Nbcot Review Ch 5: Tbi

Front 1

Traumatic Brain Injury

Back 1

Damage as a result from skull penetration or rapid acceleration/deceleration of brain.

Front 2

TBI Symptoms

Back 2

Concussion characterized by post-traumatic loss of consciousness. Often Cerebral contusion/laceration/edema accompanied by surface wounds and skull fractures.
Also hemiplegia/monoplegia, abnormal reflexes, decorticate or decerebrate rigidity, fixed pupils, coma

Front 3

Mild TBI

Back 3

*LOC < 10 min
*GCS 13-15

Front 4

Moderate TBI

Back 4

*hospitalization of at least 48 hours
*GCS 9-12

Front 5

Severe TBI

Back 5

*loss of consciousness and or postraumatic amnesia greater than 24 hours
*GCS 1-8

Front 6

Diagnostic Testing for TBI

Back 6

Glasgow Coma Scale
Ranchos Los Amigos Levels of Cognitive Functioning

Front 7

Glasgow Coma Scale: Basic Information and Range

Back 7

A neurological scale, provides objective method to record level of consciousness after a head injury.
Range of points for three tests in eye, verbal, and motor responses. Scores go from 3-15.

Severe: GCS greater than or equal to 8
Moderate: GCS 9-12
Minor: GCS greater than or equal to 13

Front 8

Glasgow Coma Scale: Best Eye Response

Back 8

Eyes opening spontaneously- 4
Eyes opening to speech- 3
Eyes opening in response to pain-2
No eye opening- 1

Front 9

Glasgow Coma Scale: Best Verbal Response

Back 9

Oriented (patient responds coherently and appropriately to questions such as the patients name and age, where they are and why, year month, etc. )- 5
Confused (patient responds to questions coherently but there is some disorientation and confusion)- 4
Inappropriate words (random or exclamatory speech, but not conversational exchange )- 3
Incomprehensible sounds (Moaning, but no words) -2
None- 1

Front 10

Glasgow Coma Scale: Best Motor Response

Back 10

Obeys commands (the person does simple things as asked) -6
Localizes to pain (purposeful movements towards changing painful stimuli) -5
Withdraws from pain (pulls part of body away when pinched) -4
Flexion in response to pain (decorticate response) -3
Extension to pain (decerebrate response) -2
No motor response -1

Front 11

Vegetative State

Back 11

Wakefulness without awareness
1. no awareness of self or environment and inability to interact with others
2. no sustained, reproducible, or voluntary behavioral responses to sensory stimuli
3. no language comprehension or expression
4. sleep-wake cycles of variable length
5. ability to regulate temp, breathing, circulation to permit survival with routine medical/nursing care
6. incontinence of bowel and bladder
7. variably preserved cranial-nerve and spinal reflexes

Front 12

Decorticate rigidity

Back 12

UEs are in spastic flexed position with IR and Add. LEs are in spastic extended position but also IR and Add. Tend to occur in comotose individuals.

Front 13

Decerebrate rigidity

Back 13

Both UEs and LEs in spastic extension, Add, IR.
Wrist and figners flex, plantar portions of feet flex and invert, trunk extends, head retracts.
Tend to occur in comotose individuals.

Front 14

Complications in TBI: Abnormal Muscle Tone

Back 14

Common is a combination of both hypotonicity (decreased tone, flaccidity) and hypertonicity (increased tone, spasticity).

Spasticity can cause muscles to shorten permanently causing contractures.

Front 15

Complications in TBI: Primitive Reflexes

Back 15

Impaired righting reactions, equilibrium reactions, protective extension.
Makes individual more at risk for injury from falls during transfers, getting out of bed, toileting, bathing, dressing.

Front 16

Complications in TBI: Muscle Weakness / decreased functional endurance

Back 16

Muscle weakness without presence of spasticity.
Decreased endurance and vital capacity usually accompany reduced muscle strength as a result of infections, poor nutrition, prolonged bed rest.

Front 17

Complications in TBI: Ataxia

Back 17

- Incoordination, impaired sitting and standing balance. - Can occur in entire body, trunk, or UEs and LEs.
- Lost ability to perform small adjustments in distal/proximal extremities necessary for smooth, coordinated movement.

Front 18

Ataxia in Trunk

Back 18

impaired postural stability when sitting/standing. has trouble maintaining trunk in stable position to free extremities for activities. May compensate by grasping stable surface like tabletop.

Front 19

Ataxia in UE/LE

Back 19

UE: dysfunction in activities when attempting to perform combination of gross/fm movements, like bringing glass of water to mouth.
LE: impaired ability to ambulate while maintaining balance, falls easily occur

Front 20

Complications in TBI: Postural Deficits (Pelvis, Trunk, Head/Neck)

Back 20

Develop as a result of imbalance in muscle tone throughout the body.
1. Pelvis: PPT due to prolonged bed rest in supine, causes loss of ROM in lower back. PPT results in sacral sitting, facilitates kyphosis. One side of pelvis sits lower than other side as result of hypertonicity.
2. Trunk: kyphosis, scoliosis, lordosis may all be present secondary to weak or spastic trunk muscles. Common to see lateral flexion to involved side with elongation of muscle on opposite side.
3. Head/Neck: forward flexion or hyperextension of neck, lateral flexion of head.

Front 21

Complications in TBI: Postural Deficits (Scapula, UE, LE)

Back 21

4. Scapula: depressed, pro/retracted, downwardly rotated.
5. UE: B or unilaterally involved. Unilateral: common to see variations in ROM, tone, strength in each muscle group and joint
6. LE: severe extension patterns (issues with wc positioning - person thrusts forward and slides out of seat). Hip Add, IR, knee flexion, plantar flexion, inversion all can be seen.

Front 22

Complications in TBI: limitations in joint ROM

Back 22

Increased muscle tone, contractures, heterotopic ossification, fractures or dislocations, pain.

Front 23

Complications in TBI: sensation

Back 23

Absent or diminished sensation (light touch, differentiation btw sharp/dull, proprioception, temp, pain, kinesthesia).
Impaired senses of taste/smell (CN injury), lost/diminished stereognosis, 2pt discrimination, graphesthesia (ability to interpret letters written on hand without visual input).
May also have hypersensitivity

Front 24

Complications in TBI: dysphagia

Back 24

Caused by CN damage, difficulty in chewing and swallowing.

Front 25

Complications in TBI: self-feeding

Back 25

May be due to apraxia (oral), attention, impulsivity, etc.

Front 26

Ideational Apraxia

Back 26

Inability to know how to complete a motor action.
Apraxia for knowing how to complete the movement.

Front 27

Ideomotor Apraxia

Back 27

Inability to carry out a motor act on a verbal command or imitation.
Apraxia for carrying out the actual movement.

Front 28

Complications in TBI: Cognition

Back 28

Impaired attention, concentration, memory, initiation and termination of activities, safety awareness, poor judgment, impulsivity, difficulty with executive functions and abstract thinking, generalization

Front 29

Complications in TBI: Visual

Back 29

Accommodative dysfunction (causing blurred vision), convergence insufficiency (inability to maintain single vision while fixating on an object), lateral or medial strabismus, mystagmus, hemianopsia, impaired scanning, pursuits, saccades (fast, jerky movements of eyes as change from one position of gaze to another, like reading book), reduced blinking, ptosis (drooping eyelid), and incomplete eyelid closure.

Front 30

Complications in TBI: Perceptual

Back 30

Visual perception, body schema perception, motor perception, speech/language perception.

Visual perception: right-left discrimination, figure-ground, form constancy, position in space, topographical orientation, visual agnosias (prosopagnosia).
Body schema perception: awareness of spatial characteristics of own body. Anosognosia: failure to recognize deficits and limitations.

Front 31

Complications in TBI: Psychosocial factors

Back 31

Issues with self-concept, social roles, independent living status, dealing with loss, affective changes (depression; increased emotional lability - crying, outbursts; decreased affect).

Front 32

Complications in TBI: Behavior

Back 32

Restlessness, combative, agitated, yelling, swearing, grabbing, biting

Front 33

Assessments for Evaluation of TBI

Back 33

- Glasgow Coma Scale
- Ranchos Los Amigos Scales
- JFK Coma Recovery Scale - cognitive scale
- Wessex Head Injury matrix (WHIM) - cognitive scale

Front 34

Intervention of the Low-Level Individual (Ranchos 1-3)

Back 34

Increase the level of response and overall awareness of self and environment.
1. Sensory stimulation
2. bed positioning
3. casting or splinting
4. wheelchair positioning
5. dysphasia management (speech/verbal comprehension)
6. emotional/behavioral management
7. family and caregiver education

Front 35

Intervention of LL: Bed Positioning

Back 35

If client exhibits abnormal tone or posturing:
- Have them do sidelying or semi-prone position to assist in normalizing tone and providing sensory input
Spine position: may elicit TLR and extensor tone
Supine with head in lateral position: may elicit ATNR

Front 36

Intervention of LL: WC Positioning (including order)

Back 36

1. Pelvis (firm, solid seat; lumbar support; wedge seat insert)
2. Trunk (solid back insert/firm contoured back; lateral trunk supports, chest strap)
3. LE (abduction wedge btw knees or lateral thigh)
4. UE (splint/cast, lap tray)
5. Head (dynamic head positioning device, forehead strap to prevent heading moving forward)

Front 37

Intervention of LL: Splinting and Casting (Indicated for what? What do they do?)

Back 37

Indicated when:
1. Spasticity interferes with functional movement and ADL independence
2. Joint ROM limitations present
3. soft-tissue contractures
4. to prevent skin breakdown

Splints provide elongation and inhibition by positioning the joint in a static position with the muscles and soft tissues on stretch.

Front 38

Intervention of LL: Types of Splints and Casts

Back 38

Splints:
1. Resting/Functional splint worm when not performing functional tasks or active movement
2. Cone splints: used in palm of hand vs. rolled cloths or carrot to keep fingers from digging into palmar surface
3. Antispasticity splint: hand and wrist in functional position and abducts fingers to decrease spasticity
4. Serial casting program when mod-severe spasticity can't be managed by splints

UE Casts:
1. Elbow cast (for loss of PROM in elbow flexors)
2. Wrist-hand cast (loss of PROM in wrist and finger flexors)
3. Elbow drop-out
4. Wrist, thumb, hand, and individual finger casts.

Front 39

Intervention of LL: Dysphagia

Back 39

Emerging from a coma patients are fed through nasogastric (NG) tube or gastrointestinal (G) tube. Once patient alert and more oriented, physician decides when dysphagia evaluation indicated (programs usually begin in intermediate - advanced stages of rehab)

Front 40

Intervention of LL: Behavioral and Cognition

Back 40

Track using assessments like WHIM, JFK, Orientation-Log.
- yes/no system (eye blinks, eye gaze, head nods, thumbs up/down)

Front 41

Intervention of LL: Family and Caregiver Education

Back 41

Get the family involved right away as likely not much rehab can be done (family maintains PROM). Allows family to be involved and alleviate feelings of helplessness. When patient more alert and mobile include family more in transfers, wc positioning, feeding programs, ADL retraining

Front 42

Evaluation of Intermediate to Higher Level Individual with TBI

Back 42

Physical Status, dysphagia, cognition, vision, perceptual function, ADL, IADL, vocational rehab, psychosocial skills

Front 43

Intervention of Higher Level (HL) Individual: Neuromuscular impairments

Back 43

Including spasticity, rigidity, soft-tissue contractures, presence of primitive reflexes, diminished or lost postural reactions, muscular weakness, impaired sensation.
To treat this, one must: facilitate control of muscle groups, progress proximally to distally, encourage symmetrical posture, facilitate integration of both sides of body in activities, encourage B weight bearing, introduce normal sensory experience.

This is done through: NDT, PNF, myofascial release, Rood techniques, PAMs, kineseo-taping.

Front 44

Intervention of Higher Level (HL) Individual: Ataxia

Back 44

Rehabilitative methods generally ineffective. Train in compensatory strategies instead.

Front 45

Intervention of Higher Level (HL) Individual: Cognition

Back 45

Make sure treatment is relevant to daily life.

Front 46

Intervention of Higher Level (HL) Individual: Vision

Back 46

Corrective lenses, occlusion, prism lenses, vision exercises, environmental adaptations, corrective surgery.
- Double vision: occlusion, prism lenses
- Environmental adaptations: colored strip of tape along one side of plate for self-feeding, large objects like clock with bold numbers or phone with large buttons, contrasting colors to highlight knobs, increasing lighting and using texture

Front 47

Intervention of Higher Level (HL) Individual: Perception

Back 47

Rehabilitative and compensatory techniques.

Front 48

Intervention of Higher Level (HL) Individual: Behavior Mgmt

Back 48

Environmental Interventions: alter objects or other features to facilitate appropriate behaviors, inhibit unwanted behaviors, maintain safety (i.e. agitated clients should be placed in quiet, isolated room without a roommate and all extra stimuli should be removed. Therapy provided same way).

Interactive Interventions: approaches staff and caregivers use with client - speaking in calm and concise manner, refrain from detailed explanations that will lead to confusion.

Front 49

Intervention of Higher Level (HL) Individual: Dysphagia and self feeding

Back 49

Self-feeding program may begin in quiet area. Graded to more social situations such as hospital dining room. Common AE used if client demonstrates decreased strength, coordination, or perceptual deficits. Other techniques used for other issues like attention and impulsivity

Front 50

Intervention of Higher Level (HL) Individual: Functional mobility

Back 50

Bed mobility, transfer training, wc mobility, functional ambulation in ADL, community mobility.

Use the rehabilitation model with acute and subacute TBI. NDT principles of B extremity use, equal weight bearing, tone normalization used to address functional mobility.

Compensatory strategies only used in later stages of recovery when client not able to demonstrate significant improvement in mobility skills (i.e. don't let someone who only has use of one arm currently use compensatory strategies b/c this will lead to hemiplegic postures, contractures, and abnormal gait)

Front 51

Intervention of Higher Level (HL) Individual: Transfers

Back 51

Be consistent in training client because of memory deficits and limited carryover of information. Train in moving to both right and left sides.

Front 52

Intervention of Higher Level (HL) Individual: Home mgmt

Back 52

Meal preparation, laundry, cleaning, money mgmt, home repairs, community shopping, possible childcare. Grade activity as client needs.

Front 53

Intervention of Higher Level (HL) Individual: Community reintegration

Back 53

Depositing or w/d money from bank or ATM, public transportation, planning a shopping list and purchasing them..

Front 54

Intervention of Higher Level (HL) Individual: Psychosocial skills

Back 54

1 or more years after injury TBI pts report psychosocial impairment is the greatest obstacle in their lives.
1. Identify desired roles lost secondary to TBI
2. Identify activities that would support desired roles
3. Identify rites of passage that were lost or never transitioned through as a result of TBI (driver's license, graduating from secondary school, living independently, dating, marrying, parenting)

Group intervention / support groups beneficial.

Front 55

Discharge Planning for HL Individuals

Back 55

- Home safety evaluation
- Equipment evaluation and ordering
- Family and caregiver education
- Recommendations for driver's training program
- Recommendations for return to school or vocational retraining and work skills

Front 56

Allen's Cognitive Disabilities Model

Back 56

Cognitive performance is placed on a continuum divided into 6 levels.
- Automatic Actions, Postural Actions, Manual Actions, Goal Directed Actions, Exploratory Actions, Planned Actions

Front 57

Level 1: Automatic Actions

Back 57

- characterized by automatic motor responses & changes in the autonomic nervous system.
- conscious response to the external environment is minimal.

Front 58

Level 2: Postural Actions

Back 58

- characterized by movement that is associated with comfort. There is some awareness of large objects in the environment, and the individual may assist the caregiver with simple tasks.
- unable to imitate a running stitch

Front 59

Level 3: Manual Actions

Back 59

- begins with the use of the hands to manipulate objects. The individual may be able to perform a limited number of tasks with long-term repetitive training.
- Able to perform running stitch 3x
- Able to handle objects, follows 1-step cues, perform activity with repetitive movement patterns

Front 60

Level 4: Goal Directed Actions

Back 60

- is characterized by the ability to carry simple tasks through to completion. The individual relies heavily on visual cues. He/she may be able to perform established routines but cannot cope with unexpected events.
- Able to perform whip stitch 3x
- Able to complete a goal, perform established routines, requires visual cues

Front 61

Level 5: Exploratory Actions

Back 61

- characterized by overt trial & error problem solving. New learning occurs. This may be the usual level of functioning for 20% of the population.
- Able to perform single cordovan stitch w/ overt trial & error
- No visual cues needed, explore new actions, make fine motor adjustments

Front 62

Level 6: Planned Actions

Back 62

- characterized by the absence of disability. The person can think of hypothetical situations and do mental trial & error problem solving
- Able to perform single cordovan stitch w/ mental trial & error
- Able to think about hypothetical situations, think before action, determine safety hazards

Front 63

Evaluating Cognitive Disabilities

Back 63

- Focus is on identifying the person's current cognitive abilities and their implications for performance, independence, the need for assistance, and the potential for improvement.
- Observation during functional tasks

Front 64

Cognitive Disabilities: Assessments

Back 64

- The Allen Cognitive Levels Leather Lacing Task (allows you to observe person perform 3 increasingly complex stitches and make determinations about their cognitive skill level)
- The Routine Task Inventory (information about ADL performance from an informed caregiver)
- The Cognitive Performance Test (assess functional performance of those with Alzheimer's. Focus on identifying effect that deficits have on ADL performance)

Front 65

Cognitive Disabilities: Intervention

Back 65

- Activities to elicit highest cognitive level
- Maintaining the highest level of function
- Environmental changes and activity adaptations made to compensate for deficits and allow greatest independence