous choices ;gestures
- Liaise with SLP and follow their recommendations
- Supported communication techniques
Paraphasia: Production of unintended syllables, words or phrases during the effort to speak
- Encourage breath control, pauses
- Ensure understanding ; clarifying words
Dysphagia: Difficulty swallowing and / or painful swallowing
- Encourage patient to follow recommendations from SLP and dietician
Who is the first and second in line for a risk of a TBI and why?
first: Young adults → Motor vehicle collision
second: Elderly 65+ → Ground level fall
How are younger people different than elder in a hospital setting when recovering?
Elder:
They recover slowly and more likely to be hospitalized
They also exhibit worse outcomes
What is known as a mild tbi?
concussion
What is the cause of a concussion?
Traumatic biomechanical force with or without a loss of consciousness
What are the 5 stages in the return to play post concussion and the objectives?
- No activity → complete cognitive and physical rest → brain recovery
- Light aerobic conditioning → walking and swimming → add movement
- Short specific exercise → running sprint in soccer or lacrosse → add movement
- Non contact training drills → passing in football or lacrosse → multitask intensity
- Full contact practice → normal training activities with medical clearance → return to sport specific intensity
What are the long term rehab goals in a severe ABI?
Range of short to long term limitations in physical and neuropsychological abilities
Rehab leads the severe ABI survivors to a better QOL from physical, functional, social and emotional POV that increases possibilities and options for the patients future
Holistic multidisciplinary approach is recommended with aim of not only functional recovery also the social reintegration of ABI survivors
what is resilience in pt with tbi?
may be a measure of “stress coping ability”
people with tbi have less resilience than the general population
resilience requires skills and characteristic like patience, tolerance, fatih, etc
