Exam 2

65% of patients after TBI have

1 neuropsychiatric diagnosis

40% of patients after TBI have

2 neuropsychiatric disorders

comorbid neuropsychiatric disorders increase the odds of

functional impairment, decreased social function, poorer health related QOL

Aspects of behavioral dyscontrol

agitation, disinhibition, and aggression

Aspects of disinhibition

physical

• sexual advances

• Impulsivity

verbal

• no filter

• breaking rules of discourse

• ecgocentric perspective

treatment of aggression

valproate, beta blockers, pyschostimulants (adderall, Ritalin), SSRIs

Mood disorders

depression, anxiety, apathy

Risk factors for depression

older, female, less education, stroke severity, prior psych disorder

TBI specific risk factors for depression

frontal pole, left injury lateralization, serotonergic dysfunction

SNRI

selective norepinephrine reuptake inhibitor

predictors for anxiety in stroke

higher severity, premorbid depression, early anxiety after injury, cognitive impairment

risk factors for anxiety after TBI

older, prior psych disorder, female, longer LOC, shorter PTA

anxiety treatment

SSRIs, benzodiazepines (Xanax, Ativan)

SNRI can increase… in depressed patients

anxiety

Treatment of apathy

dopamine agonists, pyschostimulants, acetylcholinesterase inhibitors

GCS 3-8

severe brain injury

9-12 GCS

moderate brain injury

GCS 13-15

minor brain injury

sustained attention tests

digit repetition test, test of vigilance

BLS

Burke lateropulsion scale

SCP

scale for contraversive pushing

SCP looks at

spontaneous body posture, use of nonparetic extremities, resistance to passive correction of tilted posture

UL neglect occurs in… of stroke

30%

UL is due to damage in

R parietal association areas

severity in UL neglect decreases after

3 months, plateau after 6 months

Apraxia is present in

30-80% of strokes and 19-45% of TBI

apraxia results from damage to

parietal association and frontal motor connections

aphasia is present in

20-40% of stroke and 11-30% of TBI

‘getting better’

motor recovery

‘doing better’

Functional recovery

functional diaschisis

normal brain activations during a selected task may be altered after a lesion

connectional diaschisis

distant strengths and directions of connections in a selected network are changed

connectomal diaschisis

lesion of the connectome (structurally connected) incduces widespread changes in brain network organization, including changes in connectivity

cortical reorganization will increase

absolute number and concentration of synapses on dendrites

Therapeutic question of muscle re-ed

can we directly treat the nervous system?

Product of 1966 NUSTEP conference

Neurofacilitation approaches

Neurofacilitation approaches

application of appropriate sensory inputs leads to normal movement patterns

neurofacilitation is built on

reflex theory and hierarchical organization of reflexive development

Neurofacilitation was developed by

Signe Brunnstrum and Margaret Rood

Current use of neurofacilitation

Fugl-Meyer Motor outcome measures, importance of postural control for emergence of other behaviors, progression of task difficulty, application of sensory cueing in appropriate context

Limitation of neurofacilitation

voluntary movement is not entirely reflexive in nature

Brunnstrom stages

I- Flaccidity

II- Synergy, some spasticity

III - Marked spasticity

IV - Out of synergy, less spasticity

V - Selective control of movement

VI- Isolated/coordinated movement

PNF

proprioceptive neuromuscular facilitation

Developed by Kabat, Knott, and Voss

PNF

PNF focuses on use of

sensory inputs to elicit compound muscle activation in diagonal planes

Current use of PNF

strengthening in functional positions due to combination of joint motions (not motor skill training though)

Limitations of PNF

often leaves out functional component of functional positions

NDT

Neurodevelopmental treatment

NDT

use of therapeutic handling for habilitation and rehabilitation

Developed by Berta and Karl Bobath

NDT

current use of NDT

observational movement analysis, influence of postural control, handling for pts with severe deficits

limitations of NDT

lack of functional carryover, neglects other elements of motor control, inferior to task-specific training

product of 1990 II Step conference

Task-oriented training

Therapeutic question of NDT

What do we do with new information regarding motor control processes?

Task-oriented training suggests that the injured nervous system utilizes

the same neurobiological mechanisms to learn new skills

Exploits distributed nature of motor control systems

task-oriented training

limitations of task-oriented training

sacrifices quality of motion for sake of function, hands-off approach doesn't help pts that need physical assistance, needs evidence