TBI, Glasgow Coma Scale, Rancho Los Amigos Scale of Cognitive Functioning

Severe TBI

• Open-head injury, penetration to skull due to falls, car crash, struck by object

• Closed head injury, no penetration to skull due to firearm injuries or struck by sharp object

Non-traumatic TBI

• Drug overdose: both recreational & prescribed

• Chronic substance use: Alcoholism, chronic drug use

• Carbon monoxide: Depletion of oxygen

• Environmental exposure: Toxins

• Anoxia: Depletion of oxygen

TBI: Immediate medical interventions

• Surgical Interventions

• Removal of objects ( i.e., bullet. debris)

• Evacuation of hematoma

• Tumor removal

• Bone flap

TBI: Clinical signs and symptoms - Secondary issues

• Orthopedic-weight-bearing status may interfere with ability to participate fully in the rehab program

• Pulmonary: may affect upright tolerance and endurance

• Decubitus ulcers: an ulcer initially of the skin, due to prolonged pressure

Combo injuries: SCI/TBI account for 30 to 50% of brain injury cases

OT rehab focus (general info)

• Splinting and casting-upper extremity

• Neuromuscular re-education

• Cognitive retraining

• Participation in self-care (ADLs)

• Bed positioning, transfers, and mobility (W/C)

• Transfers

• Wheelchair positioning and mobility

• Equipment needs (W/C), bath equipment

• Caregiver training

• Home evaluation

• If there is a time and need, OTs also work on:

  • Meal plan preparation, home management

  • Money-management

  • Pre-driving (usually addressed post-rehab)

  • Pre-vocational (usually addressed post-rehab)

  • Community skills

TBI: Clinical signs and symptoms

• Decorticate or decerebrate posturing

• Retrograde, anterograde, or post-traumatic amnesia

TBI: Decorticate posturing (core; abnormal flexion)

• UE in a spastic, flexed position, internal rotation (IR) and adduction

• LE spastic extended, IR and adduction

• Location: Cerebral hemisphere, internal capsule, above the superior colliculus

TBI: Decerebrate posturing (extensor response)

• UE and LE in extension, adduction and internal rotation (IR)

• wrist & fingers in flexion (lesion below the superior colliculus, brainstem region)

• poorer prognosis than clients with damage above the superior colliculus

TBI: Retrograde amnesia

• length of amnesia for events prior to injury

• unable to remember events due to neurological damage

TBI: Anterograde amnesia

• length of amnesia following impact, injury

• Tnable to consolidate information for storage and retrieval

TBI: Post-traumatic amnesia

• Following injury where patient is confused

• seems unable to store and recall new information (can refer to anterograde or retrograde subtype)

Glasgow Coma Scale: clinical tool to assess the severity of coma and impaired consciousness; one of the most commonly used scoring systems

• 3 - 8: severe TBI

• 9 -12: moderate TBI

• 13 -15: mild TBI

• Eye-opening, best motor response, verbal performance observed

• Overall coma score: add up the total numbers (E+M+V). A total of 3 is the least responsive; the highest score is 15.

Glasgow Coma Scale: Eye opening (E)

• Spontaneous-4

• To speech-3

• To pain-2

• Nil-1

Glasgow Coma Scale: Best motor response (M)

• Obeys-6

• Localizes- 5

• Withdraws-4

• Abnormal flexion- 3 (decorticate posturing)

• Extensor response-2 (decerebrate posturing)

• Nil-1

Glasgow Coma Scale: Verbal performance (V)

• Oriented-5

• Confused conversation-4

• Inappropriate words- 3

• Incomprehensible sounds-2

• Nil-1

Galveston Orientation & Amnesia Test (GOAT)

• Measures cognitive level of patients post-injury so that a more realistic recovery plan can be communicated. Including length of stay, rehab therapy plan, and prediction of recovery information for patient’s family

• LOW GOAT score: longer duration of the post-traumatic amnesic period.

• An increased duration of the post-traumatic (PTA) was found in patients with diffuse or bilateral brain injuries.

• The longer the confused state, the more difficult for the patient to return to pre-injury cognitive levels.

Rancho Los Amigos (RLA) Scale of Cognitive Functioning (8)

Rehab evaluation tool. Focuses on client’s abilities and behaviors. Clients move through the stages during recovery process; they can start or stop at any level, or skip a stage.

• No Response

• Generalized Response

• Localized Response

• Confused, Agitated

• Confused, Inappropriate, Non-agitated

• Confused, Appropriate

• Automatic, Appropriate

• Purposeful, Appropriate

Recovery Process, RLA 1-3: Requires…

Total Assistance

RLA 1 (Coma)

• Not arousable, not responsive

• Absence of awareness of self and the environment despite maximum stimuli

• No periods of wakefulness in the coma state

• When sedating and hypnotic medications are removed, coma rarely lasts more than weeks

• Coma rarely lasts > 3 to 4 weeks unless medication induce

RLA 2: Persistent vegetative state (PVS) = Awake but unaware

• No awareness of self or environment: Cannot attend, follow commands

  • No intelligible verbal response/communication, automatic motor response or localizing

  • Incontinence bowel and bladder

• Positive signs

  • Sleep/wake cycles

  • Brainstem, autonomic functions: gag, swallow, cough, temperature regulation

  • Random vocalizations, movements

RLA 3: Minimally conscious state

• Some awareness with wakefulness

• Definite reproducible behavioral evidence of some awareness of self or environment

  • Follows commands

  • Gestures or verbal response to questions

  • Intelligible sounds

  • Crying, laughing, smiling to relevant stimuli

  • Reach/hold objects

  • Visual tracking

Locked-In Syndrome

• Loss of voluntary motor control in a setting of preserved consciousness

• Tetraplegia and bulbar weakness; vertical eye movement and blinking usually intact

• Damage to corticospinal and corticobulbar pathways; lesion in basis pontis classic

• May be difficult to demonstrate conscious behavior because of motor limitations

Persistent Vegetative State (PVS) = Diagnosis (Dx)

• Describes past and current state

• After one month in a vegetative state

Permanent (Irreversible) Vegetative State

• 12 months after TBI

• 3 months after non traumatic brain insult.

• Determine level of medical support, nutrition. Advanced Directives helpful, but rarely present!

Musculoskeletal Problems from Vegetative State

Goal: allow sitting, standing, positioning

• Fractures: clarify weight-bearing parameters before admission

• Heterotopic ossification: abnormal bone growth in soft tissue

  • Symptoms 2-8 weeks post injury, usually detected by therapists, nurses, families

• X-rays, triple phase bone scan

• NSAIDs for pain, inflammation

• IV etidronate-oral for 6 to 9 months to prevent further bone deposits

• ROM: continuous passive motion

RLA 1-3: Wheelchair positioning

• Prevent deformity

• Tone normalization

• Pressure management

• Promote function

• Increase sitting tolerance

• Enhance respiratory function

• Provide proper body mechanics

• Dynamic head positioning device provides alignment & freedom of movement, promotes function

RLA 1-3: Spasticity Management = goal to normalize tone w/ minimal daytime sedation

• Position in bed, chair

• Sitting/standing opportunities: two people treatment

• Neuromuscular blocks plus casting

  • phenol: motor points for large muscles, musculocutaneous nerve (biceps), obturator nerve (thigh adductors)

  • Bupivacaine: any nerve, allows immediate casting in relaxed position

  • Botulinum toxin: every three months, small to medium sized muscles

• Systemic medications

  • Dantrolene, baclofen

  • Intrathecal baclofen pump after 4 to 6 months

  • Positioning and casting consume the most time and resources: early treatment makes a difference by reducing the need!

RLA 1-3: only cast when…

• Splinting has failed to control severe tone or contractures from developing

• Positional cast is necessary for continued use (bivalve, cut in 2 and easily removable cast)

• Range of motion is decreased and prolonged stretches necessary

RLA 1-3: Consequences of Lack of Intervention

• Contractures

• Limited head and trunk control

• Increased caregiver assistance

• Limited participation in daily occupations, limited mobility

• Transportation difficulties

Recovery Process: RLA 4-6

Confused

RLA 4/IV: Confused/Agitated (Max A)

• Alert and often a heightened level of activity

• Purposeful attempts to remove tubes, restraints, or crawl out of bed

• Absent short-term memory

• May cry or scream out of proportion to stimulus

• May exhibit aggressive and/or flight behavior

• Wide mood swings with no apparent relationship to environmental events

• Require max A

RLA IV/4: Behavior management program

• provide an environment that motivates patients to participate in a comprehensive rehab program at their optimal capacity

• To integrate family members into the rehab team and treatment plan development process

• To maintain a safe environment through a multifaceted safety program

• minimize the use of all restrictive modalities

• Provide education to patients, family, and staff

• To identify patients with substance use disorders and initiate specialized treatment

RLA IV/4: Behavior management interventions - Environment 👂

• Decreased auditory and visual stimulation

• Reduce noise levels ( TV, staff communication)

• Provide consistency and structure

• Know the patient’s care plan and unique behaviors

RLA IV/4: Behavior management interventions - Communication/interaction 💬

• Model behaviors for the patient

• Speak calmly, slowly, and in simple sentences

• For agitated/restless patients that want to walk, do not restrain them. Walk with them, this will help calm patient

• Give praise and attention for the desired behavior when it occurs

• Do not reinforce undesirable behavior

• Redirect patients when they’re agitated or perseverating

• Provide choices whenever possible

RLA 5/V: Confused, inappropriate, non-agitated

• Alert but not agitated

• Not oriented to person, place, or time

• Frequent periods of non-purposeful sustained attention

• Unable to learn new material

• Able to respond to simple commands fairly consistently with external cues

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

• Verbalizations about present events often inappropriate and confused

• Requires max A

RLA 6/VI: Confused, appropriate

• Inconsistently oriented to person, place and time

• Remote memory more accessible than recent memory

• Able to use assistive memory devices with max A

• Supervision needed for execution of previously learned tasks (self-care)

• Shows carry over for relearned familiar tasks (self-care)

• Unaware of impairments, disabilities, safety risks

• Requires mod A

RLA 7-8: Automatic, purposeful

Recovery process ✅

RLA 7/VII: automatic, appropriate (min A)

• Consistently oriented to person, place and time

• Increased attention and able to work for 30 minutes on highly familiar tasks

• Minimal supervision for new learning

• Initiates and carries out familiar self-care and household tasks but may have limited memory of events

• Unrealistic planning for the future

• Overestimates abilities

• Unable to think about consequences

• Unaware of others’ needs and feelings

• Requires min A for ADLs

RLA 8/VIII: Purposeful, appropriate (standby A)

• Consistently oriented to person, place and time

• Attention increased to 60 minutes for familiar tasks

• Able to recall past events and integrate with recent events

• Initiates and carries out steps for familiar personal, household, community, work, and leisure routines and can slightly modify a plan when needed with minimal assistance

• Requires no assistance once a new task/activity is learned

• Needs assistance to make corrective measures when a plan needs substantial alterations

• Thinks about consequences of actions

• Irritable and depressed

• Acknowledges others’ needs and feelings

• Requires stand-by A (SBA)/supervision

Involuntary Movement Disorders

• Occur most often from damage to the basal ganglia structure

• Movements occur at rest and may also be seen during volitional tasks

Involuntary Movement Disorders: Chorea

quick, jerky, involuntary movements; seen with damage to the caudate nucleus

Involuntary Movement Disorders: Hemiballism

flailing, ballistic movements (rare); seen with damage to the subthalamic nucleus

Involuntary Movement Disorders: Athetosis

slow, sinuous movements; general damage to basal ganglia

Involuntary Movement Disorders: Dystonia

slow, twisting, contorted movements; general damage to basal ganglia

Involuntary Movement Disorders: Resting tremor (person @ rest)

Damage to substantia nigra

Involuntary Movement Disorders: Clonus

Involuntary, rhythmic muscular contractions & relaxations caused by neurological conditions (ALS, brain injury, CVA, CP, etc) due to upper motor neuron lesions involving descending motor pathways

• To test: Hold the ball of the client's foot

  • Quickly dorsiflex the foot and then release pressure but DON’T let go of the foot

  • Observer/feel for alternating movement of dorsiflexion and plantarflexion of the foot after this stimulus

Voluntary Movement Disorders

• occur at rest; related to damage of the cerebellum where the grading of movement is compromised

• poor control of agonist/antagonist during the movement

Voluntary Movement Disorders: dysmetria

inability to correctly estimate ROM needed (overshooting/undershooting a target)

Voluntary Movement Disorders: Dysdiadokokinesia

Impairment of the ability to make rapid alternating movements

Voluntary Movement Disorders: Ataxia

delayed initiation, poor coordination, lack of smooth movement, wide-based gait

Voluntary Movement Disorders: Intention tremor

tremor triggered by movement toward an object

Voluntary Movement Disorders: Hypotonia

low tone that impacts movement

Voluntary Movement Evaluation: Cerebellar coordination tests

• Finger to nose

• Heel to shin

• Thumb to fingertip

• Diadochokinesia: alternating pronation/supination

• Gait assessed by PT. OT concerned about energy expenditure with abnormal gait and safety; but the PT provides intervention to correct gait deviations