PBL Case 7: TBI

WIDE SPREAD SHARING + RETRACTION of AXONS are common with what type of head injury

diffuse axonal injury (DAI)

what OUTCOME MEASURE for a patient with a TBI would be indicative of someone with the BEST REHAB POTENTIAL

Rancho Level VI

what are 3 SIGNS that indicate a TBI patient is NOT TOLERATING TREATMENT WELL

1. elevated HR

2. increased respiratory rate

3. falling BP

your TBI patient is currently a LEVEL 2 on the Rancho Scale. what would be your PRIMARY THERAPY GOAL at this time

maintain ROM of all major joints

you are assessing cognitive status on a patient status post TBI. what would be the BEST WAY to ASSESS "ABSTRACT" REASONING ABILITY

interpreting meaning of the phrase "a rolling stone gathers no moss"

what are 6 PATIENT ASSETS that play a POSITIVE ROLE in the recovery of a TBI patient

1. pre-admission/pre-injury independence + activity level (PLOF)

2. strong family support

3. pre-injury social history

- no alcohol/smoking history

- active lifestyle

4. resting vitals within functional limits

5. preserved functional strength

- able to sit with balance + stand with assistance

- no paralysis/hemiparesis noted

6. improved in Rancho Level

(suggestive possible cognitive improvements over time)

what are 9 PATIENT LIABILITIES that play a NEGATIVE ROLE in the recovery of a TBI patient

1. patient age

- advance age = impact healing, slow neuroplasticity + increase risk of complications

2. cognitive impairment

- Rancho Level

- unable to follow more than one-step commands

3. TBI classification (mild/moderate/severe TBI)

4. musculoskeletal damage to dominant side

5. postural + balance deficits

6. orthostatic hypotension

7. skin concerns

8. limited ROM

9. additional lines (catheter + G-tube)

- require additional nursing care

- increased risk of infection

what are 6 FACTORS why a patient requires MAXIMAL ASSIST of 2 PEOPLE to STAND but appears to have relatively NORMAL MOTOR STRENGTH

1. cognitive impairments (Rancho Level IV)

2. fear

3. poor postural control

4. agitation

5. inability to follow commands

6. impulsivity

what are 5 STRATEGIES to help a patient overcome the reason for needing MAXIMAL ASSIST of 2 PEOPLE to STAND while having relatively NORMAL MOTOR STRENGTH

1. implement repetition

2. structured + quiet low-stimulus environment

3. consistent verbal cues + tactile input

4. incorporate visual prompts

5. incorporate graded exposure to upright posture to reduce fear

what are 12 TESTS + MEASURES/OUTCOME MEASURE that are commonly used in patients with MILD TBI

1. immediate post-concussion assessment + cognitive testing

2. standardized assessment of concussion

3. vestibular positional tests

4. sensory organization test

5. balance error scoring system

6. dynamic gait index (DGI)

7. functional gait assessment (FGA)

8. high-level mobility assessment tool

9. post-concussion scale-revised

10. sport concussion assessment tool post-concussion symptom scale

11. dizziness handicap inventory

12. activities-specific balance confidence scale

what are 8 AREAS for a PT to EXAMINE + INTERVENE in patients with a MILD TBI

1. patient education

2. activity intolerance

3. vestibular dysfunction

4. high-level balance dysfunction

5. post-traumatic headache

6. temporomandibular disorder

7. attention + dual-task performance

8. participation in exercise

what are 18 ELEMENTS of the EXAMINATION for a TBI patient

1. aerobic capacity/endurance

2. arousal, attention + cognition

3. behavioral status

4. cranial nerve integrity

5. gait, locomotion + balance

6. integumentary integrity

7. joint integrity + mobility

8. motor function (motor control + learning)

9. muscle performance (strength, power + endurance)

10. neuromotor development + sensory integration

11. pain

12. posture

13. ROM

14. reflex integrity

15. self-care + ADL skills

16. sensory integrity

17. ventilation + respiration/gas exchange

18. work/leisure/community reintegration

what are 8 OUTCOME MEASURES used for assessing the AROUSAL, ATTENTION + COGNITION of a TBI patient

1. coma recovery scale-revised

2. disorders of consciousness sale

3. rancho los amigos levels of cognitive functioning

4. moss attention rating scale

5. test of everyday attention

6. trail making test part B

7. Galveston orientation + amnesia test

8. orientation log

what are 3 OUTCOME MEASURES used for assessing the BEHAVIORAL STATUS of a TBI patient

1. supervision rating scale

2. neurobehavioral rating scale-revised

3. agitated behavior scale

what are 7 OUTCOME MEASURES used for assessing GAIT, LOCOMOTION + BALANCE of a TBI patient

1. BERG balance scale

2. community balance + mobility scale

3. high-level mobility assessment tool

4. rancho los amigos OGA system

5. 10 meter walk test

6. 6MWT

7. modified walking + remembering test

what are 2 OUTCOME MEASURES used for assessing SELF-CARE + ADL SKILLS of a TBI patient

1. functional independence measure (FIM)

2. functional assessment measure

what are 2 OUTCOME MEASURES used for assessing WORK/LEISURE/COMMUNITY REINTEGRATION of a TBI patient

1. mayo-portland adaptability inventory

2. community integration questionnaire

what are 2 PRIMITIVE REFLEXES that arise following a TBI

1. ATNR

2. STLR

Asymmetrical Tonic Neck Reflex (ATNR)

Trigger: turning head to one side

Response:

- extension of arm + leg on face side

- flexion of arm + leg on skull side

Impact:

1. difficulty with bilateral tasks

2. interferes with bed mobility (rolling + bridging)

3. can cause unintentional UE/LE extension

4. can cause loss of balance during gait/transfers

5. maintain head in midline + avoid passive head turning during tasks

what TRIGGERS the ATNR

turning head to one side

what are the 2 RESPONSES of the ATNR when triggered

1. extension of arm + leg on face side

2. flexion of arm + leg on skull side

what are 4 WAYS the presence of an ABNORMAL ATNR can influence treatment of a TBI patient

1. difficulty with bilateral tasks

2. interferes with bed mobility (rolling + bridging)

3. can cause unintentional UE/LE extension

4. can cause loss of balance during gait/transfers

in the presence of an ABNORMAL ATNR what should be maintained + avoided

Maintain: head in midline

Avoid: passive head turning during tasks

Symmetrical Tonic Labyrinthine Reflex (STLR)

Trigger: head position relative to gravity (flexion/extension)

Response:

1. head extended = increased extensor tone in trunk + limbs

2. head flexed = increased flexor tone in trunk + limbs

Impact:

1. poor transfers (supine to sit, sit to stand)

2. exaggerated extension/flexion tone depending on head position

3. can result in loss of:

- balance

- postural instability

- unintended movement patterns during mobility

4. limit extreme head flexion/extension + facilitate trunk control in midline

what TRIGGERS the STLR

head position relative to gravity (flexion/extension)

what are the 2 RESPONSES of the STLR when triggered

1. head extended = increased extensor tone in trunk + limbs

2. head flexed = increased flexor tone in trunk + limbs

what are 3 WAYS the presence of an ABNORMAL STLR can influence treatment of a TBI patient

1. poor transfers (supine to sit, sit to stand)

2. exaggerated extension/flexion tone depending on head position

3. can result in loss of:

- balance

- postural instability

- unintended movement patterns during mobility

in the presence of an ABNORMAL STLR what should be limited + facilitaed

Limited: extreme head flexion/extension

Facilitate: trunk control in midline

what are 5 MINIMUM QUALIFICATIONS for being ACCEPTED into an INPATIENT REHAB FACILITY

1. patient needs to be medically stable enough to participate in therapy + manage potential complications arising during rehab

2. patient must have a condition necessitating an intensive program

3. patient must be able to handle 3 hours of therapy per day at least 5 days/week (PT, OT, SLP)

4. patient will make measurable functional improvement

5. patient must be able + willing to actively participate in intensive therapy

how does MEDICARE REIMBURSE for INPATIENT REHABILITATION

1. medicare uses IRF-PAI to classify patients into payment groups

2. facilities then get reimbursement based on the diagnosis, severity + patient's functional status

how long will a TBI PATIENT stay in an INPATIENT REHAB SETTING

2 weeks (13-15 days)

how long can a patient RECEIVE SKILLED NURSING CARE under MEDICARE

1. days 1-20 100% covered by Medicare part A

2. days 21-100 Medicare requires a daily co-payment

3. once 100 days are reached within a benefit period Medicare no longer covers SNF care

- patient would have to have a 60-day well-period before process restarts

what is a TBI (Traumatic Brain Injury)

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

what are 4 ETIOLOGICAL FACTORS associated with TBIs

1. falls

2. motor vehicle/traffic accidents

3. struck by/against events

4. assaults

what are the 3 DIFFERENT AGE LEVELS that TBIs PEAK at

1st peak: early childhood (1-2 years)

2nd peak: late adolescence + early adulthood (15-24 years)

3rd peak: elderly population

what is the 1st TBI PEAK (early childhood) related to

child abuse

what is the 2nd TBI PEAK (late adolescence + early adulthood) related to

risk-taking behaviors

what is the 3rd TBI PEAK (elderly population) related to

falls

what is the PATHOPHYSIOLOGY of TBIs

brain damage results from external forces that cause brain tissue to make direct contact with an object, rapid acceleration/deceleration forces or blast waves from an explosion

regarding TBI PATHOPHYSIOLOGY, what are the 3 CATEGORIES that brain tissue damage is classified under

1. primary injury (primary TBI)

2. secondary injury

3. blast injury

what is a PRIMARY INJURY due to

direct trauma to parenchyma

what does a SECONDARY INJURY result from

cascade of biochemical, cellular + molecular events that evolve over time due to initial injury + injury-related hypoxia, edema + elevated ICP

what does a PRIMARY TBI result from

1. brain tissue coming into contact with an object (bony skull/external object creating a penetrating injury)

OR

2. rapid acceleration/deceleration of brain

what is the PREDOMINANT MECHANISM of INJURY in SEVERE to MODERATE TBIs

diffuse axonal injury (DAI)

what is DIFFUSE AXONAL INJURY (DAI) common in (2)

1. high-speed motor vehicle accidents

2. some sports-related TBIs

how does BLAST INJURY lead to BRAIN DAMAGE

explosive device detonates = transient shock waves produced causing brain damage

what are the 3 TYPES of BLAST INJURIES

1. primary blast injury

2. secondary blast injury

3. tertiary blast injury

what does a PRIMARY BLAST INJURY result from

direct effect of blast overpressure on brain

what does a SECONDARY BLAST INJURY result from

shrapnel + other objects being hurled at individual

when does a TERTIARY BLAST INJURY occur

when victim is flung backwards + strikes an object

what can BLAST-RELATED BRAIN INJURY result in (5)

1. edema

2. contusion

3. DAI

4. hematomas

5. hemorrhage

what are 4 NEUROMUSCULAR IMPAIRMENTS associated with a TBI

1. paresis

2. abnormal tone

3. motor function

4. postural control

what are 6 COGNITIVE IMPAIRMENTS associated with a TBI

1. arousal level

2. attention

3. concentration

4. memory

5. learning

6. executive functions

what are 7 NEUROBEHAVIORAL IMPAIRMENTS associated with a TBI

1. agitation/aggression

2. disinhibition

3. apathy

4. emotional lability

5. mental inflexibility

6. impulsivity

7. irritability

what are 10 SECONDARY IMPAIRMENTS + CONCOMITANT INJURIES associated with a TBI

1. DVTs

2. heterotopic ossification

3. pressure ulcer

4. pneumonia

5. chronic pain

6. contractures

7. decreased endurance

8. muscle atrophy

9. fracture

10. peripheral nerve damage

Characteristics of Mild TBI

Level of Consciousness (LOC): 0-30 minutes

Alteration of Consciousness (AOC): brief >24 hrs

PTA: 0-1 days

Glasgow Coma Scale (GCS): 13-15

Neuroimaging: normal

what is the LEVEL of CONSCIOUSNESS associated with a MILD TBI

0-30 minutes

what is the ALTERATION of CONSCIOUSNESS associated with a MILD TBI

brief >24 hrs

what is the PTA associated with a MILD TBI

0-1 days

what is the GLASGOW COMA SCALE associated with a MILD TBI

13-15

is the NEUROIMAGING for a MILD TBI considered to be NORMAL/ABNORMAL

normal neuroimaging

Characteristics of Moderate TBI

Level of Consciousness (LOC): >30 minutes + <24 hrs

Alteration of Consciousness (AOC): >24 hrs

PTA: >1 + <7 days

Glasgow Coma Scale (GCS): 9-12

Neuroimaging: normal/abnormal

what is the LEVEL of CONSCIOUSNESS associated with a MODERATE TBI

>30 minutes + <24 hrs

what is the ALTERATION of CONSCIOUSNESS associated with a MODERATE TBI

>24 hrs

what is the PTA associated with a MODERATE TBI

>1 + <7 days

what is the GLASGOW COMA SCALE associated with a MODERATE TBI

9-12

what are the NEUROIMAGING results associated with a MODERATE TBI

normal/abnormal

Characteristics of Severe TBI

Level of Consciousness (LOC): >24 hrs

Alteration of Consciousness (AOC): >24 hrs

PTA: >7 days

Glasgow Coma Scale (GCS): <9

Neuroimaging: normal/abnormal

what is the LEVEL of CONSCIOUSNESS associated with a SEVERE TBI

>24 hrs

what is the ALTERATION of CONSCIOUSNESS associated with a SEVERE TBI

>24 hrs

what is the PTA associated with a SEVERE TBI

>7 days

what is the GLASGOW COMA SCALE associated with a SEVERE TBI

<9

what are the NEUROIMAGING results associated with a SEVERE TBI

normal/abnormal

what are 12 PHARMACOLOGICAL TREATMENT OPTIONS for TBIs

1. diuretics

1. anticonvulsants

3. electrolytes

4. NMDA receptor antagonists

5. barbiturates

6. calcium channel blockers

7. stimulants

8. dopamine agonists

9. SSRIs

10. antipsychotics

11. muscle relaxers

12. pain relievers

what are 7 SURGICAL TREATMENT OPTIONS for TBIs

1. craniotomy

2. decompressive craniectomy

3. Burr hole surgery

4. skull fracture repair

5. shunt placement

6. intracranial pressure monitoring

7. placement of an EVD

what are 5 GUIDELINES for the MEDICAL TREATMENT of TBI PAITENT

1. SBP should be above 90 mmHg

2. O2 saturation should be above 90%

3. patient's neck should be stabilized with a collar + head elevated 30 degrees

4. complete neurological examination performed

5. continuously monitor patient

what is INCREASED ICP

is an increase in pressure around the brain

what are 11 CAUSES of INCREASED ICP

1. increased CSF production

2. impaired/blocked CSF drainage

3. brain swelling

4. hematomas

5. high BP

6. low sodium levels

7. TBI

8. ischmeia/hypoxia of brain

9. tumors

10. infections (meningitis/encephalitis)

11. hydrocephalus

what are 7 SIGNS + SYMPTOMS associated with INCREASED ICP

1. severe headache

2. nausea + vomiting

3. drowsiness/confusion

4. vision changes (blurred vision/double vision)

5. seizures

6. loss of consciousness

7. posturing (decerebrate, decorticate + flaccid)

what does the GEGENHALTEN NATURE refer to

involuntary resistance to passive movement

what is the GEGENHALTEN NATURE classified as

form of hypertonia

what does a TOTAL SCORE of 3 on the GLASGOW COMA SCALE indicate

totally unresponsive

what does a TOTAL SCORE of <8 on the GLASGOW COMA SCALE indicate

comatose

what does a TOTAL SCORE of 15 on the GLASGOW COMA SCALE indicate

best response

what are the 8 RANCHO LOS AMIGOS LEVELS of COGNITIVE FUNCTIONING

1. no response (Level I)

2. generalized response (Level II)

3. localized response (Level III)

4. confused-agitated (Level IV)

5. confused-inappropriate (Level V)

6. confused-appropriate (Level VI)

7. automatic-appropriate (Level VII)

8. purposeful-appropriate (Level VIII)

what does LEVEL 1 on the RANCHO LOS AMIGOS LOCF mean

no response

what are 2 FEATURES of LEVEL 1 (No Response) on the RANCHO LOS AMIGOD LOCF

1. patient appears to be in a deep sleep

2. completely unresponsive to any stimuli

what does LEVEL 2 on the RANCHO LOS AMIGOS LOCF mean

generalized response

what are 3 FEATURES of LEVEL 2 (Generalized Response) on the RANCHO LOS AMIGOD LOCF

1. patient reacts inconsistently + non-purposefully to stimuli in a nonspecific manner

2. responses are limited + often the same regardless of stimulus presented

3. responses may be:

- physiological changes

- gross body movements

- vocalization

what does LEVEL 3 on the RANCHO LOS AMIGOS LOCF mean

localized response

what are 3 FEATURES of LEVEL 3 (Localized Response) on the RANCHO LOS AMIGOD LOCF

1. patients reacts specifically but inconsistently to stimuli

2. responses directly related to type of stimulus presented

3. may follow simple commands (closing eyes/squeezing hand) in an inconsistent, delayed manner

what does LEVEL 4 on the RANCHO LOS AMIGOS LOCF mean

confused-agitated

what are 9 FEATURES of LEVEL 4 (Confused-Agitated) on the RANCHO LOS AMIGOD LOCF

1. patient in heightened state of activity

2. bizarre + nonpurposeful behavior relative to immediate environment

3. doesn't discriminate among people/objects

4. unable to cooperate directly with treatment efforts

5. verbalizations frequently incoherent/inappropriate to environment

6. confabulation may be present

7. gross attention to environmental is very brief

8. selective attention often nonexistent

9. patient lacks short + long-term recall

what does LEVEL 5 on the RANCHO LOS AMIGOS LOCF mean

confused-inappropriate

what are 10 FEATURES of LEVEL 5 (Confused-Inappropriate) on the RANCHO LOS AMIGOD LOCF

1. patient able to response to simple commands fairly consistently

2. response non-purposeful, random/fragmented with increased complexity of commands or lack of any external structure

3. demonstrates gross attention to environment

4. highly distractible + lacks ability to focus attention on a specific task

5. with structure, maybe able to converse on a social automatic level for short periods of time

6. verbalization often inappropriate + confabulatory

7. memory severely impaired

8. often shows inappropriate use of objects

9. may perform perviously learned tasks with structure

10. unable to learn new information

what does LEVEL 6 on the RANCHO LOS AMIGOS LOCF mean

confused-appropriate

what are 6 FEATURES of LEVEL 6 (Confused-Appropriate) on the RANCHO LOS AMIGOD LOCF

1. patient shows goal-directed behavior

2. dependent on external input/direction

3. follows simple directions consistently

4. shows carryover for relearned tasks (self-care)

5. responses incorrect due to memory problems but appropriate to situation

6. past memories show more depth + detail than recent memory

what does LEVEL 7 on the RANCHO LOS AMIGOS LOCF mean

automatic-appropriate

what are 7 FEATURES of LEVEL 7 (Automatic-Appropriate) on the RANCHO LOS AMIGOD LOCF

1. patient appears appropriate + oriented within hospital + home settings

2. goes through daily routine automatically but frequent robot-like

3. patient shows minimal to no confusion

4. has shallow recall of activities

5. shows carryover for new learning but at a decreased rate

6. with structure able to initiate social/recreational activities

7. judgement remains impaired

what does LEVEL 8 on the RANCHO LOS AMIGOS LOCF mean

purposeful-appropriate