Neuro Rehab - TBI & Neuro-Oncology

Brain dysfunction or damage resulting from an external mechanical force

TBI

What is a primary brain injury?

Tissue damage occurring at the time of the accident

Examples of primary brain injuries?

Skull fracture, contusion, laceration, intracranial lesions, and DAI

What is a secondary brain injury?

Damage occurring after the initial injury as a consequence of the primary injury

Examples of secondary brain injury?

Hypoxia, edema, infection, neurochemical changes, increased ICP, and mass effect from bleeding

Penetrating injury or depressed skull fracture with potential infection risk

Open TBI

Brain injury without interruption of the skull

Closed TBI

Injury caused by contact of the head with an external object or surface

Focal brain injury

Widespread axonal damage caused by acceleration/deceleration and rotational forces.

Diffuse axonal injury (DAI)

What forces contribute to DAI?

Shearing, tensile, and compressive forces

Brain tissue damage directly beneath the point of impact

Coup contusion

Brain injury occurring opposite the point of impact

Contre-coup contusion

What brain regions are especially vulnerable to rotational injury?

Frontal and temporal

What mechanism commonly causes DAI?

Rapid acceleration/deceleration with rotational forces

. What GCS is commonly associated with severe DAI?

GCS <8 for approximately 6 hours

What may mild DAI resemble clinically?

A post-concussive presentation

What can severe DAI cause?

Prolonged loss of consciousness or persistent vegetative state

Severity of Injury: mild TBI

LOC 0-30 min

Alteration of consciousness: ≤24 hr

Posttraumatic amnesia: 0-1 day

GCS 13-15

Severity of Injury: moderate TBI

LOC >30 min but <24 hr

AOC >24 hr

PTA >1 but <7 days

GCS 9-12

Severity of Injury: severe TBI

LOC >24 hr

AOC >24 hr

PTA >7 days

GCS <9

What qualifies as a concussion?

LOC, memory loss, altered mental status, or focal neurological deficits

What are common physical concussion symptoms?

Headache, dizziness, nausea, sleep problems, and fatigue.

What are common cognitive concussion symptoms?

Reduced attention, concentration, mental speed, and short-term memory

What are common behavioral concussion symptoms?

Irritability, emotional lability, depression, and anxiety

Classification of Concussion: Grade 1

No loss of consciousness, all symptoms resolve within 15 minutes

Classification of Concussion: Grade 2

No loss of consciousness, symptoms last longer than 15 minutes

Classification of Concussion: Grade 3

Loss of consciousness for any period of time

Up to ____% of patients will continue to experience headache and dizziness for up to one month

90%

A more extensive collection of persistent symptoms following concussion

Post-concussive syndrome (PCS)

When can PCS symptoms develop?

4 wks after injury

When do PCS symptoms typically peak?

1 week after injury

When are most patients symptom-free?

Within 3 mths

An abnormal collection of blood under the dura mater

Subdural Hematoma

Life-threatening and result from the accumulation of blood between the arachnoid and pia mater

Subarachnoid Hemorrhage

An extra-axial collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull

Epidural hematoma

An epidural hematoma MOST commonly involves injury to a:

Meningeal artery

A devastatingcondition whereby a hematoma is formed within the brain parenchyma with or without blood extension into the ventricles

Intracerebral Hemorrhage

A patient reports the "worst headache of my life" accompanied by nausea, vomiting, and diplopia. Which diagnosis should be suspected?

Subarachnoid hemorrhage

What are priorities during emergency TBI treatment?

Establish airway

Reduce blood loss

Maintain cervical stabilization

When is endotracheal intubation used?

When ventilation is expected for <2 weeks

When may tracheostomy be used?

When ventilation is expected for >2 weeks

What GCS indicates severe injury/coma?

<9

What GCS indicates moderate injury?

9-12

What GCS indicates minor injury?

13-15

GCS: Eye Opening (Brainstem function)

• 4 - opens eyes spontaneously

• 3 - opens eyes to voice

• 2 - opens eyes to pain

• 1 - no eye opening

GCS: Motor Response (Cerebrum)

• 6 - obeys commands

• 5 - localizes to pain

• 4 - withdraws to pain

• 3 - abnormal flexor response

• 2 - abnormal extensor response

• 1 - no movement

GCS: Verbal response (Cerebrum)

• 5 - appropriate and oriented

• 4 - confused conversation

• 3 - inappropriate words

• 2 - incomprehensible sounds

• 1 - no sounds

What is normal ICP?

0-15 mmHg

When is ICP considered high?

>20 mmHg

CPP =

MAP − ICP

What cerebral perfusion pressure (CPP) should generally be maintained?

>70 mmHg

Which medication is an osmotic agent used in the management of increased ICP?

Mannitol

Paroxysmal sympathetic hyperactivity after severe brain injury

Sympathetic storming aka Paroxysmal sympathetic hyperactivity

What can trigger sympathetic storming?

Medication changes, repositioning, or environmental stimulation

Signs of sympathetic storming

Increased BP, HR, temperature, RR, sweating, rigidity, and restlessness

Why is sympathetic storming dangerous?

Prolonged episodes can cause dehydration, muscle atrophy, weight loss, pressure sores, and musculoskeletal damage

What is the primary PT goal during the acute phase?

Identify complications and develop an intervention plan

Rancho Los Amigos Cognitive Scale

Rancho Level I

No response; total assistance

Rancho Level II

Generalized response; total assistance

Rancho Level III

Localized response; total assistance

Rancho Level IV

Confused-agitated; maximal assistance

Rancho Level V

Confused-inappropriate, non-agitated; maximal assistance

Rancho Level VI

Confused-appropriate; moderate assistance

Rancho Level VII

Automatic-appropriate; minimal assistance

Rancho Level VIII

Purposeful-appropriate; standby assistance

Rancho Level IX

Purposeful-appropriate; standby assistance on request

Rancho Level X

Purposeful-appropriate; modified independent

Low Level Responsiveness Goals

1) Increase level of arousal

2) Increase consistency of response

3) Decrease hypertonia

4) Maintain ROM/Prevent contracture

5) Prevent Skin Breakdown

6) Maintain lung perfusion

7) Establish education program for family

RLACS II- III Goals

1) Increase appropriate FMTAs

2) Increase functional strength through FMTAs

3) Decrease posturing/tonal abnormalities

4) Increase alertness/attention

5) Increase participation in tasks

6) Educate family on probable course of the near term recovery

A patient inconsistently turns their head toward their spouse's voice and occasionally follows the command "squeeze my hand." Which Rancho level BEST fits?

Rancho III

What is the patient's overall state at Rancho Level IV?

Alert but confused and agitated.

What is the patient's activity level?

Increased activity; may be aggressive or try to escape

Movements are often purposeless and not on command.

How long is attention sustained?

Very brief and usually non-purposeful

Rancho Level IV Goals

- Increase Endurance

- Maintain joint mobility

- Decrease risk of secondary impairments

- Decrease outbursts and agitation

RLA lvl IV Interventions

- Automatic activities

- Prepare multiple activities

- Give patient choices

- Provide simple instructions with time to process

- Watch frustration and know when to stop or change activities

A patient is not oriented to person, place, or time and cannot learn new information but consistently follows simple commands when external structure is provided. Which Rancho level?

Rancho V

Key phrase for Rancho V?

Confused, Inappropriate, Non-Agitated

Rancho Level V Goals

-Increase Functional Activities

-Improve gait and balance

-Increase strength

-Improve motor and postural control

-Increase orientation to person, place, and time

-Increase attention span

-Improve memory

-Decrease distractibility

-Increase family participation in treatment

RLA lvl IV Interventions

-Highly structured functional tasks

• use cues/external direction

• use assistive devices

-Provide success, give positive reinforcement

-Avoid distracting stimuli

-Meaningful activities

-Use props - calendars, large clocks, schedule books

Which cognitive finding is MOST characteristic of Rancho V?

Unable to learn new information

A patient is inconsistently oriented, follows simple directions, demonstrates carryover of relearned self-care activities, but has little carryover for new learning. Which Rancho level?

Rancho VI

What are some other characteristics of lvl VI

◦ Inconsistent orientation to person, place, and time

◦ Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection

◦ Uses memory aide with max assist

◦ Shows carry over for relearned familiar tasks (e.g. self care)

◦ Remote memory has more depth and detail than recent memory

◦ Emerging awareness of appropriate response to self, family and basic needs

Which finding MOST strongly suggests Rancho VI rather than Rancho V?

Consistently follows simple directions

Rancho Level VI Goals

◦ Increase Functional Activities

◦ Improve gait and balance

◦ Increase strength

◦ Improve motor and postural control

◦ Increase orientation to person, place, and time

◦ Increase attention to specific stimuli

◦ Improve immediate and short term memory

◦ Decrease inappropriate responses to stimuli

◦ Decrease impulsivity, irritability, dependence on family

RLA lvl VI Interventions

-Highly structured functional tasks

◦ Decrease cues/external direction

◦ Decrease use assistive devices

◦ Increase speed and complexity of tasks as able

-Structure the environment

-Start sequencing tasks

A patient is consistently oriented to person and place, completes familiar routines, demonstrates new learning, but overestimates their abilities and has poor awareness of consequences. Which Rancho level?

Rancho Level VII

Rancho Level VII Goals

◦ Increase Functional Activities

◦ Improve gait and balance

◦ Increase strength

◦ Improve motor and postural control

RLA lvl VII Interventions

◦ Structured functional tasks

◦ Increase complexity of tasks

◦ Work on coordination and fine motor control

◦ Increase executive functions - planning routes, preparing food, making clothing decisions

Which lvl is a person who has aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action

VIII

A patient is consistently oriented, independently completes familiar tasks for one hour in a distracting environment, and acknowledges deficits but requires standby assistance to correct problems. Which Rancho level?

VIII

Goals of VIII

◦ Increase Functional Activities

◦ Improve gait and balance

◦ Increase strength

◦ Improve motor and postural control

◦ Increase executive functions

◦ Increase responsibility for tasks and consequences

◦ Increase concentration on specific tasks

Interventions for VIII

◦ Structured and unstructured functional tasks

◦ Increase complexity of tasks

◦ Work on coordination and fine motor control

◦ Community outings with patient managing architectural barriers, crowds, using public transportation, etc

Which lvl allows a pt to be independent with multi tasking for up to 2 hours?

Level IX

Requires stand-by assist to anticipate a problem before it occurs and take action to avoid it

Level IX

Able to multitask in all environments with occasional breaks

Level X

Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them

Level X

A patient independently manages familiar and unfamiliar activities but takes extra time and uses compensatory strategies. They recognize how their deficits may affect a task and adjust BEFORE a problem occurs. Which level?

Level X

T or F: long-term memory and memory lasting a few seconds are generally intact, whereas registration, storage, and recall of day-to-day events are commonly impaired

T

What executive functions can frontal lobe damage affect?

Goal setting, planning, execution, evaluation, and problem solving