[PT10117] [1T2S] [2.2] Traumatic Brain Injury

Neuromuscular impairments of TBI (5)

1. Abnormal tone

2. Sensory impairments

3. Impaired balance

4. Motor function

5. Paresis

[A SIMP]

Cognitive impairments of TBI (8)

1. Altered level of consciousness

2. Memory loss

3. Altered orientation

4. Attention deficits

5. Impaired insight and safety awareness

6. Problem-solving/reasoning impairments

7. Perseveration

8. Impaired executive function

Behavioral impairments of TBI (8)

1. Disinhibition impulsiveness

2. Sexual inappropriateness

3. Physical and verbal

4. Irritability

5. Egocentricity

6. Aggressiveness

7. Apathy

8. Impaired drive

Goals of acute care in TBI patients (4)

1. Improve respiratory function and prevent respiratory complications

2. Prevent secondary brain damage

3. Preserve musculoskeletal integrity

4. Facilitate arousal and active engagement

POSSIBLE ATTACHMENTS

This attachment only lets the patient make sounds but cannot speak

Intubation

POSSIBLE ATTACHMENTS

What are the two kinds of intubation attachments for breathing?

1. Endotracheal tube

2. Tracheostomy

POSSIBLE ATTACHMENTS

What level is the tracheostomy tube attached to the patient?

Hyoid level

POSSIBLE ATTACHMENTS

What is the purpose of a tracheostomy tube?

Allows easier breathing and drains secretions of pt

POSSIBLE ATTACHMENTS

Provides nutrition to pts from nose to esophagus

Nasogastric tube (NGT)

POSSIBLE ATTACHMENTS

Drainage for fluids (excess) within the lung parenchyma

Chest tubes

POSSIBLE ATTACHMENTS

True or False: A chest tube attachment is a precaution when moving the thorax.

True

POSSIBLE ATTACHMENTS

Tube through IVC to get blood sample and for administering medicines

Central venous line

POSSIBLE ATTACHMENTS

Goes through the vein to administer medicines

Swan-Ganz catheters

POSSIBLE ATTACHMENTS

From the scalp, it pierces the bone and enters the dura to monitor ICP

Intracranial pressure monitors

POSSIBLE ATTACHMENTS

Attachment that checks important VS (ex. HR, PR, BP)

Heart rate monitors

POSSIBLE ATTACHMENTS

This is inserted to either a vein or artery on the forearm to facilitate exchange of fluids and nutritional support to the blood

IV line/Arterial line

What respiratory problems are amenable to PT treatment? (4)

1. Hypoventilation impaired

2. Mucociliary clearance

3. Hyperventilation

4. Ventilation/perfusion mismatch

What are the two indications for ventilation?

1. Hypoxemia

2. Hypercapnia

Partial pressure value indicative of hypoxemia?

PaO2 < 60 mmHg

Partial pressure value indicative of hypercapnia?

PaCO2 > 45 mmHg

Rate at which the brain is perfused by blood

Cerebral perfusion pressure

Formula in calculating the CPP

CPP = MAP - ICP

Normal CPP value

5-70 mmHg

How can CPP be maintained through PT mx?

Proper positioning of the pt

What are ways to prevent secondary brain damage? (3)

1. Optimizing cerebral perfusion and oxygenation

2. Minimize the increase in ICP

3. Treatment of cerebral edema

What are ways to preserve musculoskeletal integrity? (6)

1. Maintain at risk muscles and soft tissues in a lengthened position

2. Load bone and cartilage

3. Move limbs to aid maintenance of flexibility of joins, soft tissues, and muscles

4. Positioning slow, gentle PROM

5. Serial casting

6. Periods of sitting and standing

PRESERVING MUSCULOSKELETAL INTEGRITY

What muscles are prone to contractures in UE?

Wrist and elbow flexors and extensors

PRESERVING MUSCULOSKELETAL INTEGRITY

What muscles are prone to contractures in LE?

Ankle plantarflexors

PRESERVING MUSCULOSKELETAL INTEGRITY

What muscles are prone to tightness?

Hamstrings

PRESERVING MUSCULOSKELETAL INTEGRITY

Casting at different degrees to gradually stretch tight muscles

Serial casting

PRESERVING MUSCULOSKELETAL INTEGRITY

This device can be used to the patient to gradually introduce the upright position and increase their tolerance

Tilt table

PRESERVING MUSCULOSKELETAL INTEGRITY

True or False: Both BP and ICP should be monitored during later attempts at getting the patient upright

False: Both BP and ICP should be monitored during initial attempts at getting the patient upright

PRESERVING MUSCULOSKELETAL INTEGRITY

When is attempting to get the patient in the upright position appropriate? (4)

1. Has voluntary control of breathing

2. No severe chest injury

3. No chest tube

4. No femoral/pelvic fx

Other benefits of the upright position (3)

1. Stimulation of bowel movements and bladder emptying

2. Improved ventilation

3. Decreased ICP

[SID]

What are considered in facilitating arousal and active engagement? (5)

1. Timing of interventions

2. Family involvement, education, and counseling

3. Limited carry-over of training from one session to the next

4. Family counseling important because of altered behavior

5. Re-establish [SUCE]:

   1. Swallowing

   2. Unassisted breathing

   3. Effective coughing

   4. Communication

FACILITATING AROUSAL AND ACTIVE ENGAGEMENT

What are usually the best times of a day to conduct PT activities to the patient? (3)

1. Early in the morning

2. Active parts of the day

3. Lunchtime

FACILITATING AROUSAL AND ACTIVE ENGAGEMENT

True or False: The timing of interventions must be consistently performed

True

FACILITATING AROUSAL AND ACTIVE ENGAGEMENT

How can we ensure family involvement, education, and counseling? (4)

1. Speaking to the pt

2. Considering pt’s feelings during conversation

3. Preserving a sense of dignity

4. Encouraging active response

What are the management goals for LOCF I–III? (5)

1. Prevent indirect impairments

   1. Orthostatic hypotension

   2. Pressure sores

   3. Contractures

2. Improve arousal through sensory stimulation

3. Manage effects of abnormal tone and spasticity

4. Early transition to sitting postures

5. Educate the family

MANAGEMENT (LOCF I–III)

What is the proper positioning of the head?

1. Neutral

2. Place rolls behind the neck

3. Place roll(s) parallel to the head

MANAGEMENT (LOCF I–III)

What is the proper handling of the head?

1. Gentle ROM

2. Hands at base of skull or sides of head

3. Use pillow to handle head

MANAGEMENT (LOCF I–III)

What is the proper positioning of the trunk?

1. Maintain normal alignment

MANAGEMENT (LOCF I–III)

What is the proper handling of the trunk?

1. Segmental rolling if stable

MANAGEMENT (LOCF I–III)

What is the proper positioning of the upper extremity?

1. Place roll behind scapula (as needed)

2. Cone/ball in hand

MANAGEMENT (LOCF I–III)

What is the proper handling of the upper extremity?

1. Relaxation of scapula

2. Decrease flexor tone

MANAGEMENT (LOCF I–III)

What is the proper positioning of the lower extremity?

1. Hips & knees are slightly flexed

2. Avoid pressure on ball of foot medially

3. Pillow/roll below legs to prevent excessive IR & adduction

MANAGEMENT (LOCF I–III)

What is the proper handling of the lower extremities?

1. Encourage ROM: IR, ER, Abd, Flex-ext

MANAGEMENT (LOCF I–III)

What are the different parts of the sensory stimulation program (with duration)?

Part 1: Awakening (5 mins)

Part 2: Auditory Stimulation (10 mins)

Part 3: Visual Stimulation (10 mins)

Part 4: Tactile Stimulation (5 mins)

Part 5: Olfactory Stimulation (10 mins)

MANAGEMENT (LOCF I–III)

What are the different ways to perform awakening in a sensory stimulation program?

1. A nurse or a close relative to the patient introduces themselves and speaks to the patient

2. A nurse or close relative opens the patient’s eyes

3. A nurse or close relative calls the patient while moving his/her body at the same time

4. Moisten the patient’s face with a wet gauze

MANAGEMENT (LOCF I–III)

What are the different ways to perform auditory stimulation in a sensory stimulation program?

1. Play the patient’s favorite music

2. Play taped recordings of the voice of the patient’s family members and acquaintances (directly to the patient/talking to each other)

MANAGEMENT (LOCF I–III)

What are the different ways to perform visual stimulation in a sensory stimulation program?

1. Open the pt’s eyes and show:

   1. Family picture

   2. Family film

   3. Mirror

   4. Colored paper

   5. 40-watt light bulb (red, blue, green)

MANAGEMENT (LOCF I–III)

What are the different ways to perform tactile stimulation in a sensory stimulation program?

1. A nurse or close relative to the patient touched his/her shoulder outside the patient’s visual field (using a soft brush/comb) (various body parts)

2. Touch the patient’s lips (top and bottom) with a tip of a pen or spoon

MANAGEMENT (LOCF I–III)

What are the different ways to perform olfactory stimulation in a sensory stimulation program?

1. Introduce aromatic stimuli/fragrances that the pt is accustomed to, including:

   1. Favorite perfume

   2. Coffeee

   3. Garl

MANAGEMENT (LOCF I–III)

What should you monitor in these LOCF pts before and after the stimulation program to see if there are adverse effects? (3)

1. Pulse rate

2. Mean arterial blood pressure

3. Respiratory rate

MANAGEMENT (LOCF I–III)

Why should you assess the pt’s pulse rate, mean arterial blood pressure, and respiratory rate before and after the sensory stimulation program?

To cease the intervention should a problem arise

MANAGEMENT (LOCF I–III)

What sensory stimulations give the most significant changes? (2)

1. Tactile stimulation

2. Acoustic stimulation

MANAGEMENT (LOCF I–III)

True or False: Sensory stimulation affects hemodynamic or cerebral dynamic status

False: Sensory stimulation did not affect hemodynamic or cerebral dynamic status

MANAGEMENT (LOCF I–III)

The sensory stimulations give programs should be applied for _____ to achieve a permanent effect on consciousness levels

More than 1 month

MANAGEMENT (LOCF I–III)

The sensory stimulations give programs should be applied for _____ to achieve a significant effect on consciousness levels

At least 2 weeks

Early indicators of prognosis (5)

1. Pupillary light reflex

2. GCS score

3. Hypotension

4. CT scan features

5. Age

[PGH CA]

EARLY INDICATORS OF PROGNOSIS

Which indicator is a favorable prognosticating factor?

Pupillary light reflex

EARLY INDICATORS OF PROGNOSIS

Which indicator is a not a favorable prognosticating factor?

Hypotension

EARLY INDICATORS OF PROGNOSIS

Which indicator can help identify the prognosis of the pt?

CT scan features

EARLY INDICATORS OF PROGNOSIS

If a pt is ___, there is potential for neuroplasticity

Relatively young

EARLY INDICATORS OF PROGNOSIS

Which LOCF has the following rehabilitation goal/s:

• To maintain functional capabilities

• To prevent agitated outbursts

• To assist the patient to control his behavior through a structured program

LOCF IV

EARLY INDICATORS OF PROGNOSIS

Which LOCF has the following rehabilitation goal/s:

• To maximize functional recovery of pt

• To prepare for discharge home and to community (pt and family)

LOCF V–VI

EARLY INDICATORS OF PROGNOSIS

Which LOCF has the following rehabilitation goal/s:

• To assist pt in integrating the cognitive, physical and emotional skills necessary to function in the community

LOCF VII–VIII

EARLY INDICATORS OF PROGNOSIS

Which LOCF manifests the following:

• Use of behavior modification techniques

• Consistency

• Expect no carryover

• Model calm behavior

• Expect egocentricity

LOCF IV

EARLY INDICATORS OF PROGNOSIS

Which LOCF manifests the following:

• Provide flexibility/options

• Safety and environmental modification

• Family education

LOCF IV

EARLY INDICATORS OF PROGNOSIS

Which LOCF manifests the following:

• Compensatory approach: Improve functional skills by compensating

• Restorative approach: Restore the normal use of affected limbs

LOCF V–VI

EARLY INDICATORS OF PROGNOSIS

Which LOCF manifests the following:

• Wean pt from structure and supervision

• Focus on advanced activities

• Involve pt in decision-making and problem-solving

• Incorporate endurance training

LOCF VII–VIII

Cognitive and behavioral deficits in TBI (2)

1. Impaired ability to adapt and to cope with new and different stresses

2. “Frontal pattern of behavior”

APPROACHES TO COGNITIVE–PERCEPTUAL DYSFUNCTION

Adaptive approach (4)

1. CNS has limited potential for repair and reorganization

2. Direct training of deficient functional skills

3. Does not assume automatic carryover to dissimilar tasks

4. Therapist works with pt on specific tasks that are required

APPROACHES TO COGNITIVE–PERCEPTUAL DYSFUNCTION

Remedial approach (4)

1. CNS can repair and reorganize itself after injury

2. Training of perceptual components of motor behavior

3. Training in underlying skills will carryover to tasks requiring such skills

4. Therapist works on underlying cognitive/perceptual problems

Managing communication problems (9)

1. Tolerance for slow, cumbersome speech

2. Use of pertinent cues

3. Strategies to focus attention (calling by name, waiting for eye contact, use of prompts)

4. Positive interaction

5. Simplifying form and content of language

6. Modifying environment

7. Using natural contextual clues

8. Communicating respect for the individual

9. Redirecting agitated or perseverant behavior

PERSONALITY CHANGES

Apathy often described as laziness or slowness

Drive

PERSONALITY CHANGES

Euphoria, emotional lability

Affect

PERSONALITY CHANGES

Tactlessness, hurtfulness

Social restraint and judgement

A task is _____ if the pt is

• Quiet

• Focus

• Not distractible

Suitable

A task is _____ if the pt is

• Makes frequent stops

• Easily annoyed

• Throws things

• Request frequent toilet visits

• Escalate into a crisis

Too complex

A task is _____ if the pt is

• Talkative

• Laughs too much

• Keeps looking around

• Does unnecessary things

• Twists hair

Too easy

• Simplifying information

• Reducing the amount of information given at any one time

• Ensuring minimal distraction

• Making sure information is understood

Remediating memory disorders

• Encouraging associating information with material already known

• Encouraging asking questions

• Making sure learning occurs in different contexts

Remediating memory disorders

• Adapting the environment (e.g. labeling)

• Use of external aids (e.g. diaries)

• Internal strategies (mnemonics, rehearsal)

Remediating memory disorders

• Training interesting tasks that are relevant to the pt

• Clear visual and auditory cues and feedback

• Remove distractions

• Dividing attention for open tasks

Attention impairment

• Training multiple steps, strategic thinking and multitasking in individual and group sessions

• Worksheet, photographs and video to record exercises

• Give clear cues, instructions, feedback, and goals

Dysfunction

BEHAVIORAL IMPAIRMENT

• What happens before a consequence

• Modify the environment in a way that it leads a desired effect

Antecedent-focused strategies

BEHAVIORAL IMPAIRMENT

• Provide feedback according to the consequence

Consequence-focused strategies

Strategies for decreasing behaviors (7)

1. Withhold rewards that maintain maladaptive behavior

2. Withhold all sources of positive reinforcement for a brief period after an instance of maladaptive behavior

3. Apply a predeclared penalty following a maladaptive behavior

4. Apply an aversive consequence following severe or resistant maladaptive behavior

5. Stimulus control for distractibility

6. Systematic desensitization for certain fears

7. Extinction for yelling and aggression

STRATEGIES FOR DECREASING BEHAVIOR

For distractibility

Stimulus control

STRATEGIES FOR DECREASING BEHAVIOR

For certain fears

Systematic desensitization

STRATEGIES FOR DECREASING BEHAVIOR

For yelling and aggression

Extinction

Strategies for increasing behavior (4)

1. Reward for all instances of appropriate behavior

2. Prompting

3. Chaining

4. Expanding rehearsal

STRATEGIES FOR INCREASING BEHAVIOR

“Good job, you did well!“

Prompting

STRATEGIES FOR INCREASING BEHAVIOR

Breaking a task into smaller components

Chaining

What should be considered when modifying the environment? (5)

1. Observe patient’s behavior in different settings and with different people

2. Analyze environmental variables that affect behavior positively or negatively

3. Remove variables that trigger or reinforce unwanted behaviors and replace them with variables that reinforce desired behaviors

4. Evaluate effects of environmental modificztion

5. Progress and modify intervention to facilitate further improvement

THERAPEUTIC GUIDING

What should be considered in therapeutic guiding? (4)

1. Position of therapist and pt

2. Comprehension of task goal

3. Pt should perform every step of the task

4. Verbal input is avoided during guided activity

THERAPEUTIC GUIDING

True or False: Incontinence is a learning problem as it can become a challenge for PTs during treatment

True

THERAPEUTIC GUIDING

How can you manage pts with incontinence? (3)

1. Assure pt that condition is understandable

2. Teach relatives bladder training

3. Before treatment, pt should go to the toilet and/or wear diaper

THERAPEUTIC GUIDING

A risk within the first 12 months post-injury

Posttraumatic epilepsy