Neuro PT Exam 3

What is concussion/mTBI?

A trauma-induced alteration in mental status, with or without LOC, with impaired functioning of the brainstem reticular activating system (RAS) - LOC actually only occurs in ~10% of cases...for a long time, people thought that if you didn't lose consciousness, your brain wasn't damaged (not true) 95% of people who have had mTBI have a normal CT scan and 70% of people will have a normal MRI

Guidelines/Prerequisites for Mobilization of Those With Mod-Severe TBI

Goal is perfusion to prevent hypoxia Prerequisites - MAP 60-110 mmHg - SBP 80-100 mmHg - Arterial pH >7.25 - Pulse ox >88% **pt may require ↑ O₂ or ventilator support

DAI Grades

Grade I - Widespread axonal damage in the white matter Grade II - Grade I injuries + damage to the corpus callosum Grade III - Grade I & II injuries + tissue-tear hemorrhages in the brainstem - Remember, blood is toxic to brain - Typically life-threatening

ICP Values

Normal: 4-15 mmHg Sedating meds are used to maintain ICP below 20 mmHg

Cervical SCI: Extension Injury

Site: C4-5 MOI: fall + hit chin on sink, bath, etc. ⟶ c-spine receives an anterior distraction force and a posterior compression force - Common in older adults Result: - Bony &/or ligamentous damage - Sometimes can have a unilateral fx in one of the vertebral bodies (C4/5 level)

Traumatic SCI + TBI (Macciocchi et al.)

Traumatic SCI and TBI are common co-occurring disorders (60% of the pts in the study) Most co-occurring TBIs were mild (34%) Individuals should be screened using the GCS and the Galveston Orientation and Amnesia Test (GOAT)

Unmet Needs of Brain Injury: Corrigan et al. Study

Found that ~40% of individuals hospitalized w/TBI had > 1 unmet needs requiring services 1 yr after injury (even after rehab) - Basically some things weren't addressed by the medical team The most frequent unmet needs: - Improving memory and problem solving - Managing stress and emotional upsets - Controlling one's temper - Improving one's job skills

Medical Complications After TBI: Spasticity + Rigidity

*Note: pts w/TBI can have both spasticity and rigidity - Ex: spasticity in L limbs, rigidity in R limbs Spasticity Velocity-dependent resistance to passive motion ⟶ results in muscular weakness 2/2 failure to activate motor units supplying agonist muscles Rigidity Non-velocity-dependent ↑ in muscle tone - Delayed onset (comes on slowly over time)

4 Stages of Intervention for Managing Inappropriate Behavior

1. Environmental Controls 2. Rules, Reinforcements, + Instructions 3. Collection of Strategies to Reduce Inappropriate Behaviors 4. Punishment

Leading Causes of TBI

1. Falls (48%) 2. Struck by or against something (17%) 3. MVA (14%) 75% of TBIs are concussions or other forms of mTBI (use this terminology instead of "concussion" now)

Cervical SCIs Traumatic MOIs (General List)

1. Flexion 2. Flexion Rotation 3. Extension 4. Hyperextension 5. Compression 6. Axial Loading 7. Penetrating

TBI Clinical Rating Scales

1. Glasgow Outcome Scale - Different from GCS!! 2. Disability Rating Scale (DRS)

Preventing Agitation/Aggression After TBI

1. ID the trigger to agitation, anger, or aggression 2. Remain calm, use small gestures, ask them why they feel agitated - Don't feed into their aggression 3. Defuse the situation before it escalates to aggression - Listen actively - Be sure the pt is oriented ⟶ tell them who you are, what you're doing, why you're there (do this at beginning, middle, + end of treatment) - Redirect when needed

Recommended Outcome Measures for TBI in Inpatient/Outpatient Rehab

1. 6 MWT 2. 10 m Walk Test 3. Berg Balance Scale 4. Community Balance + Mobility Score 5. Disability Rating Scale 6. Functional Assessment Measure 7. Modified Ashworth Scale 8. Patient Health Questionnaire 9. QoL After Brain Injury 10. Rancho Levels of Cognitive Functioning **Remember, most places are transitioning to using the core 6

Recommended Outcome Measures for TBI Acute Care

1. Agitated Behavior Scale 2. Revised Coma Recovery Scale 3. Moss Attention Rating Scale 4. Rancho Levels of Cognitive Functioning

Most Frequently Observed Inappropriate Behaviors After TBI

1. Agitation + physical aggression - Most often w/in first year of injury - Might see if in first few hrs after mTBI, but most commonly seen w/mod-severe TBI 2. Non-compliance 3. Self-stimulation - Ex. rocking themselves vigorously 4. Self-injurious behavior - Ex. banging head against wall (also self-stim)

TBI Examination/Evaluation: Systems Review

1. Arousal ⟶ eye responses - Respond to auditory or tactile stimulus - Blinking in response to threat - Orienting to objects/tracking 2. Attention ⟶ focused/sustained/divided 3. Consciousness ⟶ state of being aware and alert 5. Cognitive Status ⟶ examined using the Rancho Los Amigos Cognitive Functioning Scale 6. Memory ⟶ STM, LTM, Post-Traumatic Amnesia (PTA), retrograde/anterograde amnesia - Hugely involved w/TBI - Determine which kind is involved 7. Spasticity 8. Muscle Tone + Posturing 9. Integumentary Integrity 10. Sensory Integrity 11. Cranial + Peripheral Nerve Integrity 12. Gait, Locomotion, Balance 13. Functional Mobility 14. Aerobic Capacity + Endurance 15. Work, Community Integration 16. Assistive + Adaptive Devices

Recommended Outcome Measures for TBI in Outpatient Setting

1. Balance Error Scoring System (BESS) 2. High Level Mobility Assessment Tool (HiMAT)

TBI Characteristics (Acute Presentation)

1. CSF coming out of ears or nose 2. Brain matter at the scene - Poor prognosis 3. Loss of consciousness (LOC) + paralysis 4. Unequal, unreactive, or dilated pupil 5. Blurred vision + loss of eye movement - Affected vertical eye movement could be indicative of brainstem injury 6. Dizziness and balance problems 7. Respiratory failure and slow pulse 8. HA, 9. Vomiting 10. Confusion 11. Inappropriate emotional responses 12. Difficulty speaking 13. Loss of bowel + bladder control - Very serious TBI

Recovery Stages After DAI

1. Coma ⟶ a state of unconsciousness, eyes closed, no sleep/wake cycles, not aroused or aware 2. Unresponsive/Vegetative ⟶ arousal is present, return of sleep/wake cycles, normalization of respiration, digestion, + BP control - Lack awareness (of self or environment) → no sustained or purposeful response to stimuli (ex. may squeeze your hand once, but if you ask them to do it again, they won't) 3. Mute Responsiveness ⟶ show signs of fluctuating awareness 4. Confusional State ⟶ unable to form new memories (no motor learning), hypo/hyper aroused - Can't attend (and, therefore, can't learn) - All cognitive functions are influenced at this stage 5. Emerging Independence ⟶ confusion clears, some memory possible - Still have cognitive limitations (limited insight into their deficits, safety requirements, etc) - Commonly see disinhibition behaviors in this stage 6. Intellectual/Social Competence ⟶ increasing independence w/persistent cognitive, behavioral, and social deficits - Still can't engage appropriately socially, might have mood swings, and problem-solving difficulties Note: just like with stroke stages, pt may progress through all stages, or may get suck in a stage at any point

TBI Mechanisms of Injury

1. Contact Injury ⟶ any movement of the head which is suddenly halted, causing the brain to move within the skull - Can have a significant injury w/very little motion - ex. whiplash 2. Direct Blow to the Skull ⟶ produces distortion or displacement of the brain tissue - Can have brain disruption in multiple areas (not just under where you got hit) 3. Penetrating Objects ⟶ cause direct cellular and vascular damage (ex. GSW) - High velocity penetrating injury can cause remote damage due to shock waves - Low velocity injuries can cause direct damage to the tissues they impact 4. Injuries to Face + Neck ⟶ can cause TBI by damaging the blood supply to brain (or could be acceleration-deceleration mechanism) 5. Blast Injury ⟶ caused by rapidly moving wave of overheated expanding gases that compress surrounding air - Fluctuations in pressure result in barotrauma, damaging fluid-filled organs and cavities (GI tract, ears, lungs) - ~30% ↑ in atmospheric pressure can rupture the tympanic membrane → vertigo, imbalance, changes in VOR, etc - The air around the explosion is toxic and inhalation can also cause changes in brain function 6. Focal Damage ⟶ localized damage under the point of impact - No shockwave or movement of brain - Usually pretty hard to do...head would have to stay still and something falls on you, for example 7. Rotational Forces ⟶ head is hit and neck is rotated - One of the worst MOIs → will cause lower structures of brain (brainstem, posterior blood vessels) to be distorted - Can have some shifting side-to-side of the brain

Clinical Manifestations of TBI

1. Impaired affect (distorted emotional expression) 2. Impaired arousal - Arousal vs. awareness addressed on next card 3. Impaired attention - Moss Attention Rating Scale (MARS) looks at ability for pt to stay on task (canvas) - Definitions addressed later 4. Impaired expressive or receptive communications - Depends on if speech centers in dominant hemisphere were affected 5. Impaired motor function - Addressed later 6. Impaired respiratory function 7. Impaired autonomic function - Fluctuating vital signs - Excessive sweating - Fluctuating ICP - Need to continue monitoring vitals, even after pt is far out from TBI and seem fine (can remain for a while) 8. Impaired cognition + learning 9. Impaired balance + anticipatory reactions 10. Personality changes - Hardest part for family

TBI Clinical Manifestation: Frontal Lobe Pathology

1. Impaired executive functioning ⟶ difficulty with... - Problem solving - Reasoning - Impulsivity - Distractibility 2. Orbitofrontal Syndrome ⟶ behavioral change (seen with mod-severe injuries) manifested as... - Lack of empathy and emotional warmth - Disinhibition (acting inappropriate in settings) - Irresponsibility 3. Decreased motivation ⟶ - Incapable of spontaneous movement or speech - Blank stare into space, no desire to interact with ANYTHING - Can be tough to get them motivated enough to eat or engage with anything that got them excited before injury 4. Dominant Hemisphere ⟶ may result in aphasias... - Expressive aphasia - Receptive aphasia - Global aphasia - Normal aphasia

Leading Causes of TBI Deaths

1. Intentional self-harm (33%) 2. MVA (19%) Morbidity and mortality after TBI is largely due to epidural, subdural, and subarachnoid hematomas - Classified as mod-severe TBI if there's a hematoma

Causes of SCI Since 2010

1. MVA - 39% 2. Falls - 31% 3. AOV (action of violence) - 14% 4. Sports - 8%

Clinical Manifestations of TBI: Motor Abnormalities

1. Monoplegia 2. Hemiplegia 3. Abnormal reflexes - Remember, these have a relationship to spasticity → are we seeing them bc they're starting to develop spasticity - How is that influencing the way they move, what positions influence strength of spasticity 4. Loss of balance 5. Fluctuating tone: can manifest as ⟶ - Initial flaccidity progressing to spasticity or rigidity - Can exhibit extensor responses in both extremities OR - Flexor responses of UEs w/extensor responses in the LEs OR - Extensor responses in UEs w/flaccid/weak flexor responses in LEs - Note: not as clear cut as in stroke Note: the amount of resting tension/tone in the pt's muscles can be influenced by the position that the pt is in and also the environment (temperature, hunger, sleep, etc)

How do you deal with angry/aggressive TBI pts?

1. NEVER show that you're afraid 2. If they're afraid, keep your movements small + slow 3. If they're frustrated, change activity - Be concrete with what you're asking them to do 4. DON'T allow learning avoidance - Never avoid teaching someone something bc it's upsetting them - Stop, move on to something else and come back to it 5. If they're intimidating you (or trying to) ⟶ - Use closed posture - Make them understand that there's consequences for their behavior 6. Try not to show anger 7. Reduce the level of stimulation in the environment 8. Protect the pt from harming himself or others 9. Reduce the pt's cognitive confusion 10. Tolerate restlessness when possible (i.e., limit physical restraints) - If they aren't hurting themselves or you, just let them be restless

Assessment of Anger + Agitation

1. Perform a psychiatric assessment to rule in/out psychiatric or cognitive sequelae of the TBI 2. Rule out other physical causes through physical assessment + diagnostic testing

Possible Medical Complications After TBI

1. Post-Traumatic Seizures 2. Hydrocephalus 3. DVT 4. Heterotrophic Ossification 5. Spasticity 6. Rigidity 7. GI Problems

Medical Complications After TBI: Hydrocephalus

2/2 obstruction w/in the ventricular system before the exit of CSF from the 4th ventricle - May be a complication of subarachnoid hemorrhage Hydrocephalus ↑s pressure on tissues → tissue △s → nerve damage → neuro △s - We want to prevent this from causing nerve death - CT scan will ID just how pervasive the problem is Symptoms: - Nausea + vomiting - HA - Papilledema (swelling of eyes) - Dementia - Ataxia - Urinary Incontinence

PT Management of TBI by Setting

Acute Care/ICU - Positioning - ROM - Skin care - Pulmonary hygiene - Prophylactic (preventative) casting of elbows/ankles - Passive standing **Remember to be monitoring ICP and O₂ sats Inpatient/Outpatient Rehab - ADLs - Cognitive retraining - Functional tasks (transfers, gait, body weight supported treadmill training/BWSTT, CIMT, balance training) Outpatient - Community reintegration - Vocational training

What is a traumatic brain injury (TBI)?

An alteration in brain function, or other evidence of brain pathology (chemical changes), caused by an external force Alteration in brain function ⟶ - Loss or ↓ level of consciousness - Altered mental state (confusion, unaware of surroundings, etc) - Incomplete memory of the event - Neurological deficits (changes in coordination, muscle activation, muscle performance, etc)

Acquired Brain Injury

An injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma

TBI Recovery: Kimberly TJ et al. Neuroplasticity Research

Animal Studies - Results showed that 400-600 reps per day of a challenging functional tasks will promote neuroplastic/structural change - 2500 steps daily is required to improve gait Human Relevance - pts w/TBI + stroke receiving rehab perform fewer total reps in any category than what's suggested by the research to promote neuroplastic change ⟶ we aren't doing enough! - This is why it's super important to prime the system by doing something aerobic first (release of BDNF)

Clinical Manifestations of TBI: Arousal vs Awareness

Arousal is a state of alertness - Mediated thru midbrain RAS - After TBI, arousal will fluctuate or be diminished from normal Awareness is a conscious knowledge of the environment A person in a coma is neither aroused or aware

Agitated Behavior Scale

Assessment/objective measure of anger/agitation Takes <30 mins to administer 14-item scale with each item scored from 1 (absent) to 4 (present to an extreme degree) - ABS > 21 ⟶ agitation - ABS < 23 ⟶ unlikely to be violent - ABS > 28 ⟶ treatment w/pharmacological agents Limitation⟶ risk of overdiagnosis of agitation

Clinical Manifestations of TBI: Attention

Attention is the cognitive process of selectively concentrating on one thing while ignoring other things Sustained Attention: concentration on one thing without redirection - Normal/goal = 10-20 mins sustained attn w/out redirection Selective Attention: ability to select relevant/most important information to focus on - Ex. when working on transfers with someone w/diminished selective attention, the pt might focus on unlocking and locking the brake over and over rather than lifting their butt out of the seat (after you've taught them everything) Focused Attention: ability to focus without dividing attention Alternating Attention: ability to switch between tasks without going back to the previous task (not perseverating on one thing)

TBI and Afghanistan/Iraq War

Between 2003-2005, 25,000 war injuries in Iraq + Afghanistan occured ⟶ 3,000 of those required tx for severe TBI Blasts/explosions accounted for 66% of war injuries ⟶ 80% of those were mTBI

Resulting Symptoms of Moderate TBI

GCS 9-12 1. LOC > 30 mins - 6 hrs 2. Confusion that lasts from days to weeks w/cognitive changes (problems w/executive functioning, memory, problem solving, judgement, motor planning, etc.) 3. Or permanent cognitive/behavioral changes - Will have to learn how to compensate for long-term changes in function that will remain after treatment of TBI May be associated with retrograde and post-traumatic amnesia

Neurometabolic Cascade of mTBI

Brain trauma/concussive event promotes a cascade effect ⟶ 1. ↓ blood flow to brain tissue 2. Release of glutamate (excitatory neurotransmitter) - When released at appropriate levels, glutamate is good (helps w/memory + learning) - With mTBI, it is overproduced and becomes an excitotoxin → brain goes into revved up, imbalanced state 3. Creates an ion imbalance of Ca⁺⁺ and K⁺ 4. Na⁺/K⁺ pump ↑ activity to promote homeostasis 5. All of this requires ATP + glucose for energy → hypermetabolic state/energy crisis - This is why people want to sleep after mTBI and why it's harder to think → brain is taking so much energy to try to get back in balance Note: - There is currently no drug protocol to stop this cascade - There is supplementation that can disrupt the cascade to hopefully slow down or diminish the inflammatory process that occurs

GCS TBI Outcome Predictability

Can be effective in predicting life or death ⟶ - Score of < 7 → coma - Score of < 7 → ↑ probability of death than those w/scores of >8 - Scores >8 →85% chance of moderate to good recovery

What three age groups are most likely to sustain a TBI?

Children: 0-4 yo - Leading cause of TBI ⟶ falls - Also might be due to abuse Young Adults: 15-24 yo - Leading cause of death ⟶ MVA - Males are more likely to engage in risk-taking behaviors ⟶ TBI males > females (3:1) Older Adults: >75 yo - Leading cause of TBI ⟶ falls - Highest rates of hospitalization and death from TBI

Medical Complications After TBI: Deep Vein Thrombosis

Common occurrence ⟶ occurs in 54% of patients - Typically due to an injury that was missed (important for us to monitor and look for missed fxs) First clinical sign is usually sudden death due to pulmonary embolism - Other signs: SOB, chest p!, pulmonary crackles Risk Factors: - Immobility - LE fxs - Indwelling catheters Treatments: - Heparin - Intermittent LE compression

Anatomy of the Spinal Cord

Contained within the vertebral canal Extends from the medulla oblongata to the L1 or L2 vertebra Protected by the vertebral bodies anteriorly and the vertebral arches laterally + posteriorly - Damage to the vertebral column can cause injury to the SC

Cost of SCI

Cost of SCI is continuous Most expensive ⟶ high tetraplegia (C1-4) Less expensive ⟶ incomplete motor function at any level (AIS D) Still pretty damn expensive no matter the case

Resulting Symptoms of Severe TBI

GCS <8 1. LOC or awareness > 6 hrs 2. Coma 3. Vegetative state 4. Minimally responsive - The longer the person is in a coma, the poorer the prognosis becomes May be associated with diffuse axonal injury (DAI) and coma

Vertebral Column: Three-Column Model

Damage to any 2 columns ⟶ spinal instability (usually results in SCI) - In most SCIs, there's not SC severance...it could be stretched, be exposed to blood, etc Anterior - Anterior longitudinal ligament - Annulus fibrosus Middle - Posterior wall of vertebral body - Posterior longitudinal ligament - Annulus fibrosus Posterior - Vertebral arch - Supraspinous ligament - Interspinous ligament - Capsule - Ligamentum flavum - More fragile than the others; stability can be easily compromised - Tearing ligamentum flavum causes the vertebrae to move and compress the cord, allowing blood into the SC (toxic), causing swelling, pressure, etc.

Coup-Contrecoup Injury

Damage to the brain on both sides ⟶ 1. Coup: damage on the side that received the initial impact or blow 2. Contrecoup: the side directly opposite the point initial - Transmitted forces from initial impact causes brain to rebound and impact against opposite side of skull

TBI Clinical Manifestation: Temporal Lobe Pathology

Damage to the primary auditory cortex may result in... 1. Hearing Deficits - On central level - Can lose hearing without anatomical damage 2. Receptive Aphasia - Wernicke's - Primary deficit in comprehension with fluent speech - Can't process auditory information...so they can hear you, but when you ask them to do something, they don't do it bc they don't get what you're saying 3. Sequencing issues 4. Agitation + Irritability 5. Memory Deficits - Hippocampus

TBI Clinical Manifestation: Occipital Lobe Pathology

Damage to the primary visual cortex may result in... 1. Visual Field Loss - Pathology of the left occ. lobe will cause right homonymous hemianopia 2. Cortical Blindness - Total loss of vision w/out structural damage to the eyes 3. Visual Disorientation - Inability to comprehend the relevance of visual information - Would have trouble understanding gestures or facial expressions

Glasgow Coma Scale (GCS)

Designed in 1974 to assess and monitor level of consciousness ⟶ used immediately after TBI - Gold standard Eye Opening Response 4 - spontaneously 3 - to speech 2 - to pain 1 - no response Best Verbal Response 5 - oriented to time, place, + person 4 - confused 3 - inappropriate words 2 - incomprehensible sounds 1 - no response Best Motor Responses 6 - obeys commands 5 - moves to localized p! 4 - flexion withdrawal from p! 3 - abnormal flexion (decorticate posture) 2 - abnormal extension (decerebrate posture) 1 - no response

HiMAT as a TBI Outcome Measure

Designed to assess pts with high-level balance + mobility problems - Younger, mTBI (or mod) pts Minimum mobility requirement ⟶ independent walking > 20 m w/out gait aids (orthoses allowed) Protocol - Pts are allowed a trial session prior to the scored assessment - 13 high-level mobility tasks including walking + running, jumping + balance items, stairs, hopping, skipping - Patient perform each task at their maximum safe speed (except for bounding and stair items) - There is a new, 8-item version that removes the stair and bound-affected leg items Scoring - 13 items are scored on a 5-point scale - Items are summed for total score

After identifying a problem behavior in your patient (i.e., anger/agitation), what should you do/consider next?

Determine the behavior's impact: - Is it interfering with the patient's ability to learn? - Is it causing injury to the patient? - Is it a safety risk for the patient and those around them? - Is it causing others to avoid them? - Does the behavior occur as a result of a skill deficit? Is the patient frustrated at not being able to accomplish a particular task?

Ranchos Los Amigos Cognitive Functioning Scale (RLAS)

Developed for use in treatment planning, tracking recovery, and classifying outcome levels Levels I: No response ⟶ total assistance needed II: Generalized response ⟶ total assistance needed III: Localized response ⟶ total assistance needed IV: Confused/agitated ⟶ maxA needed V: Confused, inappropriate ⟶ maxA needed VI: Confused, appropriate ⟶ modA needed VII: Automatic/appropriate ⟶ min A for ADLs VIII: Purposeful/appropriate ⟶ stand-by assistance IX: Purposeful/appropriate ⟶ stand-by on request X: Purposeful/appropriate ⟶ modI

TBI Statistics: DoD vs. Civilian

DoD: TBI in Military Personnel - 82.3% of TBIs are mild TBIs (mTBI) ⟶ lots of people with some form of CNS or cognitive changes CDC: Civilian Population - ~1.7 million people sustain a TBI each year - 2.5 million ED visits are related to TBI (many people don't go to the ER) - 282,000 hospitalizations related to TBI - 56,000 deaths related to TBI ⟶ alcohol plays a huge role in mortality from TBI and having TBI in general - 812,000 ED visits among children (usually <5 yo); many related to falls, but some related to abuse - 5.3 million Americans live with disabilities related to TBI - General public cost is ~60 billion annually in medical cost and lost productivity

Resulting Symptoms of Mild TBI

GCS 13-15 1. LOC < 30 mins 2. Medical tests (CT/MRI) reveal no abnormalities 3. Disorientation 4. Irritability 3. HA 5. Sleep disturbances (RAS) 6. Visual problems 7. Fatigue 8. Light/sound sensitivity (produces p! or dizziness/other sxs) 9. Dizziness 10. Slowed reaction times 11. Disequilibrium/balance issues 12. Drowsiness 13. Changes in personality/emotional disposition (mood swings) 14. Confusion 15. Nausea mTBI may be associated with retrograde amnesia - Loss of memory before the injury In sports, follow consensus statement and assessment tool CPG (on canvas)

TBI Clinical Manifestation: Parietal Lobe Pathology

Dominant Parietal Lobe 1. Acquired Dyslexia ⟶ clinical manifestations relate to the type of aphasia - Expressive aphasia → difficulty reading (can't recognize the symbols) - Receptive aphasia → difficulty understanding words in printed form - Agraphia → form of expressive aphasia that manifests as difficulty with writing syntax (inability to put words together in a logical order) Non-Dominant Parietal Lobe 1. Visuospatial + Perceptual Disorders - Mis-reaching for visual targets, tripping on steps, bumping into furniture (depth perception issue) - Neglect of all sensory info (visual, tactile, auditory) - Neglect of the left side of the body - Inability to differentiate between left + right 2. Agnosia - Inability to recognize sensory stimuli - What does doorbell sound mean? Fire alarm lights? 3. Apraxia - Inability to carry out skilled motor tasks that's not due to weakness or ↓'d motor control - Ex. hand them a toothbrush and they can't recognize that they are supposed to brush their teeth with it (they just don't understand what you want them to do)

Medical Complications After TBI: Heterotrophic Ossification

Ectopic bone formation in the soft tissue surrounding the joints ⟶ most likely to occur within the first 3-4 mos after a severe TBI - 20-30% higher risk in severe TBI pts Usually occurs first (and most frequently) in hips, then knees, elbows, shoulders, hands, and spine Risk Factors: - Coma lasting longer than 2 wks - Limb spasticity - ↓ Mobility Symptoms: - Joint p! - ↓ ROM (incremental over days...every successive PT tx, the pt is losing ROM instead of gaining it) - Low-grade fever - Periarticular swelling - Warmth + redness Treatment: - Gentle ROM - Meds to prevent hyper-calcification - Surgery to remove it once it peaks

Medical Management of TBI Hematomas (Surgery vs. No Surgery)

Epidural Hematoma - > 30 cm³ ⟶ surgically evacuated regardless of GCS score - <30 cm³, <15 mm thickness, + < 5 mm midline shift of brain matter and a GCS >8 ⟶ non-surgical management (wait for it to evacuate itself) Subdural Hematoma - > 10 mm thickness or > 5 mm midline shift on CT ⟶ surgically evacuated regardless of GCS score - GCS <9 ⟶ undergo intracranial pressure monitoring (unequal pupils, fixed dilation, ICP over 20, probs gonna do surgery) Note: pre-surgical GCS score is the single best predictor of post-surgical outcome (↑ GCS pre-surgery → better outcomes)

Dominant Frontal Lobe Pathology: Common Aphasias

Expressive Aphasia - Broca's aphasia - ↓ fluency of speech with preservation of comprehension - Struggle to get words out Receptive Aphasia - Wernicke's aphasia - Wernicke's is in the temporal lobe and has influences from the parietal lobe (remember, the two language centers communicate) - Difficulty understanding written and spoken language - They speak "normally" but make no sense Global Aphasia - Combination of expressive and receptive aphasia (disruption of Broca's and Wernicke's) - pt unable to speak, understand language, or read/write - Not always equally effected - Usually the most common form of aphasia after a severe L hemisphere (dominant hemisphere) TBI or stroke Normal Aphasia - Difficulty naming familiar objects

PT Intervention for RLAS Levels I-III

I-III: no response to localized response; total assistance Session should be 15-30 mins long - Avoid overloading the pt - Give adequate time for pt to respond Interventions 1. ROM - Make it meaningful (ADL) 2. Positioning 3. Serial Casting - Preventing PF or elbow flexion contractures 4. Stimulation - Goal is to provide multi-sensory stimuli to ↑ rate, frequency, and quality of response - Super important not to deprive pt of stimuli at this stage (don't stick them in a quiet, dark room!) - Auditory → mild/strong bells, radio, music - Olfactory → pleasant/unpleasant odors - Visual → while pt is upright, have pt track moving objects - Cutaneous → touch, firm pressure - Kinesthetic → body positioning, tilt table, ROM - Vestibular → rocking on tilt board - Oral → swab mouth w/flavors

PT Intervention for RLAS Levels IV-VI

IV-VI: confusion + agitation to confused appropriate; max-modA Interventions 1. Reduce Environmental Confusion - Overstimulation → agitation 2. Promote Relaxation - Rocking, touching, stroking, calm voice 3. Provide structure in a closed, low stimulation environment - Consistency is super important (same time daily, same PT daily, etc) - Never give instructions while the pt is already working on a task 4. Work on already learned task-specific skills while emphasizing attention to task completion 5. Perform memory exercises + stress safety - Particularly if they have judgement issues

Pathway to Cell Death After TBI

Impact and/or inertial forces ⟶ cellular strain and deformation ↴ ↪︎ Membrane depolarization + glutamate hyperproduction ⟶ influx of Ca⁺⁺ and other ions ⤋ - Activation of caspases - Free radical generation - Activation of calpains ⟶ activates apoptotic pathway ⟶ activates necrotic pathway ⟶ activates inflammatory pathways ⇶ all lead to cell death We want to minimize this as much as possible → make sure pt has enough oxygenation, get them care as quickly as possible

TBI MOI: Blast Injury Categories

Injury depends on where you are in relationship to the blast. Also consider... - Amount of explosive involved - Open vs closed environment - How the explosive was delivered - Were they wearing protective gear or were they behind a barrier Primary - Injuries are the direct result of the over pressurization wave produced by the high-order explosive - Person is directly at the blast site - Injuries to fluid-filled spaces (ears, organs, etc.) Secondary - Injuries due to flying debris and bomb fragments - Still part of the wave of gases - Person could be sorta close blast and not get the primary injuries but can get the secondary ones Tertiary - Injuries due to being thrown by blast wind - Still part of toxic wave of gas - TBI, fractures, etc. Quaternary - All explosion-related injuries, illness/diseases not due to primary, secondary, or tertiary mechanisms - Burns, toxic gas inhalation, etc.

Disability Rating Scale (DRS)

Used more frequently in clinic than GOS Developed and tested with older juvenile + adult clients with moderate + severe TBI in an inpatient rehab setting Rates eye opening, best communication, best motor, cognitive ability for feeding, toileting, + grooming - 0 (no disability) to 29 (extreme vegetative) Lacks sensitivity for clients w/mTBI

Behavioral Assessment

Longitudinal assessment with behavioral mapping Collect data on situation, frequency, + response

Cervical SCI: Axial Loading Injury

MOI: Being struck from above ⟶ compression of the c-spine Result: - Burst fracture of vertebral bodies

Cervical SCI: Hyperextension Injury

MOI: anterior distractive forces, spinal compression by vertebral body, disc fragments, and osteophytes anteriorly, and/or ligamentum flavum + laminae posteriorly Result: - Anterior longitudinal ligament rupture - Avulsion of anterior bony fragment ⟶ float around and damage cord - Can be associated with congenital anomalies - Usually associated with central cord syndrome

Cervical SCI: Flexion Rotation Injury

MOI: falling on head basically w/head rotated ⟶ dislocation + locking of a single facet joint at a particular level Result: - Injury to one side of the SC ⟶ Brown-Sequard Syndrome or nerve root damage 30% of the time - Paralysis or ↓ motor performance on one side and lack of pain + temp sensation on other side (described in more detail later)

Goals of Acute Medical Management of TBI

Medical management begins at the scene of the injury 1. Avoid Hypoxia - PaO₂ <60 mmHg - O₂ saturation <90% - Super important! - Hypoxia ↑ neuronal death → more likely to have a poor prognosis + to be intubated - ↑ motor deficits 2. Avoid Hypotension - SBP <90 mmHg - Need adequate blood perfusion - ↑'s mortality rate 3. Avoid Thromboembolism - Check for any rib fractures/anything affecting breathing - Remember, a pt CAN have a stroke after having a TBI 4. Treat Pain 5. Decrease Agitation 6. Obtain a GCS Score 7. Perform a complete neuro-examination + establish monitoring - CT scan = best way to see bleed - Best if pts are brought to a brain injury specialty center (better outcomes) **First priorities

BESS as a TBI Outcome Measure

Method of assessing static posture in individuals w/mTBI/concussion - Younger pts Used to make decisions about return to play for athletes Protocol - Total of 6 conditions (feet together, SLS, and tandem on firm surface + foam) - Barefoot, eyes closed, hands on hips - Each stance is held for 20 seconds - Error points are awarded when the trial is stopped Scoring - Highest score (errors) on one condition: 10 - Highest score on level surface: 30 - Highest score on uneven surface: 30 - Average total score: 12 errors - Moderate to high correlations with the sensory organization test (SOT) composite scores

TBI Medical Management: ICP Monitoring

Monitored when a pt with a GCS <9 has a subdural hematoma Monitored via a catheter placed in the lateral ventricle, a screw inserted thru the skull into the subarachnoid space, or a transducer placed directly in the epidural space Precautions/Treatment: - The pt's head must remain elevated 30˚ - The pt shouldn't flex their hips > 60˚ - Medically-induced moderate hyperventilation - Pt often on sedatives + anagesics - Super important to continuously monitor ICP while you're working with them (will see transient increases when they talk, sneeze, change position, etc. concerning when high level is maintained → worse outcomes)

TBI Pathophysiology: Secondary Injury

Occur minutes to days after primary injury Causes include... 1. Cerebral hypoxia - Primary cause - Can occur when blood vessels are ruptured or compressed - Due lack of blood to the brain, or lack of O₂ in the blood 2/2 airway obstruction or chest injuries - O₂ saturation is super important for survival 2. ↑ intracranial pressure (ICP) - Usually due to swelling - Can cause herniation of brain tissue thru foramen magnum - Correlated with poorer outcomes and higher mortality rates - Important to get ICP normalized - Head needs to stay at ~30˚ elevation - Minimal exertional activities 3. Intracranial hemorrhage - Causes hypoxia to the tissues fed by the affected blood vessel 4. Traumatic hematomas - Basically just cause compression - Blood = toxic and will cause cell death 5. Focal or diffuse cerebral edema - Causes compression which limits amount of blood flow (and, subsequently, O₂) 6. Electrolyte and acid-base imbalances - Causes secondary cell death - The longer these imbalances last, the more damage you'll have 7. Infection - May occur in brain tissue 2/2 open wounds causing swelling and cell death 8. Seizures - Due to pressure or scarring - Most common immediately after injury and between 6 mos + 2 yrs after injury

mTBI General Recovery Statistics

Of people that have sxs w/mTBI... - 40% will recover within the 1st week (no sxs after 1st week) - 60% will recover within 2 weeks - 80% will self-resolve w/in 21 days with adequate rest and pacing (CFS says that vast majority of pts she sees that have post-concussion sxs didn't rest or do pacing...felt like if they pushed themselves they'd get better) Strict rest is no longer indicated after mTBI, but it's super important to pace ⟶ recognize signs of fatigue and overload of the system and know that it's time to rest

TBI Symptoms by Lobe Affected (Picture from Handout)

Organized transcript in recorded lecture: - Parietal lobe: abnormal pain sensations - Frontal lobe: judgment and planning problems - Personality or affective behavior changes - Occipital lobe: vision problems - Cerebellum: coordination issues - Brainstem: problems regulating vital functions (does the HR ↑/↓ when it should or does it ↑/↓ too much?) - Temporal lobe: memory, speech, auditory, and visual perception (and processing) → remember, all of the parts of the brain are interconnected, you cannot have good auditory understanding without parietal lobe influence (And then everything in the picture)

TBI Prognosis (+/- 1 Week Post-Injury Factors)

Positive Post-Injury Factors (Occurring 1 Week Post TBI) - Early or rapid improvement in cognitive skills - Early or rapid improvement in motor skills - Access to + continuity of TBI specialized rehab - Access to case management - Consistent communication btw professionals + pt/family - Pt/family acceptance of TBI Negative Post-Injury Factors (Occurring 1 Week Post TBI) - Balance impairment early on in recovery process ⟶ predicts worse outcome at rehab d/c - Dual sensory impairment (visual + auditory system damage) ⟶ predicts worse functional progress during the acute phase of recovery - Moderate to severe coordination deficits at rehab admission ⟶ more likely to need physical assistance for mobility + self-care both at rehab d/c + 1 yr post-injury

TBI Prognosis (Pre-Injury Factors + Injury Factors)

Positive Pre-Injury Factors - Young - High IQ - High educational achievement - No drug abuse - No previous TBI - Stable work hx (work ethic) Negative Injury Factors - Prolonged coma (> 1 wk) - Prolonged PTA (> 2 wks) - Coexisting injury (SCI, torn aorta, damaged organs, fxs) - ↑ ICP - Seizures - Metabolic instability - Delayed access to trauma care - Presence of DAI - Positive brain injury on imaging - Little change in GCS early on

Post-Concussive Syndrome

Presence of symptoms of mTBI, primarily visual problems, dizziness, and disequilibrium, being present at 3 mos post-injury Note: if these sxs occurred early (within first few hrs of having a concussive event), and the pt was a female ⟶ more likely to produce post-concussive syndrome than males - Risk increases even more if they had prior anxiety, depression, or emotional problems

Intervention for Managing Inappropriate Behavior: Punishment

Presentation of a stimulus following a behavior that results in a ↓ in the rate of that behavior Rules to follow when using punishment: - Respond early to a sequence of behaviors - Be consistent - Administer punishment in a calm + cool fashion - Deliver punishment immediately after the inappropriate behavior - Try to reinforce the good behaviors that are exhibited after the episode Timeout (form of punishment) ⟶ an opportunity for almost all reinforcement to be removed for a certain period of time - Environment must be void of reinforcers - Once the pt returns from timeout, find something appropriate that they've done and reinforce them for it - In timeout long enough for it to be effective, but not so long that they fall asleep

Causes of Anger + Agitation/Aggression After TBI (Psychiatric vs. Non-Psychiatric Causes)

Psychiatric Causes 1. Depression 2. Mania 3. Frontal lobe syndromes - Orbital frontal lobe → no empathy 4. Substance/medication induced - Withdrawal sxs Note: people who were aggressive prior to injury are more aggressive after injury (if there were interpersonal relationship issues before, they're definitely heightened after) Non-Psychiatric Causes 1. Endocrine dysfunction - Changes in insulin or thyroid hormone levels - Pituitary gland dysfunction 2. Pain - Could be experiencing p! and be unable to tell you that 3. UTI - Look at the urine - Look for changes in spasticity or rigidity 4. Constipation 5. Dental problems 6. Environment - Temp of room - Sleep disturbance 7. Fear - May be caused by confusion - Use a reassuring voice 8. Frustration - Usually occurs when pt is trying to learn a difficult skill 9. Manipulation - Tantrums, non-compliance, lack of cooperation to manipulate/intimidate caregiver - Their goal is to get you to say "ok nevermind, stay in bed" ⟶ DON'T do this 10. Intimidation - Aggressive behaviors to intimidate the caregiver - If you think they will physically lash out, put a physical barrier between you and the w/c Note: non-psych if pt is usually mild mannered but then gets agitated/aggressive (temporary)

Intervention for Managing Inappropriate Behavior: Collection of Strategies to Reduce Inappropriate Behaviors

Response Shaping ⟶ techniques used to reinforce successive approximations of the desired behaviors - Similar to CIMT - The closer they get to the desired behavior that's what we reward and reinforce Contingency Contracting ⟶ a contract btw pt and PT - If pt performs a given behavior, then the PT will provide a given reinforcement

Intervention for Managing Inappropriate Behavior: Rules, Reinforcements, Instructions

Rules - Establish limits on behavior and consequences for those behaviors - Instruct the pt NOt to perform the inappropriate behavior - Rules must be concrete (must follow through w/consequences) - Example rule: you do not hit anything or any body - Example rule: you have to stay in the W/C with the seatbelt on - Consequence: If you keep trying to do that I'm going to have to turn the buckle around and put it in the back Reinforcement - The process of presenting an event/stimulus to the pt immediately after a desirable behavior in order to increase the frequency of that behavior (positive reinforcement) - Praise that is specific to the task is more likely to ↑ the patient's understanding of the desired response - Reinforcers can be anything but should be significant to them - Ex: food, drink, music, TV, internet use, favorite magazine

Diffuse Axonal Injury (DAI)

Scattered tearing or shearing of subcortical axons and small blood vessels Can occur in conjunction with local inertial forces, or polar damage ⟶ results in neuronal death - Doesn't result in a good outcome Mild forms of DAI result in... - Memory loss - Concentration problems - ↓ attention span (get an idea of what their attention was at baseline) - HAs - Sleep disturbances - Seizures

Cervical SCI: Vertical Compression Injury

Site: C4-5 MOI: "diving injury" or falling on head ⟶ vertebral bodies absorb the force and burst Result: - Bony fragments are driven posteriorly into the spinal canal

Cervical SCI: Flexion Injury

Site: C5-6 MOI: rapid deceleration ⟶ cervical column receives a compression force anteriorly and distraction force posteriorly Results: 1. Wedge Fracture - May not cause damage - May be stable or may need to be stabilized later 2. Teardrop Fracture - WILL result in damage - Piece of bone from the fx can break off and float into spinal canal, causing damage to SCI - Worse than wedge - Poor prognosis - Associated with ligament tear or disruption and vertebral body posterior displacement (this stretches and bruises the SC)

Medical Complications After TBI: GI Problems

Stress ulcers, dysphagia, bowel incontinence ⟶ problems often get ignored bc people can't tell you what's hurting - Can cause skin breakdown (if incontinent), pain, irritability Look for: - Distended abdomen - Hard stomach - Constipation

TBI Prognosis: Future Diagnoses

TBI may be a risk factor for the development of Alzheimer's Disease as well a Parkinson's Disease - PD due to basal ganglia damage TBI may be a catalyst for any of the neurodegenerative diseases in the future

Medical Complications After TBI: Post-Traumatic Seizures

Temporary abnormal electrophysiologic phenomena resulting in... - Involuntary contraction of a body part or group of muscles - Brief loss of memory - Numbness of a body part - Sensing an unpleasant odor - Sensation of fear (feeling of impending doom) What to do ⟶ prevent them from injuring themselves (clear the space, turn on their side, don't put anything in their mouth) - If seizure lasts > 5 mins, you need to get emergency help (remember, > 10 mins = status epilepticus) Can occur immediately after injury (< 24 hrs) or later ⟶ 5% of pts experience late seizures (after first week) - After the pt has their first seizure, they're 50% more likely to have more

TBI Memory Examination

Test comprehension of... 1. Verbal instruction 2. Following multi-step commands 3. Recognition + response to verbal + non-verbal cues 4. Repetition of instructions - How many times do you have to repeat instructions? Information storage and retrieval occurs in the frontal + temporal lobes ⟶ if there's damage in those areas, the pt is less likely to use memories or have good carry over from session to session Anterograde Amnesia ⟶ inability to form new memories - Partly could be related to attention - No carry over btw sessions Retrograde Amnesia ⟶ a partial or total loss of ability to recall events that have occured during the period immediately preceding brain injury Posttraumatic Amnesia (PTA) ⟶ the time lapse btw the accident the the point at which the functions concerned w/memory are judged to have been restored - Memories about the accident and recovery don't come back until later (or at all)...missing block of time - Considered to be a clinical indicator for severity of brain injury (next card)

What does the reticular activating system do?

The RAS is responsible for arousal and the sleep-wake cycle Damage to RAS also affects HR, respiration, and BP Mediated at the brainstem level

Polar Damage

The front of the brain is forced forward against the skull and suddenly stops, then moves back against the skull (acceleration/deceleration forces) Mechanism is the same as coup-contrecoup but the presentation is different (considered "classic presentation")

PTA as a Clinical Indicator of TBI Severity

The longer it persists, the more severe the lesion, and the poorer the outcome Duration of PTA ⟶ Severity of TBI - < 5 mins ⟶ very mild - 5-60 mins ⟶ mild - 1-24 hrs ⟶ moderate - 1-7 days ⟶ severe - 1-4 wks ⟶ very severe - > 4 wks ⟶ extremely severe

TBI Recovery: Neuroplasticity

The process by which neuronal circuits are modified by experience, learning, or injury - Influenced by functional task training (super important!) After injury, you can get rewiring/rerouting of old connections to make up for the lost connection, or can also get axon sprouting (new axon collaterals) to get information from a cell that hasn't been destroyed - Picture We also know that there can be neurogenesis (forming for new neurons)

SCI Demographics/Statistics

There's ~17,000 new cases of traumatic SCI each year There's 249,000-363,000 people in the USA with spinal cord dysfunction Average person w/SCI: - Male (78%) - White (60%) - Single (45%) - Injured in a MVA or fall - 50% of all injuries btw 16-30 yo - Average age for SCI is 43 yo (has ↑'d a lot; has been an ↑ in SCI to 10.9% in ppl over 60 yo)

TBI Pathophysiology: Primary Injury

Tissue damage that occurs at the scene of the accident/event May involve... 1. Skull fx 2. Contusions 3. Lacerations - Could be loss of blood (and, subsequently, oxygenation) 4. Intracranial hematomas 5. Cranial n damage 6. DAI

Glasgow Outcome Scale

Used primarily as a research tool - Has been replaced by the DRS Categories 1. Dead ⟶ dead (no shit lol) 2. Vegetative ⟶ no obvious cortical function 3. Lower Severely Disabled ⟶ able to follow commands, needs help with all activities; unable to live alone 4. Upper Severely Disabled ⟶ able to follow commands, needs help with most activities; unable to live alone 5. Lower Moderately Disabled ⟶ able to live independently, requires some assistance; unable to return to work or school 6. Upper Moderately Disabled ⟶ able to live independently, requires little assistance; unable to return to work or school 7. Lower Good Recovery ⟶ able to return to work or school w/mild difficulty 8. Upper Good Recovery ⟶ able to return to normal activities Don't need to memorize the details for each, just put them in here for completion

Intervention for Managing Inappropriate Behavior: Environmental Controls

Used to prevent behavioral problems 1. Keep the environment predictable - Makes the pt feel safe 2. Monitor the level of difficulty of the task 3. Monitor the level of environmental stimulation - Closed vs open 4. Consistency is essential - Everyone must respond to a given behavior in a similar fashion each time it occurs - The time they eat, the time they go to bed, the temperature of the room, the time of therapy, where you take them all must be the same

PT Intervention for RLAS Levels VII-X

VII-X: automatic appropriate w/minA of ADLs to purposeful appropriate and modI Interventions 1. Promote independence in functional tasks 2. Move from a closed to open environment 3. Emphasize higher cognitive skills - ↑ memory and goal setting skills 4. Gradually ↑ task complexity 5. Encourage general fitness + ↑ CV endurance 6. Prepare for community re-entry - Give concise FB about behavioral, cognitive, + emotional reintegration

When should a behavior reduction program be developed?

When behaviors... 1. Occur frequently 2. Last a long time 3. Are performed with concentrated force 4. Have the probability of continuing Note: - Consider the pt's age ⟶ pt's behaviors must be consistent with their peers - Consider the effects of the environmental structure (temp or room, number, type, + proximity of other people in the room)

Women and Post-Concussion Syndrome

Women, in particular, are more susceptible to post-concussion syndrome, especially if they have... 1. Immediate onset of HA, vomiting, confusion, and dizziness 2. Prior hx anxiety/depression