Stanbridge - T6 - Neuro2 - W5 - Traumatic Brain Injury

Populations at Risk for Traumatic Brain Injury (TBI)

• People aged 75 years and older had the highest numbers and rates of TBI-related hospitalizations and deaths in 2020, accounting for approximately 32% of TBI hospitalizations and 28% of TBI deaths.
• Males are nearly twice as likely to be hospitalized and three times more likely to die from a TBI compared to females, with age-adjusted hospitalization rates of 79.9 versus 43.7 and mortality rates of 28.3 versus 8.4.
• Falls are the most common cause of TBI, followed by unknown causes, being struck by an object, motor vehicle accidents (MVA), and assaults.

Influential Factors in TBI Recovery

• Predicting recovery from TBI is difficult due to various factors.
• Amount of immediate damage from the impact or insult influences recovery.
• Low initial scores on the Glasgow Coma Scale (GCS), especially in eye opening and motor response categories, can affect recovery.
• Cumulative effects of secondary brain damage can impede recovery.
• Individual's pre-morbid cognitive characteristics, such as intellect, education level, and memory, play a role.
• Substance abuse and pre-injury personality, including interpersonal relationships and work history, affect the recovery process.

Classifications of TBI

• Open TBI involves a penetrating injury with a skull fracture or displacement.
• Closed TBI does not involve a skull fracture.

Contusion

• Characterized by bruising on the surface of the brain from hemorrhaging small blood vessels.
• Coup injury occurs at the site of impact, while counter-coup injury occurs on the opposite side of the brain from the impact.
• Diffuse Axonal Injury (DAI) results from high-velocity and rotational injuries, leading to widespread damage to the brain's white matter tracts.
• Corpus callosum, basal ganglia, periventricular white matter, and superior cerebellar peduncles are prone to DAI.
• DAI is associated with loss of consciousness and is a frequent cause of vegetative state and morbidity.

Hematomas

• Epidural hematoma occurs due to rupture of blood vessels in the epidural space, often from a blow to the side of the head or MVA.
• Epidural hematoma can have a period of unconsciousness followed by a lucid period, and requires craniotomy and removal due to rapid deterioration.
• Subdural hematoma results from rupture of cortical bridging veins and accumulates more slowly over hours to weeks, often seen in older adults after a fall.
• Subdural hematoma resembles CVA symptoms and may require surgical removal.

Locked-In Syndrome

• Can occur after TBI, leading to complete loss of all voluntary muscles except for ocular muscles.
• Cognition remains intact, but prognosis is poor.

Other Causes of Brain Injury

• Damage may occur at the cellular level due to airway obstruction, near-drowning, MI, CVA, exposure to toxins, electric shock, or lightning strike.

Secondary Complications from TBI

• Intracranial Pressure (ICP) refers to increased pressure inside the skull.
• Anoxic injury is brain damage caused by a lack of oxygen.
• Seizures can occur as a secondary complication.

Increased Intracranial Pressure (ICP)

• Occurs in 70% of severe TBI cases, often resulting in decreased blood perfusion.
• ICP is identified if above 20 mm Hg; normal is 5-10 mm Hg.
• Signs of increased ICP include decreased responsiveness and consciousness, severe headache, vomiting, irritability, and papilledema, accompanied by changes in heart rate and blood pressure.

Anoxic Injuries

• Result from inadequate oxygen supply, frequently caused by cardiac arrest, leading to diffuse damage across the cortex.
• The hippocampus, cerebellum, and basal ganglia are at heightened risk.

Posttraumatic Epilepsy

• Seizures are discrete clinical events reflecting temporary, physiologic brain dysfunction, characterized by excessive hypersynchronous cortical neuron discharge.
• Triggers include stress, poor nutrition, electrolyte imbalance, missed medication, drug use, flickering lights, infection, fever, lack of sleep, anger, worry, and fear.
• Common in open penetrating injuries and contusions
• Physical therapy contraindications include fast spinning, acceleration and deceleration at rapid speeds, bright lights, and loud noises.

Emergency Seizure Management

• Quickly move the patient to the floor or a stable surface to avoid injury.
• Notify the physician or charge nurse and supervising PT.
• Put the patient into side-lying position post-seizure to avoid aspiration.
• If unconscious, call 9-1-1; if conscious, transport to the ER or their MD immediately.

Treatment of Seizures

• Therapeutic intervention works with seizure medications.
• Common medications: Dilantin, Keppra, Neurontin (Gabapentin), Lamictal.
• Side effects: lowered arousal or alertness, decreased cognition and memory, ataxia, diplopia, dysarthria.
• Deep Brain stimulators: long-term solution for seizure activity not controlled by medication or surgery.
• Contraindications: electrical stimulation, diathermy, ultrasound over the implant site, defibrillators, MRI.
• Stimulator must be turned off during CT scans or radiation therapy.

Levels of Brain Injury

• Brain injury levels are defined by severity and Rancho levels

Severity of TBI

• Measured using Glasgow Coma Scale (GCS), which assesses arousal and cortical function.
• Severity is classified as mild, moderate, or severe.

Glasgow Coma Scale (GCS)

• Eye Opening: Spontaneous (4), To speech (3), To pain (2), No response (1).
• Motor Response: Obeys verbal command (6), Localized (5), Withdraws to pain (4), Decorticate posturing (3), Decerebrate posturing (2), No response (1).
• Verbal Response: Oriented (5), Conversation confused (4), Use of inappropriate words (3), Incomprehensible sounds(2), No response (1).

Severity Classification Based on GCS

• Mild: GCS > 13, Loss of Consciousness (LOC) < 20 minutes, normal CT scan, permanent changes unlikely, dazed signs and symptoms, confused headache, fatigue, motor deficits unlikely, dizziness.
• Moderate: GCS 9-12, permanent physical, cognitive and behavioral deficits are likely, increased confusion signs and symptoms, dizziness is likely.
• Severe: GCS 3-8, coma upon hospital arrival, permanent changes in functional mobility and cognition are very likely, comatose signs and symptoms.

Rancho Los Amigos Levels of Consciousness Scale

• Measures and describes cognitive and behavioral function through 10 levels.
• Patients can exhibit behaviors from more than one level at a time as they transition between levels.
• Patients may plateau at any given level based on their prognosis.

Rancho Level I

• Cognitive Level I : No Response
• Patients do not respond to sounds, sights, touch, movement, or painful stimuli.

Rancho Level II

• Cognitive Level II: Generalized Response
• Patients respond to external stimuli with generalized physiologic changes, gross body movements, and/or non-purposeful vocalization.
• Responses may be significantly delayed; demonstrate generalized reflex response to painful stimuli and respond to repeated auditory stimuli with increased or decreased activity.

Rancho Level III

• Cognitive Level III: Localized Response
• Patient's response is directly related to stimulus type.
• The patient vocalizes or withdraws in response to painful stimuli. The patient turns toward or away from auditory stimuli.
• Patient Blinks with strong light crossing visual field. Patient inconsistently responds to Commands but may respond to some people (family/friends) but not others

Rancho Level IV

• Cognitive Level IV: Confused and Agitated
• Patients are alert and in a heightened state of activity. May perform motor activities without purpose, may have brief non-purposeful movements, and absent short-term memory.
• Agitation. Is unable to cooperate with treatment efforts. Mood swings from euphoric to hostile.

Rancho Level V

• Cognitive Level V: Confused and Inappropriate
• Patient will be alert. Become agitated in response to external structure
• Is not oriented to person, place or time. Is unable to learn new information.

Rancho Level VI

• Cognitive Level VI: Confused and Appropriate
• A person at this level can attend to familiar task in non-distraction environment for at least 30 min with moderate redirection.
• The patient is emerging aware of appropriate response to self, family and basic need.

Rancho Level VII

• Cognitive Level VII: Automatic and Appropriate
• Consistently oriented to person and place in familiar environments.
• Able to attend familiar tasks in non-distracting environments for 30 minutes.
• Aware of others feelings is unrealistic.

Rancho Level VIII

• Cognitive Level VIII: Purposeful and Appropriate
• Consistently oriented to person, place, time.
• Is independently attends completes familiar tasks for one hour in distracting environments.
• This person has the ability to recall and integrate past and recent events.

Rancho Level IX

• Cognitive Level IX
• Patient need SBA. Patient express to be purposeful and appropriate.
• The client uses memory devices to recall daily schedule and record information.

Rancho Level X

• Cognitive Level X
• The patient is purposeful and appropriate. This patient is completely independent while performing multiple tasks.
• Social interaction behavior is consistently appropriate.

Impairments Following a TBI

• Cognitive deficits: Disorientation, poor attention span, loss of memory, poor planning/organizational skills, problem solving/abstract thinking, and confabulations.
• Motor Deficits: Abnormal Posturing, abnormal primitive reflexes, motor impairments, ataxia.
• Sensory Deficits: Damage to the sensory system: smell, taste, auditory, light, touch, proprioception.
• Communication Deficits: Lost/Impaired communications, can look for verbal communication.
• Behavioral Deficits: Personality, Neuroses, Psychoses, Sexual disinhibition.

Decorticate vs. Decerebrate Posturing

• Decorticate Posturing : LEs in extension. UEs flexed, adducted, IR at the shoulder, elbow, wrist / finger flexion, proration of forearms.
• Decerebrate Posturing: LEs in extension, adduction, IR, planterflexion, foot supination. UEs IR and extended shoulders, flexed elbows, forearm proration, flexed wrists and fingers.

Associated Problems

• Orthopedic, neurologic, integumentary

Physical Therapy Interventions after TBI

• Three phases of care; acute, inpatient, outpatient.

Acute Care Goals

• Increase arousal and prevent secondary impairments. Improve patient function, patient & family education.

Acute Care Emphasis

• Bed positioning; adjust at- risk patient every two hours. For high-risk patients, adjust positioning every hour because of frailness.
• Activities to increase alertness and sensory stimulation.
• Cognitive conditioning to improve cognitive function. Provide patient, family education.

Acute Care Positioning

• Decrease risk of skin breakdown; prevent contractures.
• When possible, prevent abnormal posturing. (Tonic labyrinthine reflex is greatest in supine, so put patient in side lying instead.)

Acute Care Reflex inhibiting Postures

• Sidelying
• Prone/semi Prone

Acute Care positioning when there is decorticate or decerebrate tone

• Place in opposite position as the tone.

Acute Care positioning/heterotopic ossification

• Haterotopic Ossification is abnormal pone formation surrounding joints. Immobilization can lead to HO. Signs include localized swelling.

Acute Care/increase Awareness

• Get patient out of bed as needed. Communicate with the patient as though they understood you.

Acute Care/sensory stimulation

• Provide no more that one stimulation; may use sounds, visual stimulation.

Acute Care/cognitive function

• Have cognitive training for for 1-2 Rancho skill levels. Focus on orientation (person, place, time).

Acute Care / Family education

• Education about the disease process, potential impairments, provide limitations of therapy.

Inpatient Rehab

• Goals include position changes in bed and inhibiting reflexes, functional mobility sensory awareness.

Inpatient Positions in Wheelchair

• Coordinate with medical team to set up time to allow the patient up to sit coordinate with other disciplines

Inpatient Rehab/ Range of motion

• Positioning facilitates stretching. Approximation through feet and hands and stretch muscles.

Inpatient Rehab/ Increased Awareness

• Coordinate with speech therapy on goals,

Inpatient Rehab Family Education

• Provide memories. Other therapy goals balance of motion.

Inpatient Rehab/Functional Mobility training

• Using verbal and visual communication to teach hand over hand techniques
• Core-treat and collaborate with other disciplines (OT/ST0

Inpatient Rehab/Attention Deficits

• To improve cognition, follow theses rules when treating -Ensure the patient has adequate rest and are aware of their treatment plan.

Rehab/Poor inhibitions

• Redirect their attention if their behaviour or action is inappropriate.

Problem solving during inpatient rehab

• Cognitive or topographic problem solving

Rehab Family Education

• It's important that the therapists communicates with other members

Rehab behavioral Deficits

-Communicate how their behaviour affect the therapist

Rehab/Agression

• Eliminate outside stimuli.

Discharge safety Planning

• In hospital evaluate how safe the therapist is what the patient.

Outpatient Physical Therapy

• Community, occupational and recreational integration. Is important

Outpatient PT Goals

• Focus on goals that include, balance, weakness, motor control, cognitive, behavioral, and/or visual, positioning, w/c modifications.