1. Shayla Haynes
2. Epidemiology
   1. ~1.5-2 million ppl will incur TBI ea/yr
   2. ~ 50,000 will die ea/yr ; 230,000 are hospitalized & survive
      1. Of these 80-90K ppl will develop intellectual, behavioral &/or physical disabilities; thus 2.5-6.5 million Americans living w/its consequences
   3. Mechanism of Injury
      1. MVA=1/2 of all TBIs
      2. Falls=25%
      3. Assaults & Violence= 15%
      4. Sports & Recreation= 10%
   4. Age
      1. Typical pt: 15-24 y.o. @ time of injury
3. Pathophysiology
   1. Focal Injury
      1. is localized to the area of brain under site of impact on skull
      2. damage type/form:
         1. hematoma, edema, contusion, laceration or combo
      3. Coup-Contrecoup Injury
         1. caused by back & forth movement of brain in skull
         2. coup=occur @ site of impact
         3. contrecoup=occur in brain opp initial point of impact
      4. Common sites of focal injury:
         1. Anterior-inferior temporal lobes
         2. Prefrontal Lobes
   2. Diffuse Axonal Injury
      1. microscopic damage that occurs in several parts of the brain where there is widely scattered shearing of axons
      2. Common sites of injury:
         1. Cortical white matter
         2. Corpus Callosum
         3. Basal Ganglia
         4. Brainstem
         5. Cerebellum
   3. Hypoxic-Ischemic Injury
      1. results from lack of oxygenated blood flow to brain tissue
      2. can be caused by:
         1. Systemic Hypotension; Anoxia, or damage to specific vascular territories of brain
      3. assoc: w/poor cognitive fnx & lower expected outcomes
   4. Increased Intracranial Pressure
      1. normal ICP= 4-15 mm Hg
      2. Elevated ICP may result from Hematomas such as:
         1. Epidural
         2. Subdural
         3. Intracerebral
      3. Severely increased ICP may result in herniation of the brain such as:
         1. Uncal
            1. mass lesion in temporal lobe or middle fossa
            2. Paresis of nerve III; Hemiparesis; Coma; Homonymous Hemianopia
         2. Central (Transtentorial)
            1. mass lesion in frontal, parietal, or occipital lobe.
            2. Decerebrate Rigidity; Coma
            3. Progression of uncal herniation
         3. Tonsillar (Foramen Magnum)
            1. mass lesion in posterior fossa
            2. Neck pain & stiffness; Flaccidity; Coma; Alternation of PR, RR, BP
            3. Progression of uncal or transtentorial herniation
4. Dx
   1. CT scan
      1. ID hematomas, ventricular enlargement & atrophy
   2. CT vs MRI
      1. CT is relatively insensitive to many of the lesions present after trauma vs MRI
      2. MRI provides superior soft tissue discrimination vs CT
   3. PET, SPECT, fMRI
      1. Detect regional cerebral blood flow, metabolism, cerebral perfusion, or increases in neuronal activity
   4. Neuropsychological testing
      1. to provide further insight into cognitive & behavioral deficits
5. Sequelae of TBI
   1. NM Impairments
      1. Abnormal tone
         1. Decorticate Rigidity
         2. Decerebrate Rigidity
      2. Sensory Impairments
         1. impairments in light touch, pain, deep pressure, & temp
         2. impairments in proprioception & kinesthesia
      3. Motor Control (& Learning) Impairments
         1. Monoparesis; Hemiparesis; Tetraparesis; Abnormal reflexes
         2. Coordination; Timing; Sequencing of movement
            1. Cerebellum damage
      4. Impaired Balance
         1. as cerebellar injury is common
      5. Paresis/Paralysis
   2. Cognitive Impairments
      1. Altered LOC/Altertness
         1. Terminology
            1. Coma
            2. not obeying commands, not uttering words & not opening eyes
            3. GCS score of 8 or less
            4. usually lasts a few wks tops
            5. Vegetative State
            6. decreased level of awareness w/intact eye opening & sleep-awake cycles but no ability to follow commands or speak
            7. Persistent Vegetative State
            8. pts have no meaningful motor or cognitive fnx & a complete absence of awareness of self or environment
            9. > 1 yr for TBI
            10. > 3 mos for Anoxic Brain Injury
            11. Minimally Conscious
            12. severely altered consciousness w/min but definite evidence of self or environmental awareness
            13. Stupor
            14. unresponsive state from which the pt can be aroused only briefly w/vigorous, repeated sensory stim
            15. Obtunded
            16. pt sleeps often & when aroused exhibits decreased alertness & interest in the environment & delayed rnxs
      2. Memory Loss
         1. retrograde amnesia
         2. anterograde amnesia
         3. posttraumatic amnesia
            1. the time btwn the injury & the time when the pt is again able to remember ongoing events
            2. is as though each moment exists in isolation; no carryover of info from hour-to-hour or day-to-day
            3. pt. w/PTA may not be able to describe memories (declarative memory) or verbalize steps necessary to complete a task
            4. but pt w/PTA may show carryover skills that don't req verbal explanation (procedural memory)
         4. Declarative Memory
            1. recall facts & previous events; used in explicit learning
         5. Procedural Memory
            1. how to do motor tasks; used in implicit learning
      3. Altered Orientation
         1. often disoriented to person, place, & time
      4. Attentional Deficits
         1. Hyperactivity; Impulsiveness; Decreased Attn Span
      5. Impaired insight & safety awareness
         1. lack of insight into their impairments
      6. Problem solving/reasoning Impairments
      7. Perseveration
      8. Impaired Executive Functioning
         1. intact skills allow pt to successfully develop & carry out purposeful goal oriented behavior
         2. Skills refer to 4 overlapping Capabilities:
            1. 1. Volition
            2. 2. Planning
            3. 3. Purposive Action
            4. 4. Effective Performance
   3. Behavioral Impairments
      1. Disinhibition
      2. Impulsiveness
      3. Physical & Verbal Aggressiveness
      4. Apathy
      5. Lack of concern
      6. Sexual Inappropriateness
      7. Irritability
      8. Egocentricity
   4. Communication Impairments
      1. Receptive Aphasia
      2. Expressive Aphasia
      3. Dysarthria
      4. Auditory Deficits
      5. Impaired Reading Comprehension
      6. Impaired Written Expression
      7. Impaired Pragmatics (use of language)
   5. Visual-Perceptual Impairments
      1. Visual:
         1. Hemianopsia
         2. rare occasions: Cortical Blindness
      2. Perceptual:
         1. Spatial neglect
         2. Apraxia
         3. Spatial Relations Syndrome
         4. Somatagnosia
         5. Right-Left Discrimination Deficits
   6. Swallowing Impairments
      1. Dysphagia
      2. caused by damage to CNs, motor control impairments, apraxia & poor postural control
   7. Indirect Impairments
      1. Soft tissue Contractures
      2. Skin breakdown, Decubitus Ulcer
      3. DVT
      4. HO
      5. Decreased bone density
      6. Muscle Atrophy
      7. Decreased Endurance
      8. Infection
      9. Pneumonia
6. Clinical Rating Scales
   1. Glasgow Coma Scale (GCS)
      1. • Most widely used clinical scale; can be used as prognostic measure • Measures level of consciousness • Helps define & classify severity of injury • Has 3 response course: motor response, verbal response & eye-opening • Scores from separate responses are some to provide a score between 3 – 15 • Coma= less than or equal to 8; severe brain injury • 9-12=moderate brain injury • 13-15=mild brain injury • High inter-rater reliability
   2. Galveston Orientation & Amnesia Test (GOAT)
      1. • Is a measure of posttraumatic amnesia • Administered by asking a series of standardized questions related to orientation & ability to recall events prior to & after injury • Score 100-76=normal; below this=PTA • High interrater reliability
   3. Rancho Los Amigos Level of Cognitive Functioning (LOCF)
      1. • Descriptive scale to examine cognitive & behavioral recovery in TBI pts as they emerge from coma • Useful for communicating general cognitive &/or behavioral status & for treatment planning; not for specific cognitive deficits • 8 category this describe typical cognitive & behavioral progress after injury • Reliable & valid • Most widely used with GCS
   4. Glasgow Outcome Scale (GOS)
      1. • Used as a general outcomes measure after a TBI • Used in prognostic studies at discharge & 6 months-1 yr after injury • 5 Categories: dead, vegetative, severely disabled, moderately disabled, & good recovery • Good reliability
   5. Disability Rating Scale (DRS)
      1. • Used to classify levels of disability from death to know disability • Used to track individual progress from coma through community integration • Max score= 29; extreme vegetative state • Lowest score= 0; no disability • Good reliability
   6. Functional Independence Measure (FIM)
      1. • Commonly used measure of fnxal mobility & ADL fnx • Measure level of disability in individs undergoing inpatient rehab • Useful for monitoring pt progress & eval outcomes
   7. Functional Assessment Measure (FAM)
      1. • adjunct to FIM • inclds functional areas not addressed in FIM: • incld: community access, reading, writing, safety, employability, & adjustment to limitations • FIM w/FAM=valid & reliable measures of disability after TBI
7. Prognosis & Goal Setting
   1. Factors That Help Predict Outcome/Disability after TBI
      1. Initial Severity of Injury (GCS)
      2. Duration of Coma
         1. ie >2wk=moderate or severe disability after 1 yr
         2. ie <1wk=moderate disability or good recovery
      3. Length of PTA
         1. ie > 12wks= moderate to severe disability
         2. ie <4wks= good recovery or moderate disability after 1yr
8. Medical Management
   1. @ the scene: early resuscitation w/goal of stabilizing cardiovascular & respiratory systs to maintain sufficient blood flow & O2 to brain
      1. if unresponsive=intubate & ventilate
   2. Use GCS to determine severity of brain injury
   3. Do Complete Neurological Exam
   4. Neuroimaging Studies: X-ray, MRI, CT
   5. ICP monitoring; maintain ICP below 20 mm Hg
   6. Use of meds
      1. Analgesics
         1. NSAIDS: Aspirin, naproxen, ibuprofen
         2. Acetaminophen
         3. Opioids: Morphine, Codeinie, Oxycodone, Pentazocine; Naloxone
      2. Insomnia
         1. Sedatives-Hypnotics: Benzos, Barbiturates
         2. Zolpidem, Zaleplon
      3. Depression
         1. SSRIs, TCAs, MAOIs
      4. Antiseizure
         1. Carbamazepine, Valproic Acid
      5. Antipsychotic
         1. Chlorpromazine, Haloperidol, Clozapine
      6. Antiemetic Drugs
         1. Antihistamines
            1. Diphenhydramine, Hydroxyzine; Scopolamine
         2. Phenothiazines
            1. Promethasine
         3. Metoclopramide
         4. 5-HT3 Inhibitors
            1. Ondansetron
         5. Spasmolytics
            1. Gabapentin; Diazepam; Baclofen; Dantrolene; Botulinum toxin; Cyclobenzabine; Tizanidine
9. Rehabilitation Perspective
   1. Team Members Involved In The Care of TBI Survivors:
      1. Patient & Family
      2. MD
         1. Physiatrist
            1. • Has expertise & training in physical medicine, rehab & function • Knowledge in neuropharmacology
         2. Neurologist
            1. • Skills lie in the realm of brain & nervous system • Have particular knowledge related to how the brain may recover & what impairments are likely to be seen given the location & extent of injury • Knowledge in neuropharmacology
      3. Speech-Language Pathologist
         1. Examines, evaluates & treats communication, swallowing & cognitive impairments
         2. + Collaborating
            1. • The team will be able to devise the most effective & consistent way to communicate w/pt • SLP can instruct the team in how the pt's cognitive impairments may impede new learning, which in turn will affect everyone's interactions w/pt & the treatment plan
      4. OT
         1. Examines, evaluates & treats the pt's diminished ability to perform ADLs, visual/perceptual impairments, UE functional loss & sensory integration problems & work with SLP to tx cognitive impairments
      5. Rehab Nurse
         1. • Responsible for dispensing meds & closely monitoring their effects • Initiate a bowel & bladder retraining program • Performs daily monitoring of vitals • Inspect skin daily
      6. Case Manager/Team Coordinator: nurse, med social work or other health prof.
         1. • Direct team meetings, schedule family conferences & act as a liaison with third-party payers • Promote good communication among all team members • In constant communication with patient & family • Coordinate payment & insurance benefit issues • Responsible for setting up follow-up & discharge services
      7. Medical Social Worker
         1. Provides education and counseling for the family and patient
      8. Neuropsychologist
         1. • Perform neuropsychological testing to determine pt's baseline cognitive functioning • Assist in developing a behavioral management program • when pt with a brain injury has severe behavioral impairments, the neuropsychologist assumes role of team leader
      9. Others:
         1. Respiratory Care Practitioner
            1. Vital participant in the evaluation & treatment of respiratory impairments
         2. Respiratory Therapist
            1. Contributes to monitoring the pt's pulmonary status & providing appropriate tx
         3. Recreational Therapist
            1. Assists pt's return to activities enjoyed prior to TBI or in helping ID new activities that patient will find rewarding
10. PT Exam & Tx
    1. Ranchos Levels I, II & III: Decreased/Low-Level Response Levels of Recovery
       1. Exam
          1. 1. Conduct a complete chart review to form a comprehensive picture of the patient & complete understanding of the precautions & contraindications 2. Check with pt's primary nurse before beginning any session because the pt's medical status may be dynamic at the stages 3. Always observe universal precautions 4. After reviewing the chart & receiving an update on the pt's status from the nurse staff, PT is ready to begin the exam 5. Initial portion of exam should focus on observing the patient & documenting how he/she response to stimuli in the environment 6. Exam PROM & muscle tone (modified Ashworth scale) 7. If not contraindicated, attend to sit patient up on side of bed with assistance & monitor vital signs & document any changes in tone or head & trunk control 8. When appropriate transfer patient into a wheelchair
       2. Eval, Prognosis, & POC
          1. List of General Goals & Outcomes Anticipated
             1. • Physical function & level of alertness are increased • Risk of secondary impairments is reduced • Motor control is improved • Effects of tone are managed • Postural control is improved • Tolerance of activities & positions is increased • Joint integrity & mobility are improved remain functional • Family & caregivers are educated on pt’s dx, PT interventions, goals & outcomes • Cares coordinated among all team members
       3. Interventions
          1. Prevent Indirect Impairments
             1. when in bed; head neutral, hips & knees slightly flexed; turn every 2 hrs
             2. Proper w/c positioning: proper pelvic & head positioning
             3. PROM
             4. when moving UE, carefully mobilize scapula & maintain proper jt mechanics @ GHJ; if not=impingement & destabilized jt capsule
             5. ROM
             6. Avoid forceful/aggressive motions
          2. Improve Arousal Thru Sensory Stimulation
             1. no reliable evidence on effectiveness
          3. Manage effects of Abnormal Tone & Spasticity
          4. Early Transition to Sitting Postures
             1. Tilt table=allows early WB thru LEs
             2. Therapeutic Guiding Techniques to provide tactile, proprioceptive & kinesthetic stim when performing a task
       4. Documentation p. 913
    2. Ranchos Level IV: Confused-Agitated Level of Recovery
       1. Exam
          1. • PT should Utilize observation skills & the ability to estimate • PT should examine optional mobility, balance in sitting & standing if appropriate, ROM, strength, motor control, tone, facial & reflexes • Begins determining pt's cognitive abilities
       2. Eval, Prognosis & POC
          1. List of General Goals & Outcomes Anticipated
             1. • Pt’s endurance is or improve • Joint mobility & integrity are maintained • Risk of secondary impairments is reduced • Tolerance of activities is increased • Pt's family is educated regarding pt's dx, prognosis, PT interventions & outcomes • Care is correlated among all team members
             2. overall goals: maintain pt's fnxal capabilities & prevent agitated outbursts & assist pt to control behavior
       3. Intervention
          1. Work near pt's physical level of fnx & attempt to improve endurance rather than progress to more challenging skills that req new learning
          2. May need to Utilize behavioral modification techniques
          3. Pt. should be seen by same person @ same time in same location every day in order to provide consistency and decrease confusion
          4. Better to provide orientation information than challenge pt to provide it, esp if not expected to succeed
          5. Teaching new skills=unrealistic; instead begin to perform a functional task: brushing teeth, walking
             1. May use charts/graphs to help pt progress each day
          6. Expect Egocentricity; don't stress the pt w/attempts to do otherwise
          7. Due to limited attn span, be prepared w/numerous activities. When can't be redirected to selected task, attempt to engage in another task
       4. Documentation p. 914
    3. Ranchos Levels V & VI: Confused-Inappropriate & Confused-Appropriate Levels of Recovery
       1. Exam
          1. • Attention & cognition • Cranial nerve integrity • Balance (both sitting & standing) • Gait • Skin integrity • Joint mobility • Motor control • Muscle strength • Sensory motor integration • Pain • ROM • Reflexes • ADL skills (including functional mobility) • Sensory integrity • Functional abilities done in a variety of environments
       2. Eval, Prognosis & POC
          1. List of General Goals & Outcomes Anticipated
             1. • Performance of functional mobility & ADL skills is increased • Gait, mobility, & balance are improved • Motor control & postural control are increased • Risk of secondary impairments is reduced • Strength & endurance are increased • Safety with functional mobility tasks & ADL skills is improved • Pt & family are educated on dx, prognosis, PT interventions & goals • Tolerance of activities improve • Care is coordinated among all team members
       3. Intervention
          1. • Developmental Sequence (Postures) & muscle facilitation techniques
             1. Prone-on-elbows; Quadruped; Bridging; Sitting; Kneeling & Half-Kneeling; Modified Plantigrade; Standing
          2. • Constraint Induced Movement Therapy
             1. involves promoting the use of the most affected UE for up to 90% of waking hours & reducing the use of the least affected UE
          3. • Locomotor training w/BWS & TM
          4. • Task-Oriented approach to interventions
          5. • Task specific interventions with large amounts of practice can induce beneficial neuroplastic changes in the CNS & restore fnx
          6. • Restorative approach treatment strategy
             1. seeks to restore the "normal" use of the affected UE
          7. • Compensatory approach treatment strategy
             1. seeks to improve fnxal skills by compensating for the lost ability
          8. • Utilize feedback (explicit >intrinsic in early stages
          9. • Practice should be distributed
          10. • Sessions that are thoughtfully planned with sufficient rest.
       4. Documentation p. 918
    4. Ranchos Levels VII & VIII: Appropriate Response Levels of Recovery
       1. Exam, Eval, Prognosis & POC & Intervention
          1. Exam=same as Level V & VI
          2. List of General Goals & Outcomes Anticipated
             1. • Pt & fam are educated about dx, prognosis, PT intervention & goals • Safety of patient & families improve • Ability to perform physical tasks related to ADL skills, community & work reintegration, & leisure activities is increased • Functional mobility is improved • Motor control, balance, & postural control are improved • Self-management of sx is increased • Strength & endurance are increased • Level of supervision & assistance for task performance is decreased
             2. Assist pt in integrating the cognitive, physical, & emotional skills necessary to fnx in community
             3. Skills in judgment, problem solving, planning, self-awareness, health & wellness, & social interaction are emphasized
          3. Interventions
             1. Focus on advanced activities such as community skills, social skills & daily living skills Table 22.9 p. 919
             2. involve pt in decision-making
             3. Focus on maintaining & improving performance while decreasing external structure & supervision
             4. Group Treatment
             5. Honest Feedback
             6. Trial pds of independent living & supported work
             7. Adaptations
       2. Documentation pp. 919-920
11. Special Considerations
    1. Abnormal Tone
       1. Spasticity characteristics:
          1. Brisk DTRs; Involuntary flexor & extensor spasms; Babinski sign; Velocity dependent increase in stretch reflexes
       2. + Increased Tone
          1. may help improve fnx
             1. ie allow transfers easier on PT or help w/WB LE
       3. - Increased Tone
          1. May make personal hygiene hard; Contractures & Pressure sores; Pain; Interfere w/Transfers
       4. Foundations of Spasticity Mgmt
          1. Therapeutic stretching & strengthening exercises w/adjunctive modalities & functional retraining; PROM & Selective strengthening of antagonist muscles; Proper Positioning
    2. Serial Casting
       1. Often used for Plantarflexor or Biceps Contractures
       2. Removed after 1 week, muscle stretched & another cast applied
       3. Theoretical support for use: consistent, prolonged stretch & the warmth & tot pressure supplied by cast
       4. Support for its use ti improve PROM; limited evidence on effectiveness to decrease tone & improve fnx
    3. Rehab Technology
       1. + to increase social participation & independence
       2. Range from computer based augmented communications systs to environmental control units (ECU) that will allow individual to open doors, answer phone, turn on tv & other tasks from a w/c
       3. + Virtual reality technologies=improving cognition, ADL fnx, driving skills, UE fnx & balance