EHR525 Lecture 06b ABI (1 Slide) PDF

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of th...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice School of Allied Health, Exercise and Sports Sciences 1 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 1 EHR525 EXERCISE FOR NEUROLOGICAL & MENTAL HEALTH CONDITIONS Traumatic Brain Injury Presenter: Jack Cannon School of Allied Health, Exercise and Sports Sciences 2 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 2 What We Will Cover: ■ Pathophysiology of TBI. ■ Methods to assess the severity of TBI. ■ Long-term consequences following TBI. ■ Initial and long-term treatment of TBI. ■ Benefits of exercise for persons with a TBI. ■ Guidelines for exercise testing and prescription in TBI. ■ Special considerations for exercise in TBI. School of Allied Health, Exercise and Sports Sciences 3 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 3 Introduction ■ TBI: A form of ABI involving damage to the brain caused by an external force to the head causing a tear, penetration, bruising, or swelling of the brain resulting in neurological injury. ■ Mild TBIs may cause a temporary impairments in neural function while more serious injuries can result in long-term complications or death. ■ TBIs are different to other ABIs due the mechanism of damage: □ TBI often has more diffuse effects with more generalised impairments. School of Allied Health, Exercise and Sports Sciences 4 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 4 Acquired Brain Injury Injury that occurs after birth. Excludes neurodegenerative disorders. Non-Traumatic Brain Injury Stroke, tumour, poison, anoxia, disease, infection, etc. School of Allied Health, Exercise and Sports Sciences Traumatic Brain Injury Impact to head or violent head movement. 5 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 5 TBI Statistics ■ TBI rates are not well known in Australia: □ □ □ □ Not all individuals that present to emergency will be admitted Some consult with their GP. Some will not consult medical services at all. Limited research funding. ■ Mild TBIs account for 80% of injuries. ■ 25% of TBI discharge form hospital has some degree of residual impairment that will therefore a post-injury service. Hillier, SL. (1997). Brain Inj, 11(9); 649-659. School of Allied Health, Exercise and Sports Sciences 6 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 6 TBI Statistics School of Allied Health, Exercise and Sports Sciences 7 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 7 Pathophysiology ■ Two broad categories of TBI: □ Closed TBI: No penetration to the skull. • Falls, motor vehicle accidents, sporting injuries, assault, violent shaking, blast, etc. □ Open TBI: Penetration of the skull. • Bullet wounds, surgery, fractures, assault, etc. School of Allied Health, Exercise and Sports Sciences 8 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 8 Four (4) Mechanisms of Injury ■ Direct injury: □ Involves external impact to the head with physical contact between brain and skull. □ Results in coup injury causing focal vascular/axonal lesion. ■ Indirect injury: □ Do not require external impact. □ Unrestricted movement with brain within cranial cavity. □ Results in coupe/contrecoup injury causing diffuse axonal lesion. School of Allied Health, Exercise and Sports Sciences 9 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 9 Four (4) Mechanisms of Injury ■ Penetrating injury: □ Produce damage when objective passes through skull into cerebral tissues. □ Results in laceration, crush, intracranial hematomas and pressure, and ischemia. □ Injury occurs due to local tissue necrosis. ■ Blast injury: □ Exposure to shock wave from explosive device may result in brain injury. □ Injury occurs to the brain swelling cause diffuse lesion. School of Allied Health, Exercise and Sports Sciences 10 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 10 Mechanisms of Injury School of Allied Health, Exercise and Sports Sciences 11 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 11 School of Allied Health, Exercise and Sports Sciences 12 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 12 Assessing TBI Severity ■ Initial score on Glasgow Coma Scale. ■ Duration of loss of consciousness. ■ Length of post-traumatic amnesia. School of Allied Health, Exercise and Sports Sciences 13 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 13 Glasgow Coma Scale ■ Glasgow coma scale may be used for initial and ongoing assessment and to determine the severity of brain injury when patient is unconscious. ■ Shorter coma with higher GCS is associated with better recovery. School of Allied Health, Exercise and Sports Sciences 14 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 14 Duration of loss of consciousness ■ Mild TBI: Brief loss of consciousness, usually a few seconds or minutes (PTA for less than 1 hour). □ Normal brain imaging results. ■ Moderate TBI: Loss of consciousness for 1 – 24 hours. □ Abnormal brain imaging results. ■ Severe TBI: Loss of consciousness or coma for >24hrs. □ Abnormal brain imaging results. School of Allied Health, Exercise and Sports Sciences 15 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 15 Westmead Post-Traumatic Amnesia ■ Standardised assessment of PTA used to evaluate the client’s state of confusion immediately following TBI. School of Allied Health, Exercise and Sports Sciences 16 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 16 Initial Treatment For TBI ■ Initial treatment may involve intensive care (e.g. ventilator, etc). ■ Surgery may be performer for secondary complications (e.g. remove clots, bony fragments, or open window). ■ Appropriate imaging to determine nature and extent of the injury and best treatment strategy. ■ Medications: Diuretics, anti-seizure medications, and comainducing drugs. School of Allied Health, Exercise and Sports Sciences 17 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 17 Long-Term Impairments Following TBI ■ Recovery after TBI is variable between individuals. ■ The location and severity of the injury will determine what functions will be impaired and to what extent. ■ Impairments may temporary or permanent and involve: □ □ □ □ □ Sensorymotor. Cognition. Behaviour. Emotional/Psychosocial. Communication. School of Allied Health, Exercise and Sports Sciences 18 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 18 Sensory-Motor Impairments ■ ■ ■ ■ ■ ■ ■ ■ ■ Increased muscle tone and contractures. Loss of muscle strength and endurance. Loss of ROM. Involuntary posturing. Fatigue (physical and mental). Disturbed Balance. Chronic pain. Loss of vision. Vestibular deficits. School of Allied Health, Exercise and Sports Sciences 19 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 19 Cognitive Impairments ■ ■ ■ ■ ■ ■ ■ Attention and concentration. Planning. Problem solving. Memory. Learning. Motivation. Judgement. School of Allied Health, Exercise and Sports Sciences 20 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 20 Behavioural Impairment ■ ■ ■ ■ ■ ■ Changes in personality. Loss of behavioural inhibitions. Impulsiveness. Self-abuse. Irritability. Anger problems. School of Allied Health, Exercise and Sports Sciences 21 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 21 Emotion/Psychosocial Impairment ■ ■ ■ ■ ■ ■ ■ Mood swings. Anxiety. Low self-esteem. Depression. Social withdrawal. Loneliness. Grief and loss. School of Allied Health, Exercise and Sports Sciences 22 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 22 Recovery and Rehabilitation from TBI ■ Highly variable between individuals. ■ Treatment may require a MDT approach involving any AHPs; □ □ □ □ □ □ GPs. Psychologists. Social Workers. Speech Patholgists Physios. EPs. ■ Seizures and depression are common long-term effects. School of Allied Health, Exercise and Sports Sciences 23 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 23 Long-Term Disability Resulting From TBI By Age and Gender Selassie, et al. (2008). J head Trauma Rehabil, 23(2); 123-131. School of Allied Health, Exercise and Sports Sciences 24 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 24 Long-Term Disability Resulting From TBI By Mechanism Selassie, et al. (2008). J head Trauma Rehabil, 23(2); 123-131. School of Allied Health, Exercise and Sports Sciences 25 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 25 Survival After TBI By Functional Severity Brooks et al. (2013). Arch Phys Med rehab, 94:2203-2209. School of Allied Health, Exercise and Sports Sciences 26 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 26 Benefits of Exercise After TBI ■ Up-regulation of brain functions: Increased BDNF along with associated proteins involved in neuroplasticity. ■ Increased physical/motor function: VO2, strength, 6MWT, gait speed, balance, observed ambulatory status. ■ Improved mood: Exercisers have lower rate of depression, mood swings, and irritability. ■ Reduced cognitive problems: Fewer complains related to cognition, sleep issues, and memory. School of Allied Health, Exercise and Sports Sciences 27 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 27 Pre-Exercise Screening and Assessment ■ Normal ESSA Adult Pre-Exercise Screening procedures apply: □ Risk factors for CVD and diabetes frequently present. □ Resting ECG/stress test? ■ Thorough medical history: □ General trauma, surgery, medications, side-effects, post-trauma complications, comorbidities, lifestyle issues (exercise history, anthropometry). ■ Many TBI clients develop depression so a psychological referral may be necessary. School of Allied Health, Exercise and Sports Sciences 28 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 28 Pre-Exercise Screening and Assessment ■ A brief physical exam may be useful to determine extent of motor impairments and regions affected. ■ Special attention should be given to evidence of: □ □ □ □ □ □ Postural misalignment. Weakness/paresis. Restricted ROM. Spasticity (Modified Ashworth scale). Gait. Balance. School of Allied Health, Exercise and Sports Sciences 29 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 29 Response to Exercise ■ Overall physical capacity is generally low after TBI. ■ VO2 may be ~50% that of age-matched healthy persons. ■ Higher submax HR and BP response to a given workload. ■ Fatigue faster. School of Allied Health, Exercise and Sports Sciences 30 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 30 General Exercise Testing Considerations Palmer-McLean & Harbst, (2013), ACSM Exercise Management For Persons with Chronic Disease & Disabilities, Human Kinetics. School of Allied Health, Exercise and Sports Sciences 31 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 31 Aerobic Exercise Prescription (ACSM, 2013) ■ Can consist of: □ □ □ □ Ground/treadmill walking. Cycle ergometer. Treadmill. Seated stepper. ■ Frequency: 3-5 days /wk ■ Intensity: 40-80 % HRR □ RPE 11-13 ■ Duration: 15-30 minutes ■ Progress from low to high intensity and to longer durations. ■ Because of biomechanical limitations, intensity by HR should be superseded by RPE. □ Interval training? School of Allied Health, Exercise and Sports Sciences 32 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 32 Resistance Exercise Prescription (ACSM, 2013) ■ Should include all major muscle groups and functional exercises. ■ May include: □ □ □ □ Weight machines Free weights Body weight Therabands ■ Frequency: 3-5 days/wk. ■ Volume: 1-3 sets of 8-12 reps, up to 80% 1RM. ■ Progression as tolerated. School of Allied Health, Exercise and Sports Sciences 33 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 33 Flexibility Exercise Prescription (ACMS, 2013) ■ Goal: To improve ROM of involved extremities and prevent contractures. ■ Frequency: 3-5 days/wk (before or after aerobic or strength activities). ■ Intensity: Below point of discomfort. ■ Progression as tolerated. ■ Emphasis on stretching muscles on the paretic side, particularly in muscle groups experiencing spasticity. School of Allied Health, Exercise and Sports Sciences 34 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 34 Neuromuscular Exercise (ACSM, 2023) ■ Balance exercise may include: □ Yoga, Pilates, Tai Chi, stork stand, tandem stand/walk, standing on an unstable surface (i.e. BOSU ball, dura-disc, wobble board, etc.). □ Frequency: 2-3 days per week. □ Intensity: “Postural instability” Challenging static and dynamic (postural instability). ■ Mobility. ■ Gait. School of Allied Health, Exercise and Sports Sciences 35 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 35 Special Considerations for Exercise ■ Consider behavioural factors and supervision needs. ■ Depression and apathy are common. ■ Communication issues related to cognitive impairment. ■ Be aware of orthopaedic injuries that may also need exercise. ■ Avoid impact activities for 3-mths. School of Allied Health, Exercise and Sports Sciences 36 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 36 Summary ■ TBI occurs as a result of damage following physical impact. ■ Severity of TBI is based on a combination of coma and PTA. ■ Consequences of TBI may include sensorymotor, cognitive, and emotion/behaviour changes. ■ Long-term treatment of TBI may include medications and physical therapies. ■ Exercise after TBI is associated with improved recovery and QOL. ■ Guidelines for exercise in TBI are similar to stroke. School of Allied Health, Exercise and Sports Sciences 37 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 37