Traumatic Brain Injuries (TBI)

Glasgow Coma Scale

Score of 3-15, 3 = bad, 15 = good

3-8 = severe head injury

• H8 to be severe

9-12 = moderate head injury

13-15 = mild head injury

• lucky number 13 to be mild

RLA Level 1 & interventions

No response

Appears asleep (coma)

Positioning & ROM to prevent contractures

RLA Level 2 & interventions

General response to stimulation

Reflexive response to pain

Not localized

Same as level 1

RLA Level 3 & interventions

Localized response to stimuli

STILL DEPENDENT ON ADL’s

Inconsistent and delayed response to simple commands (closing eyes)

Turns toward stimulus

Attempting to get localized response/attention

AAROM

RLA Level 4 & interventions

Confused-agitated

Alert, heightened state

Aggressive behavior and responses that are overresponsive to type of stimuli presented

Assist with simple ADLs

Restraints may be necessary (physician’s orders required)

RLA Level 5 & interventions

Disoriented/Confused-inappropriate

Follows simple commands (1-2 steps) when provided structure

Unable to initiate ADLs

New learning is not possible

Build habits of self-orienting, checking external sources

Multi-step tasks

RLA Level 6 & interventions

Confused-appropriated

Inconsistent orientation to time and place

Selective attention is impaired

Max A for new learning

Uses cues

Task re-learning, utilizing external self-cueing

RLA Level 7 & interventions

Automatic-appropriate

Orientation to person and place with consistency

Moderate assist for orientation to time

Increased superficial awareness of the condition

Limited judgment, insight, problem-solving, and planning

IND for ADLs

Supervision is required for home and community skills

Working on IADLs, role-playing useful

RLA Level 8 & interventions

Purposeful-appropriate minimum assistance

Alert and oriented to person, place and time

IND for ADLs and home/community skills

Problem solving

Routine tasks are fine

difficulty with one-off problems

Ranchos Los Amigos Scale Keyline

• Response (stimulation)

• Response (stimulation)

• Response (stimulation)

• Agitated (restraints per physician’s order)

• No Clue

• Check your watch (task relearning)

• Hang of basics (IADL practice, role-play)

• One off problems (problem solving)

Components of Evaluation in levels 1-3

• Arousal level and cognition

• Vision

• Sensation

• Joint ROM

• Motor control

• Dysphagia

• Emotional and behavioral factors

Components of Evaluation in levels 4-8

• Physical status

• Dysphagia

• Cognitive, visual, and perceptual skills

• ADLs

• Driving (evaluated at advanced RLA level)

• Vocational rehab (evaluated at advanced RLA level)

• Psychosocial skills (evaluated at advanced RLA level)

A client who has experienced a TBI and has prolonged bedrest will likely result in a posterior pelvic tilt (true or false)

True

Decorticate Rigidity

• Affects the UE

• UE is flexed, internally rotated, and adduction position

Decerebrate Rigidity

• UE and LE in an extended position with adduction and internal rotation

• More severe

Frontal Lobe

• Associated with safety awareness, executive dysfunction, judgment, and impulsivity

Temporal Lobe

• Associated with auditory stimuli and includes the primary auditory cortex

Parietal Lobe

• Associated with sensation and contains the primary sensory cortex

Occipital Lobe

• Associated with visual information and contains the primary visual cortex

What is the OT’s role in the acute stage of TBI recovery?

• To increase the client’s awareness of himself/herself, along with the environment of the acute care setting

Multi-focal/Difuse Injury

• Associated with sudden deceleration (motor vehicle accidents)