236-TBI & Neuro Info

Types of TBI injuries

Severe TBI: Open head or closed head injury

Non-traumatic: drug overdose, chronic substance use, carbon monoxide, toxins, anoxia (depletion of O2)

Immediate medical interventions after TBI

Reduce inc intracranial pressure (ICP) monitor for >40; Hypotension/hypoxia monitored

Surgical interventions (remove object; evacuate hematoma; bone flap to reduce pressure)

Decorticate posturing (decorticate rigidity) & location of trauma

UE in a spastic flexed position, internal rotation (IR) and adducted

LE spastic extended, IR and adducted

Location: injury in cerebral hemis, internal capsule, above the superior colliculus

Decerebrate posturing (decerebrate rigidity) & location of trauma

UE & LE in extension, adduction and IR, wrist and fingers in flexion

location: Lesion below the superior colliculus-brainstem region

Retrograde amnesia

cannot remember events prior to injury

Anterograde amnesia

cannot form memories or store/retrieve information after injury

Post-traumatic amnesia (PTA)

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

length of PTA is predictor of prognosis

Secondary medical issues related to TBI

WB status may interfere w/participation of rehab

pulmonary restrictions

Decubiticus Ulcers (from prolonged pressure of skin)

SCI+TBI (30% of cases)

OT rehab focus in TBI cases

Splinting/casting UE; neuromuscular re-edu; cognitive training; ADL participation; transfers; w/c mobility; equipment training/needs; home eval; caregiver training

Glasgow Coma scale & scoring

designed to assess severity of coma and impaired consciousness

3-8: severe TBI

9-12: mod TBI

13-15: mild TBI

Glasgow scoring aspects

Eye-opening response: 1 (NR), 2 (R to pain), 3 (R to speech), 4 (spontaneous R)

Motor Response: 1 (NR), 2 (extensor response--Decerebrate posturing), 3 (abnormal flexion--Decorticate posturing), 4 (withdraws), 5 (localize), 6 (obey)

Verbal response: 1 (NR), 2 (random sound), 3 (inappropriate words), 4 (confused convo), 5 (oriented)

overall score (E+M+V)

lowest 3 - highest 15

Galveston orientation and amnesia test GOAT

measures cognitive level of patients post-injury-so realistic recovery plan can be communicated

low GOAT = longer PTA period

Longer PTA found in patients w/diffuse/bilateral brain injury

RLA I

Total A: No Response;

lack of awareness (orientation), no wakefulness period (in coma); coma rarely lasts 3-4wks unless induced

TBI Clinical signs and symptoms

Autonomic fxns: vital signs

Consciousness: level of arousal, cognition, length of coma

Motor fxns: reflexes etc.

Pupillary response: Depth of coma-pathological signs of coma

Ocular movement: If cranial nerves has been impacted--Abnormalities in pupil size, shape and light

RLA II

Total A: persistent vegetative state (PVS);

No awareness of self/env

No automatic motor response/localizing

Incontinence bowel and bladder

Positive signs: sleep/wake cycles; Brainstem, autonomic fxns: gag/swallow, random vocalizations / movements

RLA III

Total A: minimally conscious state

Some awareness w/wakefulness

Follows commands, gestures/Verbal response to Qs

Crying, laughing, smiling/relevant stimuli

Visual tracking

reaching/holds objects

W/C positioning goals for RLA I-III

Prevent deformity, tone normalization; pressure management, promote fxn; inc sitting tolerance; provide proper body mechanics; enhance respiratory fxns

RLA I-III other interventions

Dynamic head positioning device;

spasticity management (normalize tone)--neuromuscular blocks that can be used in addition to casting

When do you cast

When splinting has failed to control severe tone/contracture

ROM is dec and prolonged stretches necessary

consequences of lack of intervention

Contractures

Limited head/trunk control

Inc caregiver assistance

Limited participation in daily occupations

RLA IV

max A: confused/agitated

Alert and often heightened level of activity

Absent short-term memory

May exhibit aggressive bx/flight bx

RLA V

Max A:confused, inappropriate, non-agitated

Alert not agitated

Not oriented to person/place/ time

Unable to learn new material

Can respond to simple commands; can converse on social automatic level briefly; consistent with external cues

Verbalizations about present events often inappropriate and confused

RLA VI

mod A: confused, appropriate

Inconsistently oriented to person/place/time

Remote memory more accessible than recent memory

Able to use assistive memory devices max A

Show carryover of previously learned tasks (self-care)

Unaware of impairments, disabilities, safety risks

RLA VII

min A for ADLs; automatic & appropriate

Oriented to person/place/time

Inc attention & able to work for 30 min on familiar tasks

Min supervision for new learning

Initiates & carries out self-care/household tasks but may have limited memory of events

Unrealistic planning for future; overestimates abilities

Unable to think about consequences

Unaware of others needs/feelings

RLA VIII

stand by A (SBA)/supervision: purposeful & appropriate

Oriented to person/place/time

Attention has inc to 60 min for familiar task

Recalls past events and integrate recent events

Initiates and carries out steps for familiar person, household, community, work, leisure routines and can modify a plan when needed w/ min A

Requires no A once a new task/activity is learned

Needs assistance to make corrective measures when plans needs substantial alterations

Thinks about consequences; irritable/depressed

Acknowledges others needs/feelings

CN I & Tests

Olfactory; sensory fxn

Test ability to detect odor (does not need to ID it)

Test w/common orders (coffee/orange etc)

Do not use noxious odors

CN II & Tests

Optic; Sensory fxn

Visual acuity and visual fields

Asses w/eye chart--Test for visual cuts (peripheral vision)

Bitemporal hemianopsia

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

Homonymous Hemianopsia

visual defects involving either two right or two left halves of visual field of both eye (lose vision of same side on both eyes)

CN III

oculomotor; motor fxn

constricts pupil

CN IV

trochlear motor fxn

moves eyes

CN VI

abducens; motor fxn

moves eyes

CN III, IV, VI tests

tracking/pursuits, convergence, pupil reactivity

CN V & Tests

Trigeminal; Both

Motor: chewing

Sensory: light touch on face, cl must localize touch on both sides of face, compares sides for diff in sensation

CN VII & Tests

facial Nerve; Motor & Sensory fxn

Motor: facial muscles of expression--Ask cl to smile or other expression to inspect facial droop or asymmetry

Also checks for motor planning

Sensory: taste on tip of tongue, salivation

CN VIII

Vestibulocochlear; Sensory: both branches

Cochlear: ability to hear

Test: rub fingers by ear canal w/eyes closed

Test if they know which side the sound is coming from

Vestibular: detects info about position of head/body for balance, equilibrium

Status labyrinth: from utricle and saccule

Linear motion, position of head when static

Dynamic labyrinth: semicircular canals

Movement of head, initial speed of movement

Monocular vision loss

loss of vision in one eye

central scotoma

blind spot in the center of the visual field surrounded by an area of normal vision

CN IX

glossopharyngeal; Both

Sensory for taste in various parts of tongue

Motor for swallow to elevate the palate & propel the bolus chewed food

initiates swallowing and gag reflex

Nystagmus

involuntary, rapid, repetitive eye movements

Two phases:

Slower phase/movement-mediated by brainstem

Rapid phase w/re-fixation back to midline-mediated by cortex

CN X

vagus; Both

sensory fxns

Somatic: sensations felt on skin/muscles

Visceral: sensations felt in organs

Motor fxn: stimulates muscles in pharynx, larynx, soft palate (near roof of mouth), stimulates muscles in heart (helps lower Resting HR); stimulates involuntary contractions of digestive tract (i.e. esophagus, stomach, intestines)--allows food to move through tract

CN XI

Spinal Accessory; Motor Fxn

Allows you to turn head side to side & elevate shoulders

CN XII

Hypoglossal; Motor fxn

Allows tongue mobility (pushing tongue from side to side inside mouth to collect bolus chewed food

Hyperreflexia

Exaggerated reflex response

SC movement disorders

spasticity & four components

Hypertonia, Hyperreflexia, clonus (spastic involuntary contraction; induced by sustained stretching of spastic muscles), degrees of paralysis

Brain stem movement disorders

-Locked-in syndrome: Loss of voluntary motor control

-Decerebrate rigidity

-Associated reactions: inc in tone of parts not involved in particular movement (i.e. when grabbing object in R hand the L hand will do grasping motion)

Basal Ganglia movement disorders

Athetosis: involuntary, continuous, arrhythmic movement disorder

Parkinsons disease: resting tremors; affects timing & rhythm of gait and movements (difficulty stopping movement once they started)

Cerebellar level movement disorders

Ataxia: seen as clumsiness or uncertainty of movement (c/ walk with wide gait)

Dysmetria: difficulties w/ calibration

Dysdiadochokinesia: inability to perform rapidly alternating movement ( cant pronate-> supinate or tap fingers twice w/thumb)

intention tremors: tremors inc in rate/duration when picking up small objects

asthenia: excessive weakness/fatigue in voluntary muscles