Chapter 19 - TBI

Decerebrate rigidity (Has more E's in the word than decorticate, E for extension)

Abnormal extensor response. The elbows are extended with shoulders adducted, forearms pronated, and wrists and fingers flexed. The LE's are held in stiff extension with plantar flexion.

decorticate ridigity (upper limbs in flexion)

Abnormal flexion response. Posturing of the UE in flexion and LE in extension. The elbows, wrist and fingers are in flexion with shoulder adducted, while LE's are held in extension, internal rotation, and plantar flexion.

inside; outside

Activity Limitations refer to _______ the home whereas Participation Restrictions are __________ the home.

Older adults (>75 years) Infants (0-4 months) Young adults (14-24 years)

Ages of greatest risk:

TBI (Traumatic Brain Injury)

An alteration in brain function, or other evidence of brain pathology, caused by an external force.

2.8 million

Approximately _____________ individuals are admitted to the ER, hospital or die because of a TBI each year.

• Non-goal directed body movements and agitation. • Inappropriate goal-directed behaviors such as attempting to remove own or other patient's tubes. • Screaming, moaning, incoherent disorganized or bizarre verbalizations. • Disinhibited behavior such as uncontrolled laughter, inappropriate sexual behavior. • Accusations of neglect or abuse by staff.

Behavior Disorders: Principle behavioral disorders seen in the initial recovery phase:

inability

Behavioral Factors: Persons with TBI often exhibit changes in behavior and may demonstrate an ____________ to control their behavior.

Neuromuscular Impairments - impaired motor function. Cognitive Impairments Neurobehavioral impairments Communication - related to cognitive impairments Dysautonomia - Increased sympathetic activity. Post-traumatic seizures Secondary impairments and Medical Complications - due to prolonged immobility

Body Structure/Function Impairments following TBI:

• Use simple one-step directions • Allow additional time for the patient to respond. • Talk to the person at eye level. • Remove external sources of agitation.

Clinical tips when trying to stimulate a patient at levels II and III of LOCF.

Vegetative State

Cognitive Impairments following TBI: Dissociation between wakefulness and awareness. No meaningful motor or cognitive function. (Movement is not reproducible)

Obtunded

Cognitive Impairments following TBI: Sleeps often and when aroused exhibits decreased alertness and interest in the environment and delayed reactions.

Minimally conscious sate

Cognitive Impairments following TBI: Some evidence of self or environmental awareness. (Behavior can be differentiated from reflexes, reproducible behavior is present.)

Stupor

Cognitive Impairments following TBI: Unresponsive state from which the patient can be aroused only briefly with vigorous, repeated sensory stimulation.

agitated; oriented; unable to learn

Cognitive Level Five, the patient may easily become ___________. The individual is not ____________ to person, place, or time and is ___________________ new information.

heightened

Cognitive Level Four is described as confused and agitated due to a _______________ state of activity.

Headache nausea dizziness poor balance fatigue difficulty sleeping eye strain visual difficulties feeling confused or foggy frustration light sensitivity noise sensitivity difficulty hearing irritable more emotional difficulty concentrating and remembering

Commonly reported symptoms for Mild TBI:

Physician Speech-Language Pathologist Occupational Therapist Rehabilitation Nurse Case Manager/Team Coordinator Social Worker Neuropsychologist Other Team Members

Continuum of Care and Interdisciplinary Team for TBI patients could include:

acceleration-deceleration; rotational; stretching

DAI injuries occur in response to _________________ and _______________ forces. Rapid movement of the brain within the skull causes widespread _____________ and tearing of the neuronal axons within their myelin sheaths.

Rancho Los Amigos Levels of Cognitive Functioning Scale

Developed by the head injury treatment team at the Rancho Los Amigos Hospital in California Describes behavior of individuals with head injury. Defines eight levels of cognitive functioning ranging from 'no response' to 'purposeful and appropriate'. Persons with head injury may demonstrate behavior represented by ANY of the eight levels and may progress to a higher level. Each individual's pattern of presentation and progression is variable and unpredictable.

20; invert

Early Medical Management: ICP is monitored via a catheter into the brain. ICP shoulder be less than ____ mm Hg. When treating an individual with TBI it is the therapists responsibility to monitor ICP values. Document changes that occur, and contact nursing if necessary. Never ________ an individual with elevated ICP.

restore vital functions; secondary brain damage

Early Medical Management: Once the patient arrives at the medical center, the primary goals are to _________________ and prevent ______________.

Principal of use it or lose it

Failure to drive specific brain functions can lead to functional degradation.

⦿ Recognize that the patient's loved ones have also been 'traumatized' by this event. ⦿ Remind family members to take time for themselves. ⦿ Family members may find themselves under much stress, such as emotional, physical, and financial stress. ⦿ Resume a family routine that is as normal as possible. ⦿ Family members should pace self to get enough rest and allow the needed time for self. - Arrange a rotating visitation schedule with other family members. ⦿ Don't neglect other members of the family - important to know they have not been forgotten. ⦿ Learn to accept and ask for help from others. ⦿ Make an effort to express feelings - Don't keep everything inside. ⦿ Patient's new dependence may mean role changes for family. - Take time to evaluate the situation and discuss plans, concerns and fears with others.

Family education at an early stage is critical, the following statements are important to for the therapist to remember:

Dysautonomia

Following a TBI the sympathetic nervous system may become overactive. Increased sympathetic activity results in increased heart rate, respiratory rate, and blood pressure; diaphoresis (excessive sweating); and hyperthermia. Other symptoms include decerebrate and decorticate posturing, hypertonia, and teeth grinding.

13-15

Glasgow Coma Scale: What score is considered a mild brain injury?

9-12

Glasgow Coma Scale: What score is considered a moderate brain injury?

3-8

Glasgow Coma Scale: What score is considered a severe brain injury?

A score of 3-8 with eye opening absent.

Glasgow Coma Scale: When is the patient considered to be in a coma ?

3 and 15; severity

Glasgow Coma Scale: Scores from the separate responses (eye opening, best motor response, best verbal response) are added up to provide a score between _________. (Eye + Motor + Verbal = _________)The score is then used to categorize the ________ of the brain injury.

brainstem; coma

If a DAI is severe, damage will extend into the ____________ and lead to ________ and correlates with less clinical recovery.

balance

In most cases involving moderate to severe TBI, clinical management will likely require a _____________ between both restorative and compensatory approaches. As an example a therapist may determine that a restorative approach to gate training is indicated but may also choose to ensure that the client and caregiver have adequate training in the use of an assistive device for safety during the early stages of recovery should it be needed.

Neuromuscular Impairments

Individuals with TBI commonly exhibit impaired motor function. UE and LE paresis, impaired coordination, impaired postural control, abnormal tone, and abnormal gait may be present as lifelong impairments. Abnormal, involuntary movements such as tremor and chorea (involuntary jerky movements) form and dystonic movements are less common. Patients may also present with impaired somatosensory function, depending on the location of the lesion. (Basically getting at anything can be seen from a TBI)

Activity Limitations

Involve difficulties walking, carrying/handling objects, changing, and maintaining body position, washing/bathing, dressing, eating, drinking and other ADL's.

the stages of grieving

It is normal for the family to experience __________________. How an individual progresses through each stage is unique.

Play favorite music. Read messages from family and friends. Provide pictures of familiar people and events. Call patient by most familiar name.

Levels of Cognitive Functioning I and II: Clinical Tips to help elicit a response:

Increase their level of arousal and provide stimuli that may eventually elicit a response.

Levels of Cognitive Functioning I and II: The Goal

1. Prevent contractures or loss of range of motion. 2. Positioning the patient to increase arousal and prevent decubitus ulcers.

Levels of Cognitive Functioning I and II: Treatment suggestions for a patient at this cognitive level:

Serial casting

May be used to maintain or improve ROM. Often used for plantar flexor or biceps contractures. (ex. ankle is put into dorsiflexion and casted for 2-5 days. The muscle is stretched again and another cast is applied.)

behavioral changes

Neurobehavioral impairments: Patients can exhibit profound _______________ as they progress through recovery.

intracranial hematomas

Open head injuries are associated with ________________.

stimuli

Patients at levels II and III are responding to ____________ either generally or with a localized response.

At the moment of impact (due to direct trauma)

Primary Brain Damage (TBI) occurs when?

Focal Brain Injuries

Primary Brain Damage: Occurs at the site of impact. Brain coming in contact with bony protuberances on the inside of the skull or damage from the penetrating object. Damage may be in the form of a hematoma, edema, contusion, or laceration, or combination of all four.

Diffuse Axonal Injury (DAI)

Primary Brain Damage: Occurs in response to acceleration-deceleration and rotational forces. Rapid movement of the brain within the skull causes widespread stretching and tearing of the neuronal axons within their myelin sheaths. If the injury is severe, damage will extend into the brainstem and lead to coma and correlates with less clinical recovery.

Participation Restrictions

Problems an individual may experience in involvement in life situations.

Level VII - Automatic, Appropriate

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient appears appropriate and oriented within the hospital and home settings. Goes through daily routine automatically, but frequently robot-like. Patient shows minimal to no confusion and has shallow recall of activities. Shows carryover for new learning but at a decreased rate. With structure patient is able to initiate social or recreational activities. Judgement remains impaired (Unrealistic planning for the future, Unable to think about consequences of a decision or action, Overestimates abilities). Unaware of others' needs and feelings.

Level I - No Response

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient appears to be in a deep sleep. Completely unresponsive to any stimuli.

Level VIII - Purposeful, Appropriate

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient is able to recall and integrate past and recent events and is aware of and responsive to environment. Shows carryover for new learning and needs no supervision once activities are learned. May continue to show a decreased ability relative to premorbid abilities, abstract reasoning, tolerance for stress, and judgement in emergencies or unusual circumstances.

Level V - Confused-Inappropriate Non-Agitated

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient is able to respond to simple commands fairly consistently. May become agitated in response to external stimulation, and/or lack of environmental structure. Highly distractible. With structure, may be able to converse on a social automatic level for short periods of time. Verbalization is often inappropriate and confabulatory. Memory is severely impaired. Often shows inappropriate use of objects. May perform previously learned tasks with structure but is unable to learn new information.

Level IV - Confused-Agitated

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient is in a heightened state of activity. Behavior is bizarre and nonpurposeful relative to immediate environment. Does not discriminate between persons or objects. Unable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent and/or inappropriate to the environment. Confabulation may be present. Gross attention to environment is very brief. Selective attention is often non-existent. Patient lacks short and long term recall.

Level II - Generalized Response

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient reacts inconsistently to stimuli in a nonspecific manner. Responses are limited and often the same regardless of the stimulus presented. Responses may be physiological changes, generalized gross body movement and/or vocalization.

Level III - Localized Response

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing eyes or squeezing hand in an inconsistent, delayed manner.

Level VI - Confused, Appropriate

Rancho Los Amigos Levels of Cognitive Functioning Scale: Patient shows goal-directed behavior but is dependent on external input or direction. Follows simple directions consistently and shows carryover for relearned tasks such as self-care. Responses may be incorrect due to memory problems, but they are appropriate to the situation. Past memories show more depth and detail than recent memory.

slides

Read slides 35-40

Secondary Injury (TBI)

Results from a cascade of biochemical, cellular, and molecular events that evolve over time due to the initial injury and injury-related hypoxia, edema, and elevated intracranial pressure (ICP). Occurs within minutes to hours after injury. Includes intracranial hematomas. The intracranial hemotomas lead to a rise in intracranial pressure (ICP) as blood accumulates. This leads to a shifting and compression of brain structures, thus leading to secondary brain damage.

Hypoxic-Ischemic Injury

Secondary Brain Damage: Results from a lack oxygenated blood flow to brain tissue. Can be caused by systemic hypotension, anoxia, or vascular damage.

A herniation of brain tissue may occur causing potentially life threatening secondary impairments

Secondary Brain Damage: What will happen is ICP continues to rise?

Intracranial hematomas (Epidural, Subdural, Intracerebral) Herniations Hypoxic-Ischemic Injuries

Secondary brain damage can occur from:

Compensatory Approach

Seeks to improve functional skills by compensating for the lost ability.

five senses

Sensory stimulation techniques to arouse the patient and elicit movements includes providing the patient with sensory stimulation through the ______________.

Vegetative State - Dissociation between wakefulness and awareness. No meaningful motor or cognitive function. Minimally conscious state - Some evidence of self or environmental awareness. Stupor - Unresponsive state from which the patient can be aroused only briefly with vigorous, repeated sensory stimulation. Obtunded - Sleeps often and when aroused exhibits decreased alertness and interest in the environment and delayed reactions.

Soon after injury, TBI patients, often present with disorders of consciousness such as the following:

• Be consistent • Expect no carry over • Expect egocentricity • Pt has limited attention span. • Safety Risk (unpredictable) • Use closed environment

Special Considerations for Confused and Agitated Patients:

Acceptance (Stage 4)

Stages of Grieving: Acceptance that changes have occurred in their loved one and in their lives. Only after acceptance can they attend to their own recovery and begin to make the necessary lifestyle changes.

Anger, frustration, and guilt (Stage 2)

Stages of Grieving: Anger toward anyone who could be seen as the cause of the injury, or anger toward the hospital staff. Feelings of being victimized may arise.

Denial, shock, and disbelief (Stage 1)

Stages of Grieving: Feeling that, "this couldn't have happened to us".

Depression, withdrawal (Stage 3)

Stages of Grieving: Withdrawal from friends and social contacts. Lack of motivation to take care of their own needs and relationships. May result in poor nutrition, lack of sleep, or ineffective at work.

leading

TBIs are the ___________ cause of injury-related death and disability in the U.S.

1. Eye opening 2. Best motor response 3. Best verbal response

The Glasgow Coma Scale is a standardized 15-point test that uses three measures:

24

The Glasgow Coma Scale is typically performed within the first ____ hours after injury - provides a good baseline.

1. Denial, shock, and disbelief 2. Anger, frustration, and guilt 3. Depression, withdrawal 4. Acceptance

The Stages of Grieving include 4 stages:

Primary Injury - Due to direct trauma. Blast Injury - Shock wave results in overpressure of the brain. Secondary Injury - Results from a cascade of biochemical, cellular, and molecular events that evolve over time due to the initial injury. Open Head Injury - Skull is fractured. Closed Head Injury - Skull remains intact.

The different types of TBI injuries include:

less affected; affected

The last decade of transitional and applied research in the areas of neural plasticity motor learning and neurological rehabilitation has heightened awareness that real learning is directly related to the rehabilitation experience patients are exposed to. Using the example above, interventions that seek compensation will result in learning how to use the ____________ extremity as well as learning not to use the more affected extremity. Alternatively a restorative rehabilitative experience that allows the patient to practice using the affected arm for every day task will result in greater functional independence and ___________ extremity use. This knowledge is useful in clinical decision making when developing the POC.

Falls and MVA

The leading causes of TBI are....

⦿ Establish and maintain a consistent daily routine. ⦿ Never discuss the patient's condition with someone else when the patient can hear you, even if you think he cannot understand. ⦿ Treat the patient at an age-appropriate level. ⦿ Respect the patient's likes and dislikes about food, clothing, music, entertainment, etc. - Likes and dislikes may have changed. ⦿ Avoid telling the patient "you'll soon be well" - Such remarks result in disillusionment. ⦿ Do not answer for the patient if he is capable of speaking for himself. ⦿ Keep instructions consistent. - Talk about the same things in the same way using the same words - allows pt to be more successful. ⦿ Try to include the patient in conversation and family affairs. ⦿ Don't overestimate the patient's capability to understand what is said. ⦿ Don't act like you understand when you don't.

Things to consider and remember with Patients and Family:

Blast Injury

This type of injury is considered a signature injury of the U.S. military conflicts in the Middle East. When an explosive device detonates, a transient shock wave is produced, which can cause brain damage. Primary blast injury results from the direct effect of blast overpressure on organs (in this case the brain), secondary injury results from shrapnel and other objects being hurdled at the individual, and tertiary injury occurs when the victim is flung backward and strikes an object.

Principle of use it and improve it

Training that drives a specific brain function can lead to an enhancement of that function.

Restorative Approach

Treatment seeks to restore the "normal" use of the affected area.

Focal Brain Injuries Diffuse Axonal Injury (DAI)

Two types of primary brain damage (TBI):

The Glasgow Coma Scale

Used to assess level of consciousness and neurological functioning after a TBI.

Intracerebral

What is usually the most deadly type of hematoma?

Epidural Hematoma

When blood accumulates between the skull and dura mater

Intracerebral Hematoma

When intrinsic cerebral arterial blood accumulates within the brain.

reflex responses; avoidance

When trying to arouse the patient and elicit movement through sensory stimulation, be careful with sensory stimulation and watch for adverse responses. Sensory bombardment can lead to an increase in ________________ or an ____________ reaction.

increases in respiration, heart rate, or diaphoresis

When trying to arouse the patient and elicit movement through sensory stimulation, watch for and document subtle responses including........

Subdural Hematoma

When venous blood accumulates beneath the dura mater.

compound; dural

With an open head injury, if the scalp is cut it is considered a ______________ skull fracture. This is associated with ________ tears and increases the risk of intracranial infections.