Unit 4 - Traumatic Brain Injury

Traumatic brain injury

is defined as evidence of brain pathology as a result of an external force. This force may vary widely from gunshot wounds, motor vehicle accidents, or falls to the head

Traumatic brain injury: Consequences

• Long-standing disability

• Financial burdens

• Changing family dynamics

• Premature death

Mechanisms of Injury

• Primary Injury

• Blast Injury

• Secondary Injury

Primary Injury

• Where contact was made

• Coup-Contrecoup Injuries

• result in a contusion at the area of contact, in addition to the damage or laceration created by whatever that external force was

• usually localized to the site of the injury

Coup-contrecoup injuries

• occur with rapid acceleration and deceleration as the brain floats within the cranium

• The brain essentially bounces off of one aspect of the cranium

Coup

the frontal aspect if the collision is in a forward direction

ContreCoup

reverts backward to hit the posterior aspect of the cranium

Blast Injury

• No “direct” hit

• Overpressure = edema

Secondary Injury

• Inflammatory Response

  • Histamine

  • Micro/Macronutrients

  • Edema

  • Increased ICP

Normal Intracranial pressure

5-20 mmhg

Interdisciplinary Collaboration

Early Medical Management

• Stabilize

• Minimize complications

• Identify injuries

• Monitor

Minimize secondary complications by…

restoring cerebral blood flow, identifying all injuries, and monitor continuously

LOC

loss of consciousness

AOC

alteration of consciousness

PTA

post-traumatic amnesia

Glasgow Coma Scale (GCS)

• Eye Opening

• Motor Response

• Verbal Response

Glasgow Coma Scale (GCS): Eye Opening

• Spontaneous (4)

• To Speech (3)

• To Pain (2)

• No Response (1)

Glasgow Coma Scale (GCS): Motor Response

• Follows commands (6)

• Localizes to pain (5)

• Withdraws from pain (4)

• Decorticate Posturing (3)

• No Response (1)

Glasgow Coma Scale (GCS): Verbal Response

• A & O x 3 (5)

• Confused (4)

• Inappropriate words (3)

• Incomprehensible sounds (2)

• No Response (1)

Glasgow Coma Scale (GCS): Mild TBI

• LOC: 0-30 min

• AOC: brief >24 hr

• PTA: 0-1 day

• GCS: 13-15

• IMAGING: norm

Glasgow Coma Scale (GCS): Moderate TBI

• LOC: >30 min & <24 hrs

• AOC: >24 hrs

• PTA: >1 & <7 days

• GCS: 9-12

• IMAGING: norm or abnorm

Glasgow Coma Scale (GCS): Severe TBI

• LOC: >24 hrs

• AOC: >24 hrs

• PTA: > 7 days

• GCS: <9

• IMAGING: norm or abnorm

Galveston Orientation and Amnesia Test, or GOAT

• can be used to detect orientation in amnesia post TBI

• set of 14 questions pertaining to person, place, time, and situation

Imaging

necessary in cases of traumatic brain injury prior to medical intervention

• First line is usually a CT scan

Causes of elevated ICP

• Increase in Brain Volume

• Mass Effect

• Increase in CSF

• Decreased Resorption of CSF

• Increase in Blood Volume

• Other causes

Mass effect

can also be a cause related to hematomas, tumors, abscesses, or other infarcts of brain tissue

Subfalcine herniation

characterized by the cingulate gyrus herniating against the falx cerebri

Central herniation

herniation of both temporal lobes through the tentorial notch

Transcalvarial herniation

occurs when the brain tissue is squeezed through a fracture in the skull or a surgical incision

Uncal herniation

occurs as the medial temporal lobe is squeezed by a mass under and across the tentorium

Upward herniation

occurs when a mass in the posterior cranium causes superior displacement of the cerebellum through the tentorial notch

Downward, or tonsillar herniation

caused when a mass forces the cerebral tonsils down through the foramen magnum

Management of Elevated Intracranial Pressure

• Evacuation of the mass

• Pharmaceutical management

• Positioning

• Ventilation

• CSF Drainage

• Hyperventilation

• Hypothermia

• Coma

• Decompressive Hemicraniectomy/Craniotomy

Communication/Speech, Swallowing

Aphasia, Dysarthria, Dysphagia

Cognitive Impairments

• Coma

• Vegetative state

• Minimally conscious state

• Stupor

• Obtunded

Coma

No arousal

• may be placed into a medically-induced coma in order to decrease cerebral edema and allow for healing to occur

Vegetative state

Unaware of surroundings

• the higher brain centers are not integrated fully with the brainstem. So wakefulness and consciousness are not one and the same

Minimally conscious state

Mild awareness

• Behavior and responses such as reaching toward objects may be demonstrated and reproduced but are very inconsistent

• Patients can also localize to stimuli

• So instead of withdrawing from noxious stimuli, they may withdraw but turn their head toward that stimulus

• Visual pursuit is also possible in this stage, as is sleep and wakefulness cycle

Stupor

Arousal with vigorous stimuli

Obtunded

Sleepiness/Delayed reaction

Visual/Perceptual Deficits

Similar to those seen with acquired brain injury (CVA)

General hemispheric differences

• Similar to those seen in ABI

• Frontal Lobe Dysfunction

  • executive decision making and behavioral deficits may arise

Additional Clinical Presentations

• Seizure activity

• Dysautonomia

  • Posturing

Dysautonomia

deficits in functioning of the sympathetic nervous system

• may demonstrate an overactive response to stimuli, including elevated heart rate, respiratory rate, and blood pressure, and diaphoresis

• decerebrate and decorticate posturing

Decorticate posturing

• an abnormal flexion posturing where the

  • shoulders, elbows, and wrists and fingers are flexed

  • lower extremities are extended and internally rotated

  • ankles plantar flexed

  • toes hyperextended

• can also be termed decorticate rigidity or response

• occurs with more rostral injuries to the cerebrum, including lesions to the forebrain, diencephalon, or rostral midbrain

  

Decerebrate posturing

• an abnormal extensor posturing where the

  • head and neck extension

  • upper extremities extended

  • forearms pronated

  • fingers flexed

  • lower extremities also extended, internally rotated

  • ankles plantarflexed

  • toe hyperextension

• This type of posturing results from a disconnect with the higher brain modulating centers with the vestibular nuclei

• Animal studies have indicated that it only occurs with noxious stimuli, passive hyperextension of the head, or with metabolic abnormalities from hypoxia

• This specific type of posturing is usually associated with a severe destructive cerebral lesion

  

Posturing can present asymmetrically…

decorticate unilaterally and decerebrate on the contralateral side.

• Asymmetrical patterning, such as this, has been suggested to indicate a less severe form of injury, the anatomical divide between decorticate and decerebrate posturing being the intercollicular line at this level of the red nucleus

Lesions above the red nucleus tend to cause…

decorticate posturing

Lesions below the red nucleus tend to cause…

decerebrate posturing

Rancho Los Amigos (RLAS - R) Scale - Revised

• Describes cognitive/behavioral patterns after BI

• Developed in 1972 – Included 8 stages

• Revised in 1997 – Included 10 stages

  • Level I: No response

  • Level X: Purposeful and Appropriate: Modified Independent

• Discussed at length in an additional lecture

Activity and Participation Restrictions

• Walking

• Upper extremity handling

• Activities of Daily Living

• Return to work

• Return to family

• Caregiver roles

Comorbid Factors Post-TBI

• Seizure

• Bowel & Bladder

• Cardiopulmonary Deficits

• DVT & PE

• Osteoporosis

Factors in Prognosis Development

• A variety of factors assist in clinical decision-making poststroke

• Extent of recovery versus compensation

• Clinical tests and measures

• Physical therapy practice setting

• Principles of neuroplasticity

Clinical Tests Used in Predicting Outcomes

Glasgow Coma Scale (GCS)

• Scale helps define and classify severity of brain injury

• Three response scores:

  • Motor response

  • Verbal response

  • Eye opening

• Scores

  • 8 or less- Severe TBI

  • 9-12- Moderate TBI

  • 13-15- Mild TBI

Glasgow Outcome Scale: 5 Levels

• Good recovery

  • minor deficits with full independence

• Moderately Disabled

  • may require work accommodations

• Severely Disabled

  • need help with daily activities

• Vegetative

  • unresponsiveness with no higher mental functions

• Dead

Glasgow Outcome Scale: Predictive Poor Recovery

• Low initial GCS scores

• Pupillary reactivity

• Age

• CT showing mass lesion

• Raised ICP

CRASH

• Developed by the Medical Council

• Corticosteroid randomization after significant head injury

• Web based calculator for TBI prognosis

• Inputs: Age, GCS score, pupil reactivity, extracranial injury, CT findings

• Outputs: 14-day mortality risk, 6-month outcome prediction

Galveston Orientation and Amnesia Test (GOAT)

• Evaluates cognition during the subacute stage of recovery

• Used during the inpatient rehabilitation to predict the following:

  • Functional independence

  • Employment

  • Good overall recovery

  • Independent living 1 year after injury

Impact of Recovery and Compensation on Prognosis

• Recovery is fastest in the first 6 months post TBI but can continue months to years after Chronic traumatic brain injury recovery

• Initial GCS Score

• CT showing mass lesion

• Personal factors

Impact of Physical Therapy Setting on Prognosis

• Continuum of Care

• Long-Term Care vs. Inpatient Rehab:.

• Specialized Intensive Rehab:

  • Time-sensitive for functional recovery, especially in disorders of consciousness (DoC) (Zhang et al., 2023)

• Interdisciplinary Team

• Outpatient Transition

Application of Neuroplasticity to Prognosis

• Use it or lose it and use it to improve it

• Specificity, intensity, and repetition

• Salience

• Timing

• Age

• Interference

TBI EDGE Outcome Measures

The task force reviewed 88 outcome measures covering the domains of body structure and function, activities and participation evaluating each for psychometrics and clinical utility for patients with traumatic brain injury

TBI EDGE Outcome Measures

Recommendations were formulated for outcome measures that are:

• Highly recommended (Excellent Psychometric and clinical utility)

• Recommended (Good Psychometric and clinical utility)

• Reasonable to use (Good or excellent Psychometric and clinical utility BUT insufficient study in target group)

• Do not Recommend (Poor Psychometric and/or clinical utility)

Types of TBI EDGE Outcome Measures

• for inpatient and outpatient rehab

• for acute care

• for research

• for entry-level education

TBI EDGE Outcome Measures:

Highly Recommended (Inpatient only)

• Coma Recovery Scale-Revised

• Moss Attention Rating Scale (MARS)

Coma Recovery Scale-Revised

• Used to establish diagnosis, monitor behavioral recovery, predict outcome, and assess treatment effectiveness.

• It can be used in all life span age ranges.

• ICF Domain: Body Structure & Body Function.

• Time to administer: 15-30 minutes

Moss Attention Rating Scale (MARS)

• Used to measure attention-related behaviors after TBI

• ICF Domain: Body Structure & Body Function

• Time to administer: 5 minutes

TBI EDGE Outcome Measures:

Highly Recommended (Outpatient only)

High Level Mobility Assessment (Hi-MAT)

High Level Mobility Assessment (Hi-MAT)

• Assesses the high-level motor performance in TBI patients

• The minimum mobility requirement independent walking over 20 meters without gait aids (orthoses are permitted).

• ICF Domain: Body Structure & Body Function and Activity.

• It can be used in all age ranges staring from 13 y/o or older.

• Time to administer: 5-10 minutes

TBI EDGE Outcome Measures:

Recommended Measures (Inpatient only)

• Disorders of Consciousness Scale (DOCS)

• Agitated Behavioral Scale (ABS)

• Cog-Log and Orientation-Log

• Barthel Index

• Functional Independence measures (FIM)

Disorders of Consciousness Scale (DOCS)

• Used to monitor recovery of consciousness.

• Evaluate the effects of interventions in adults following a severe traumatic brain injury

• DOCS-25 is the most up-to-date and current version

Agitated Behavioral Scale (ABS)

• It measures the behavioral aspects of agitation during the acute phase of recovery from acquired brain injury including aspects of aggression, disinhibition, and lability.

• 14-item instrument, Minimum score is 14; maximum score is 56.

• Each item is rated on a scale from 1 to 4:

  • 1 = NO agitated behavior

  • 2 = Mild agitated behavior

  • 3 = Moderate agitated behavior

  • 4 = Extreme/severe agitated behavior

TBI EDGE Outcome Measures:

Recommended Measures (Outpatient only)

• Action Research Arm Test

• Global Fatigue Index

• Apathy Evaluation Scale

• Sydney Psychosocial Reintegration Scale

• Balance Error Scoring Scale (BESS)

• Community Integration Questionnaire

• Dizziness Handicap Inventory (DHI)

Community Integration Questionnaire

• Used to assess the social role limitations and community interaction of people with acquired brain injury.

• Can be self-administered or administered over the phone

Recommended measures (Both inpatient and outpatient)

• 6-minute walk

• 10-meter walk

• Berg Balance Scale

• Community Balance and Mobility Scale

• Disability Rating Scale

• Functional Assessment Measure (FAM)

• Modified Ashworth Scale

• Patient Health Questionnaire

• Quality of Life after Brain Injury

• Rancho Levels of Cognitive Function

Community Balance and Mobility Scale (CB&M)

• evaluates balance and mobility skills necessary for full participation in the community in ambulatory adolescent and adult patients.

• All tasks are performed without ambulation aides, except (descending stairs) for which a cane can be used.

• Orthoses are permitted

Functional Assessment Measure (FAM)

• Adjunct to the FIM (can't be used alone).

• Includes functional areas:

  • Community access

  • Reading and writing

  • Safety

  • Employability

Acute Hospital: LOS, STG, LTG, Considerations

• LOS: 7.9 days

• STG time: <1 wk

• LTG time: Expected LOS

• considerations: Discharge Disposition: Post Acute Rehab vs Home

Post Acute Rehab: LOS, STG, LTG, Considerations

• LOS: 17 days

• STG time: 1 wk

• LTG time: Expected LOS (2-6 wks)

• considerations: Recovery vs Compensation

Outpatient: LOS, STG, LTG, Considerations

• LOS: 2-6 mo

• STG time: 1 mo

• LTG time: Expected LOS (2-3 mo)

• considerations: LOS dependent on dx and insurance; once d/c from OP, therapy is complete

Home Health: LOS, STG, LTG, Considerations

• LOS: 1-2 mo

• STG time: 2 wks

• LTG time: 1-2 mo

• considerations: D/c disposition = OP vs completed therapy

Creating “Task / Activity” Specific Goals

1. Review your Outcome / Objective Statement from your Task Analysis

2. Identify the measurable aspects of the statement

3. Based on setting (post-acute rehab) & clinical reasoning, you progress the measurable aspects of the statement and connect to a participation restriction.

Outcome Measure Goals – Activity & Beyond

• What to do with the higher level patients in outpatient?

  • Consider Higher Level OMs from the TBI EDGE recommendations