Class 6 - Assessment & Management of TBI

What TBI is a GCS score of 3-8?

• Severe TBI

What TBI is a GCS score of 9-12?

• Moderate TBI

What TBI is a GCS score of 13-15?

• Mild TBI (mTBI)

Glasgow Coma Scale 1:

• No response!

Glasgow Coma Scale 2:

• Eye opening to pain

• Extension of limbs

• Incomprehensible

Glasgow Coma Scale 3:

• Eye opening to speech

• Flexion of limbs

• Inappropriate

Glasgow Coma Scale 4:

• Spontaneous eye opening

• Withdraws from stimulus

• Confused

Glasgow Coma Scale 5:

• Localizes sensory stimulus

• Oriented x3

Glasgow Coma Scale 6:

• Obeys commands

• Appropriate for speech therapy!

What is post-traumatic amnesia (PTA)?

• PTA is the time between injury & recovery of continuous memory –ability to remember events for a 24-hour period

• Does not include time in coma

• Basic assumption–amount of time taken to recover full consciousness reflects the quantity of brain tissue destroyed

• Return of memory for day-to-day events is last stage in restoration of consciousness

What test assesses PTA?

• the GOAT!

What is the GOAT?

• Galveston Orientation & Amnesia Test (GOAT)

  • Should be administered at least once daily (simple questionnaire)

  • Termination of PTA is when patient receives consistent scores of 75 or greater (100 possible)

  • Consistent 3x in a row

TBI video:

• naming deficits (anomia)

• language (minimal substance to language)

• approximating speech sounds/slurring

What is the injury severity level of a mild injury?

• Glasgow Coma Scale Score: 13-15

• <24 hours Post Traumatic Amnesia

• concussion → GCS & PTA → mTBI is less than 30 minutes, PTA less than 24 hours, severity of deficits might not be as severe 

What is the injury severity level of a moderate injury?

• GCS → 9-12

What is the injury severity level of a severe injury?

• GCS → 3-8

• > 24 hours Post Traumatic Amnesia

What are 3 scales & observational checklists?

• Ranchos Los Amigos Levels of Cognitive Functioning

• Functional Independence Measures (FIM)

• Disability Rating Scale

When is a patient appropriate for therapy on the RLAS?

• Level 6

When thinking about patient’s discharge and level of independence, what assessment should you administer?

• Functional Independence Measures (FIM Scores)

• higher the score the better → more independent

TBI Severity Measurements & Progress Monitoring:

• Level of Consciousness

• Glasgow Coma Scale

• Disability Rating Scales

• PTA

Self-Report & QOL Measures:

• Behavior Rating Inventory of EF (BRIEF-A)

• Quality of Life after Brain Injury (QOLIBRI)

• National Institute of Health Toolbox Measures

• Brain Injury Screening Questionnaire (BISQ)

• Mayo-Portland Adaptability Inventory (MPAI)

• Motivational Interview Techniques

What are screening tools for TBI?

• MMSE

• MoCA

• SLUMS

• Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)

• Cognitive Linguistic Quick Test (CLQT)

(Cognitive Subtests & Batteries) Options for cognitive tests for specific subdomains:

• EF: Functional Assessment of Verbal Reasoning & Executive Strategies

• Attention: Test of Everyday Attention

• Memory: Rivermead Behavioural Memory Test (RBMT)

(Cognitive Subtests & Batteries) Additional assessments for use with TBI across domains:

• The Brief Test of Head Injury

• Scales of Cognitive Ability for TBI

• Ross Information Processing Assessment-II (RIPA-II)

Discourse Analysis:

• People w/ TBI may have communicative deficits not readily captured by standardized testing methods

• __________ can be particularly powerful because it can measure various areas of deficits ranging from those less likely to be affected in TBI (e.g., grammar & syntax) to those likely be affected (topic maintenance, organization)

What types of discourse should be evaluated?

• Non-interactive: story retell, story generation, personal event retell, & procedural descriptions

• Conversational discourse

Treatment for TBI:

• Involves a team of professionals so that care is carefully coordinated

• No single standard approach

• Selection of a specific approach may depend on a # of factors (e.g., timeline for treatment, patient preference, research evidence, clinical expertise, patient & family goals)

What is most important to consider when treating TBI?

• Determine if a selected goal & subsequent treatment is aimed at restoring functioning & remediating deficits (e.g., drill & practice), compensating for present deficits (e.g., strategy training), &/or environmental management

Why is sensory stimulation done?

• To maximize arousal & awareness of surroundings in a person w/ impaired consciousness

• To increase person’s FREQUENCY, VARIETY, & SPECIFICITY of responses by manipulating the RATE, AMOUNT, DURATION, & COMPLEXITY of stimulation

early stage aac:

• Simple choice-based systems Yes/no systems

• Eye gaze or direct selection

Middle Stage AAC:

• Complex choice making w/ picture, letter, or word board

• Written Choice Communication Strategy

• Simple voice output for basic info

Late stage AAC:

• Familiar listeners:

  • Alphabet board for supplemented speech (no verbal modality)

  • Gestures combined w/ natural speech

• Unfamiliar listener & specific contexts

  • Text-to-speech

  • Stored message complex voice output systems

Attention:

• Direct attention training → includes improvement of the neurocognitive system through repetition of exercises that stimulate attention (e.g., writing down address)

• Metacognitive strategies → computer-based interventions can be used as a supplement

Memory:

• External memory aids (mild & severe memory impairments)

• Internalized strategies (mild memory impairments)

• Spaced retrieval (mild to severe memory impairments)

• Individual & group treatments

Multitasking instruction:

• have patient do task that is very simple & requires less cognitive resources & pair it with another simple task to see how patient is able to perform w/o showing errors

Communication - Discourse & Pragmatics:

• Individuals w/ TBI may also experience difficulties connecting in social situations & may benefit from treatment aimed at various pragmatic goals”

  • increasing awareness of listener needs,

  • improving use of social conventions,

  • reducing ToM deficits

• Evidence supports the use of specific interventions aimed at improving pragmatic conversational skills

• Additionally, group-based interventions, sometimes called social communication skills training, increase effective communication skills after TBI

• Concept of talking about emotions & how others would feel when certain comments are made

Other Considerations:

• Treat for other conditions secondary to TBI →

  • Aphasia

  • Dysarthria

  • Apraxia

(PER) What are the EF-Cognitive-Language Goals in the Early Stages (Maximal Support)?

• Increase alertness & arousal

• Improve external focus

• Increase recognition of objects & people

• Increase engagement in overlearned activities

• Improve basic communication: comprehension of simple, everyday language; expression of basic wants, needs, & reactions

(PER) What are the EF-Cognitive-Language Goals in the Middle Stages (Moderate Support)?

• Increase duration of attention; ability to shift attention from object to object and activity to activity; ability to filter out distractions.

• Improve perceptual scanning abilities

• Use organizing schemes, including external organizers, to complete functional tasks.

• Use a prosthetic log/memory system to aid orientation, organization, memory, & self-management

• Improve organization of spoken & written discourse, with external supports

• Improve awareness of needs & strategies to compensate for deficits

(PER) What are the EF-Cognitive-Language Goals in the Late Stages (Relative Independence; Support as Needed)?

• Improve awareness of self as a thinker, learner, communicator, & self-manager

• Increase independent use of strategies to compensate for ongoing cognitive deficits

• Improve organization of discourse w/ decreasing use of external organizers

• Improve comprehension of vocabulary & extended texts related to vocational & avocational interests

• Improve independent goal setting, planning, initiating, & self-evaluation

• Increase independent creation, implementation, review, & revision of compensatory strategies