Non-motor impairment after ABI (cognition, perception, communication)

Consciousness

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

Rancho Levels of Cognitive Function evaluates

emerging cognitive and emotional behaviors

Rancho levels progress

in a linear fashion, and levels cannot be skipped

Rancho levels requiring total assistance

I-III

Rancho Level I name

No response

Rancho Level II name

Generalized response

Rancho Level III name

Localized Response

Characteristics of Rancho level I

No observable response to external stimuli, either automatic or voluntary

Rancho level II charcteristics

inconsistent, non-purposeful responses, same response regardless of stimulus

Rancho level III characteristic

Specific, inconsistent responses, reacts to painful stimuli, more responsive to familiar peoplè

A localized response still has

alteration of consciousness

Rancho levels confused states

IV-VI

Maximal assistance Rancho levels

IV, V

Rancho level IV name

Confused, agitated

Rancho level V name

confused, inappropriate, non-agitated

Rancho Level VI name

Confused appropriate

Rancho moderate assist level

VI

Rancho level IV characteristics

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

Rancho level V characteristics

follows simple commands inconsistently, inappropriate verbal behavior, poor memory, can perform tasks if demonstrated

Rancho level VI characteristics

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

Rancho levels only assess

cognition

Minimal assist Rancho level

VII

Stand-by assist Rancho level

VIII

Stand-by on request assist Rancho level

IX

Modified independent assist Rancho level

X

Rancho level VII name

Automatic, appropriate

Rancho level VIII name

purposeful, appropriate

Rancho level IX and X name

purposeful, appropriate

Rancho level VII characteristics

performs routine automatically, superficial awareness of condition, poor judgment and safety, interested in structured activities

Rancho level VIII characteristics

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

Rancho level IX characteristics

shifts tasks independently, recognizes impairments with support, uses compensatory strategies, needs help anticipating problems

Rancho stage X characteristics

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

Tests for sustained attention

digit repetition test, test of vigilance

Tests for divided attention

cognitive-cognitive, cognitive-motor, motor-motor

Test of vigilance

series of letters, tapping for every A (for example)

Normal value for digit repetition test

7

Cognition

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

Cog-log

test of multiple cognitive domains with emphasis on memory and executive function, administered multiple times per day

Cut off score for cog-log

25 (<25 has impaired cognition)

GOAT

Galveston Orientation and Amnesia Test

GOAT assesses

orientation, retrograde and anterograde amnesia

GOAT is administered

once daily

Cutoff score for GOAT

≥78 three consecutive trials

≥ 78 on 3 consecutive trials means that a pt has

cleared PTA

PTA

post traumatic amnesia

Perception

integration of sensory information into a meaningful representation

In pusher syndrome the pt pushes

away from unaffected side and onto the affected side

10% of acute stroke has

Pusher syndrome

In pusher syndrome, pts will lean

~20° from midline towards their affected side

pusher syndrome often occurs with

unilateral neglect

Pusher syndrome typically resolves within

6 months

Pusher syndrome is caused by

damage to posterolateral thalamus (most often), insula, and/or post central gyrus

pusher syndrome is usually due to

lesion to R hemisphere

Outcome measure for pusher syndrome

Scale for contraversive pushing (SCP)

SCP is based on

observation

SCP

Scale for contraversive pushing

SCP is used more often than

BLS

BLS

Burke lateropulsion scale

Compared to the SCP, the BLS may be

more sensitive

unilateral neglect happens in

30% of strokes

Unilateral neglect

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

unilateral neglect is due to

damage to R parietal association area

spatial unilateral neglect

inattention to or neglect of visual stimuli presented in contralateral extra personal space

body/personal unilateral neglect

failure to report, respond, or orient to body side (personal space) contralateral to a cerebral lesion

Unilateral neglect decreased in severity

after 3 months, plateau in recovery after 6 months

Apraxia occurs in … of strokes

30-80%

Apraxia occurs in … of TBIs

19-45%

Apraxia typically results from

dominant sided lesion to parietal association areas and frontal motor connections

apraxia

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

Constructional apraxia

unable to reproduce a figure

ideomotor apraxia

able to perform a task spontaneously, but not on command

ideational apraxia

cannot produce movement spontaneously or on command

Communication

exchange of information, ideas, or feelings through non-verbal or verbal methods

Aphasia occurs in … of stroke survivors

20-40%

Aphasia occurs in … of individuals with TBI

11-30%

In stroke and TBI patients, aphasia generally improves more in

TBI

fluency

rate, flow, ease of speech production

repetition

ability to repeat words, phrases, or sentences

comprehension

ability to understand spoken language

transcortical sensory aphasia is a

connection problem

transcortical motor aphasia is an issue

with connection between Broca’s and other areas