Functional and Cognitive Outcomes After Traumatic Brain Injury

Ranchos Los Amigos Revised Scale: level 1

No Response + Total Assistance

Ranchos Los Amigos Revised Scale: level 2

Generalized Response + Total Assistance

Ranchos Los Amigos Revised Scale: level 3

Localized Response + Total Assistance

Ranchos Los Amigos Revised Scale: level 4

Confused/ Agitated + Maximal Assistance

Ranchos Los Amigos Revised Scale: level 5

Confused, Inappropriate Non-Agitated + Maximal Assistance

Ranchos Los Amigos Revised Scale: level 6

Confused, Appropriate + Moderate Assistance

Ranchos Los Amigos Revised Scale: level 7

Automatic, Appropriate + Minimal Assistance for Daily Living Skills

Ranchos Los Amigos Revised Scale: level 8

Purposeful, Appropriate + Stand By Assistance

Ranchos Los Amigos Revised Scale: level 9

Purposeful, Appropriate + Stand By Assistance on Request

Ranchos Los Amigos Revised Scale: level 10

Purposeful, Appropriate + Modified Independent 

how do we define Ranchos Level I- No Response- Coma

"...a state of pathologic unconsciousness in which the eyes remain closed and the patient cannot be aroused. The defining feature of coma is the complete loss of spontaneous or stimulus-induced arousal."

What is the hallmark sign of level 1 on the Ranchos scale indicating coma

No evidence of sleep/wake cycles on EEG

What are the characteristics of Ranchos level 1: Coma

- No evidence of sleep/wake cycles on EEG

- Behavioral responses consist of reflex activity (Pupil, corneal, pain)

- Signals loss of function of cortex and reticular systems

- Rarely lasts longer than 2-4 weeks

How do we define Ranchos Level II - Generalized Response - Vegetative State

"...a condition in which there is no sign of consciousness, awareness of self or environment, with complete absence of purposeful behavior, although the capacity for spontaneous or stimulus-induced arousal is preserved."

What is the key characteristic of Ranchos Level II - Generalized Response - Vegetative State

No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to any type of stimulus

In Ranchos Level II - Generalized Response - Vegetative State, the patient presents with no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to what types of stimuli

- visual

- auditory

- tactile

- noxious stimuli

What is the primary difference between Ranchos Level 1 and Ranchos Level 2?

Sleep wake cycle comes back but they are not responsive

What is the Hallmark sign of Ranchos level 2

Intermittent wakefulness manifested by the presence of sleep-wake cycles

What is the patient presentation for Ranchos Level II - Generalized Response - Vegetative State

- No evidence of language comprehension or expression

- Intermittent wakefulness manifested by the presence of sleep-wake cycles

- Sufficient preservation of autonomic functions to permit survival with adequate medical care

- Bowel and bladder incontinence

- Variable preservation of cranial nerve and spinal reflexes

- Vegetative states

What are the classifications of Vegetative states under Ranchos Level II - Generalized Response - Vegetative State

- Persistent: >1 month after injury

- Permanent: >3 months after injury

What does a persistent vegetative state entail

>1 month after injury

What does a permanent vegetative state entail

>3 months after injury

How do we define Ranchos Level III - Localized Response - Minimally Conscious State

"...a condition of severely altered consciousness in which there is minimal, but definite behavioral evidence of self or environmental awareness."

What are key points on differentiating Ranchos level 3 Localized Response - Minimally Conscious State from Ranchos level 1 and 2

- Differs from coma and VS by presence of specific behavioral manifestations of consciousness

- Behaviors occur inconsistently, but can be differentiated from reflexive and random, spontaneous behavior

What are the criteria for being classified as Ranchos Level III - Localized Response - Minimally Conscious State

- Simple command following

- Gestured or verbal yes/no responses

- Intelligible verbalization

- Movements or affective behaviors that occur in contingent relation to relevant environmental stimuli and are not attributable to reflexive activity

What are examples of actions that patients who classify as Ranchos Level III - Localized Response - Minimally Conscious State should be able to perform

- Episodes of crying, smiling, or laughing in response to the linguistic or visual content or emotional stimuli

- Vocalizations or gestures that occur in direct response to the linguistic content of comments or questions

- Reaching for objects that demonstrates a clear relationship between object location and duration of reach

- Touching or holding objects in a manner that accommodates the size and shape of the object

- Pursuit eye movement or sustained fixation that occurs in direct response to moving or salient stimuli

What are the criteria for defining a vegetative state

Eye opening and reflexes

What are the criteria for defining a minimally conscious state

Voluntary movements on commands

What are the criteria for defining an emergence state (i.e. moving out of the first 3 levels of the Ranchos scale)

Consistent communication or Functional object use

What is the prognosis and expected outcomes of survival for patients in a vegetative state

Overall life expectancy is shortened in VS

for patients who present in a vegetative state what are the key predictors for returning to consciousness

- Time post-injury

- Current functional level

- Rate of functional change

What are key points about prognosis and outcomes for patients in a vegetative state

- No temporal cutoff

- No point at which consciousness cannot return

- Odds are better for children than adults

- Traumatic injuries vs. anoxic or vascular events

What are common complications that can occur following a severe TBI

- Elevated ICP

- Hydrocephalus

- Seizures

- Sympathetic storming

- Critical illness polyneuropathy (CIP)

- Heterotopic ossification (HO)

What are common complications that can occur following a severe TBI that are more pertinent to PT

- Sympathetic storming

- Critical illness polyneuropathy (CIP)

- Heterotopic ossification (HO)

What is Sympathetic storming

Autonomic dysregulation from loss of cortical control

How long can sympathetic storming last

Can persist weeks to months

What are the symptoms associated with Sympathetic Storming

- Diaphoresis

- Hyperthermia

- Hypertension

- Tachycardia

- Tachypnea

- Extensor posturing

- Pupillary dilation

What does the treatment for Sympathetic Storming entail

- Medication management

- Minimize complications that trigger symptoms

TRUE or FALSE: Sympathetic Storming is associated with longer hospital LOS and poorer outcomes following TBI

True

What is Critical Illness Polyneuropathy

Distal axonal sensory-motor polyneuropathy affecting limb and respiratory muscles

What are key points about Critical Illness Polyneuropathy

- Proximal musculature can be affected but is less common

- Affects critically ill patients (multiorgan dysfunction and failure)

- Early rehabilitation is beneficial

What is Heterotopic Ossification

Formation of bone in extra skeletal sites such as soft tissues and joints

What are common sites for the formation of Heterotopic Ossification

Most common in hips, shoulders, elbows, knees

What is the incidence of Heterotopic Ossification in patients with TBI

20%

What are risk factors of Heterotopic Ossification associated with TBI

Risk increased by length of coma and ventilation, surgical fixation of fractures, and spasticity

What are signs/symptoms associated with Heterotopic Ossification

- Stiffness

- limited ROM

- edema

- erythema

- pain

What does treatment of Heterotopic Ossification entail

- Treated with medication, surgical resection

- Always refer for this since it cannot be managed through PT

What do Disorders of Consciousness Programs provide

- Patient-specific measures that are relevant and sensitive

- Collection of data to overcome variability and sampling errors

- Objective measures and statistical analysis to overcome clinician bias/memory limits

What is the purpose of Disorders of Consciousness Programs

- Evaluate low-level patients to determine: Level of consciousness, Sensory functions, and Command following

- Evaluation focuses on change over time

What are common complications that can appear during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Cognitive impairments

- Seizures

- Neuropsychiatric disorders

- Post-traumatic agitation

- Post-traumatic amnesia

- Post-traumatic neuroendocrine disorders

- Visual impairments

- Hydrocephalus

- Spasticity

What are common cognitive changes that can appear during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Decreased attention

- Confusion/confabulation

- Disorientation

- Impaired arousal and awareness

- Decreased memory (Particularly working memory)

- Slowed processing speed

- Impaired executive function

- Poor insight and judgement

What are common Neuropsychiatric Disorders that can present from Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Major Depression

- Anxiety

- Posttraumatic Stress Disorder

- Psychosis

- Paranoia

- Pseudobulbar Affect

- Aggression

What are key points about Major Depression seen during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Most common mood disorder associated with TBI

- Prevalence range from 6% - 90%

- Premorbid depression associated with depression post injury

What are key points about Anxiety seen during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Second most common disorder behind depression

- Associated with cognitive fatigue

- Selective serotonin reuptake inhibitors (SSRIs) can be effective in patients with TBI

What are key points about PTSD seen during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Increased severity of injury may be protective against this

- Patients with TBI do not need to recall the event to develop this condition

What are key points about Psychosis seen during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Ensure not caused by medication side effects (amantadine)

- Can be well managed with atypical antipsychotics

- Avoid typical antipsychotics caused by dopamine-depleting properties

What are key points about Paranoia seen during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Associated with PTA

- Commonly persists long term after TBI

- Reports of success with atypical antipsychotics

What are key points about Pseudobulbar Affects seen during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Characterized by inappropriate emotional response, such as random outbursts of laughing/crying

- Treatment options include dextromethorphan HBr and quinidine sulfate, SSRIs, tricyclic antidepressants (TCAs)

What are key points about Aggression seen during Emerging Traumatic Brain Injury (Ranchos levels 4, 5, and 6)

- Associated with emergence from PTA but can present at any time after TBI

- Multimodal management with behavioral, environmental, and

medication strategies

- Beta-blockers, mood stabilizers, SSRIs, and atypical antipsychotics are medications most often used

What are the characteristics of Ranchos Level IV - Confused/Agitated

- Heightened activity state

- Bizarre, non-purposeful, agitated behavior

- Verbalizations are often incoherent or inappropriate

- Very short attention span

- Absent short-term memory and severely impaired long-term recall

What is Post-Traumatic Agitation

Aggressive behavior, disinhibition, and/or emotional lability

TRUE or FALSE: Post-Traumatic Agitation is common in the acute phase following TBI and can persist long term

True

What are some Strategies to reduce agitation in TBI patients

- Pharmacological management

- Low stimulation

- Perform familiar but simple tasks

- Change activities frequently

- Use of an enclosed bed

- One to one observation

What is the benefit of using the Agitated Behavioral Scale for TBI patients?

Serves as a way to track a person's behaviors and what triggers them in order to create a management plan

What are management strategies for Aggressive patients following TBI

- Maintain a safe distance, avoid physical force, and stay calm

- Utilize a low-stimulation environment

What are management strategies for Distractibility in patients following TBI

- Utilize a low-stimulation environment

- Identify motivators and use positive reinforcement

What are some strategies to manage restlessness in patients with TBI

- Provide a safe outlet (ambulation, wheelchair mobility, manual task)

- Utilize a low-stimulation environment

What are some management strategies for Non-compliance/refusal in patients with TBI

- Identify motivators and use positive reinforcement

- Provide clear directions and expectations and stick to them

How can we manage impulsivity in patients with TBI

- Review consequences of unsafe movements

- Provide verbal cues for safety

What is Post-Traumatic Amnesia (PTA)

Period between the initial TBI and recovery of active memory

What are the types of Post-Traumatic Amnesia (PTA)

Retrograde vs anterograde amnesia

TRUE or FALSE: The type and length of Post-Traumatic Amnesia (PTA) can help Predict recovery and functional ability of patient

True

How do we assess emergence from Post-Traumatic Amnesia (PTA)

- Galveston Orientation and Amnesia Test

- Orientation Log

What are the characteristics of Ranchos Level V - Confused/Inappropriate

- Somewhat consistent response to simple commands

- Inconsistent responses with complex commands or unstructured activities

- Improved attention to environment but highly distractable

- Short automatic social conversations are possible

- Verbalization still tends to be inappropriate or confabulatory

- Severe memory impairment persists

- Some ability to perform previously learned tasks, but struggles with learning novel tasks

What are the characteristics of Ranchos Level VI - Confused/Appropriate

- Goal-directed behavior with external input or direction

- Consistent simple command following

- Demonstrates carryover of simple relearned tasks (i.e. ADLs)

- Improved awareness of overall situation, but continues to lack understanding of specific deficits

- Memory problems persist but responses are situation-appropriate

What are key points about patient memory during Ranchos Level VI - Confused/Appropriate

- Memory problems persist but responses are situation-appropriate

- More noticeable improvement in long-term memory

- Short-term memory remains challenging

What are key points about prognosis and outcomes for Ranchos Levels 4, 5, and 6

- Longer periods of LOC leads to greater cognitive and emotional problems

- Bilateral lesion associated with worse outcomes

- PTA < 2 months better prognosis

What are cognitive and emotional problems that longer periods of LOC can lead to during Ranchos Levels 4, 5, and 6

- Increased agitation

- Memory deficits

- Apathy and disinhibition

During Ranchos Levels 4, 5, and 6 Bilateral lesion are associated with worse outcomes such as:

- Increased occurrence of anxiety and depression

- Greater impairment in executive function and working memory

What are key considerations for prognosis and outcomes of Ranchos Levels 4, 5, and 6 based on PTA

- < 2 months better prognosis

- >3 months decreased functional recovery

What are the criteria to be classified as Ranchos Level VII - Automatic/Appropriate

- Appropriate and oriented in familiar settings

- Can perform daily routine "automatically" - robot-like

- Capable of carryover of new learning, but recall is slow

- Can initiate social or recreational activities with structure

What deficits still remain in patients with TBI who are classified as Ranchos Level VII - Automatic/Appropriate

- Judgement and safety

- Insight into deficits and limitations

What is a defining characteristic of Ranchos Level VII - Automatic/Appropriate

Someone at this level tends to overestimate their abilities

What are the criteria to be classified as Ranchos Level VIII - Purposeful/Appropriate - Standy-By Assistance

- Consistently oriented in all settings

- Can recall and integrate past and recent events

- Demonstrates carryover of new learning

- Independently completes learned activities in non-distracting environments

- Emerging awareness of deficits and their impact on function, but assistance required assistance to select compensatory strategies

What deficits still remain in patients with TBI who are classified as Ranchos Level VIII - Purposeful/Appropriate - Standy-By Assistance

- Abstract reasoning

- Tolerance for stress

- Judgement in emergencies or novel situations

What are the psychosocial presentations of patients at Ranchos Level VIII - Purposeful/Appropriate - Standy-By Assistance

Depression, irritability, and low frustration tolerance is common

What is primary difference between patients at Ranchos levels 8, 9, and 10

Assistance level

What are the criteria to be classified as Ranchos Level IX - Purposeful/Appropriate - Standy-By Assistance on Request

- Can independently shift between tasks

- Aware of deficits and can self-manage with compensatory strategies

What might patients at Ranchos level IX - Purposeful/Appropriate - Standy-By Assistance on Request, need assistance with?

- Anticipate challenges that may arise

- Think about consequences of actions/decisions

What are the psychosocial presentations of Ranchos Level IX - Purposeful/Appropriate - Standy-By Assistance on Request

Depression and low frustration tolerance persist

What are the characteristics of Ranchos Level X - Purposeful/Appropriate - Modified Independent

- Can multitask in varied environments with increased time or assistive devices

- Independently selects compensatory strategies and anticipates challenges

- Independently makes appropriate decisions

- Independently interacts in social situations

- With increased stress levels, depression and low frustration tolerance can persist

What are key points about Hypoxic-Ischemic Brain Injury (HI-BI)

- Brain is susceptible to loss of oxygenation due to decreased blood supply

- Ischemia onset results in decreased concentrations of brain glucose, glycogen, ATP and phosphocreatine

Within minutes to hours neuronal and irreparable brain damage occurs due to

Ischemia onset resulting in decreased concentrations of brain glucose, glycogen, ATP and phosphocreatine

What happens to oxygen supply as a result of Hypoxic-Ischemic Brain Injury (HI-BI)

reduction of oxygen supply

What happens to oxygen supply as a result of Anoxia

complete loss of oxygen supply

What can cause Hypoxic-Ischemic Brain Injury (HI-BI)

- Cardiac arrest

- Significant hypotension

- Asphyxia

- Hypovolemic shock

- Drug overdose

What cortical Areas are Affected by Hypoxia

- Hippocampus (memory)

- Purkinje cells of cerebellum (coordination)

- Basal ganglia (refining/initiating movement)

- ACA/MCA/PCA (somatosensory/motor)

What are key points about prognosis and outcomes following Hypoxic-Ischemic Brain Injury (HI-BI)

- 30-60% will develop persistent cognitive, behavioral, and neurological problems

- Lower level of functional independence vs TBI

- Longer rehab stays, lower FIM scores, less likely to d/c home

What are Movement disorders

abnormal and/or involuntary motor patterns affecting desired movement

What are movement disorders that can develop following Hypoxic-Ischemic Brain Injury (HI-BI)

- Parkinsonism

- Dystonia

- Chorea

- Tremor

- Tics

- Athetosis

- Seizures

- Myoclonus

- Ataxia