Understanding Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI)

Damage to brain tissue caused by an external mechanical force resulting in loss of consciousness, posttraumatic amnesia, and skull fracture or objective neurological findings.

Falls and TBI

Account for the majority of TBI ER visits, especially common in older adults

Suicide and TBI

Leading cause of TBI-related deaths, especially in the 15-24 age group

Closed Brain Injury

Injury caused by brain movement within the skull, often from falls, car crashes, or blunt force

Penetrating Brain Injury

Injury caused by a foreign object entering the skull, such as firearm injuries

Drug overdose and TBI

Including recreational and prescribed drugs, chronic substance use, and alcoholism

Substance Use and TBI

Highly associated with TBI

- with over 50% of adults with TBI having used substance near the time of injury

- drug overdose most common cause of trauma

Post-traumatic amnesia (PTA) duration levels

Mild: <1 hour, Moderate: 1-24 hours, Severe: 1-7 days, Very severe: 1-4 weeks, Extremely severe: >4 weeks

Decorticate Posturing

Abnormal posture with upper extremities in a spastic, flexed position and lower extremities in a spastic extended position

Decerebrate Posturing

Abnormal posture with both upper and lower extremities in extension, adduction, and internal rotation

Retrograde Amnesia

Inability to remember events prior to injury due to neurological damage

Anterograde Amnesia

Inability to consolidate new information following impact or injury

Length of Post-traumatic Amnesia (PTA)

Time after injury when day-to-day recall returns and full orientation is present, classified as mild, moderate, severe, very severe, or extremely severe

- can refer to anterograde or retrograde subtype)

Secondary Medical Issues in TBI

Including orthopedic weight bearing status

pulmonary- may affect upright tolerance or endurance

decubitus/pressure ulcers

combo injuries like SCI/TBI

Predictors of TBI outcomes

Factors such as age, lifestyle, social support, drug/alcohol use, and length of coma/PTA

Rehabilitation Team for TBI

Includes MDs specializing in physical medicine and rehabilitation, RNs, therapists, case managers, and psychologists

Occupational Therapy Areas in TBI

Covering activities like eating, grooming, bathing, dressing, toileting, and transfers

-splinting

-neuromuscular re-education

-cognitive retraining

-participating in self-care (ADLs)

-bed positioning, transfers, and mobility (w/c)

-caregiver training

-home evaluation

Glasgow Coma Scale (GCS)

Clinical tool to assess coma severity and impaired consciousness

3-8 severe

9-12 moderate

13-15 mild

GCS scoring

Eye opening

Best motor response

Verbal performance

E+M+V= score

3 is lowest, 15 highest possible score

Cognitive Retraining in TBI

Therapeutic approach to improve cognitive functions affected by TBI

Community Skills Training in TBI

Rehabilitation focused on preparing TBI patients for independent living and community integration

Trauma Care System for TBI

Organized trauma care essential for TBI patients, with specific criteria for monitoring and treatment

Eye Opening (E)

Part of the Glasgow Coma Scale measuring the patient's response to stimuli, with scores ranging from 1 (no response) to 4 (spontaneous).

Best Motor Response (M)

Component of the Glasgow Coma Scale evaluating the patient's motor function, with scores from 1 (no response) to 6 (obeys commands).

Verbal Response (V)

Part of the Glasgow Coma Scale measuring the patient's verbal output.

Oriented-5

Confused- 4

Inappropriate-3

Incomplete sounds-2

Nil-1

Spontaneous

A score of 4 on the Glasgow Coma Scale, indicating the patient opens their eyes without stimulation.

Obeys

A score of 6 on the Glasgow Coma Scale, denoting the patient follows commands.

Localizes

A score of 5 on the Glasgow Coma Scale, showing the patient moves towards a noxious stimulus.

To pain

A score of 2 on the Glasgow Coma Scale, where the patient responds to pain.

Nil

A score of 1 on the Glasgow Coma Scale, indicating no response.

Abnormal flexion

Also known as decorticate posturing, a score of 3 on the Glasgow Coma Scale.

Extensor response

A score of 2 on the Glasgow Coma Scale, indicating extension in response to pain.

Oriented

A score of 5 on the Glasgow Coma Scale, where the patient is aware of person, place, and time.

Confused conversation

A score of 4 on the Glasgow Coma Scale, showing disorientation in conversation.

Inappropriate words

A score of 3 on the Glasgow Coma Scale, where the patient speaks inappropriately.

Incomprehensible sounds

A score of 2 on the Glasgow Coma Scale, with unintelligible vocalizations.

Measures cognitive level

Assessment tool post-injury to determine cognitive status for treatment planning.

GOAT score

Glasgow Outcome Assessment Tool score, with lower scores indicating longer post-traumatic amnesia.

-longer the confused state, the more difficult for the patient to return to pre-injury cognitive levels

Persistent Vegetative State (PVS)

Describes a state of wakefulness without awareness, with permanent PVS after specific timeframes post-injury.

Rancho Los Amigos Scale (RLA) of cognitive functioning

Rehab evaluation tool

Focuses on clients abilities and behaviors

Clients move through the stages during recovery process

RLA I

Coma- A state of unarousable unconsciousness with no response to stimuli

No periods of wakefulness

Rarely lasts more than 3-4 weeks unless medically induced

RLA II

Awake but unaware

No awareness of self or environment

Positives: sleep cycles, autonomic functions

RLA III

Some to total awareness with wakefulness

Follows commands, responds to questions

Appropriate responses (crying, laughing, smiling)

Reach/hold objects

Visual tracking

W/C positioning Goals for RLA 1-3

Prevent deformity

Tone normalization

Pressure management

Promote function

Increase sitting tolerance

When do you cast?

-splinting has failed to control severe tone or contractures from developing

-positional cast is necessary for continued use

-ROMis decreased and prolonged stretches necessary

Consequences of lack of intervention

Contractures

Limited head and trunk control

Increased caregiver assistance

Limited participation in daily occupations, limited mobility

Transportation difficulties

RLA IV

Alert and heightened level of activity

Attempt to remove tubes, restraints, OOB

Absent short-term memory

Cry or scream out of proportion

Aggressive behavior

Mood swings

Require max A

behavior management RLA IV

Minimize restrictive modalities

Educate parents, staff

Identify substance use disorders to provide specialized treatment

RLA IV environment changes

For behavior management:

-decrease sounds and visual stimulation

- reduced noise

- provide consistent and structure

Behavior Management Interventions

Model behaviors

Speak calmly, slowly, simple sentences

Do not restrain if patient wants to walk

Redirect

Provide choices

RLA V

Alert not agitated

Not oriented

Unable to learn new material

Consistent responses

Can converse briefly

Verbalizations about present events often inappropriate and confused

Requires max A

RLA VI

confused, appropriate, mod assist

Sometimes oriented

Shows carry over for familiar tasks (self-care)

Unaware of impairments, disabilities, safety risks

RLA VII

automatic, appropriate

Consistently oriented

Increased attention (30 min)

Initiates familiar tasks

Overestimated abilities

Does not think about consequences

Unaware of others needs/feelings

Requires Min A for ADLs

RLA VIII

Purposeful, Appropriate

Attention 60 min

Requires A for new tasks

Thinks about consequences

Irritable and depressed

Acknowledge others needs/feelings

Requires SBA

Contractures

Permanent shortening of muscles or tendons restricting movement.

Automatic / Purposeful

Stage of the recovery process where the patient's responses become more purposeful and appropriate.

Environment

Creating a setting with reduced stimulation and structured routines.

Alert but not agitated

A state of consciousness with attention but lack of orientation.