traumatic brain injury

definition

alteration in brain function or other brain patho caused by external force
characterized by: LOC at scene, possible seizure, gradual progression through stages of recovery, recovery may not be complete

etiology

MVA, falls, assaults, violence, sports and recreation

epidemiology

leading cause mortality children and young adults
men > women, 15-24 yrs and >75 yrs

sympathetic storm

paroxysmal sympathetic hyperactivity
1/3 of pts in ICU, pts in a coma
dysfunction of diencephalon or connections from diencephalon that mediate autonomic function
noxious stimuli may trigger, may persist weeks or months, negative prognostic indicator

sympathetic storm s/s

intermittent agitation, diaphoresis, hyperthermia, HTN, tachycardia, tachypnea, extensor posturing

TBI s/s

related to area of damage
decreased level of consciousness stages, cognitive deficits, communication, behavioral, sensorimotor, balance, vestibular, visual

coma

last only a few weeks

unresponsive wakefulness

rancho II, indicates brainstem function
characterized by: eye opening with sleep-wake cycles, normal vitals and digestion, ability to track with eyes, non-stereotypical mvmt, limited awareness
if remain >1 yr: persistent vegetative state

minimally conscious state

rancho III, indicates brainstem and frontal and parietal function
characterized by increasing awareness self and surrounds, follow commands, communicate (yes/no questions inconsistently), track visually/visual fixation, orient to sound

emerging

post traumatic confusional state (rancho IV and V), emergence from disorder of consciousness

cognitive deficits

learning disorder, memory deficits, problems with complex info processing, inability to attend, inability to limit distractions, short attention span, inability to plan and execute, agitation, lack of interest/apathy, inability to follow multi-step directions

communication deficits

receptive or expressive aphasia, swallowing deficits

behavioral deficits

sexual disinhibition, apathy, confabulation, wandering, aggression, low frustration tolerance, lack of motivation, depression

sensorimotor deficits

where PT has most impact, same as other CNS injury
hemiparesis, bilat paresis (coup-contrecoup), increased reaction time, general deconditioning from long hospital stay, balance deficits, increased tone, ataxia/incoordination

balance deficits

low level will have problems with sitting without support
increased sway, slower weight shifting, worse with visual deprivation, use posturography

vestibular deficits

dizziness, BPPV, difficulty with target following, dynamic visual acuity, and gaze stabilization

ADL and mobility deficits

may vary depending on severity and amount of recovery, typical deficits observed with particular lesion location

common gait patterns

unilat: spastic or nonspastic hemiparesis, ataxia/dyspraxia
bilat: spastic or nonspastic bilat paresis, ataxia/dyspraxia

visual disturbances

anomalies of accommodation, version, vergence, photosensitivity, visual field integrity, ocular health
prism glasses for visual field loss

headaches

usually resolves within 6 months
cervicogenic or secondary HA

somatic pain

pain may be present

TBI secondary impairments

seizures, DVT, pressure ulcers, pneumonia, chronic pain, contractures, decreased endurance, muscle atrophy, fx, peripheral nerve damage

medical dx

determined by HPI, neuro exam, GCS, imaging

medical/surgical interventions

determine brain death (cerebrum: lack of response to pain, brainstem: absent reflexes)

irreversible loss of activity

cause of coma established, no possibility of recovery brain function, cessation function persists appropriate period of time

interventions for increased ICP

ICP bolt or shunt
normal is 15 mmHg, 5.9-8.3 upright
if increased ICP raise HOB
PROM decreases, AROM no change, isometrics increase if ICP elevated

surgical interventions for increased ICP

craniotomy or craniectomy (helmet for mobility)

body temp regulation

hypothermia for 24 hr period soon after onset results in better outcomes, hyperthermia deleterious

medical interventions for behavior/cognition

sedation is a concern
bromocriptine and amantadine may be beneficial

medical interventions spasticity

acute: oral baclofen
chronic: intrathecal infusion baclofen

PT exam Rancho I-III

SBP >90 and O2 sats above 90%
cotreat with OT
little ability to interact with environment
evaluate PROM, spontaneous activity, response to stimulation, reflexes, gross motor skills
voluntary initiation 1st sign emergence
early bed mobility and transfers most likely max assist

PT intervention Rancho I-III

sensory input stimulates reticular formation, vertical positioning increases arousal and awareness, early mobilization

ROM Rancho I-III

often develop contractures from spastic hypertonia, improper positioning, inadequate ROM
all major joints susceptible, PF most common
mobilize scapula
check skin integrity
PROM, prolonged stretching, casts, positioning, splints, tilt table, meds, cryotherapy, nerve motor block points, estim TA

Ranchos I-III splint/cast

to decrease risk of PF
positioning splint
short leg cast: more fixed to maintain stretch PFs, best if knee flexed
bi-valved short leg cast: cut to check for skin integrity, cut at achilles and stick wedge in for increased DF to increase longevity

Rancho I-III sensory stimulation

repeated stimulation in controlled multisensory manner with intermittent rest
short, frequent intervals
e-stim, auditory, visual, olfactory, gustatory, tactile, vestibular
document response: deep coma will be cardiopulm response, medium should result in increased head and eye mvmt and spontaneous mvmt

Ranchos I-III positioning

change position to assist with pulmonary hygiene (post lower lobe prone to pneumonia), ROM, skin integrity
change position every 2 hours, at end of session
transfer to w/c or recliner as soon as medically stable, OOB orders from physician in acute

Ranchos I-III physical activity

increase cardiovascular demands, help emerge

Ranchos I-III family ed

general process of recovery stages, POC and family participation, educate that pt can hear, assisting with PROM/positional changes, reflexive vs voluntary mvmt

Ranchos IV

confused and agitated, have emerged from comatose state
may use agitated behavior scale or moss attention rating scale
start working on functional activities, work within abilities, familiar skills, treat in quiet area
won’t have carryover

caution Rancho IV

leave door open, position between pt and door, step away if aggressive, ensure pt safety if safe to do so
may have video monitor, sitter, modified bed, bed alarm, be on locked unit

PT preparation for Rancho IV

model calm behavior, have longer plan than normal - if go through start again, offer a few options to give control but not confuse

working with Rancho IV

expect egocentricity, if become too irritable leave room and come back in a few minutes, redirect inappropriate behaviors, implement reward system

characteristics of Rancho V-VI

patients are confused, inappropriate behaviors may be present, follow commands well but may not be able to think for self, new learning difficult

intervention guidelines Rancho V-VI

maintain structure, emphasize safety, keep instructions to a min, use props, limit distractions, have them double check work, positive reinforcement, repeat instructions to self

evidence for interventions Ranchos V-VI

intensive task oriented training, implement BWS training, CIMT, use HiMAT tasks and progress difficulty, strengthening exercise parameters

Ranchos VII-VIII

reintegration into society, decrease structure and supervision
go to busy environments and see if they can navigate, vocational rehab, driving assessment

PT considerations Ranchos VII-VIII

high level balance activities, ballistic mvmt, quality of mvmt, running, aerobic endurance, assess fatigue psych vs physio, dual tasking

documentation

write goals for supervision PRN
make sure cognition, self-control, coordination good before recommending power w/c

motor learning principles

learning will take longer, blocked practice especially early on, distributed practice, high reps

expected outcomes

physical recovery often before cognitive and behavioral, rehab can benefit all 3
can range from persistent vegetative state to no deficits

long term risk of developing

alzheimer’s, PD, frontotemporal dementia, CTE, depression, anxiety
decreased life expectancy by 4 years

post traumatic amnesia

period where pt will not be able to remember events within a day or between days, chronological “dense” fog, ability for cognitive learning is lost but ability for motor learning may be intact
<53 days likely to live w/o assistance, <27 days likely to be employed

inebriation at time of accident

some neuroprotection from ETOH in pts experiencing TBI at least in regards to mortality

premorbid persona

those who live recklessly more susceptible to TBI

additional effects of trauma

fx, abdominal injuries, SCI

other prognostic indicators

age, premorbid/comorbid health conditions, medical complications, support system, access to resources, timeframe for transition from one stage of recovery to next

outcome studies

therapy intensity predictive of motor functioning but not cognitive gain
older pts improve slower and have longer LOS
severity of injury matters for functional status but not emotional or QOL measures
greater likelihood getting back to ADLs more than IADLs and recreation
length impaired consciousness, GCS and Rancho are good predictors

outcome/participation measures

mayo-portland adaptability inventory, community integration questionnaire, participation assessment with recombined tools, QOL after brain injury, DHI, CHART

glasgow outcome scale

most common outcome measure
high score is good outcome, low is bad

predictors of employment post TBI

age, injury severity, severity cognitive/behavioral impairments, preinjury employment, hospital LOS

strongest independent risk factors for death >1 yr post injury

being older, male, less education, longer hospitalization, many years post-injury, unresponsive or minimally conscious at rehab d/c
more likely to die of aspiration pneumonia, seizures