~TRAUMATIC BRAIN INJURY (TBI)

CLASSIFICATION

• closed brain injury

Direct impact (e.g., car accident, football injury) or indirect impact (e.g., whiplash, shaken baby syndrome) without penetration of the brain tissue

• Results from dynamic (e.g., brain is getting shaken) and static (e.g., a crush injury- such as getting crushed by earthquake debris) loading

CLASSIFICATION

• open brain injury

Penetrating the cranial cavity (e.g., bullet, pole etc.)

CLASSIFICATION

• Blast injuries

specific type of TBI (can be open or closed brain injury)

PHASES

1. Pre-injury

2. Medical Treatment 

3. Rehabilitation 

4. Survivorship

SEVERE TBI

• Exhibit any number of altered states of consciousness

• Rancho Los Amigos Levels of Cognitive Functioning: for closed brain injuries <less than a year

  • Purpose:

    • An assessment that does not require the cooperation of the patient

    • Provide behavioral descriptions from no behaviors to complex cognitive responsiveness

    • Provide staff and family members with a common language

    • Provide staff & family with increased understanding of the behavioral stages & milestones during recovery

    • To assist with treatment objectives

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• Overall looks at:

• Attention

• Associations- cause & effect

• Sequencing of performance

• Categorize information

• Ability to reason

• Problem solving

• Memory

• Executive functioning

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• Considerations

• Some will progress through all level, and some will stay at level 1

• Time in the stage is dependent on the severity of TBI

• Fluctuations of levels throughout the day

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• Typical recovery pattern

• Phase 1- fluctuation among levels 2, 3, 4

• Phase 2- fluctuation among levels 3, 4, 5

• Phase 3- fluctuation among levels 4, 5, 6

• Phase 4- fluctuation among levels 5, 6, 7

• Phase 5- fluctuation among levels 7 & 8

• Phase 6- fluctuation among levels 8 & 9

• Phase 7- fluctuation among levels 9 & 10

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• I – No response (total assist)

not responding to any stimuli (e.g., auditory, tactile, etc.)

• Comatose state

• Deep sleep

• No observable behavior when presented with visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli

Treatment= lots of prevention measures

• Contracture prevention

• Skin integrity

• Bed positioning

• ROM

• Stimulation (organized)

  • some start of stimulation (e.g., different spices, peppermint (oral), verbal and visual stimuli)

  • Be careful not to overstimulate

• Family education

• Talk even if they do not respond (normal tone of voice)

• Look for responses to any type of stimulation (eye tracking, pain, startle response, movement)

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• II – Generalized response (total assist)

any stimuli they get, they will respond the exact same way; response has nothing to do with the type of stimuli they are getting (e.g., touch hand —> move head; lift arm —> move head)

• Reacts inconsistently and non purposefully in a nonspecific manner (response regardless of stimuli)

• Responses may be vocalization, gross body movements, or physiological changes

• Delayed responses

• Earliest response is deep pain

• Treatment

  • Continue with level I

    • Treatment= lots of prevention measures

      • Contracture prevention

      • Skin integrity

      • Bed positioning

      • ROM

      • Stimulation (organized)

        • some start of stimulation (e.g., different spices, peppermint (oral), verbal and visual stimuli)

        • Be careful not to overstimulate

      • Family education

      • Talk even if they do not respond (normal tone of voice)

      • Look for responses to any type of stimulation (eye tracking, pain, startle response, movement)

  • Oral stimulation- taste info

  • Hand over hand (e.g., washcloth to face, lotion on arm)

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• III – Localized response (total assist)

can localize a stimuli, and can react appropriately to the stimulus you are giving them (e.g., touch their face —> they move their head to that side)

• Patient reacts specifically, but inconsistently to stimuli

  • Turns toward or away from auditory stimuli

  • Blinks when light crosses the visual field; follows a moving object passes within the visual field

  • Withdraws extremity when presented with a painful stimulus

• Begin to recognize family and friends

• Follows one-step commands (e.g., look at me, squeeze my hand)

• Once external stimuli are removed, the patient lies quietly and looks unresponsive

• Treatment

  • Continue with level I & II treatment

    • Level I treatment= lots of prevention measures

      • Contracture prevention

      • Skin integrity

      • Bed positioning

      • ROM

      • Stimulation (organized)

        • some start of stimulation (e.g., different spices, peppermint (oral), verbal and visual stimuli)

        • Be careful not to overstimulate

      • Family education

      • Talk even if they do not respond (normal tone of voice)

      • Look for responses to any type of stimulation (eye tracking, pain, startle response, movement)

    • Level II treatment

      • Oral stimulation- taste info

      • Hand over hand (e.g., washcloth to face, lotion on arm)

  • Educate family to keep person stimulated when not in therapy (organized)

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• IV – Confused & Agitated (maximal assist)

having bizarre behaviors 

• Alert, but cannot process the environment (internal confusion)

• Agitation part of recovery, but difficulty for families

  • Remove tubes, IVs, or crawl out of bed

  • Motor activities without any purpose (e.g., flailing arms)

  • Behaviors are bizarre and not relevant to the immediate environment

  • May cry or scream out of proportion to the stimulus, even if removed

• May be restrained so they don’t hurt themselves

• Verbalization is incoherent and/or inappropriate to the activity

• Flip-flop of emotions

• Unable to cooperate with treatment

• Treatment

  • Allow for safe movement (e.g., mittens so not to pull out tubes, extension to wheelchair so they can’t tip them)

  • Familiar gross motor activities that are calming (e.g, washing face, catching a ball, hitting a balloon if able), walking in the hall if able, or being wheeled in the hall

  • Do not force them to do things

  • Be prepared to change activity, take a rest break, move to another environment when agitation begins, and offer water or food if cleared

  • Avoid reinforcement of undesirable behaviors

  • Be calm and confident

  • Family education

    • Educate them that this is a normal stage of recovery

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• V – Confused & inappropriate (maximal assist)

• Alert but not oriented x3

• Can respond to simple commands more consistently with external structure and cues; however difficulty with complex commands 

• Often demonstrates inappropriate use of objects

• Able to converse on a social automatic level for brief periods of time with cues

• Deficits in attention & concrete thinking

• May be able to perform previously learned tasks but not new ones

• Poor memory & make things up to fill in gaps (confabulation)

• Treatment

  • Very structured treatment intervention with a lot of prompting, repetition, redirection, and step-by-step instruction

  • Can perform basic ADLs with ***structure and maximal cues

  • Help with the organization and initiation of the task

  • If hemiparetic, will have difficulty learning hemi dressing strategies; will require assistance

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• VI – Confused & Appropriate (moderate assistance)

• Alert and inconsistently orient to person and place

• Emerging awareness of appropriate response to self, family, and basic needs (but still confused, disorganized, and having difficulty with problem solving)

• Able to attend to highly familiar tasks for 30 minutes with moderate redirection

• Emerging awareness of the appropriateness of goal-directed behavior 

• Limited insight into disability, especially thinking problems

• Treatment

  • Basic ADLs & simple IADL with structure

  • Assistive memory aid with max assist

  • Will need help with organization and continuation of tasks, but can do it

  • Set up a routine: schedule for therapy, visits from family, eating, bathroom (confused with changes in routine)

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• VII– Automatic & Appropriate (minimal assist)

person can be on their own as long as there is supervision around (can do basic ADLs; but anything more novel or complicated, they may need assistance with)

• AOx3 and goes through routine automatically with minimal to absent confusion (robotic-like)

• Increased awareness of self, body, family, food, people, and interaction in the environment, but lacks insight (e.g., poor judgment, reasoning, problem solving, and limited emotions)

• Decreased cognitive ability in an unfamiliar environment or during stress

• Shows carryover for new learning, but at a decreased rate

• Treatment

  • Treat and talk to the person as an adult (e.g., no need to use simple words or sentences)

  • With more complex tasks, help the individual and show them the problems in their thinking (e.g., work-related tasks, complex IADLs); however not ready for work at this time

  • Encourage memory book, daily planner (book, computer, phone)

  • Coping strategies

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• VIII – Purposeful & Appropriate (stand by assistance)

starting to get more aware of what’s happening; coping strategies are more important, as self-awareness increases!

• Recognizes cognitive deficits and can start to implement compensation strategies (increased insight)

• Can learn 

• Stress, fatigue, and unfamiliar causes decompensation (i.e., failure to generate effective psychological coping mechanisms in response to stress)

• Difficulty with managing time and money

• Depression, irritable, low frustration tolerance

• Treatment= can start to think about higher-level ADLs

  • Similar to previous stage

    • Treat and talk to the person as an adult (e.g., no need to use simple words or sentences)

    • With more complex tasks, help the individual and show them the problems in their thinking (e.g., work-related tasks, complex IADLs); however not ready for work at this time

    • Encourage memory book, daily planner (book, computer, phone)

    • Coping strategies

  • Discuss with the MD about return to work, school, and driving

  • Reinforce memory book, daily planner (book or on phone/computer)

  • Reinforce coping strategies

  • Energy conservation strategies

  • Repetition

  • Referral for psychiatry

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• IX – Purposeful & Appropriate (stand by assistances if requested)

• Assistance when requested for unfamiliar tasks (e.g., household work, leisure, etc.)

• Difficulty with anticipating problems and taking action to avoid them

• Depression may continue, but with less irritability and better frustration tolerance

• Treatment 

  • Reinforce memory book, daily planner (book or on phone/computer)

  • Reinforce coping strategies

  • Problem-solving strategies

  • Initiate multi-tasking activities

  • If back to work, work-related tasks

RANCHO LOS AMIGOS LEVELS OF COGNITIVE FUNCTIONING

• X – Purposeful & Appropriate (modified independence)

• Does not require assistance, but increased time and effort

• Treatment

  • Coping strategies

  • Problem-solving strategies

  • Compensatory strategies