Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI)

• TBI is an alteration of brain function or evidence of brain pathology caused by external factors.
• External factors leading to TBI can be categorized as closed (brain hitting against the skull) or open (something piercing/damaging the brain).
• Non-traumatic brain injury is acquired and caused by internal factors like a brain tumor.
• Prevention strategies include helmet and seatbelt use, especially for the elderly, children, and middle-aged risk-taking males.

Primary vs. Secondary Brain Injury

• Primary brain injury occurs at the time of the injury and can be focal (damage to a specific part of the brain) or diffuse (widespread damage).
• Coup injuries represent the first point of impact.
• Contrecoup injuries represent the rebound hit.
• Diffuse Axonal Injury (DAI), also known as Traumatic Axonal Injury (TAI), happens when the coup-contrecoup phenomenon is combined with brain rotation.
• Secondary brain injury occurs in response to the primary injury, with military personnel more at risk from IED explosions.
• Secondary injuries include hematomas (subdural, epidural, intracerebral) and hemorrhage (intracerebral, subarachnoid, intraventricular).
• Epilepsy can also result.

Medical Management of TBI

• Severity is categorized as mild, moderate, or severe, and measurement depends on imaging, time of loss of consciousness, and post-traumatic amnesia (PTA).

• PTA, measured by Galveston Orientation and Amnesia Test (GOAT), assesses the time from the injury to when the individual regains ongoing memory.

• Medical interventions include craniotomy, burr holes, and ventriculostomies to drain and collect cerebral spinal fluid.

• The Glasgow Coma Scale (GCS) is used as a point system.

• Eye-opening responses:

• 4: spontaneous

• 3: in response to voice

• 2: in response to to pain

• 1: none

• Verbal responses:

• 5: normal conversation

• 4: disoriented conversation

• 3: words, not coherent

• 2: no words, only sounds

• 1: none

• Motor responses:

• 6: normal

• 5: localized to pain; pushes pain source away

• 4: withdrawal to pain; moves into fetal position when stimulus is applied

• 3: decorticate posture; legs extended, arms flexed onto chest (not always bilateral)

• 2: decerebrate posture; legs and arms extended, feet turned in, hands turned out (high tone)

• 1: none

• Total GCS scores: 3-8 severe, 9-12 moderate, 13-15 mild.

• The JFK Coma Recovery Scale tracks objectively monitor patient progress to assess suitability for discharge to rehab or skilled nursing facility (SNF).

States of Consciousness

• Coma is characterized by absent awareness.
• Individuals in a coma are typically sedated for recovery.
• Vegetative State is considered after 1 month of TBI with continued absent awareness.
• Regaining consciousness is statistically rare after 1 year in a vegetative state, or after 3 months if the injury was acquired or non-traumatic.
• Includes wakefulness, no awareness, and persistence
• Minimally Conscious State is characterized by reproducible behavior like command following, yes/no responses, intelligible verbalization, or purposeful movement and is where OT comes in.
• Requires a motor response of 5 or 6.
• Rancho Los Amigos Cognitive Scale is the gold standard for assessment.
• Level I: No response (Total A), complete absence of observable change in behavior with stimuli.
• Level II: Generalized response (Total A), respond to painful stimuli with generalized reflex, even if grossly delayed.
• Level III: Localized response (Total A), withdraw or vocalize to pain, follow moving object inconsistently.
• Level IV: Confused-agitated (Max A), no short-term memory, alert heightened state, movements lack purpose, may be in restraints, may have a behavioral plan.
• Level V: Confused-inappropriate (Max A), wandering, intent on going home, converse at automatic level, follow simple commands, use objects inappropriately, may have a behavioral plan, sexually inappropriate behavior should be redirected.
• Level VI: Confused-appropriate (Mod A), inconsistently oriented, AD for memory, safety risks, attend to familiar tasks for more than 30 minutes.
• Level VII: Automatic-appropriate (Min A), oriented to person, place, mod A for time, unaware of peoples' feelings, unrealistic, carry-over.
• Level VIII: Purposeful-appropriate (with SBA), depressed, irritated, low frustration, can use AD
• Level IX: Purposeful-appropriate (with occasional SBA or request), may have low tolerance, depression may occur.
• Level X: Purposeful-appropriate (with mod. Independence).

Clinical Picture of Client with TBI

• Physical Status: issues with Mm tone, weakness, ataxia, postural deficits, sensation, endurance, dysphagia, and self-feeding.
• Cognitive Status: impaired attention, memory, initiation & termination, safety awareness, processing, executive function, generalization, perseveration.
• Visual Status: ability to accurately see stimuli, motor visual skills (visual perceptual hierarchy).
• Perceptual skills are impaired, including interpreting stimuli, apraxia, aphasia, and neglect.
• Psychosocial Factors: altered self-concept, social roles, independent living status, coping with loss, and affective changes.
• Behavioral Status: agitation, confusion, yelling, swearing, grabbing, biting, and inappropriate sexual remarks.

Evaluation of Client at Lower RLA Level

• Focus on level of arousal and cognition, vision (scanning and attention), and sensation (hot, cold, 2-point, stereognosis).
• Assess joint ROM in relation to tone, motor control, coordination, fine/gross motor skills, and dysdiadokokinesia.
• Assess dysphagia and emotional/behavioral factors.

Intervention for Client at Lower RLA level

• Sensory stimulation and wheelchair positioning (pelvis, trunk, U/E & L/E, head).
• Bed positioning (rotate from supine to side-lying), splinting/casting, dysphagia management, behavior/cognition intervention, family/caregiver education.

Evaluation of Client at Intermediate or Higher RLA Level

• Assess physical status, dysphagia, cognition, vision, perceptual function, ADLs, driver rehabilitation needs, vocational readiness, and psychosocial skills using Barthel Index, FIM, BIT, or BIVABA.

Intervention for Client at an Intermediate or Higher RLA level

• NM impairments, ataxia, cognition, vision, perception, behavioral management, dysphagia/self-feeding, home management, community reintegration, psychosocial skills.

Quick Check

• TBI severity can be measured using Glasgow coma scale, post-traumatic amnesia, imaging, and states of consciousness.
• DAI or TAI occurs when the brain accelerates, decelerates, and rotates in the skull.
• Sensory stimulation, pain/motor response interventions are appropriate for Rancho levels 1-3 (severe TBI).
• Decerebrate posturing is marked by spastic extension, adduction, and internal rotation in all extremities and is more severe.

Mild TBI, Post-Concussion Syndrome and Chronic Encephalopathy

• 75% of TBIs are concussions or mTBIs.
• Assessment involves Glasgow Coma Scale (GCS) and Immediate Post-Concussion Assessment and Cognitive Testing (IMPACT).
• Recovery typically lasts weeks to months.
• Post-concussion syndrome is diagnosed if symptoms persist more than 1 year.
• Acute stress can negatively impact recovery from mTBI.

mTBI Criteria

• Any period of loss of consciousness (LOC) up to 30 minutes is considered mild vs. moderate TBI.
• Any loss of memory immediately before or after the event can last up to 24 hours.
• Alteration of mental state at the time of the event (dazed, disoriented or confused).
• A Glasgow Coma Scale (GCS) score is 13-15 after 30 minutes following the event.
• Not all will seek treatment.

mTBI Signs and Symptoms

• Physical: headache, dizziness, visual changes, sensitivity to light/noise, nausea/vomiting, blurred/double vision, balance problems, tinnitus, fatigue, sleep disturbances.
• Behavioral: depression, anxiety, agitation, irritability, impulsivity, aggression.
• Cognitive: feeling in a 'fog', slowed processing, difficulty concentrating, memory difficulties, judgment, executive function.
• Visual perceptual changes are very common for clients who have had multiple blows to the head.
• Symptoms can be confused for PTSD, or vice versa.

Post Concussive Syndrome

• Concussion/mTBI symptoms that persist longer than 3 months
• About 15-30% of concussions
• Risk factors:
• Reported for ages 20s-30s
• Women more likely to be diagnosed and seek care
• Correlation with mental health (history of anxiety)
• Increased risk for people with history of headaches
• It is not well known why it happens for some and not others

OT Evaluation

• Occupational profile: detailed history related to frequency, intensity and nature of symptoms.
• Screenings and standardized assessments: Rivermead PCS Questionnaire, The Developmental Test of Visual Perception, The Developmental Eye Movement Test, The King-Devick Test, Dynavision D2.
• Should review medications and over the counter supplements for possible causes exacerbating the symptoms (caffeine, chocolate, nicotine, alcohol).
• Areas: ADLs, IADLs (household management), visual-perception, cognition, assistive technology, sensory processing, home modification, organization, physical rehabilitation, emotional regulation, sleep hygiene, pain, relaxation and mindfulness, study skills, vocational needs, community re-entry, return and transition to life roles

OT Goal Development

• Collaborative with client and unique to evaluation results

OT Intervention

• Nature and common manifestations of concussion/mTBI
• Recovery patterns and expected outcomes
• Guidance for increasing insight
• Physical:
• Modifying tasks and the environment
• Remediating visual skills
• Consider sensory sensitivities: light, sound
• Managing symptoms
• Facilitating a guided, graded return to meaningful activities
• Emotional:
• Mindfulness is KEY!
• Stress reduction techniques
• Relaxation techniques
• Biofeedback
• Mind-body techniques
• Assertiveness and self-efficacy training
• Guided return to engagement in meaningful activities
• Emotional regulation and coping skills
• Cognitive:
• Remediating executive function skills
• Developing strategies

Sleep

• Clients w/ mTBI typically able to follow through w/ routine tasks but difficulty w/ problem-solving, insight, and self-control (tend to be impulsive).
• Education on the importance of sleep and a healthy sleeping pattern
• Make environmental modifications
• Assist with managing symptoms

Work/School

• There are some specific protocols related to the transition back to school or work.
• Initial period of rest
• Adaptations for reading, glare, noise, etc. may be needed

Shaken Baby Syndrome

• Also called abusive head trauma/inflicted brain injury or AHT (abusive head trauma)
• Group of signs and symptoms resulting from violent shaking and impacting of the head of an infant or small child
• Neurologic changes due to destruction of brain cells
• Caused by trauma, lack of oxygen to brain cells, and swelling of the brain
• Approx. 1,200-1,400 cases each year in the U.S.
• 1 out of 4 shaken babies dies each year
• Victims are an average age of 6-8 months
• Men tend to predominate in 65-90% of the cases / in their 20s, father or boyfriend/ Impulsive men who lack coping skills.
• More common in females who are babysitters or day care providers. The child's mother is less common.
• Can be diagnosed via skull fractures, swelling of the brain, subdural hematomas, rib and long bone fractures around the head and neck.
• CT Scans: Narrow beam of x-rays which rotate in a continuous 360 motion to obtain cross-sectional slices

Assessment for shaken baby syndrome

• Client factors and contexts: tone, coordination, visual acuity, visual motor, fine motor, active and passive range of motion, mobility, sensory processing, behavior, and family knowledge and goals.
• Assessment- formal measures: Modified Ashworth Scale
• Bayley Scales, DAY-C, Brigance, PDMS3, ASQ3
• Tracking and visual motor coordination
• VMI-6
• Active and passive range of motion
• Skilled, dynamic activity analysis
• SP-2, SP-3
• Functional Behavior Assessment (FBA)
• COPM
• Home assessment
• Intervention: Occupation as a means...as an end...
• Arousal, Sensory Stimulation
• Pain and tone management
• Neuromuscular re-education (NDT, Rood)
• Promote fine motor and visual motor skills
• Electrical- stimulation protocols
• Cognitive retraining
• Behavior management
• Assistive technology
• Adaptive equipment
• Mobility equipment training
• Family education and support
• Sleep and rest
• Play
• Social skills
• Preventing shaken baby syndrome: 100% preventable Hospital based programs