Neval: TBI

Strategies that INC or DEC behavior:
1. Withhold rewards/positive reinforcement that maintain maladaptive behavior

2. Prompting (giving cues/assistance)

3. Chaining (chopping a complex task into simple steps)

4. Apply an aversive consequence following severe or resistant maladaptive behavior

1. DEC behavior

2. INC behavior

3. INC behavior

4. DEC behavior

Strategies that INC or DEC behavior:

1. Reward all instances of appropriate behavior

2. Expanding rehearsal (spaced repetition to ↑ retention of learned skills)

3. Stimulus control for distractibility

4. Extinction for yelling & aggression

5. Systematic desensitization for fears

1. INC behavior

2. INC behavior

3. DEC behavior

4. DEC behavior

5. DEC behavior

T or F. In a guided activity, verbal input is promoted. 

Verbal input is AVOIDED during guided activity

In TBI, until when is the risk for Post traumatic Epilepsy?

Risk is high within 1st-12th month post-injury. After that time frame, risk gradually decreases.

What to do during an epileptic attack:
1. If on bed?

2. If exercising?

3. If in ward?

1. Put rails up & surround c pillows

2. Let patient lie down on floor

3. Drape c curtain

In Cardiovascular training, what are the 3 things that people c post-TBI demonstrate?

1. Improvement post-circuit training

2. Sense of accomplishment

3. INC mental capabilities

1. What is the leading indicator of recovery after TBI?

2. What is the solution to such problem-solving, memory, organizational skills, and post-traumatic epilepsy issues?

1. Return to work

2. Continued assistance in all aspects of disability

What are the 3 impairments of TBI?

1. Neuromuscular

2. Cognitive

3. Behavior

Name the 5 Neuromuscular impairments of TBI

1. Abnormal tone

2. Sensory impairments

3. Motor Function

4. Impaired balance

5. Paresis

Name the 8 Cognitive Impairments of TBI

1. Altered LOC

2. Memory loss

3. Altered orientation

4. Attention deficits

5. Impaired insight and safety awareness

6. Problem solving/reasoning impairments

7. Perseveration

8. Impaired executive functioning

Name the 7 Behavioral Impairments of TBI

1. Disinhibition Impulsiveness

2. Physical and verbal aggressiveness

3. Apathy

4. Sexual inappropriateness

5. Irritability

6. Egocentricity

7. Impaired drive

4 strategies that INC behavior

1. Reward all instances of appropriate behavior

2. PROMPTING

3. CHAINING

4. EXPANDING REHEARSAL

Give at least 3 of the Acute Care goals:

1. Improve respiratory function

2. Prevent secondary brain damage

3. Preserve musculoskeletal integrity

4. Facilitate arousal and active engagement

What are the 2 indications for ventilation?

PaO2:

PaCO2:

PaO2: < 60 mmHg (hypoxemia)

PaCO2: >45 mmHg (hypercapnia)

nice to know:
hypoxia = ↓ O2 in tissues

hypoxemia = ↓ O2 in blood (often leads to hypoxia)

Cerebral Perfusion Pressure or CPP = ?

Cerebral Perfusion Pressure = MAP - ICP

1. MAP = ?

2. Normal ICP?

1. Systolic + 2(Diastolic) / 3

Example: 120 + 2(80) / 3 = 120 +160 / 3 = 93.33 mmHg

2. 5 - 20 mmHg (remember if ICP goes above this, it could lead to ↓ CPP → ↓ blood flow to brain)

1. When there is ↑ ICP, CPP____

2. This leads to ____ CBF

3. When the effect on CBF happens, this causes_____

4. After that, this triggers a certain reflex to compensate/restore blood flow

1. When there is ↑ ICP, it squeezes blood vessels, which leads to ↓CPP

2. This leads to ↓ CBF cuz brain gets less blood

3. ↓ CBF causes Cerebral ischemia 

4. Cushing’s Triad

What is Cushing’s triad composed of?

• ↑ BP (to overcome ↑ ICP and maintain CPP)

• ↓ HR or reflex bradycardia (to counter HTN),

• Irregular breathing (d/t brainstem compression)

How to preserve MSK integrity/

1. Proper positioning (put at-risk muscles in a lengthened position)

2. Slow PROMs

3. Serial Casting

4. Periods of sitting and standing

5. Load bone and cartilage (Wolff’s Law for bone)

6. Promote mobility (moving limbs)

What are the 2 physiologic pressures that should be monitored during initial attempts at getting the patient upright?

Both BP & ICP

1. 3 benefits of upright posture

2. What to re-establish in arousal & engagement (4)?

1. stimulation of bowel movements, improved ventilation, ↓ ICP

2. swallowing, unassisted breathing, effective coughing, communication

How to manage LOCF 1-3 (No response, General Response, Localized Response)?

1. Prevent indirect impairments

2. Improve arousal through sensory stimulation

3. Manage effects of abnormal tone and spasticity

4. Early transition to sitting postures

5. Family education

LOCF 1-3:

1. Proper head positioning?

2. Proper trunk positioning?

3. Proper head handling?

4. Proper trunk handling?

1. Head in neutral; place roll behind neck & parallel to head

2. Maintain normal alignment

3. Gentle ROM; put hand at base of skull/side of head; use pillow to handle head

4. Segmental rolling if stable

LOCF 1-3:

1. UE positioning?

2. UE handling?

3. LE positioning?

4. LE handling?

1. Place roll behind scapula (as needed); cone/ball in hand

2. Relax scapula + ↓ FLEXOR tone

3. Hip & knee slight FLEX, avoid pressure on ball of foot medially, prevent excessive IR + ADD via pillow/roll below legs

4. Encourage IR + ER + ABD + FLEX-EXT

LOCF 1-3:

How many minutes?

1. Awakening

2. Auditory Stimulation

3. Visual Stimulation

4. Tactile Stimulation

5. Olfactory Stimulation 

1. Awakening - 5 min

2. Auditory Stimulation - 10 min

3. Visual Stimulation - 10 min

4. Tactile Stimulation - 5 min

5. Olfactory Stimulation - 10 sec

1. What are the 2 sensory stimulations that give the most significant changes?

2. T or F. Sensory stimulation did NOT affect hemodynamic or cerebral dynamic status

3. How long should sensory stimulation training be applied for? How long do you have to wait to see significant effects?

1. Tactile + Auditory stimulation

2. True

3. 1 month to see a permanent effect on levels of consciousness; at least 2 wks required for any effect

LOCF 4: Confused-Agitated

Management?

1. To maintain pt’s functional capabilities

2. Prevent agitated outbursts

3. Assist pt control his behavior through structured program

4. Use Behavior mod techniques

5. Expect egocentricity (tendency to focus mainly on oneself; difficulty seeing things from others’ POV)

Should you expect carry-over in LOCF 4?

Expect NO carry-over

LOCF 5-6 (Confused-Inappropriate, Confused-Appropriate)

Management?

1. Maximize functional recovery of patient

2. Prepare pt & family for d/c home & to community

3. Compensatory approach seeks to improve functional skills by compensating or the lost ability

4. Restore use of affected limbs

LOCF 7-8 (Automatic-Appropriate, Purposeful-Appropriate)

Management?

1. Assist pt in integrating the cognitive, physical & emotional skills to function in community

2. Wean pt from supervision

3. Focus on advanced activities (community, social, & ADL skills)

4. Let pt join in decision-making & problem-solving

5. Do endurance training

1. This is the impaired ability to adapt to and to cope with new and different stresses

2. What is “Frontal pattern of behavior”

1. Cognitive and Behavioral deficits

2. ↓ productivity, (-) initiative, difficulty shifting attention, difficulty changing movement, problems c modulating ongoing behavior, difficulty planning

Adaptive vs Remedial Approach:

1. CNS can repair & reorganize itself p injury

2. Training in underlying skills will carry-over to tasks requiring such skills

3. CNS has limited potential for repair & reorganization

4. Therapists work on underlying cognitive/perceptual problems

1. Remedial

2. Remedial

3. Adaptive

4. Remedial

Adaptive vs Remedial Approach:

1. Direct training of deficient functional skills

2. Training of perceptual components of motor behavior

3. Does NOT assume automatic carry over

4. Therapists works c pt on specific tasks required

1. Adaptive

2. Remedial

3. Adaptive

4. Adaptive

Adaptive vs Remedial Approach:

1. Using alarm for forgetfulness

2. Teaching one-handed dressing after hemiplegia.

3. Cognitive drills like recalling lists or solving puzzles

4. Making logical associations

1. Adaptive

2. Adaptive

3. Remedial

4. Remedial

Personality changes:

1. Apathy often described as laziness or slowness

2. Tactlessness, hurtfulness

3. Euphoria, emotional lability

1. Drive

2. Social restrain & judgement

3. Affect

1. If task is too complex

2. If task is suitable

3. If task is easy

1. Pt is easily annoyed, makes frequent stops, wants to go CR

2. Pt is quiet but focused and not distracted

3. Pt is talkative, laughs too much, does unnecessary things

Remediating Memory Disorders management:

1. Ensuring minimal distraction

2. Encouraging asking questions

3. Internal strategies (mnemonics, rehearsal)

4. Relating info to info you already know

5. Adapting the environment (e.g., labeling)

6. Use of external aids (e.g., diaries)

4 Attention impairments:

1. Training interesting tasks that are relevant to the patient

2. Clear visual and auditory cues and feedback

3. Remove distractions

4. Dividing attention for open task

Antecedent vs Consequence focused strategies:

1. Aims to prevent problem behaviors before they occur by changing or controlling what happens before the behavior

2. Shape behavior by reinforcing appropriate responses and discouraging negative ones.

3. To either increase desired behaviors or decrease unwanted ones.

4. Modify triggers, cues, or environmental factors that lead to maladaptive behavior.

1. Antecedent

2. Consequence

3. Consequence

4. Antecedent