L7: Non-motor Impairments after ABI

Consciousness definition

Complex arousal state that implies self-awareness, unity, intentionality

What does the glasgow coma scale assess

Level of consciousness

3 categories on glasgow coma scale

Eye opening, Verbal response, Motor response

Score range for eye opening on glasgow coma scale

1-4

Score range for verbal response on glasgow coma scale

1-5

Score range for motor response on glasgow coma scale

1-6

Glasgow coma scale score ranges

3-15

Severe brain injury glasgow coma scale range

3-8

Moderate brain injury glasgow coma scale score range

9-12

Minor brain injury glasgow coma scale score range

13-15

Eye opening response score of 4

Eyes open spontaneously

Eye opening response score of 3

Eye open to verbal command or sppech

Eye opening response score of 2

Eyes open to pain

Eye opening response score of 1

No eye opening

Verbal response score of 5

Oriented

Verbal response score of 4

Confused conversation but able to answer questions

Verbal response score of 3

Inappropriate response

Verbal response score of 2

Incomprehensible sounds

Verbal response score of 1

No verbal response

Motor response score of 6

Obeys commands for movement

Motor response score of 5

Purposeful movement to painful stimulus

Motor response score of 4

Withdraws from pain

Motor response score of 3

Abnormal flexion or decorticate posture

Motor response score of 2

Extensor response or decerebrate posture

Motor response score of 1

No motor response

Decorticate rigidity lesion location

Cortico-subcortical level

Decorticate rigidity mortality

50%

Decerebrate rigidity lesion location

Caudal diencephalon-upper brainstem

Decerebrate rigidity mortality

85%

Mixed decerebrate rigidity lesion location

Pons

Mixed decerebrate rigidity mortality

100%

Decerebrate posturing position

• Extended arms

• Extended legs

• Wrists flexed

• Arched back

• Rigid muscles

Decorticate posturing position

• Wrists clenched

• Arms flexed at the elbow towards the body

• Legs extended

What does ranchos levels of cognitive function evaluate

Emerging cognitive and emotional behaviors

Ranchos levels 1-3 assistance level

Total

Ranchos level 1

No response

Ranchos level 1 key characteristics

No observable response to external stimuli

Ranchos level 2

Generalized Response

Ranchos level 2 key characteristics

Inconsistent, non-purposeful response; same response regardless of stimulus

Ranchos level 3

Localized Response

Ranchos level 3 key characteristics

Specific, inconsistent responses; reacts to painful stimuli; more responsive to familiar people

Ranchos levels 4-5 assist level

Maximal

Ranchos level 4

Confused & agitated

Ranchos level 4 key characteristics

Bizarre, hyperactive, non-purposeful behavior; agitation from internal confusion; no short-term memory

Ranchos level 5

Confused & inappropriate

Ranchos level 5 key characteristics

Follows simple commands inconsistently; inappropriate verbal behavior; poor memory; can perform tasks if demonstrated

Ranchos level 6 assist level

Moderate

Ranchos level 6

Confused & appropriate

Ranchos level 6 key characteristics

Follows simple directions consistently; retains old learning; lacks new learning; some awareness but poor safety insight

Ranchos level 7 assist level

Minimal

Ranchos level 7

Automatic & appropriate

Ranchos level 7 key characteristics

Performs routine automatically; superficial awareness of condition; poor judgment and safety; interested in structured activities

Ranchos level 8 assist level

Stand by

Ranchos level 8

Purposeful & appropriate

Ranchos level 8 key characteristics

Oriented, completes familiar tasks independently, some awareness of deficits; uses memory aids; better emotional responses

Ranchos level 9 assist level

Stand by on request

Ranchos level 9

Purposeful & appropriate

Ranchos level 9 key characteristics

Shifts tasks independently; recognizes impairments with support; uses compensatory strategies; needs help anticipating problems

Ranchos level 10 assist level

Modified independent

Ranchos level 10

Purposeful & appropriate

Ranchos level 10 key characteristics

Independently manages tasks with aids; anticipates obstacles; appropriate social interactions; may still struggle under stress

Way to remember the ranchos catergories

• Response

• Confused

• Appropriate

Treatment for ranchos levels 1-3

• Sensory stimulation

• Passive ROM

• Positioning

• Upright tolerance

• Caregiver/family education

Considerations with sensory stimulation

• Don't be loud or abrupt

• Turn lights on

• Tell pt what you are doing even if in coma

  • Will increase arousal, encourage plasticity and help brain process sensory signals for integration of info

• Vagus nerve stimulation - may help with tone

• Move object back and forth

PROM considerations

• Muscle length

• Circulation

• Heterotrophic ossificans prevention

• Prevent contractures

• Short term relief of tone (maybe)

Positioning considerations

• Bone health/pressure injuries

• Quarter roll every 2 hours to offload bony prominences

Upright tolerance considerations

• ANS effects

• 10° at a time and check vitals

• Better mechanics for breathing/swallowing/speaking

• Bone health

• HOB progressing or tilt table/standing frame

Family/caregiver education considerations

• Inform about sensory stimulation, PROM, positioning, upright tolerance

• Transfers

• Hygiene

What can you have the family do to help with consciousness

Share stories/memories

Treatment ideas ranchos levels 4-6

• Check environment

• Routine

• Direct

• Salient

What to do if patient is getting agitated

• Let patient calm down if getting agitated

  • Could try leaving room and coming back (lacks ST memory)

Environment for ranchos levels 4-6

• Calm

• Limit visitors

• Use familiar, repetitive motor tasks

Ranchos 5 important things to implement into treatment

• Simple commands

• Be direct

• Redirect/stop patient if not following instructions

Ranchos 6 treatment considerations

Follow simple commands so can progress to what is salient to them

Treatment consideration if ranchos 5 or 6 perseverate

Distraction/redirecting skills

Treatment ideas ranchos levels 7-10

• Dual tasking

• Community integration

• Problem solving

• Return to work/school

• Driving

Sustained attention

The cognitive ability to maintain consistent mental focus on a specific task over an extended period of time

Sustained attention tests

• Digit repetition test

• Test of vigilance

What is the digit repetition test

Standard neuropsychological tool used to measure short-term memory, attention, and working memory capacity

What is test of vigilance

• Scientific gold standard for measuring behavioral alertness and sustained attention

  • Tracks reaction time to visual stimuli to quantify fatigue and sleep deprivation

Divided attention

The brain's ability to process multiple stimuli and perform multiple tasks simultaneously (dual tasking/multi-tasking)

Cognitive-cognitive divided attention

Doing 2 cognitive tasks at once

• (matching letters of alphabet to numbers)

Cognitive motor divided attention

Completing a motor task with a cognitive task

• Walking, alternating word finding in alphabetical order

Motor-motor divided attention

Completing 2 motor tasks at same time

• Walking while tossing/catching ball

Normal score for digit repetition test

7 ± 2 digits

• Inability to repeat 5 = defective attention

Cognition

Set of mental processes by which individuals acquire, process, store, and use information

Cognitive dysfunction tests

• Cog-log

• Galveston orientation and amnesia test (GOAT)

What is cog-log

Test of multiple cognitive domains (emphasis on memory and executive function

How often is cog-log administered

Multiple times per day

Cut off score for cog-log

25

What does GOAT assess

Orientation, retrograde and aterograde amenesia

How often is GOAT administered

Once daily

What score clears you of post traumatic amnesia for GOAT

≥ 78

Perception

Integration of sensory information into a meaningful representation

How often does pusher syndrome occur in strokes (%)

10.4%

With pusher's syndrome, the patient actively pushes _______ their unaffected side

Away from

How will pt with pushes syndrome present

Leaning towards affected side ~20° from midline

Damage to what structures causes pushers syndrome

• Posterolateral thalamus

• Insula

• Post-central gyrus

What does pushers often co-occur with

Neglect

How long does it take pushers to resolve

~ 6 months