OCTH 236 Midterm 1: TBI, SCI, movement disorders, CN

Traumatic Brain Injury (TBI)

Damage to brain tissue casused by an external mechanical force with resultant loss of conciousness, posttraumatic amnesia, and skull fracture or objectuive neurological findings that can be attributed to the trauamtic event by radiological findingsm physical, or mental status exam

TBI stats

Underreported; Don't include Er visits that didn't result in admission to hospital

80% are mild

-most common among men

Causes of TBI

Falls are majority (47%)

-most common in older adults

-intentional self hard is leading cause of TBI related deaths

Demographic disparities of TBI

More common among men

Natives- higher rates of hospitalization/death (higher crashes, substance abuse, suicide, less access to care)

POC- less likely to receive follow up care=poorer outcomes

Low income- less likely to receive surgery/services/die in hospital

Rural- more likely to die from TBI/less access to specialized care

What are the different types of brain injuries?

Severe TBI: open/closed

Non traumatic brain injury

Open Head Injury (OHI)

An injury to the brain caused by a foreign object entering the skull; causes may include firearm injuries or being struck with sharp object

-There is penetration to the skill

Closed Head Injury (CHI)

An injury to the brain caused by movement of the brain within the skull; causes may include falls, MVC, or being struck by or w an object

-there is NO penetration to the skull

non-traumatic brain injury

damage to the brain caused by internal factors, such as depletion of oxygen (carbon monoxide or anoxia), exposure to toxins, drug overdose or chronic substance use

Guidelines for management TBI

Absence of increased ICP

Steroids are not recommended to reduce ICP

Prophylactic are not recommended for preventing seizures

Hypotension/hypoxia must be monitored/corrected immediately

>40 yrs/GCS 3-8/hematomas: ICP monitoring is appropriate

If ICP exceeds values, treatment should be initiated to lower it

Surgical interventions for TBI

Removal of objects (bulletin/debris)

Evacuation of hematoma

Tumor removal

Bone flap

Predictor outcomes of TBI

Immediate

Autonomic functions (pulse, RR, temp, Bl press, diaphoresis)

Consciousness (arousal, cognition, length of coma)

Motor functions (reflexes, voluntary mov, abnormal postures)

Pupillary response

Ocular movements (pupil size, shape, light)

Decorticate posturing

UE in a spastic, flexed position, Int rot and adduction

LE spastic extended, Int rot and adduction

Cerebral hemisphere, internal capsule, above superior colliculus

Decerebrate posturing

UE and LE in extension, adduction, int rot

Wrist/fingers in flexion

Lesion below superior colliculus, brainstem region

Poorer prognosis than clients with damage above superior colliculus

What are the different types of amnesia?

Retrograde

Anterograde

Post-traumatic

retrograde amnesia

Length of amnesia for events prior to injury, unable to remember events due to neurological damage

Anterograde amnesia

Length of amnesia following impact, injury, unable to consolidate info for storage and retrieval

Post-traumatic amnesia

Following injury where patient is confused and seems unable to store and recall new info

-can refer to anterograde or retrograde subtype

Length of post-traumatic amnesia

the time after injury when day to day recall returns and full orientation is present

Categories of post-traumatic amnesia

Mild: < 1 hour

Moderate: 1-24 hrs

Severe: 1-7 days

Very severe: 1- 4 weeks

Extremely severe: > 4 weeks

What are some secondary medical issues affecting those with TBI

Orthopedic-weight bearing status: ability to participate in rehab

Pulmonary- endurance/tolerance

Decubitus ulcers- pressure

Combo injuries- SCI/TBI

Combo injuries SCI/TBI account for ________% of brain injury cases

30-50%

prognosis of TBI depends on

Predictors

Age

Social support group

Premorbid drug/alcohol abuse

Length of time in coma/PTA

The length of stay in hospital is based on

Insurance authorization, functional goals, progress

Initial team evaluation consists of...

Interview and observation

Clinical evaluation (ROM, tone, sensation, balance, movement)

Cognition/perception/vision

Performance of mobility and functional activities

Endurance and pain

Behavior

Goal setting is based on...

Length of stay

FIM scale 1-7

Discharge destination/caregiver availability

Purpose of Evaluation

Identify problems that affect cognitive performance

Language

Perceptual, motor, visual deficits

Education/culture

Medications

Sensory deficits

Physical limitations

Previous level of expertise w/ task

Occupational therapy focus

Splinting/casting UE

Neuromuscular re-education

Cognitive retraining

Participation in ADLs (self care)

Bed positioning, transfers, mobility (w/c)

Transfers

Equipment needs

Caregiver training

Home evaluation

Glasgo Coma Scale (GCS)

A clinic tool designed to access the severity of coma and impaired consciousness and is one of the most commonly used scoring systems

-assess/monitor level of consciousness

Glasgo coma scale (GCS) categories

Severe TBI: 3-8

Moderate TBI: 9-12

Mild TBI: 13-15

What three aspects of coma are independently observed with the GCS?

Eye-opening (E)

Best motor response (M)

Verbal performance (V)

How are the overall GC scores obtained?

By adding up the total numbers (E+M+V)

A total of 3 is the least responsive

The highest score is 15

What are the other classification systems of TBI?

Abbreviated injury scale (AIS)

The trauma score

Abbreviated trauma score

What are the GCS scores for eye opening (E)?

Spontaneous (4)

To speech (3)

To pain (2)

Nil (1)

Eye Opening Response (GCS) - 4

Eyes open spontaneously

Eye Opening Response (GCS) - 3

Eyes open to speech

Eye Opening Response (GCS)- 2

Eyes open to pain

Eye Opening Response (GCS) - 1

no response

What are the GCS scores for Best Motor Response (M)?

obeys (6)

localizes (5)

Withdraws (4)

Abnormal flexion (3); decorticate posturing

Extensor response (2); decerebrate posturing

Nil (1)

Best Motor Response (GCS) - 6

Obeys

Best Motor Response (GCS) - 5

Localizes

Best Motor Response (GCS) - 4

Withdrawal (flexion)

Best Motor Response (GCS) - 3

Abnormal flexion (decorticate)

Best Motor Response (GCS) - 2

Extensor response (decerebrate)

Best Motor Response (GCS) - 1

None

What are the GCS scores for Verbal response (V)?

Orientated (5)

Confused conversation (4)

Inappropriate words (3)

Incomprehensible sounds (2)

Nil (1)

Verbal response (GCS) - 5

Oriented

Verbal response (GCS) - 4

confused conversation

Verbal response (GCS) - 3

inappropriate words

Verbal response (GCS) -2

incomprehensible sounds

Verbal response (GCS) - 1

none

Galveston orientation and amnesia (GOAT)

Measures cognitive level of patients post-injury so that a more realistic recovery plan can be communicated

(LOS, rehab plan, prediction of recovery info for family)

Low score=longer duration of PTA amnesia period

Increased duration of PTA found w/ diffuse/bilateral brain injuries

Longer confused state=more difficult to return to pre-injury cognition

Rancho Los Amigos (RLA) Scale

Scale of cognitive functioning; rehab evaluation tool that focuses on clients abilities and behaviors

I-VIII

-Clients move through the stages during recovery process

Rancho level I

no response (coma); Total A

-not arousable, not responsive

-absence of awareness

-no periods of wakefulness

-coma rarely lasts > 3-4 wks unless medication induced

Rancho level II

Generalized response, persistent vegetative state (PVS); awake but unaware; Total A

-no awareness of self/environment (no attend, verbal, motor, incontinence)

-positive signs (sleep cycles, autonomic functions, random vocalizations/movements)

What are the types of vegetative states?

Persistent vegetative state (PVS)

Permanent (irreversible) vegetative state

Persistent Vegetative State (PVS)

condition in which a person is alive but unable to communicate or to function independently at even the most basic level; Past and current state

-after 1 mo in this state

Permanent (irreversible) vegetative state

12 months after TBI

3 months after non traumatic brain insult.

Determine level of medical support, nutrition

Advanced Directives helpful, but rarely present!

Rancho Level III

Localized response, minimally conscious state; Total A

Definite reproducible behavioral evidence of some awareness of self or environment

-follows commands

-gestures/verbal response to Qs

-intelligible sounds

-crying/laughing/smiling to stimuli

-reach/hold objects

-visual tracking

Locked-in syndrome

Loss of voluntary motor control in a setting of preserved consciousness; damage to corticospinal/corticobulbar pathways

Tetraplegia/bulbar weakness, vertical eye movement/blinking intact

-May be difficult to demonstrate conscious behavior because of motor limitations

Rancho Level IV

Confused/agitated; Max A

-alert/heightened activity

-purposeful attempts to remove tubes, crawl out bed

-absent short term mem

-cry/scream out of proportion to stimulus

-aggressive/flight behaviors

-mood swings w/ no relationship to environment

Rancho Level V

Confused, inappropriate, non-agitated; Max A

-alert but not agitated

-not oriented person, place, time,

-frequent periods of non-purposeful sustained attention

-unable to learn new material

-respond to simple commands matching external cues

-verbalizations often inappropriate and confused

Rancho Level VI

Confused, appropriate; Mod A

-inconsistently oriented to person, place, time

-remote mem more accessible than recent mem

-use assistive mem devices w/ Max A

-carry over for relearned familiar tasks (self care)

-unaware of impairments, disabilities, safety risks

Rancho Level VII

automatic, appropriate; Min A for ADLs

-Consistently oriented person, place, time

-incr attention/able to work for 30 mins on familiar tasks

-Min supervision for new learning

-initiates/carries out familiar self care/household tasks (may have limited mem of events)

-unrealistic planning for future/ overestimates

-unable to think about consequences

-unaware of others needs/feelings

Rancho Level VIII

Purposeful, appropriate; SBA/supervision

-consistently orientated to P, P, T

-attention incr to 60 min for familiar tasks

-recall past events/ integrate w/ recent events

-initiates/carry out steps for familiar tasks (personal, house, community, work, leisure) can slight mod plan w/ min A

-no A one new task is learned

-needs A to make corrective measures to plans

-thinks about consequences

-irritable/depressed

-acknowledges others needs/feelings

Neurological Examination process

Clients history

Present condition

Prior history

Familial history

Neurological examination basics

Mental status (Orientation, Memory, Cognition)

Orientation status

Person, place, time, situation- 0 x 4 etc

-Take into consideration if client has been unconscious, etc. when deciding orientation status

Memory status

Objects- show 4-5 objects, then cover and have client name the objects

Events- what did they eat for breakfast

Cognition status

Serial 7s

Interpret proverbs- developmentally/culturally appropriate

The cranial nerves

12 paired nerves coming off of the ventral side (underneath) the brain and bringing info to and from the brain, face, tongue, ears, eyes, throat, and visceral organs

CN I

Olfactory nerve (sense of smell); sensory

-test with coffee, lemon

CN II

Optic nerve: vision; sensory

-visual acuity and visual fields, assess w/ eye chart

central scotoma

a partial loss of vision or a blind spot in an otherwise normal visual field.

Hemianopsia

blindness in half the visual field

Monocular vision loss

A lesion to the optic nerve of one eye will lead to loss of the complete visual field of that eye.

-The other eye can still perceive the entire visual field.

Bitemporal hemianopsia

loss of both temporal half of the vision in each eye due to damage to optic chiasm

homonymous hemianopsia

a visual field defect involving either two right or the two left halves of the visual fields of both eyes

CN III

Oculomotor nerve: motor to eye/eyelid (movement) and pupil constriction; Motor

CN IV

Trochlear nerve: eye movement (superior oblique moving eye down/lateral); Motor

CN V

Trigeminal nerve: chewing muscles, sensory (touch/pain) to face/head (somatosensory); Both

-light touch on face

-have client close eyes and use a a tip to touch face randomly (client identifies location of touch)

CN VI

Abducens nerve: eye movement (lateral movement); Motor

CN VII

Facial nerve: taste (taste for ant 2/3 of tongue), facial expression muscles, somatosensory from ear; Both

-taste on tip of tongue (sugary/salty)

-ask client to smile, close eyes, wrinkle forehead (watch for spontaneous movement, droop, symmetry)

Bell's Palsy

Unilateral facial paralysis resulting from damage or trauma to CN 7

-usually temporary due ti inflammation of nerve

CN VIII

Vestibulocochlear nerve: hearing and balance/equilibrium; Sensory

-rub fingers by ear w/ eyes closed

static labyrinth

utricle and saccule

linear motion, position of head when static

dynamic labyrinth

Semi-circular canals

Movement of head, initial speed of movement

nystagmus

Involuntary, rapid, repetitive eye movements (vert, horizontal, rotary)

Slower phase/movement

Rapid phase w/ refixation back to midline

-induced to check CN VIII function

CN IX

Glossopharyngeal nerve: taste (post 1/3 of tongue), somatosensory from tongue, tonsils, pharynx, motor to swallowing muscles; Both

CN X

Vagus nerve: sensory, motor and autonomic functions of the viscera (digestive organs, heart, glands), some taste; Both

-somatic/visceral components

CN XI

Accessory nerve: motor control of head movement/swallowing; Motor

-(spinal accessory) turn head side to side and elevate shoulders

CN XII

Hypoglossal nerve: motor control to tongue; Motor

-tongue mobility for protrusion, push tongue side to side inside mouth to collect bolus after chewing

How do you check the integrity of CN VIII?

Cold calorics

COWS: cold opposite, warm same

physician does this test NOT OT

cold calorics

irrigating one ear canal w/ cold water, normally induces nystagmus to opposite side

-if system intact there will be fast phase and then opposite slow phase for few beats

-if only slow phase w/ eyes deviating towards cold water, indicates lack of activity

Deep tendon reflex

involuntary muscle contraction in response to striking muscle tendon with reflex hammer; test used to determine whether muscles respond properly

-use quick stretch to elicit response from muscle spindle

-two scales to rate

What are the two scales to rate a deep tendon reflex?

+/-

Normal= +

Absent= -

Or

0= no response; always abnormal

1+= slight but present response; may/may not normal

2+= brisk response; normal

3+= very brisk response; may/may not normal

4+= repeating reflex; always abnormal

Muscle tone

resting tension of the muscles

Hypotonia

Too little muscle tone, compromises posture/core stability

-damage to cerebellum

Low tone that impacts movement (voluntary movement disorder)

Hypertonia

Too much muscle tone, compromises efficiency of movement strategies

-cortical damage

High tone

Spasticity

Resistance to movement in only one direction for each degree of freedom, velocity dependent, classically termed clasp knife spasticity

-more tone during the initial part of movement

Rigidity

Resistance to movement in both directions for each degree of freedom, velocity independent

-does not vary w/ speed of movement of muscle groups involved

Types: cogwheel rigidity and lead pipe rigidity