Neurological Impairments

DX TBI

-Glasgow Coma Scale -Rancho Los Amigos Levels of Cognitive Functioning -CT scan -MRI scan

RANCHO people example: -Leroy -Quai -BB -G -HP

-LEVEL III Leroy (fatigued, "look at cup") -LEVEL VI Quai (GTFOM guy) -LEVEL V, BB (sexist, racist, scrambled egg making guy) -LEVEL VI G (music, yoga guy) -VII HP (mobster, banker, deviled egg guy)

Medical management C7

-low stamina, but breathing with diaphragm -limited assistance for personal care -partial assistance for heavy-duty domestic care

Medical management C6

-low stamina, but breathing with diaphragm -moderate assistance for personal care -complete assistance for domestic care

Medical management C8

-low stamina, but breathing with diaphragm -primarily independent in personal care -partial assistance for heavy-duty domestic care

Rancho Los Amigos Scale

-measurement of awareness and cognitive function after traumatic injury -scored from Level I to Level X

Postacute rehabilitation phase of TBI Optimize cognitive function

-memory problems and executive function deficits. -stable and consistent environment -increasing the client's self- awareness

Glasgow Coma Scale and Scoring

-method to assess levels of consciousness -quantifies the severity of TBI -scores range from 3 to 15 ●Scores below 8 indicate a SEVERE brain injury. ● Scores between 9 and 12 indicate a MODERATE brain injury. ● Scores above 14 indicate a MINOR brain injury.

Nervous system C5

-sympathetic nervous system compromised -possible autonomic dysreflexia -no bowel or bladder control

TBI Symptoms

-concussion then loss of consciousness -abnormal muscle tone -spasticity -deficit in primitive reflexes -muscle weakness -ataxia -postural deficits -limitation of joint motion -changes in sensation

Mobility C5

-electric wheelchair with hand controls

Mobility C6

-electric wheelchair with hand controls -manual wheelchair for short distances -may drive a vehicle with hand controls

Mobility C1-C4

-electric wheelchair with sip and puff possible

Postacute rehabilitation phase of TBI Restore competence in work

-emphasizing punctuality -ability to respond to feedback -ability to follow work schedules -vocational rehabilitation is useful in this skill development and in identifying appropriate work or volunteer settings

Inpatient rehabilitation phase of TBI Optimize visual abilities

-environmental adaptation -vision correction -introduction of compensatory strategies (e.g., contrasting colors, textured tapes, sunglasses)

Rancho Los Amigos Scale Level I-III What the can the family do?

-explain to the person what you are about to do ("I am going to move your leg") -keep comments and questions short and simple -tell the person who you are -limit visitors to 2-3 people -keep calm and quiet -bring favorite belongings and pictures -give rest breaks -engage them in familiar activities

Inpatient rehabilitation phase of TBI Optimize voice and speech function

-expressive aphasia may be treated with conversation exercises -compensation through communication devices, pictures, or charts may be used if significant gains are not found from treatment.

Movement C7

-full head and neck -ability to raise arms and flex and extend elbows -wrist flexion and extension -partial finger movement

Movement C8

-full head and neck -ability to raise arms and flex and extend elbows -wrist flexion and extension -partial finger movement

Movement C5

-full head and neck -ability to raise arms and flex elbows (no extension)

Movement C6

-full head and neck -ability to raise arms and flex elbows (no extension) -some wrist extension

Mobility T1-T5

-generally independent in their wheelchair mobility -independent transfers (might need assistance with transfers because of lower extremity paralysis) -manual wheelchair (recommendations include a rigid or folding lightweight wheelchair) -may drive with hand controls

Rancho Los Amigos Scale Level VI What can the family do?

-help with starting and continuing activities -encourage participation in therapy

Postacute rehabilitation phase of TBI Contribute to behavioral and emotional adaptation

-increase self-awareness and coping skills

Medical management S1-S5

-independent in personal care -partial assistance for heavy-duty domestic care

Mobility C8

-independent transfers -electric wheelchair with hand controls -manual wheelchair for short distances -may drive with hand controls

Mobility T6-T12

-independent transfers -may use manual wheelchair ***may stand in standing frame or walk with braces -may drive with hand controls

Mobility L1-L5

-independent transfers -may use manual wheelchair ****may walk with braces -may drive with hand controls

Mobility C7

-independent transfers (shoulder depression, slide board) -electric wheelchair with hand controls -manual wheelchair for short distances -may drive with hand controls

Inpatient rehabilitation phase of TBI Contribute to behavioral and emotional adaptation:

-interventions focus on decreasing or mediating problem behaviors ● Environmental interventions: Agitated clients should be provided a quiet, isolated room without a roommate -assistive technology (e.g., wander guards) may be used if wandering or breach is suspected. -environmental cues are also useful in orienting the client to place and time. ● Interactive interventions: interventionists' speech should be calm, concise, and deliberate. -behavioral management programs may be necessary to promote appropriate behavior.

Postacute rehabilitation phase of TBI Optimize visual and visual-perceptual function

-interventions focus on environmental adaptations and strategies to compensate for deficits that remain

TBI

-is damage to the brain *open: penetration to the skull *closed: blunt external force

Overview of Rancho Los Amigos Scale Levels

-levels I-III: total assistance -levels IV-VI: confused (attention divided) -levels VII-VIII: automatic or purposeful (new learning, correct/modify behavior)

Movement C1-C4

-limited head and neck movement; tetraplegia

Nervous system C6

-little bowel or bladder control

Nervous system C7

-little bowel or bladder control

Nervous system C8

-little bowel or bladder control

Nervous system L1-L5

-little bowel or bladder control

Nervous system T1-T5

-little bowel or bladder control

Nervous system T6-T12

-little bowel or bladder control

Medical management C5

-low stamina, but breathing with diaphragm -complete assistance for personal and domestic care

Inpatient rehabilitation phase of TBI Optimize motor function

-motor learning -skill acquisition -exercise -ataxia: (without proper movement) uncoordinated and balance *ataxia may be treated through intervention focused on compensatory strategies for control, including weighting of body parts or use of weighted utensils and cups -apraxia: loss of motor function *apraxia may be treated with hand-over-hand exercise to repair damaged neural pathways. The client may also compensate by following steps depicted in pictures or written on a card

Glasgow Coma Scale (3) areas assessed

-motor responses (6) -verbal responses (5) -eye opening (4)

Inpatient rehabilitation phase of TBI Optimize visual-perceptual function

-neglect treated by encouraging the client to use the neglected side during functional activities -environmental adaptation (ie: moving the television or meal tray) -compensate by placing all objects in the field of vision to maximize success

Medical management L1-L5

-normal respiratory system -independent in personal care -partial assistance for heavy-duty domestic care

Movement T1-T5

-normal upper-extremity ROM and strength -arms unaffected

Movement T6-T12

-normal upper-extremity ROM and strength -core control

Movement L1-L5

-normal upper-extremity ROM and strength -partial paralysis in hips and legs *can start to get forward motion of leg: -hip flexion -knee extension -dorisflexion (kicking a soccer ball)

Evaluation of TBI

-occupational profile -motor functioning -vision and visual- perceptual skills -cognitive functioning -emotional regulation -context is evaluated for cultural, personal, temporal, and virtual demands, and physical and social environment is evaluated

TBI Interventions Postacute rehabilitation

-optimize cognitive function -optimize visual and visual-perceptual function -restore competence in self-maintenance roles -restore competence in leisure and social participation -restore competence in work -contribute to behavioral and emotional adaptation

TBI Interventions Inpatient rehabilitation

-optimize motor function -optimize visual abilities -optimize visual-perceptual function -optimize cognitive function -optimize voice and speech function -restore competence in self-maintenance tasks -contribute to behavioral and emotional adaptation -support family caregivers

Inpatient rehabilitation phase of TBI

-patients are generally at Rancho Level V and higher.

TBI Interventions Acute phase

-positioning -PROM -splinting and casting -sensory stimulation -management of agitation -family education

Stages of TBI

-primary: at the moment of injury -secondary: several days to weeks after injury

Rancho Los Amigos Scale Level IV What can family do?

-reassure them they are safe -bring in personal items and pictures -allow his as much safe movement as possible -give rest breaks -do familiar, calming activities -keep room quiet

Rancho Los Amigos Scale Level V What can the family do?

-repeat things -help them organize and get started on an activity

Medical management T6-T12

-respiration capacity and endurance may be compromised -independent in personal care -partial assistance for heavy-duty domestic care

Medical management T1-T5

-respiration capacity and endurance may be compromised -independent in personal care, feeding and eating -partial assistance for heavy-duty domestic care

Medical management C1-C4

-respiratory assistance required -complete assistance for personal and domestic care

SCI Pathophysiology

-results in tetraplegia (also referred to as quadriplegia or paraplegia) -is referred to in terms of the location of the lesion, identified using the letter and number of the specific cervical (C), thoracic (T), lumbar (L), or sacral (S) vertebra. -complete lesions result in the absence of motor and sensory function below the level of the injury. -incomplete lesions may involve a number of neurological segments, and sensorimotor function may be partially or completely intact. -zone of partial preservation refers to complete injuries that have some innervation of dermatomes below the level of injury. -The American Spinal Injury Association (2013) Standards for Neurological Classification of Spinal Cord Injury provide a method for assessing the neurological status of someone with SCI. -initial stages of SCI are called spinal shock and may last between 24 hours and 6 weeks. Reflex activity ceases below the level of the injury, resulting in spasticity.

Inpatient rehabilitation phase of TBI Optimize cognitive function

-self-awareness of deficits, attention, memory, and executive function through participation in functional activities -engagement in ADLs and IADLs allows the client to develop problem solving, planning, organization, concentration, frustration tolerance, sequencing, and categorization -compensatory approaches to address memory impairment

Postacute rehabilitation phase of TBI Restore competence in self-maintenance roles

-self-care and homemaking tasks -repetitive practice through errorless learning, fading cues, and positive encouragement

Postacute rehabilitation phase of TBI Restore competence in leisure and social participation

-social skills training groups -role-playing -self-reflection through video feedback -role modeling

Splinting and Casting in Acute Phase of TBI

-spasticity -ROM deficiencies -soft- tissue contractures -resting or functional position splint -cone splints(keep fingers from digging into palm) -antispasticity splints -elbow casts

Rancho Los Amigos Scale Levels VIII-X Purposeful/Appropriate

-standby assistance -is alert and oriented and able to re-call and integrate past and recent events -attend to and complete task (60 minutes) even with distracting environment -assistive memory devices-eg: lists Each level (VIII, IX, and X) represents a decreasing need for assistance with routine daily living skills.

Nervous system C1-C4

-sympathetic nervous system compromised -possible autonomic dysreflexia -no bowel or bladder control

Rancho Los Amigos Scale Level II Generalized response

-total assistance -exhibits inconsistent and nonpurposeful reactions to stimuli -responds to external stimuli with gross body movement -respond slowly, inconsistently or delay -person will being to respond to sound, sight, touch, movement -responses include chewing, sweating, breathing faster, moaning -demonstrates generalized reflex in response to pain

Rancho Los Amigos Scale Level I No respone

-total assistance -appears asleep -is completely unresponsive to any stimuli presented -person will not respond to sound, sight, touch or movement

SCI Etiology

-trauma *motor vehicle accidents *gunshot or stab wounds *falls *diving accidents -secondary to disease *tumors *myelomeningocele *MS *ALS

Positioning in Acute Phase of TBI

-w/c -bed *prevents skin breakdown *prevents joint and muscle deformity *inhibits primitive reflexes *increases sitting tolerance *improves respiration and swallowing ability *provides engagement

Modified Ashworth Scale

0: no increase in tone 1: slight increase in muscle tone 1+: slight increase in muscle tone 2: increase in muscle tone 3: considerable increase in muscle tone 4: rigid in flexion or extension

Rancho Los Amigos (OT Exam Prepper)

1232 NRCA -No response -Response -Confused -Appropriate "Good Luck Andy, Grace Is Not Always Pretty And Pink"

Glasgow Coma Scale Verbal responses (min score of 1, max score of 5)

1= no response 2=Incomprehensible sounds (ie: moaning) 3=inappropriate Words 4=Confused conversation but able to answer questions 5=Oriented to person, place, and time *Our Country WIN oriented, confused, words(inappropriate), incomprehensible sounds, nothing

Glasgow Coma Scale Eye opening (min score of 1, max score of 4)

1=No response 2=eyes open to Pain 3=eyes open to Speech 4=Eyes open on own, spontaneous *ESPN eyes open, speech, pain, nothing

Glasgow Coma Scale Motor responses (min score of 1, max score of 6)

1=no response 2=Extends to pain (decErebrate) 3=flexes to pain (decorticate) 4=pulls away from pain (ie: pinched) 5=purposeful movement to painful stimulus 6=obeys simple Commands when asked *Can't Live Without FANs commands, localizes pain, withdrawals from pain, flexion, extension, nothing

A goal for a client with traumatic brain injury is to be accurate with orientation to place and time. The client is at Rancho Level IV (i.e., with confusion and agitation). What intervention is appropriate to meet this goal? A. Have client use a logbook that provides a calendar with the current therapy session schedule B. Engage the client in a daily self-care routine of showering, dressing, and grooming C. Allow the client to guide intervention sessions by providing minimal structure to the sessions D. Organize an orientation group in which the client can share perceptions of orientation

A. A logbook allows a client to experience passive orientation provided by family or staff. Providing the current therapy schedule in the logbook may increase the client's awareness of timing. B: Providing a structured ADL routine produces stability in the client's daily routine but does not increase the client's awareness of orientation. C: The client is not yet able to self-direct intervention sessions; structure and routine are needed to minimize distraction and disorientation. D: Participating in a group activity to share perceptions is difficult for a client with traumatic brain injury who is disoriented. Group treatments may, however, be used to provide repetition of orientation information for rehearsal and awareness training.

During an initial screening with a client who had a recent TBI, the OTR® asks the client to arrange picture cards in an order that will tell a story. This client arranges the cards in an incorrect sequence. What action should the OTR® take based on the client's performance during this task? A. Further assess neurobehavioral skills and abilities. B. Select intervention tasks that require sequencing. C. Identify modifications for the client to use during self-care. D. Administer a standardized test of cognitive abilities.

A. Because the screening was based on a picture card sequencing task, gathering additional information on the client's neurobehavioral skills and abilities related to task performance would be most beneficial. B, C: The OTR® has not gathered enough data through the evaluation process to implement an intervention plan. D: The OTR® may decide that administering a cognitive assessment may be necessary; however, assessing the client's neurobehavioral skills and abilities will provide more essential information for establishing functional goals through the evaluation process and planning for intervention.

An OTR® working in an acute care hospital has completed the initial self-care evaluation with a patient who has had a recent TBI and is functioning at Level VI (Confused-Appropriate) on the Rancho Los Amigos scale. During grooming and hygiene tasks the patient is able to stand at the sink with stand-by assistance, is easily distracted and consistently requires verbal and tactile prompts. The OTR® observed that the patient put toothpaste on a washcloth when preparing to brush teeth and attempted to brush hair with a toothbrush. Additionally, the OTR® noted that the patient has minimal spontaneous functional movement of the left upper extremity and uses synergistic movements when asked to grasp and hold objects. What information about the patient is MOST IMPORTANT to document in the evaluation? A. Factors affecting performance B. Level of family interaction with the patient C. Projected time frame for recovery D. Scores from a standardized perceptual assessment ***Synergistic movement happens when you try to make one movement on your affected side, and you end up making multiple movements. For example, trying to move your affected arm might result in hand and shoulder movements too.

A. Documenting factors that affect performance is essential in the initial evaluation because it serves to support the need for occupational therapy services and establishes the areas to be addressed in the intervention plan.

An OTR®; is treating a client who is in a vegetative state after a traumatic brain injury (TBI). The OTR has identified the need to use restorative strategies with the client. Which restorative strategy is MOST appropriate for this client? A. Upright positioning strategies in a wheelchair to normalize muscle tone and facilitate arousal B. A sensory stimulation program to facilitate return to consciousness C. A self-feeding program that simplifies the task and provides success for the client D. A behavioral reinforcement program to reinforce the client's on-task performance

A. Positioning a client with TBI upright in a wheelchair provides optimal positioning to minimize abnormal tone and increase stimulation of the client's visual and vestibular systems. B: Sensory stimulation should be implemented on a case-by-case basis and is useful in supporting the client's emergence from coma. However, evidence supporting the effectiveness of sensory stimulation programs is not sufficient to warrant their use as a primary intervention

The movements of a client diagnosed with a TBI are exaggerated and oscillating. What term BEST describes the client's movements? A. Spasticity B. Ataxia C. Bradykinesia D. Tremor

B

a person with TBI has a score of 6 on the Glasgow Coma Scale. Which should the OT use to initiate intervention with this person? A. Demonstrated Directions B. Sensory Stimulation C. VC D. HOH

B.

An OTR® receives evaluation orders for a client who has recently experienced a traumatic brain injury. The client is swearing and anxiously looking for something. What Rancho Los Amigos level BEST corresponds with the client's behavior? A. VI B. IV C. V D. II

B. Because the client is confused and agitated, the behavior most closely resembles Level IV: confused-agitated. A: At Level VI, the client would, although confused, generally not be agitated. C: Although confusion and memory issues are profound at Level V, the client would generally not be behaving erratically. D: Level II implies low levels of activity and limited responses.

An OTR® working in an acute care hospital has completed the initial self-care evaluation with a patient who has had a recent TBI and is functioning at Level VI (Confused-Appropriate) on the Rancho Los Amigos scale. During grooming and hygiene tasks the patient is able to stand at the sink with stand-by assistance, is easily distracted and consistently requires verbal and tactile prompts. The OTR® observed that the patient put toothpaste on a washcloth when preparing to brush teeth and attempted to brush hair with a toothbrush. Additionally, the OTR® noted that the patient has minimal spontaneous functional movement of the left upper extremity and uses synergistic movements when asked to grasp and hold objects. Which neurobehavioral deficit is the patient exhibiting during grooming tasks? A. Constructional disorder B. Ideational apraxia C. Stereopsis D.Visual agnosia ***Synergistic movement happens when you try to make one movement on your affected side, and you end up making multiple movements. For example, trying to move your affected arm might result in hand and shoulder movements too.

B. Ideational apraxia involves a patient using an object improperly or using the wrong tool with the action that is required, such as putting toothpaste on the washcloth or brushing the hair with a toothbrush. A: Constructional disorder occurs when a patient has a deficit in organizing and assembling parts into a whole. C: Stereopsis occurs when a patient is unable to perceive depth in relation to self or other objects. D: Visual agnosia occurs when a patient cannot verbally identify objects from visual input.

An OTR® working in an acute care hospital has completed the initial self-care evaluation with a patient who has had a recent TBI and is functioning at Level VI (Confused-Appropriate) on the Rancho Los Amigos scale. During grooming and hygiene tasks the patient is able to stand at the sink with stand-by assistance, is easily distracted and consistently requires verbal and tactile prompts. The OTR® observed that the patient put toothpaste on a washcloth when preparing to brush teeth and attempted to brush hair with a toothbrush. Additionally, the OTR® noted that the patient has minimal spontaneous functional movement of the left upper extremity and uses synergistic movements when asked to grasp and hold objects. What additional information is MOST IMPORTANT to obtain as part of the initial evaluation in order to select intervention activities? A. Contexts for preferred leisure and social activities B. Performance skills displayed during activities of daily living C. Types of architectural barriers within the patient's home D. Upper-extremity strength based on a manual muscle test ***Synergistic movement happens when you try to make one movement on your affected side, and you end up making multiple movements. For example, trying to move your affected arm might result in hand and shoulder movements too.

B. Once occupational performance analysis has been initiated, identifying performance skills of the client during activities of daily living would be beneficial information to gather. A: Contextual information may be beneficial to further understand the client's occupational needs but is not the most important information to obtain. C: Home assessments are not a first priority when seeing patients in the acute care environment and are generally deferred until the inpatient rehabilitation setting. D: Manual muscle testing is not indicated given the information that was gathered in the initial self-care evaluation, and in this situation assessment of muscle tone over muscle strength is indicated.

Rancho Los Amigos Scale Level V Confused/Inappropriate Nonagitated

BB (sexist, racist, scrambled egg making guy) -max assistance -appears alert with fairly consistent reactions, although increased complexity of commands causes more random responses -person will be able to pay attention for few minutes -highly distractible, inability to focus on task without frequent cueing -brief conversation but may drift or become inappropriate -can respond to simple commands -step by step instructions -can perform self-care with strong supervision/cues (feeding, washing face) -needs repetitive tasks (repetitive brushing hair) -be confused and have difficulty making sense of things -displays severe memory impairment -not know the date, where they are and why they are there -not be able to start or complete everyday activities -will try to fill in gaps for memory by making things up -become overloaded and restless with too many people

An OTR® receives evaluation orders for a client who has recently experienced a traumatic brain injury. The client only opens the eyes when the OTR® applies a mild pinch to the client's arm. What score should the OTR® give the client on the Glasgow Coma Scale (eye-opening response category)? A. 7 B. 3 C. 2 D. 4

C

An OTR® receives evaluation orders for a client who has recently experienced traumatic brain injury. The client displays severe memory impairment and can only respond to simple commands without being distracted. What Rancho Los Amigos level BEST corresponds with the client's behavior? A. VII B. III C. V D. II

C. Because the client is highly distractible and displays severe memory impairment but can respond to simple commands, the client most closely resembles Level V. A: A Level VII client has limited distractibility and is capable of carrying out a intelligible conversation despite minimal confusion. B: A Level III client inconsistently responds to stimuli and would not be capable of intelligibly responding to simple commands. D: A Level II client responds to stimuli only through physiological changes, gross body movement, or vocalization.

The extremities of a client with brain injury in an acute care unit are in a position of spastic extension, adduction, and internal rotation. The client is displaying symptoms of which condition? A. Decorticate rigidity B. Torticollis C. Decerebrate rigidity D. Athetosis

C. Decerebrate rigidity involves the client's lower and upper extremities in a position of spastic extension, adduction, and internal rotation A: Decorticate rigidity involves upper extremities in spastic flexed position with internal rotation and adduction and the lower extremities in spastic extended position with internal rotation and adduction. B: Torticollis is a dystonic posture of the neck. D: Athetosis involves slow movements of the face, tongue, or limbs.

An OTR®; is providing dressing skills training for a client with traumatic brain injury (TBI). The client has a sequencing deficit and continually places underwear over pants and socks over shoes. What strategy is appropriate for the OTR to use with this client? A. Use picture cards of dressing and have the client put the steps of dressing in order B. Have the client write out the steps in dressing using paper and pencil C. Hand the client each item of clothing and provide assistance in donning the item D. Ask the client which clothing item should be selected next

C. Minimizing environmental distractions and decreasing the complexity of the task will allow the client to experience success in completing one step of the task at a time. A, B: Tabletop activities will not generalize or transfer to the client's ability to dress successfully. D: Asking the client questions about which step of the task comes next may present too great a challenge and increase the client's frustration.

An OTR® working in an acute care hospital has completed the initial self-care evaluation with a patient who has had a recent TBI and is functioning at Level VI (Confused-Appropriate) on the Rancho Los Amigos scale. During grooming and hygiene tasks the patient is able to stand at the sink with stand-by assistance, is easily distracted and consistently requires verbal and tactile prompts. The OTR® observed that the patient put toothpaste on a washcloth when preparing to brush teeth and attempted to brush hair with a toothbrush. Additionally, the OTR® noted that the patient has minimal spontaneous functional movement of the left upper extremity and uses synergistic movements when asked to grasp and hold objects. Which recommendation should the OTR® provide nursing staff to maximize this patient's independence with BADLs? A. Encourage the patient to select items needed for each task. B. Provide multisensory cues for locating self-care items. C. Provide task setup and simple instructions. D. Use hand-over-hand assistance during dressing. ***Synergistic movement happens when you try to make one movement on your affected side, and you end up making multiple movements. For example, trying to move your affected arm might result in hand and shoulder movements too.

C. Providing task setup and simple instructions allows for the appropriate tools to be used for the desired activity, and the simple instructions allow for guided support in task completion. A: The patient is demonstrating ideational apraxia and will be unable to select items needed for tasks. B: Use of multisensory cues is not appropriate for a patient at the Level VI Confused-Appropriate functional ability, because too much sensory information may overwhelm the patient. D: Providing hand-over-hand assistance does not provide appropriate support for apraxic motor perception disorder, which benefits more from repetitive active basic motor sequences.

An inpatient had a traumatic brain injury several days ago. The OTR® is completing an initial mobility screening with the patient. When assisting the patient to move from supine to sit, the patient's body moves into an extensor thrust pattern. This interferes with the patient's ability to move independently to upright sitting. Which primitive motor response is inhibiting this bed mobility skill? A. Associated reaction B. Asymmetrical tonic neck reflex C. Optical righting reflex D. Tonic labyrinthine reflex

D. Tonic labyrinthine reflex is a response that results in extensor tone while in supine. A: Associated reactions occur when a motion in one extremity is copied in the opposite extremity. B: Asymmetrical tonic neck reflex occurs when the head is turned to one side and the arm on the skull side flexes while the arm on the face side extends. C: Optical righting reflex occurs when the head is unable to align with a horizontal object from a starting position of lateral head flexion.

A client with traumatic brain injury is displaying decorticate rigidity. How would the client's upper-extremity position BEST be described? A. Flaccid and extended, with internal rotation and adduction B. Spastic and flexed, with external rotation and abduction C. Flaccid and flexed, with external rotation and abduction D. Spastic and flexed, with internal rotation and adduction

D. Upper extremities in decorticate rigidity are spastic and flexed, with internal rotation and adduction

Rancho Los Amigos Scale Level VI Confused/Appropriate

G (yoga guy) -moderate assistance -exhibits goal-directed behavior but is dependent on external input for direction -person will be somewhat confused, they will remember the main points from a conversation but forget or confuse details -follows schedule with assistance for routine -confused if routine changes -can initiate new learning -pay attention for 30 minutes but has trouble concentrating when it is noisy or too many steps -can do meal prep (make a sandwich) CUES!!!!

Rancho Los Amigos Scale Level VII Automatic/Appropriate

HP (deviled egg guy, banker guy) -minimal assistance -can do new learning with assistance -behaves appropriately and is oriented to place and routine but frequently displays shallow recall -follow a set schedule -will be able to do self care without help -have planning problems, starting and following through -trouble with attention in distracting or stressful situations -not realize how thinking and memory problems may affect future plans and goals -lack insight to into condition -still unrealistic -judgement impaired, decreased safety awareness -unaware of how others feel, unaware of social roles -capable of carrying out a intelligible conversation despite minimal confusion. -community re-entry activities (taking bus)

Rancho Los Amigos Scale Level III Localized response

LEROY (fatigued, look at the cup) -total assistance -reacts specifically to stimuli though inconsistently -reacts more specifically to what they see and feel (ex: turn toward a sound, withdraw from pain) -reacts slow and inconsistently -begin to recognize family and friends -follow simple directions such as "squeeze my hand" "look at me" -responds inconsistently to question with "yes" or "no" -not be capable of intelligibly responding to simple commands. -person will be awake on and off -make more movements

Rancho Los Amigos Scale Level IV Confused/Agitated

QUAI (GTFOM guy) max assistance -has heightened state of activity with severely decreased ability to process information -aggressive behaviors -may initiate gross mobility but not under direction or with purpose -person will be confused and frightened -not understand what they feel or what is happening -overreact to what they see, hear or feel -cry or scream out -restrained so they don't hurt themselves -highly focused on basic need (eating, going back to bed, going home) -not pay attention or concentrate for only a few seconds -difficulty following directions -recognize family and friends at times -with help they can do simple routine activities such as feeding, dressing. -alert and heightened state, don't know where you are or why you are there, don't recognize people, don't know the time

Decerebrate rigidity posturing

UE/LE: -spastic extension -internal rotation -adduction

Decorticate rigidity posturing

UE: -spastic flexed -internal rotation -adduction LE: -spastic extended -internal rotation -adduction

An OTR® receives evaluation orders for a client who has recently experienced traumatic brain injury. The client's chart lists a Glasgow Coma Scale (GCS) score of 7. What does this score imply? A. The client has experienced a severe head injury and will provide minimal feedback. B. The client has experienced a moderate head injury and may not be able to provide discernible feedback. C. The client has experienced a mild head injury and may be confused but able to follow simple commands. D. The client has experienced an extreme head injury and will provide minimal feedback.

severe head injuries include GCS scores of 8 or less.

Inpatient rehabilitation phase of TBI Restore competence in self-maintenance tasks

● Dysphagia and feeding: feeding instruction may begin in an isolated and quiet area to prevent distraction and then be graded to include social situations. -adaptive equipment used may include rocker knife, plate guard, and nonspill mug. -impulsivity may be controlled by requiring the client to place the fork down after each bite to ensure that a full chew-and-swallow routine is completed. ● Bed mobility: training in bed mobility skills progresses from scooting up and down in bed to rolling, bridging, and moving from and to supine and from and to sitting and standing positions. ● Wheelchair management: pelvic and trunk alignment is supported through proper positioning and adaptive supports. Wheelchair management also includes management of wheelchair parts and ability to functionally propel wheelchair. ● Functional ambulation: high-level activities are provided, including those involving both lower and upper extremities such as advanced IADLs (e.g., sweeping, raking, child rearing). -compensatory devices include walkers with bags and baskets, canes, and reachers. ● Community mobility: The ability to negotiate the community environment is client dependent. -electric scooters or wheelchairs may be recommended to assist clients with extended mobility requirements. . ● Transfers: memory impairments and carryover difficulties necessitate consistent transfer training among all care providers. -family members should also be trained to promote consistency. ● Home management: the degree of assistance required is client dependent. Some clients can prepare simple meals in a microwave, and others are able to perform higher-level activities including meal planning and budgeting. ● Community reintegration: reintegration can be accomplished through community trips to practice IADLs in natural environments.