TBI

what are the types of traumatic brain injury?

primary: either contact or acceleration-deceleration (diffuse axonal injury— brain sheers axons accross the skull)

secondary: due to bleeding

diffuse: generalized concussion

focal: localized contusion from the head being bashed or hit by something

what is primary brain damage?

damage that is complete at the time of impact

what are the types of primary brain damage?

• skull fracture

• contusion/bruises/hematomas: point of contact where the force of the blow has driven the brain against the skull

• hemorrhages: internal bleeding in the brain

• lacerations: tearing of the frontal and temporal lobes or blood vessels of the brain (the force of the blow causes rotation across the hard ridges of the skul, causing the tears)

• diffuse axonal injury: arises from a shearing force that damages nerve cells in the brains connecting nerve fibers

what is secondary brain damage?

damage that evolves over time after the trauma, most commonly due to increased ICP

types of secondary brain damage include…

• brain edema

• increased ICP

• epilepsy

• intracranial infection

• fever

• hematoma

• low or high blood pressure

• low sodium

• anemia

• too much or too little carbon dioxide

• abnormal blood coagulation

• cardiac changes

• lung changes

• nutritional changes

what is an open vs closed head injury?

open: penitration to the skull resulting from a gun shot and stab wounds

closed: no penetration to the skull resulting from falls, motor vehicle crashes, etc. may affect one area of the brain, or different areas

what all should be included in our systems review here?

• CV

• balance

• strength

• cognitive

what are the common body structure impairments?

• hemiparesis

• ataxia

• apraxia

• abnormal behavior

• impulsivity

• decreased safety awareness

• decreased coordination

• decreased proprioception

• impaired sensation

• perception

• vision/hearing

• cognition

• affect/mood

what are the common cognitive impairments?

difficulties with…

• attention: usually have to treat individually in a quiet room

• memory: tend to be confused ans wander

• initiation

• comprehension

• expression

• sequencing

• organization

• problem solving

• confabulation: filles in the blanks with things that are not true because they have loss of memory

• judgement

what are behavioral characteristics of BI?

• slowed response

• suspiciousness

• inflexibility: don’t do good with changes to we’d need to keep this in mind with our scheduling

• impatience

• irritability

• depression

• inappropriate outburst

• lability (crying)

• denial

• perseveration

• egocentricity

• loss of control

• over dependency

• perceptual problems

• increased sexual focus

• new learning problems

• inappropriate social behavior

• family abuse— behavioral and physical

what are common activity limitations?

• poor balance both seated and standing

• difficulty with transfers

• difficulty with bed mobility

• difficulty with gait and stairs

what are impairments specific to gait?

• ataxia

• hemiparesis

• decreased foot clearance

• hip hiking/trendelenberg

• narrow base of support

• poor postural control

• decreased hip extension

• poor knee control and stance

• decreased proprioception/coordination

• asymmetrical step length

• altered stance and/or swing phase

what are common participation limitations?

• unable to return home

• unable to return to work/school

• unable to participate in previous recreational activities

what is the Moss Attention scale used for?

it is an observational tool used to measure attention related behaviors after TBI

what is the Apathy Evaluation Scale used for?

the measures addresses characteristics of goal directed behavior that reflects apthy including behavioral, cognitive, and emotional indicators

what is the coma recovery scale used for?

to determine if the person is in a vegitative, minimally conscious, or emerging state

what is the Community Balance and Mobility Scale used for?

This is a high level balance scale created specifically for those with TBI. it measures for detecting dynamic instability and evaluating change in ability in the higher functioning ambulatory patient with TBI

what is the FIM + FAM used for?

completely assesses cognitive and behavior issues important for community reintegration

what is the High Level Mobility Assessment Tool (HIMAT) used for?

high level balance scale we can use interchangeably with the community balance and mobility scale that assess skipping, hopping, stairs, bounding, running, and walking

what is the quality of life after TBI outcome measure used for?

a 37 item scale that assess a persons satisfaction level with their QoL

what is the Motivations for TBI rehab questionnaire used for?

developed to assess motivation to participate in post acute rehab, including factors of denail, anger, apathy, compliance, medical information seeking, and excessive enthusiasm

what ist he Disability Rating Sacel for TBI used for?

evaluates 8 areas of fucntion within the categories of consciousness, cognitive ability, dependence on others, and employability

what are the different levels of arousal?

• arousal: primitive wakefulness via reticular activating systems. signs include eyes open and sleep—wake cycle present

• awareness: conscious of internal/external stimulation. sings include responding purposefully to stimuli

• consciousness: aware of self and environment. signs include that they are oriented or disoriented but interactive

• coma: no arousal and no awarness. their eyes will be closed with no sleep—wake cycles; the ventilator is often needed

• minimally responsive: the person is not vegitative, showing intermittent signs of awareness. they will show inconsistent purposeful responses

• vegitative state: they will have arousal but no awarness. they appear awake but unaware of environment

• permanent vegitative state: being in a vegitative state greater than 1 year with no expected improvement

what is Rancho level 1?

no response: total assistance— they will have no response to pain, touch, sound or sight

what is Rancho level II?

generalized reflex responses: total assistance— they will have general responses to all stimuli but they are not purposeful so they respond the same way no matter the types of stimulation

what is Rancho level III?

localized response: total assistance— consistent purposeful responses specific to stimulus (withdraws from pain, turns toward sound)

what is treatment we can do for those in Rancho Level I and II?

• PROM

• positioning/splinting/stretching

• righting/balance reactions for RL II

• sensory stimulation

• gross motor tasks

• simple VC, familiarity, low stim

• use the neuroplastic principles of repeition and saliency

what is sensory stimulation?

• program that attempts to increase th input from sensory receptors to the brain of a person exhibiting little or not arousal

• one component of early recovery management programs that would also include positioning, passive ROM, inhibitive casting, and aggressive treatment in upright positions

• goal is to get some kind of response

why do we do sensory stimulation?

• patients in coma’s experience a form of sensory deprivation— their ability to respond to internal and external stimuli is decreased

• physical isolation, and unfamiliar environment, altered nutritional sources, artificial airways, immobility, absence of a familiar noise, and sedation contribute to an impoverished envrionment

how do we perform sensory stimulation?

test smell, auditory, and visual each at a time. for smell, repeatedly introduce a strong smell. for auditory, play music or have someone they care about talk to them. for visual, show them pictures of people they care about or have those people there

what are the ways to treat Racho Level III?

• set up low stimulation environment

• PROM and AAROM/positioning and splinting

• stimulation to follow commands or elicit responses

• transfers, EOB balance and postural control/awarness of body, facilitation of purposeful tasks

• initiate gait as appropriate

discuss Rancho Level IV presentation

• confused/agitated: maximum assistance

• alergy

• aggressive or bizarre behaviors

• motor activities may be non purposeful

• extremely short attention span

• decreased attention with overstimulation— so be prepared to pivot really quick and make a change in location or activity

what is agitation?

unpleasant state of extreme arousal (stirred up or excited), increased tension and irritability

what is aggression?

a form of agitation involving a direct verbal threat to harm oneself or another person or a physical assault directed at oneself or another person

what are forms of agitation?

• yelling

• pacing

• perseveration

• biting

• hitting

• crying

• threats

• irritable

• pulling tubes/IV/Dressings

• laughint inappropirately

• inappropriate language

• sexual langauge/gestures

• getint out of bed or climbing

• frequent hand movements

• refusing or noncompliant

• wandering

what is the purpose of the agitated behavior scale?

measures the nature and extent of agitation during acute recovery from acuired brain injury

what are our treatment priorities for Ranchos IV in regards to structure and environment?

• establish a predictable routine

• reduce noise, lights, and distractions

• avoid increasing demands with agitation

• provide frequent orientation to where they are but if they argue, then just let it go

• avoid teaching complex new skills

what are our treatment priorities for Ranchos IV in regards to communication and cognition?

• use short, simple directions

• allow extra processing time

• redirect rather than argue/reason

• use prompts and positive reinforcement

• observe performance rather than repeatedly “test”

what are our treatment priorities for Ranchos IV in regards to activity and endurance?

• allow movement, then refocus

• incorporate familiar/automatic tasks

• provide rest periods

• break evaluation/treatment into shorter sessions

• use guided activity/walking as appropriate

how can we prevent the buildup of agitation in Ranchos Level IV?

• identify triggers

• reduce stimulation

• maintain routine

• anticipate basic needs/fatigue

• use consistent caregivers/approach

• prepare meaningful activities

what do we do when agitation begins in Ranchos Level IV?

• stay clam; control your response

• decrease demands

• use brief, concrete directions

• redirect to another task/activity

• allow movement or a “reset”

• do not argue, lecture, or reason

what do we do if behavior becomes aggressive in Ranchos Level IV?

• maintain a safe distance

• keep access to an exit

• call for assistance early

• use a clear, calm voice

• give clear safety commands

• follow facility safety procedures

what are our different redirection strategies we can use for Ranchos Level IV?

• move: walk, wheelchair mobility, change position/location

• engage the hands: familiar task, activity kit, busy lap activity

• change the environment: quiet room, reduce people/noise, change setting

• use familar memories/tasks: long term memories, previously learned skills

• simplify communication: “stand up” — pause — next direction

• redirect: shift to a different activity instead of persisting

• reset: step away and return after a brief break

• build trust: validate emotion, calm body language, meet the patient where they are at

how is behavior management for a TBI pt a team intervention?

it takes a team approach with a shared behavior plan, consistent care, interdisciplenary communication, appropriate brain injury management, and daily structure

what are ways we can approach treatment for Rancho level IV?

• gross motor tasks

• transfers, EOB balance and postural control/awarness of body, facilitation of purposeful tasks

• functional activities using old skills the patient is familiar with and incorporating familiar objects

• redirect behavior throughout the treatment to decrease agitated episodes

• increase attention

• re-oreient to time and place frequently

• use neuroplasticity principles of repetition, salience, and use it or lose it

discuss rancho level V

• confused, inappropraite, non-agitated: maximum assistance— gross attention span

• dostractible

• redirection

• difficulty learning new tasks

• may still be agitated from some stimuli

• social conversation may be automatic, but inappropriate

• wandering

discuss rancho level VI

• confused, approprate: moderate assistance— inconsistently oriented to a person, time and place

• long term memory is better than short term memory

• emerging awareness of appriopriate response to self, family, and basic needs

• begins to recall the past but still have difficulty remebering the accident

• goal directed behavior with assistance

• some awareness of impairments, disabilities, and safety risks, max assist for new learning

• consistently follows simple directions

*we can begin to do more formal testing here because they are not aggrivated as easily and can follow simple commands

what are different treatment approaches we can use for rancho level V-VI?

assess/consider: treatment approach

• attention and memory: maintain structure, task oriented treatment. can then progress to automatic purposeful tasks

• ability to follow verbal/nonverbal cues: give one instruction at a time. can then progress to systematically increasing task complexity

• ability to redirect: speak slowly; allow processing time. can then begin to problem solve ae and increase participation

• carryover of new/relearned skills: orient throughout treatment. can then progress to use of memory aids as appropriate

• perseveration/confabulation: correct inaccuracies with brief, factual information. can progress toward community based activities

• judement and safety awarness: emphasize safety and progress to increased independent as cognition allows

how can we manage inappropriate/impulsive behavior at Rancho level V-VI?

• calmly orient to person/place/situation

• state the behavioral limit clearly

• redirect to an appropriate behavior

• provide an acceptable alternative

• avoid prolonged arguing or reasoning

• reinforce appropriate behavior

how can we manage inappropriate sexual behavior at Rancho level V-VI?

• remain calm and matter of fact

• clearly state the behavioral boundary

• redirect to another activity

• reorient to situation/environment

• avoid shaming or emotional reactions

• maintain consistent team response

how can we manage low initiation/apathy at Rancho level V-VI?

• provide a “jump start” to initiate

• use familiar, meaningful activities

• connect tasks to hobbies/interests

• incorporate family/personal context

• use simple cues and extra processing time

• progress automatic purposeful activity

why is it important that we work on cognition as PTs?

while we are not directly working on it like OT and SLP, it is helpful when we incorporate it into PT and communicate together to provide shared strategies

what are the 3 global elements that make up cognition?

• time awareness: comes back fastest

• environmental awarness

• interpersonal awarness: being aware of how your coming off to people and adjusting. this comes back last or wont fully come back

what is cognition?

• conscious mental activity that informs a person about his or her environment

• cognitive actions include percieving, thinking, reasoning, judging, problem solving, and remembering

the complex functions of cognition are regulated, controlled and monitored by the __________.

frontal lobe

when does cognitive deficit recovery peak?

within 6 months to a year after the injury and gradually after that

what are the main types of cognitive rehab therapy?

• process training: direct retraining through memory drills

• strategy training: environement and internal and external strategies to help compensate

• functional activities training: applying memory strategies to real life

• education: teaching on cognitive weakness and strengths

*combination of these 4 approaches is best practice

discuss adaptive (strategy) training for cognition.

• this is the top down approach

• focuses on adapting the task and environment to capitalize on the patients strenght

• emphasizes compensation strategies

• used when full restoration is unlikely

• strategies must be practiced across multiple contexts

• may require external supports to initiate

• goal is functional performance and participation

• examples include planners, memory notebooks, and reminders

discuss the remedial (restorative) approach for cognition

• this is the bottom up approach

• focuses on underlying cognitive impairments causing disability

• emphasizes resoration of function

• used when recovery of function is expected/possible

• relies on repeated drills and exercises

• goal is to promote new neural connections through practice

• examples include attention drills and memory exercises

how can we incorporate cognition in functional activities?

• faciliation of cognitive progress during ADL’s

• cognitive motor tasks

• compensatory strategies

• provide opportunities for increased time, error recognition and correction, sequencing, initiation, safety, problem solving, and time awarness/management

what are the memory clinical guidlines?

• clearly define intervention goals by selecting goals that are personally meaningful and functionally relevant to the person

• allow suffiecient time and opportunity for practice through repeated practice across sessions and contexts

• break tasks into smaller components using task analysis

• use distributed practice by spacing it over time rather than mass practice

• vary stimuli and information by teaching using multiple examples and real world tasks

• promote effortful processing by encouraging verbal elaboration, visual imagery, and deeper engagement with material

• use error contstraining teaching strategies through applying errorless learning and spaced retrieval for new information

discuss attention

• the brain only has so much capacity for multiple power demands

• often the major factor hindering progress in most areas of communication as well as physical improvement

• foundation for everything else

what are the types of attention?

• sustained: most basic functional tasks so the ability to maintain consistent focus on a task overtime

• selective: ability to tune out distractions and stay focused on one stimuli

• alternating: ability to switch back and forth, shifting focus between tasks with different cognitive demands

• divided: ability to attend to simultenous tasks

how do we frame therapy with attention issues?

1. put in quiet room with no distractions

2. work on selective attention and then slowly add small distractions

3. work on alternating by now having them go between 2 tasks

4. add in dual tasking to work on divided attention last

what are attention strategies we can use?

• limit stimuli/distractions

• quiet environment

• encourage self talk

• verbal rehearsal

• establish and maintain routines

• making short lists

• redirection to task

• schedules

• set finite liste of goals and or timeframes

how can we make measurable goals for cognition?

• use number of minutes they can hold attention or the number of redirections

• use the number of episodes of increased agitation

• use the number of verbal, tactile cutes for initiation, sequencing, safety, error identification, or corrections

when documenting cognition, what should we note changes in?

• social interaction

• resistance to care or cooperation

• frusteration tolerance

• tolerance to wait for caregiver assistance

• pragmatics

discuss rancho level VII

• aumoatic appropriate: minimal assistance for daily living skills

• the patient can perform all self care activities and are usually coherent. they have difficulty remembering recent events and discussions. if physically available, can carry out routine activities. rational judgements, calculations, and solving multistep problems present difficulties, yet patients may not seem to realize this

• still don’t have insight of what they can and cant do so they will jump into things and therefore, supervision is needed for safety

discuss Rancho level VIII

• purposeful, appropriate: standy by assistance

• the patient is independent for familiar tasks in a distracting environment for one hour. he or she acknowledges impairments but has difficulty self monitoring (can’t fix the impairments). emotional issues such as depression, irribability and low frusteration tolerance may be observed

discuss Rancho Level IX

• purposeful, appropraite: stand by assistance on request

• the patient is able to shift between tasks for several hours. requires some assistance to adjust to life demands

• emotional and behavioral issues (more social problems) may still be of concern

• if they need help they can ask for it

discuss Rancho Level X

• purposeful, appropriate: modified indpendent

• the patient is goal directed, handling multiple tasks independently using assistive strategies. prone to breaks in attention and may require additional time to complete tasks

discuss Rancho level VII-VIII treatment

• social history/medical history: provide information accurately and get oriented

• promote behavior that is purposeful, appropriate, and supervision to modified independence

• focus on treatment and progress to higher level executive functioning

• ability to function in real life situations

• ability to make good decisions that address safety

• ability to follow 1,2,3 step commands

• STM/LTM

• initiation of necessaary actions

• insight into condition

• coordination, agility, spped

• attention, memory, problem solving, executive function

• advanced mobility skills, fitness, wellness

• vocational and driving assessment referrals

• incorporate dual tasking

for the neurological population, what is the primary task in which we need to make sure the person can perform without considerable attention before adding in dual tasking?

walking

how can we measure dual task performance?

• TUG COG: make them count a certain way or list all of something in a category while walking

• TUG Manual: walk while actually doing something

• the goal is that the pt will have no more than a 10% decline from their TUG to TUG COG or manual

what are the factors that influence dual tasking?

• individual factors: executive function, attention, gait impairment

• task factors: cognitive or postural tasks

• environmental factors: ambient conditions or instruction

what gait impairments do we often see with dual task walking comapred to a single task?

• reductions in gait speed and stride length

• decreased symmetry and coordination

• increased stride to stride variability

what does the research say about dual tasking?

• there is a decline in both congitive and motor function in the subjects with CNS dysfunction during dual task conditions

• decrease memory accuracy and gait during dual tasks in healthy older adults

• decreased postural control during dual tasks in cogntively impaired geriatric subjects

how should we approach static/dynamic standing dual tasking interventions

• choose whether you are introducing a separate motor, visual, auditory, or cognitive task

• task difficulty needs to be considered

• should be salient

what should our rehab approaches be for dual tasking?

• we are in charge of continuous assessment of the patients performance to see if the dual task is too difficult or unsafe. if so, we may want to focus on a single task first and then incorporate dual component in

• we want the patient to benefit from the physical task or cognitive task separately

• we want to set the patient up for success

• we may need to decide if dual tasking is even appropriate or should we teach to compensate

how can we provide family training for these individuals?

• get them inolved and equipped early on, often, and at a level they understand

• balance giving them hope and managing expectations

• provide opportunities for hands on facilitation of physical and cognitive assistance such as through overnight stays

• educate on community accessibility

• disease specific education

• setting up appropriate exercise program

• set up cognitive home exercise program

what are the emotions these individuals will struggle with that we should prepare the family for?

• adjustment issues to the new normal

• depression

• self worth

• grief

• chemical abuse

what 3 things define community integration?

• employment or other productive activity

• independent living

• social activities

what are our discharge location options?

• independent living

• living with family

• supported independent living/supervised housing

• assisted living facility

• gropu home

• transitional living services

• SNF

what are challenges that should be taken into consideration when choosing discharge location.

• person needs 24/7 supervision

• behavioral/psychological issues— all involved must approach as in a team effort

• removal of harmful weapons/objects

• keys to the car need to be inacessible/monitoring of exit doors

• electrical equipement/cooking

• beware of access to alcohol/prescriptions

• location of facility—away from support system

• funding

• age group

what are important parts of community integration?

• return to work/school via disability services at schools, center for independent living, vocational rehab, volunteering, return to driving

• participation in community outings

• inofmration and personal invitation to local support groups

• resources

what are school/employment challenges after a TBI

• memory deficits/retaining new information

• time management for assignments

• organization problems

• impulsive

• decreased response time

• disorietned on campus or in workplace

• decreased attention/distractibility

• maintaining peer relationships

• behavioral issues

• transportation

*a persons pre-injury educational and/or career goals may have to be reexamined

what are transportation challenges after a TBI

• funding to pay for drivers

• access to a vehicle

• interactions with law inforcement as they often get accused of drunk driving

• time fram for scheduled rides

• not living on bus routes

• expense

• having to rely on others

why are recreation/leisure options so important after a TBI?

• improves skills, building morale, restoring self confidence, and developing social relationships

• participation in familiar rec activities can reduce frusteration/sense of loss

• can include family involvement to help identify activities that are at the interest of the individual

• allows for daily structure and routine physical and cognitive stimulation

what are recreation/leisure challenges after a TBI?

• changes in friendships— former friends are often not as available

• more difficult to establish new relationships due to changes in personlality or behavior

• activities/social interactions involving alchohol or drug use

• tranportation

• funding