Traumatic Brain Injury Recovery Stages

Traumatic Brain Injury (TBI) Recovery Stages

• Coma: A state of unconsciousness where there is no arousal or awareness. Eyes remain closed, and there is no sleep-wake cycle.

• Unresponsiveness/Vegetative State: Marked by a return of sleep-wake cycles and normalized vegetative functions (respiration, digestion, blood pressure control). Patients may occasionally open their eyes and move their limbs in response to stimuli, but lack awareness and cognitive function. Persistent vegetative state is determined if the patient remains in this state for more than a year after TBI.

• Mute Responsiveness/Minimally Responsive: A state where the patient is not in a vegetative state, but shows fluctuating awareness, even if intermittent.

• Confusion State: Primarily a disturbance of attention mechanisms. All cognitive operations are affected, and the ability to form new memories is impaired. May exhibit hyper or hypoarousal.

• Emerging Independence: Confusion clears, and some memory may be present. However, significant cognitive problems and limited insight remain. Frequently exhibit uninhibited social behavior.

• Intellectual/Social Competence: Increasing independence, although cognitive difficulties (e.g., problem-solving, reasoning) persist. Patients may plateau at any stage or regress under conditions of stress or repetitive brain injuries.

Severity Classification Scales

• Glasgow Coma Scale (GCS): Evaluates eye opening, motor response, and verbal response performed in four steps (check, observe, stimulate, rate). Scores vary from 3-15, with higher scores indicating less severe injury. Severe head injury (score 3-8), moderate head injury (score 9-12), mild head injury (score 13-15).

• Rancho Los Amigos Level of Cognitive Functioning (LOCF): Describes the general level of cognitive and behavioral status. Doesn't address specific cognitive deficits. Based on 8 levels of cognitive and behavioral functions, reflecting increasing levels of awareness and responsiveness.

• Glasgow Outcome Scale (GOS): Expanded from the original scale to 8 categories. Primarily used in research.

Common Classification

• Severity: Correlates Glasgow Coma Scale (GCS) score with length of loss of consciousness (LOC) and post-traumatic amnesia (PTA).

• Post-Traumatic Amnesia (PTA): A loss of memory of events immediately following the injury. A typical diagnostic question: "What is the first thing you remember after your injury?" If the first memory occurred more than 24 hours after the injury, a moderate TBI is likely.

Rancho Los Amigos Level of Cognitive Functioning (LOCF)

• (Note: The provided study guide doesn't follow a strict sequential numbering scheme, but instead utilizes titles in a somewhat free form.)* LOCF grades are ordered according to increasing cognitive function. They are:

• No Response: Completely unresponsive to stimuli.

• Generalized Response: Inconsistent and non-purposeful responses to stimuli.

• Localized Response: Responds specifically, but inconsistently, typically with delays, to stimuli, such as following simple commands for motor actions (e.g., opening eyes, squeezing a hand).

• Confused-Agitated: Bizarre, non-purposeful, and inappropriate behavior; short- and long-term memory loss; incoherency in speech.

• Confused-Inappropriate: Consistent responses to simple commands; inappropriate or nonsensical responses when commands grow in complexity; difficulty focusing attention; forming new memories remains difficult.

• Confused-Appropriate: Goal-directed behavior needing external guidance; some memory retention, but recent memory is often problematic - past memories may be stronger.

• Automatic-Appropriate: Appropriate behavior in familiar environments; consistent daily routines; shallow recall of recent activities.

• Purposeful-Appropriate: Demonstrates carryover of learned skills in new settings; independent daily functioning; judgment may still be impaired in emergencies.

Functional Assessment Measures

• Functional Independence Measure (FIM): An 18-item rating scale frequently used in medical rehabilitation.
• Functional Assessment Measure (FAM): Developed to supplement the FIM, focusing on cognitive and behavioral aspects. It includes additional 12 items to better measure cognitive and behavioral aspects. The combined FIM+FAM has 30 items which assess dependence (7 items) or performance (5 items). This is commonly used with TBI patients.

Common TBI Symptoms

• Headaches
• Neck stiffness
• Confusion
• Drowsiness
• Nausea and vomiting
• Seizures
• Coma