TBI

what is a TBI?

- an alteration in brain function, or other evidence of brain pathology caused by an external force

what is the leading cause of injury-related death and disability in the US?

TBI

what are lead causes of TBI?

- falls

> 1. older adults

> 2. 0-4mo infants

> 14-24yo

what is the most common cause of TBI in young adults?

MVAs

what are the chances of return to work post TBI?

- 50% with mod to severe TBI return to work

- only 33% return to their pre-injury employment

is the brain considered an open or closed system

closed

does blood mix well with neurons?

no

does the skull offer adequate protection to the brain?

- skull offers SOME protection

what is included in the gray matter?

- neuronal cell bodies, dendrites, synapses

- cortex

- nuclei

- horns of the spinal cord

what is included in the white matter?

- tracts

- pathways

- columns

does the pia mater come in contact with white or grey matter?

grey

which is more vascularized - grey or white matter?

- grey

what is the corona radiata?

- 2 paired sheets of white matter fibers that transmit afferent and efferent neurons to and from the cerebral cortex

- continuous ventrally with the internal capsule, and dorsally with the centrum semiovale

- associated with the primary motor cortex

what motor tracts are included in the corona radiata?

- corticobulbar

- corticospinal

what is the flow of cerebrospinal fluid? (8)

1. lateral ventricles

2. interventricular foramina (of Monroe)

3. third ventricle

4. cerebral aqueducts (of Sylvius)

5. fourth ventricle

(exits ventricles)

6. subarachnoid space

7. arachnoid granulations

8. venous bloodstream

what are the enlarged areas where CSF is collected?

cisterns

what are the 4 functions of CSF? (4)

- protect brain and spinal cord

> shock absorption

- nourish and remove waste

> delivers nutrients and removes waste

- maintain brain function

> regulate intracranial pressure and provide buoyancy to reduce stress on brain

- circulate chemicals

> distribute hormones and neurotransmitters

what is a primary brain injury?

- damage is immediate

what is secondary brain injury?

- happen gradually over the course of hours, days, weeks

what is the process of primary brain injury? (5 steps)

1. cerebral contusion

2. axonal shearing

3. BBB damage

4. vascular dysfunction

5. cell death

what is the process of secondary brain injury? (8 steps)

1. NT release

2. increased intracerebral pressure

3. oxidative stress (free radicals)

4. inflammation

5. edema

6. ischemia

7. hypoxia

8. cell death (delayed or immediate)

what are causes of primary brain injuries?

- penetrating (open-head)

- nonpenetrating (closed-head)

> acceleration (whiplash, coup, countercoup)

> non-acceleration (blow to the head)

what are some types of primary injury (traumatic)?

- skull fracture

- contusions (brain bleed) lead to hematoma

- concussions

- lacerations

- diffuse axonal injury

what is a diffuse axonal injury?

- widespread shearing and stretching of axons

- leads to tearing of nerve fibers in the white matter tracts

what are the 3 types of diffuse axonal injuries?

- stretching (tensional forces)

- twisting (rotational forces)

- shearing forces

how is TBI classified?

- glasgow coma scale

what is consciousness?

- awareness of ones self and surroundings

> internal awareness

> external awareness

what is alert?

fully aware and attentive

what is clouding of consciousness?

- brain fog

- state characterized by confusion, impaired capacity to think and respond, disorientation, reduced attention, and memory defects

what is delirium?

- mental state in which you are confused, disoriented, and not able to think or remember clearly

- can be due to medications

what is obtundation?

- sleeps often

- when aroused, exhibits decreased alertness and interest in the environment

- delayed reactions

What is stupor?

- unresponsive state from which the patient can be aroused only briefly with vigorous, repeated sensory stimulation

what are disorders of consciousness (DOC)?

- coma

- unresponsive wakefulness (previous vegetative state)

- minimally conscious state

what is a coma?

- arousal system is not functioning

- arousal and awareness are absent

- patients eyes are closed

- there are no sleep/wake cycles

- ventilator dependent

what is unresponsive wakefulness?

- previously vegetative state

- dissociation between arousal and awareness

- higher CNS centers are not integrated with the brainstem

- pt may be aroused but they are not aware of self or environment

what is minimally conscious state?

- evidence of self or environmental awareness

- patients may localize to round and have sustain visual fixation

- inconsistently communicate through yes/no

what is ranchos los amigos?

TBI rating scale

what is an intracranial pressure monitor?

- a catheter is inserted into the ventricle of the brain to monitor ICP

- if pressure is high, CSF can be drained from ventricle

what is a brain oxygen monitor (licox)

- brain oxygen and cerebral blood flow monitor is inserted into the brain tissue and secured to the skill with a bolt

what are 2 surgeries that can be done with TBI?

- craniotomy

- decompressive craniectomy

> bone flap is stored in freezer and replaced when able (cranioplasty)

T/F: TBI rehab is a multidisciplinary approach?

true

what is the frontal lobe responsible for?

- personality

- behaviors

- emotions

- judgement

- speech (broca)

- problem solving

what is the parietal lobe responsible for?

- interpreting language

- sense of touch, pain, temperature

- interpret vision, hearing, memory

- spatial and visual perception

what is the occipital lobe responsible for?

- interprets vision

what is the temporal lobe responsible for?

- understanding language (wernicke)

- memory

- hearing

- sequencing

what is the cerebellum responsible for?

- balance

- coordination

- posture

what is the brainstem responsible for?

- automatic functions

> breathing

> HR

> swallowing, sneezing, coughing

what is anterograde amnesia?

- unable to create new memories

- usually last to recover after a coma

what is post-traumatic amnesia?

- cant remember events from injury to point of recovery

what is retrograde amnesia?

- inability to remember events prior to the injury

- usually decreases with recovery

what causes decorticate and decerebrate posturing?

- damage to the structures that control motor tone associated with CST

what is decorticate posture?

- lesion above the red nucleus

what is decerebrate posture?

- lesion below the red nucleus

what is the decorticate/decerebrate progression?

- decorticate progresses to decerebrate with progressive destruction/compression of brain structures

what neuromuscular impairments are seen with TBI?

- mostly UMN

- abnormal tone

> initially may be paralytic, then spastic/hyperreflexive

- weakness (hemi/tetra)

what is the JFK coma recovery scale?

- characterise and monitor patients with RLA I-IV

- arousal facilitation protocol

> deep pressure to face, neck, shoulder, arm, hand, chest, back. leg, foot, toes bilaterally

what is community integration questionnaire?

- scales whether the patient does certain community/household/social activities or if they have someone else do it

what are interventions for RLA levels I-III (low level) (4)

- prevent secondary impairments

> prevent contractures, wounds

- monitor changes in status

- provide upright activity challenges

- family education and involvement

T/F: early treatment sessions should be shorter durations, increased frequency?

true

T/F: early exercise post TBI may have adverse effects and impair cognitive recovery?

true

T/F: delayed exercise (2-5wks post) may be more beneficial for neurorehab?

true

does exercise lead to increased or decreased neuroplasticity?

increased

does exercise lead to increased or decreased neuroinflammation?

decreased

does exercise lead to increased or decreased apoptosis?

decreased

does exercise lead to increased or decreased neuroprotection and repair?

increased

what are interventions for RLA levels V-VI (intermediate levels)? (3)

- provide consistent and routine structure

- work on basic mobility and ADL

- improve activity tolerance

what are interventions for RLA levels VII-VIII (high functioning)? (2)

- return to life and community activities

- include cognitive challenges