Non-Motor Impairments after ABI (Cognition, Perception, Communication)

Consciousness

Complex arousal state that implies self-awareness, unity and intentionality

Consciousness is a baseline requirement for?

Every cognitive process

For arousal disorders, what is used for acute assessment?

GCS, after ABI to access severity

GCS has two different versions. What are they?

Adult and Pediatric

GCS limitations

Patient could be intubated, which could have difficulty with verbal response

Arousal

brain’s ability to wake up and maintain alertness (ARAS)

Rancho Levels of Cognitive Function

For evaluation of emerging cognitive and emotional behaviors

Rancho levels are what kind of progression?

Linear: hierarchical return of brain function

Someone may never progress pass each stage of the Rancho's. Why?

A person may plateau at any level (never progress beyond Level II)

Coma States are categorized by Rancho levels?

1-3

Level 1 of Rancho

Name: No response

Assistance Level: Total assistance

Key Characteristics: No observable response to external stimuli (brain dead)

Rancho Level 2

Name: Generalized Response

Assistance Level: Total Assist

Key Characteristics: Inconsistent, non-purposeful response, same response regardless of stimulus. Non-specific responses

Rancho Level 3

Name: Localized Response

Assistance Level: Total Assistance

Key Characteristics: Specific, inconsistent responses, reacts to painful stimuli, more responsive to familiar people (turning toward voice, or withdrawing from pain)

Confused states are categorized on the Rancho level by?

4-6

Rancho Level 4

Name: Confused, agitated

Assistance Level: Max Assist

Key Characteristics: Bizarre, hyperactive, non-purposeful behavior, agitation from internal confusion, no short term memory

*NO COMPLEX INSTRUCTIONS

Rancho Level 5

Name: Confused, inappropriate, non-agitated

Assistance Level: Max Assist

Key Characteristics: Follows simple commands, inconsistently inappropriate verbal behavior, poor memory and can perform tasks if demonstrated

*May appear "better" due to reduced agitation but still lacks awareness

Rancho Level 6

Name: Confused, appropriate

Assistance Level: Moderate

Key Characteristics: Follows simple directions consistently, retains old learning, lacks new learning, some awareness but poor safety insight

*Behavior becomes more appropriate, rely on what they knew previously, memory still affected, lack insight impairments and safety awareness

Post- Confusional States are what levels on Rancho?

Levels 7-10

Rancho Level 7

Name: Automatic, appropriate

Assistance Level: Minimal Assist

Key Characteristics: Performs routine automatically, superficial awareness of condition, poor judgment and safety, interested in structured activities

*Follow schedule for the day

Rancho Level 8

Name: Purposeful and Appropriate

Assistance Level: Standy by

Key Characteristics: Oriented, completes familiar tasks, independently, some awareness of deficits, uses memory aids, better emotional responses

*Phone reminders and planners are utilized, and begins to recognize limitations and adjust behavior

Rancho Level 9

Name: Purposeful, and Appropriate

Assistance Level: stand-by and request

Key Characteristics: Shifts tasks independently, recognizes impairments with support, uses compensatory strategies, needs help anticipating problems in stressful scenarios

*May use hearing aids

Rancho Level 10

Name: Purposeful and Appropriate

Assistance Level: Modified Independent

Key Characteristics: Independently manages tasks with aids, anticipates obstacles, appropriate social interaction, may still struggle under stress

Rancho scale does not?

do not directly tell you how much physical assistance a person needs for manual or motor tasks like transfers, gait, or ADLs. Instead, they describe cognitive and behavioral recovery after brain injury

Sustained Attention Tests

Digit Repetition Test – Therapist says a string of numbers (5–9 digits), patient repeats them back in order. Good for working memory

Test of Vigilance – Respond to a specific letter/sound over a long period while ignoring others (press button only when you hear "A").

Divided Attention Tests

Cognitive–Cognitive: Listening while doing mental math

Cognitive–Motor: Talking while performing a fine motor task

Motor–Motor: Walking while carrying a tray

Sustain and Divided attention tests show what?

If they need blocked/simple tasks or if they need a private room

Cognition

Set of mental processes by which individuals acquire, process, store and use information

What are the two cognitive dysfunction tests?

Cog-Log and Galveston Orientation and Amnesia (Test)

Cog-Log

Rapid bedside screening of global cognition, with emphasis on memory and executive function

Can be administered multiple times per day, during rounding on patients

Cut off score is 25, out of 30

Cog-Log contains?

Repeat addresses

Count backwards 20-1

Months reversed

30 sec test

Fist-edge-palm

Go/No-go

Address recall

Date, time, hospital name

Galveston Orientation and Amnesia Test

Assesses orientation, retrograde and anterograde amnesia (PTA)

Administered once daily

Need a score >78/100 on 3 consecutive time trials which cleared from PTA

GOAT tests contain?

Orientation (person, time, place)

Retrograde amnesia (events before injury)

Anterograde amnesia (new learning since injury)

Perception

Integration of sensory information into a meaningful representation allowing to spatially construct environment and internal representation of body and movement in space

Pusher's Syndrome

10.4% occurrence in acute stroke

Pushes away from the non-paretic side and actively leans or falls toward the hemiparetic (weaker) side (20 deg past midline)

Resists passive correction toward vertical

What brain regions are damaged with Pusher's syndrome?

Posterolateral thalamus (common site of damage), Posterior insula and Postcentral gyrus

Pusher's Syndrome often co-occurs with?

Neglect, due to affecting the right hemisphere (non-dominant)

Pusher's Syndrome resolves in?

6 months

Compared to someone with a stroke without Pusher's, the pusher's syndrome patient takes 3-6 months extra in recovery

Scale for Contraversive Pushing

Spontaneous Body Posture: Patient's habitual lean toward the hemiparetic side

Use of Non-Paretic Extremities: Actively pushing with uninvolved limb (e.g., hand or foot)

Resistance to Passive Correction: Patient’s physical resistance to being moved upright

*Specific and used more often in Pusher's syndrome

BLS - Burke Lateropulsion Scale

More sensitive than SCP in detecting milder or evolving cases of Pusher Syndrome

Unilateral Neglect

30% Stroke occurrence

Disorder of perception, attention and action in the space opposite to a cerebral lesion

Damage to the right parietal association cortex

What test do you do to diagnose Unilateral neglect?

Line bisection test

Spatial Unilateral Neglect

Inattention to or neglect of visual stimuli presented in CL extra personal space (Left)

Body/Personal unilateral neglect

Failure to report, respond, or orient to body side (personal space) CL to a cerebral lesion (Left)

Unilateral Neglect TImeline

0-3 Months: Most significant improvement occurs; early therapy is crucial

6 Months: Recovery plateaus for most patients; lingering deficits may persist

Chronic Phase (>6 months): Recovery is minimal

Apraxia

30-80% of strokes, 19-45% of TBIs

Inability to perform tasks or natural actions in the absence of sensory, motor or coordination deficits

Damage to parietal association areas and frontal motor connections

constructional apraxia

Unable to reproduce a figure (Cube and Legos), often non-dominant hemisphere

Copy drawing tasks (to test)

Ideomotor Apraxia

Able to perform a task spontaneously, but not on command

Often dominant hemisphere

Ideomotor Apraxia tests

Gesture imitation tasks (“Show me how to use a hammer”)

ideational apraxia

Cannot produce movement spontaneously or on command

MULTISTEP ACTIONS (brushing teeth, making coffee)- Errors in tool use, sequence, or object selection)

Often dominant hemisphere

Communication

Exchange of information, ideas, or feelings through non-verbal and verbal methods

Aphasia

20-40% of stroke survivors, 11-30% individuals with TBI

Aphasia affects what?

Fluency: Rate, flow, and ease of speech production

Repetition: Ability to repeat words, phrases or sentences

Comprehension: Ability to understand spoken language

Broca's Aphasia

-fluency, -repetition, +comprehend

Transcortical Motor (Broca's)

-fluency, but +repetition and +comprehension

Global Aphasia

Fluency, Repetition, and Comprehension are GG

Wernicke's

+Fluency, -Repetition, and -comprehension

Transcortical Sensory (Wernicke's)

+Fluency, +repetition, and -comprehension

Conduction Aphasia

+fluency, -repetition, and +comprehension

What brain area is damaged in conduction aphasia?

Arcuate fascicules. Supports verbal working memory, however, due to disrupted Broca's and wernicke's areas, patients struggle to repeat phrases (repetition)