NEUROEXAM_2.1 TRAUMATIC BRAIN INJURY EXAMINATION.docx.pdf

PT10116 | NEUROLOGICAL EXAMINATION LEC 2.1 TRAUMATIC BRAIN INJURY EXAMINATION 3PTA | First Shift, First Semester A.Y. 20...

PT10116 | NEUROLOGICAL EXAMINATION LEC 2.1 TRAUMATIC BRAIN INJURY EXAMINATION 3PTA | First Shift, First Semester A.Y. 2023-2024 CONTENT OUTLINE NON-TRAUMATIC BRAIN INJURY Internal injury to the brain I. TRAUMATIC BRAIN INJURY A. Non-Traumatic Brain Injury B. Epidemiology TOXIC METABOLIC ANOXIC C. Lobes of the Brain II. SUBJECTIVE EXAMINATION Mn Calcium Cardiac Arrest A. Demographics Zinc Gaucher’s/ CVD B. Chief Complaint Copper Niemann-Pick CO poisoning 1. Neuromuscular Areas prone 2. Cognitive to anoxia a) Important notes ○ Hippo- 3. Neurobehavioral campus 4. Communication ○ Basal C. History of Present Illness: HPI Ganglia 1. Mechanism of Injury a) Primary Injury Toxins which are neurotoxic to the brain b) Secondary Injury Mn: Associated with Parkinson's disease c) Blast Injury Zinc: Associated with Multiple sclerosis d) Ancillary procedures Copper: Associated with Wilson's disease (a disorder e) Medications wherein the body cannot excrete copper and thus f) Duration of PTA accumulates in liver and brain) D. Past Medical History E. Physical Environment Metabolic F. Social Environment Calcium: Metabolic disorders that can lead to deficiency in G. Lifestyle calcium metabolism, and can cause neurologic and H. Patient’s Goal psychologic symptoms, such as confusion, memory loss, III. OBJECTIVE EXAMINATION delirium, depression, and hallucinations A. Vital Signs Gaucher’s/Niemann-Pick: Genetic disorders related to B. Ocular Inspection inadequate lipid metabolism, wherein fatty cells deposit in C. Palpation different organs (e.g. liver, spleen), and in the progression D. Neurological Tests of the disease, leads to progressive loss of function of 1. Cerebrum nerves and brain 2. Cerebellum 3. Cranial Nerves Anoxia 4. Sensory Testing Lack of O2 to the brain 5. Reflex Testing Can be a result of cardiac arrest (d/t sudden stoppage of IV. PROGNOSIS blood flow to the brain) V. STRATEGIES PER RLA LEVEL CVD - such as stroke A. RLA Level 2: Generalized Response CO poisoning - wherein the CO molecules replace the O2 B. RLA Level 3: Localized Response molecules in the bloodstream, leading to serious tissue C. RLA Level 4: Confused Agitated damage and even death D. RLA Level 5: Confused Inappropriate E. RLA Level 6: Confused Appropriate F. RLA Level 7 & 8: Automatic Appropriate and EPIDEMIOLOGY Purposeful Response A major cause of death and disability (Leading cause of death in the US) TRAUMATIC BRAIN INJURY Leading Cause: ○ Falls in the elderly (rapid increase of 80%) Injury to the brain caused by EXTERNAL forces that may ○ Struck by or against an object (58% increase) cause alteration in brain function and other pathology Other Causes ○ Can be due to blow to the head or from a penetrating ○ MVA crashes injury ○ Assault Traumatic VS Non–Traumatic Injury ○ Unspecified mechanism ○ NTBI are internally acquired such as stroke or brain ○ Intentional self harm tumors TBI VS Head Injury ○ Head Injury: blow or laceration to the head, and may occur without causing injury to the brain Open TBI VS Closed TBI ○ Open: Head is hit by an object and the skull breaks, thus penetrating the brain tissue and disrupting the dura mater ○ Closed: Skull is intact but with injury to the brain Mild, Moderate and Severe TBI ○ Mild: occurs 80% of the time, including head contusions ○ Moderate: occurs 10% of the time ○ Severe: occurs 10% of the time 1 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Hospitalization: ○ Falls: 0-14 and >45 y/o ○ MVA: 14 – 44 y/o individuals in this age group are more aggressive and high risk takers; not wearing proper protective equipments like helmet or seat belts during the time of accident) Deaths: ○ Falls: 0-14 and >45 y/o ○ Intentional self harm - gradually increased may be d/t increase incidence of mental health problems and The brain lies in the cranial cavity continuous with the spinal inefficient coping mechanisms of cord via the foramen magnum individuals that lead them to Adult brain: 2% of the BW weight approximately: 1500g committing crimes against Normal blood flow should be at 50ml/min/100g of brain themselves tissue ○ MVA: 14 – 44 y/o Surrounded by 3 meninges: Dura, Arachnoid, and Pia mater MVA deaths gradually decreased, (most superficial to deep) probably bc of the new safety CSF is a clear colorless liquid produced by the choroid mechanisms in the designs and plexus. The brain floats in CSF in the subarachnoid space. manufacturing of vehicles nowadays Is capable of antero posterior movement (limited by the attachment of the superior cerebral veins to superior sagittal DELISA BRADDOM SULLIVAN sinus) and lateral gliding (limited by the falx cerebri which is the extension of the tough dura mater, thus less Leading Falls Falls Falls displacement is allowed) Cause MVA – highest Traffic- Related MVA fatality rates Crashes Struck Assaults Struck by/against an by/against an Object object/Sports Assaults Assaults Risk Alcohol intake Lower Factors prior to MVA socioeconomic status ADHD Rural Anti – Social populations Behavior Firearm use (violence) Child abuse LOBES OF THE BRAIN Psychosocial Factors Comprised of lobes with different purposes: Frontal lobe: is the seat of intelligence where most cognitive function takes place (such as judgment, long term memory, LEADING CAUSE critical thinking skills, calculations, communication as well In this comparative table, the leading direct cause of TBI is as the individual’s personality are housed) still (1) unintentional and accidental falls especially in the ○ Planning, programming and execution of motor elderly and children movements are also found in the frontal lobe Followed by (2) MVA in young adults. Temporal lobe: responsible for reception of auditory stimuli, According to Braddom and Sullivan, the third leading cause sensory aspect of speech, and short term memory is (3) being struck by or against an object which usually Parietal lobe: Processing, interpreting and discriminating happens in sports. different sensory inputs ○ Diving is the leading cause of sports related TBI Occipital lobe: reception and interpretation of visual stimuli followed by contact sports such as football and rugby. Cerebellum: Unconscious regulation of motor coordination, (4) Violence related such as assaults or battery. and control of voluntary movements ○ Also involved in unconscious proprioception, balance RISK FACTORS control of the body Alcohol is the single largest indirect cause of TBI especially Brainstem: where most reflexes and autonomic responses leading to vehicular crashes. of the body are regulated (such as breathing, digestion Attention deficit and hyperactivity disorder (ADHD) process, vasomotor control, wakefulness) ○ prone to accidental falls from high places or ground level falls Anti social and other psychosocial factors appear to play a role in intentional self harm. Environmental factors such as low economic status and rural living ○ are seen to be related to TBI incidences as individuals in this living situation are less educated in the use of proper protective gears, engage in violence and resort to alcoholic drinking. Firearm use whether legal such those issued to military and police personnel or illegal resulting to violence pose a risk as well. 2 M.C | M.D. | W.D. | K.E | J.K. | V.M. Brodmann's Areas Learning The brain is divided in different areas according to the tissue Executive functions structure and cellular organization. These areas are called Planning - strategic problem-solving skill Brodmann's area. Cognitive flexibility - ability to adapt thinking There is a total of 52 BA and behavior Review the common areas with clear functionality. Initiation and self-generation - self initiated in-coding of information BA 312 - Primary somatosensory Response inhibition - ability to repress BA 4, 6 - Primary motor, premotor and supp motor cortex inappropriate responses BA 44, 45 - Broca’s Area (motor speech programming) Serial ordering and sequencing BA 17 - Primary visual cortex ○ NOTE: As PTs, we get these complaints from patients BA 22 Auditory and/or relatives. We examine cognitive functions when BA 22 Wernicke's area (language comprehension) we do neurologic examination of the cerebrum if the BA 39-40 Gerstmann: left-right disorientation, finger agnosia, patients and/or relatives include these in their agraphia, acalculia subjective reports. ○ Altered Levels of Consciousness Main complaint of relatives, especially in RLA 1-3 of SUBJECTIVE EXAMINATION TBI Some pts are discharged from hospitals in low levels of consciousness DEMOGRAPHICS If pt is in confused stage, ask relative Male>Female Age ALTERED LEVELS OF CONSCIOUSNESS ○ Peak Ages (Teenage and Young Adult years) Braddom: 0-4 y/o and 15-19 y/o Description De Lisa – 15-24 y/o Both references refer to teenage years and early Comatose No response to any stimuli; not usually adult years permanent (may go brain death, vegetative These particular age groups are explorers / state, minimally conscious state or __ full rebellious, openly seeking exhilarating adventures recovery → occurrences of motor vehicular accidents, sports head injuries, head traumas in recreational Ventilator dependent; eyes are closed, arousal activities, and assaults are very common system is non functional, no sleep wake cycle, TBI at a very young age is associated with no auditory and visual function, no Shaken-baby Syndrome or child abuse communicative functions, abnormal and ○ Elderly – highest level of mortality postural reflexes may be present >65 y/o Highest d/t unintentional accidental falls Vegetative Dissociation between wakefulness and Higher incidence in younger groups as they are generally State awareness. more adventurous/rebellious leading to an increased risk of accidents or incidences of trauma Higher centers are not integrated with the brainstem, hence the dissociation; May be awake but not aware of the environment; Have CHIEF COMPLAINT a sleep wake cycle; may startle to visual and auditory stimuli, no meaningful cognitive or Weakness communicative function, movements are Inability to move non-purposeful and usually reflexive (may be Deconditioning misinterpreted by relatives as purposeful - e.g. ○ d/t prolonged immobilization and hospitalization whether the pt grasps their hands when they Sleep dysregulation talk to them). Also withdraws from painful Visual complaints (like Oscillopsia where objects seem to stimuli vibrate or jiggle) Mood issues / Mood swings Minimally Minimal evidence of self or environmental Behavioral problems Conscious awareness. State Cognitive behaviors are inconsistent, NEUROMUSCULAR reproducible, or sustained. Presence of sleep wake cycle; pt may localize painful stimuli, sound stimuli, and may perform visual pursuit Impairments vary depending on the area of lesion; can also of an object. be seen in pts with CVA UE and LE paresis Impaired coordination Stupor Unresponsive state where there is arousal with Impaired postural control strong noxious stimulus Abnormal tone Abnormal gait Returns to an unconscious state when strong Abnormal involuntary movements (e.g. tremor or chorea – noxious stimulus is withdrawn. less common) Impaired somatosensory function Obtunded Difficulty to arouse Needs CONSTANT stimulus to stay awake CONFUSED when awake/conscious COGNITIVE Unproductive interaction Often asleep; When aroused, exhibits Cognition is the mental process of knowing and applying decreased alertness and interest in the information, its processes are intricate and localizing specific environment anatomic structures involved is difficult. But most of these cognitive functions are housed and controlled in the frontal lobe; Lethargy Arousal with stimulus hence, most patients with TBI tend to have cognitive Falls asleep when stimulus is withdrawn impairments Loss of train of thoughts Morbid drowsiness Cognitive - controlled in the frontal lobes ○ Complex neural processes: Disoriented Arousal Attention Alert* Awake Concentration Attentive---normal stimulation Memory 3 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Brain tissue coming into contact with an object or Interact meaningfully with clinicians external object that can penetrate the bone (e.g. knife, bullet) Also occur when the head is prevented from IMPORTANT TO TAKE NOTE moving after it is struck ○ Inertial forces Occur when the head is set into motion and brain SEQUENCE OF RECOVERY AFTER COMA: rapidly accelerates or decelerates 1. Eye Opening - CN3 Secondary Injury 2. (+) Brainstem Function - Sleep Wake Cycle ○ any damage to brain tissue that takes place after the 3. (+) Hypothalamus Function - Follows Commands initial (primary) injury 4. ABLE TO TALK (and communicate appropriately) - Best Cell death occurs as a result of events that follow Indicator Of Recovery after tissue damage ○ treatable and theoretically preventable. PERSISTENT VEGETATIVE STATE → condition persisted for Both primary and secondary MOIs are not mutually exclusive more than 1 month of unconsciousness and often do not occur in isolation ○ (+) sleep wake cycle ○ (+) pupillary constriction - when tested for light reflex ○ (+) oculocephalic reflex - good prognosis Also called the Doll's-eye reflex HPI > MOI: PRIMARY INJURY Indicates an intact CN 3 and 6 function Is the movement of the eyes opposite to the movement of the head when the head is moved DIFFUSE AXONAL INJURY (DAI) passively Microscopic disruption and tearing of axons and small E.g. when the head is tilted upward, the eyes roll blood vessels from shear-strain of angular acceleration downward Distinguishing feature of TBI E.g. when the head is rotated to the right, the eyes ○ Most common cause of DAI = motor vehicular move to the left accidents; bc there are acceleration, deceleration and ○ (+) Primitive behavior (chewing and roving eye rotational forces involved movement) ○ DAI is the predominant MOI in most pts with severe to ○ Spontaneous response moderate TBIs Initial loss of consciousness after TBI and results in more generalized deficits (e.g. confusion and incoordination). NEUROBEHAVIORAL Recovery from DAI is usually gradual. Neurobehavioral - closely linked to cognitive impairments ○ Commonly linked to the duration of coma More debilitating in the long-run than physical disabilities Coma – common manifestation of DAI ○ Loss of consciousness is d/t direct axonal shearing and MANIFESTATIONS disruption of the intra-axonal cytoskeleton Low Frustration Tolerance ○ D/t shearing force→ Axons get damaged → Disruption Agitation leads to swelling and disconnection of axons Disinhibition Common sites: ○ The inability to withhold a response or suppress an ○ Corpus callosum inappropriate or unwanted behavior ○ Subcortical white matter Apathy ○ Brainstem ○ Lack of interest or concern Spared: Emotional Lability ○ Upper medulla ○ Rapid, often exaggerated changes in mood ○ CN 9 and 11 ○ E.g. uncontrollable crying or laughing Mental Inflexibility ○ Inability to switch between thinking about two different concepts Aggression Impulsivity Irritability COMMUNICATION Some pts and/or relatives will complain about the pts difficulty in communication Non – aphasic in nature Deficits include ○ disorganized and tangential oral or written CEREBRAL/CORTICAL CONTUSION communication, imprecise language, word retrieval Also known as Parenchymal Contusion/ Cortical Bruising difficulties, and disinhibited and socially inappropriate Result from relatively low-velocity impact such as blows (or language. blunt trauma) and (ground-level) falls. Other problems include With translational acceleration result in head movement ○ Difficulties communicating in distracting environments, ○ In contrast with DAI, which involves high-velocity impact reading social cues, and adjusting communication to Common areas meet the demands of the situation ○ Frontal lobe – long term amnesia Communication deficits can affect employability, social ○ Temporal lobe – short term amnesia interaction and quality of life in the long-run Undersurface of frontal and anterior temporal lobes bc of the presence of bony prominences on the HISTORY OF PRESENT ILLNESS: HPI base of the skull → creating brain tissue and vascular disruptions How the pt developed the condition and what procedures Elevate the risk for seizures and are more likely to produce were done on the pt focal deficits (e.g. aphasias and motor weakness). Usually bilateral but can also be asymmetric HPI > MECHANISM OF INJURY ○ Coup Injury – Site of impact ○ Countercoup – opposite cortex (away from injury, Start by asking, when did the pt acquire the condition and opposite side of impact) the mechanism of injury ○ Coup –Countercoup - combined TBI is a diverse injury with a wide range of mechanisms Primary Injury ○ Contact forces 4 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Image A: Crossed cerebellar diaschisis can be visualized with Positron Emission Tomography is seen as a decrease E.g. MVA - forward acceleration of body is suddenly stopped in blood flow in the cerebellar hemisphere, C/L to a cortical by the impact stroke ○ Since the brain is floating in CSF, the brain is still Image B: Functional connected regions in the neocortex, accelerating but the body has already stopped which is the area for higher brain functions, may also Brain tissue moves forward → hitting skull = Coup undergo diaschisis d/t a loss of afferent connections after a injury focal stroke ○ Sudden recoil of body after impact → lead to deceleration and will translate to the brain slightly BRAIN HEMATOMA delayed Epidural Hematoma Brain translates backward → hitting skull = ○ Associated with damaged artery Countercoup injury ○ Local impact and subsequent laceration of underlying dural veins and arteries CONCUSSION ○ Neurologic emergency Characterized as a Mild TBI bc of it’s quick expansion and rapidly causing Manifestations neurological degeneration ○ memory loss, poor concentration, impaired emotional ○ Most common: meningeal artery rupture control, post traumatic headaches, sleep disorders, Subdural Hematoma fatigue, irritability, dizziness, changes in visual acuity, ○ Less severe than epidural hematoma depression, anxiety, personality changes, and seizures ○ Inertial forces and the tearing of bridging veins Symptom duration (persistent deficits): 3 – 12 months ○ When angular acceleration shears vessels located in Key Criteria the subarachnoid space ○ at least one of the following confusion, disorientation, ○ Intracerebral hemorrhage (happens with a concomitant loss of consciousness for less than 30 minutes, PTA for penetrating injury) less than 24 hours, or other transient focal neurologic abnormalities PTA - post traumatic amnesia ○ GCS score of 13 to 15 after 30 minutes or presentation to a healthcare facility ○ Findings should be made in the absence of illicit drugs, alcohol medications with sedating side effects or other injuries or problems POST CONCUSSIONAL SYNDROME ○ Three months after concussion ○ Manifestations: 1. Loss of concentration 2. Memory Deficit 3. Irritability 4. Agitation 5. Headache - frequent 6. Fatigue HPI > MOI: SECONDARY INJURY Most commonly used: AAN Concussion Grading Scale Develops hours and days after the initial impact Cause: ○ Disruption of cerebral blood flow ○ massive release of neurochemicals ○ cerebral edema ○ disruption of ion hemostasis INCREASED INTRACRANIAL PRESSURE Normal ICP: ○ 5 – 20 cm of H20 (Sullivan) ○ Increased: beyond or >20 mmHg (DeLisa) DIRECT LACERATION Leads to decrease CPP (normal: 50 and 70 mm Hg) A less common cause of parenchymal injury ○ CPP - cerebral perfusion pressure caused by metallic or bony fragments: Can cause: ○ gunshot or other missile injury ○ Cushing’s Triad – ominous manifestation of an ○ depressed skull fracture increased ICP ○ significant blunt trauma Triad: Hypertension, Irregular breathing, ○ penetrating injury Bradycardia (manifestation of an increased ICP); must be monitored in pts with comatose states NOTE: Every structure of the brain is directly or indirectly ○ Herniations - specifically the tonsillar part of the brain connected to all other structures – focal cortical lesions can affect C/L cortical functioning by way of interconnections in the BRAIN INFECTION Corpus Callosum HEMORRHAGE (EPIDURAL, SUBDURAL, INTRACEREBRAL) DIASCHISIS Refers to neurons remote from a site of injury, but HYPOXIC – ISCHEMIC INJURY anatomically connected to the damaged area, becoming lack of oxygenated blood flow to the brain tissue functionally depressed ○ Can cause damage to parenchymal tissues Recovery of function 5 M.C | M.D. | W.D. | K.E | J.K. | V.M.  caused by systemic hypotension, anoxia, or damage to Classification specific vascular territories of the brain ○ Mild TBI: 0-1 day (less than 1 day) ○ Moderate TBI: > 1 day to < 7 days ○ Severe TBI: > 7 days HPI > MOI: BLAST INJURY MEMORY LOSS Signature injury of military conflicts Retrograde Amnesia/Evocation This particular mechanism of injury is very important to ask ○ Loss of previous memories after the accident in patients whose occupation involved military or police Anterograde Amnesia/Fixation Amnesia services. ○ Inability to learn new things ○ Blast injury is major problem for active combat military PTA personnel due to frequent use of explosives in the battlefront PAST MEDICAL HISTORY (PMHx) TYPES OF INJURY Other injuries to the same area, cardiac and pulmonary, Primary injury: direct effect of blast overpressure musculoskeletal systems ○ Blast injuries may occur due to the direct blast wave ○ Previous hospitalizations, injuries to other systems of propagation transcranially. the body ○ The transfer of blast energy to the blood vessels will trigger oscillations going to the brain, thus increasing CSF or venous pressure. PHYSICAL ENVIRONMENT ○ The increased venous pressure may be due to the compression of thorax and abdomen brought about by House type, stairs, rails, barriers at home, distances of the the blast wave propagation different rooms in the house, possible overhead cabinet , ○ E.g. eardrum rupture, lung injury work environment Secondary injury: may be brought about by shrapnel or other objects hurled to the individual SOCIAL ENVIRONMENT ○ e.g. blunt or penetrating traumas Tertiary injury: when the victim flung backward and hits an Home and work, (if pt has a) primary caregiver, capacity for object (wall/ground) long-term support of relatives and family members Quarternary injury (Braddom): Occurs as a concomitant closed injury brought about by asphaxia (lack of oxygen), and exposure to toxic inhalants. LIFESTYLE Smoker, alcohol intake, hobbies and interests, occupation, other leisure activities like sports PATIENT’S GOAL Pt’s Goal or the relative’s goal OBJECTIVE EXAMINATION VITAL SIGNS Increased VS (HR, RR, Temp and BP) HPI > ANCILLARY PROCEDURES ○ Dysautonomia: Elevated SNS activity occurs as a normal response to trauma Once we have established how the pt. acquired the Mean Arterial Pressure (MAP): Average pressure in the condition, we also have to ask different ancillary procedures arteries in one cycle that were performed on the patient ○ [ SBP + 2 (DBP) ] / 3 ○ Best indicator of perfusion in vital organs such as the In a TBI, common ancillary procedures are the ff: brain Skull x-rays: Bone lesions/fractures ○ Since blood pressure is usually elevated, it is not Ventriculography: Tumors, increase in ICP necessarily followed that examination or treatment will CT Scan: Tumor, calcifications, hemorrhage, cerebral edema, be deferred. cerebral infarction ○ If MAP is within prescribed range, PT management can MRI: Blood flow, primary method in examining tumors and be done with care vascular abnormalities ○ Related to the Cerebral Perfusion Pressure ○ Cerebral edema: within 30 mins p vascular occlusion Cerebral Perfusion Pressure ○ Infarction: within 2 hrs ○ MAP - ICP (Intracranial pressure) PET: Imaging cerebral blood flow; brain metabolism ○ A decrease in CPP can lead to brain ischemia ○ Lacks detailed resolution of CT scan or MRI ○ N: 50-70 mmHg HPI > MEDICATIONS OCULAR INSPECTION Phenytoin: Anti-convulsant MANNER OF ARRIVAL ○ Post-traumatic seizure is commonly seen in patients Ambulatory who suffered from severe TBI Wheelchair-borne Corticosteroids: Lowers inflammatory process of the body Bed-ridden ○ Found to be associated with increased mortality rate Bed-bound after 2 weeks of treatment d/t elevated CSF cortisol in Bed-fast the body Progesterone: Neuroprotective properties BODY BUILT Ectomorph/Asthenic Mesomorph/Athletic HPI > DURATION OF PTA Endomorph/Pyknic POST TRAUMATIC AMNESIA LEVEL OF CONSCIOUSNESS Length of time between the injury and the time at which the Comatose pt. is able to consistently remember ongoing events Vegetative State Loss of memory but with ability to recall Stupor 6 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Obtunded NEUROLOGICAL TESTS Lethargic Awake ATTACHMENTS CEREBRUM Common attachments seen during acute and subacute pt management of pts with TBI: ORIENTATION Neuro bonnet ○ Person, Place, Time, Situation Mechanical ventilator ATTENTION SPAN Tracheostomy tube ○ Digital Retention ○ can be attached to a mechanical ventilator MEMORY Neck collars ○ LTM, STM, Immediate Recall at 5-10 min interval ○ Soft cervical / Philadelphia collar GENERAL INFORMATION Oxygen Cannula/Mask ○ Remote Memory, Basic Intellect IV line CALCULATION Heplock ○ Serial 7s, Simple Mathematics Indwelling catheter ABSTRACT THINKING Pneumatic Compressions ○ Proverb Explanation Compressive stockings JUDGMENT Arm/leg restraints ○ Societal Norms BRUISES/HEMATOMA Important to note location especially on the face because it GLASGOW COMA SCALE (GCS) may signify basal skull fractures Raccoon’s eyes/Panda bear sign - bruises around the eyes Battle Sign - bruises behind the ears Most widely used primary initial assessment tool for determining the severity of brain injury Score is obtained by rating the best visual, verbal, and motor responses (eye opening); ○ Lowest score: 3 ○ Highest: 15 ○ Low initial score, especially motor and eye responses, are poor prognosticating factors for recovery in patients with moderate to severe TBI SWELLING Also take note areas where swelling is present Categories (severity of TBI): DIAPHORESIS Mild = 13 to 15 Excessive sweating Moderate = 9 to 12 d/t an increased sympathetic nervous system activation Severe = 8h/d 5. Lower moderate disability (Lower MD) Independent in ADL and can shop and travel independently on public transportation, but has not returned to previous position or lifestyle 6. Upper moderate disability (Upper MD) Able to resume previous position or lifestyle with alternative/modified duties or part-time due to injury 7. Lower good recovery (Lower GR) RANCHOS LOS AMIGOS Able to resume previous position or lifestyle (may be LEVEL OF COGNITIVE FUNCTIONING (RLA-LOCF) modified, but reporting some problems) 8. Upper good recovery (Upper GR) Is a well known and widely used clinical tool used to rate Complete return to previous lifestyle with no reported how people with brain injury are recovering in terms of problems cognition Cognitive recovery after TBI and the capacity to interact effectively with the environment Each level describes a general pattern of recovery with focus on cognition and behavior Each level is accompanied by a lengthy description of behaviors that meet the criteria for placement at that level Below is the updated version of the scale, wherein there are 10 levels ○ Levels 9 and 10 are just expanded versions of Level 8 8 M.C | M.D. | W.D. | K.E | J.K. | V.M.  CN 2 Scotoma ○ Scotoma is the blurring of the central part of an image ○ When testing for visual acuity, also important to ask the pt if they can see the whole image or letter clearly CN 3 2nd most injured ○ Must be routinely tested, including the Pupillary light Reflex & extraocular muscle movements ○ Ptosis is also an indication of CN 3 affectation Here is the old version of the scale wherein there are only 8 levels CN 4-6 Testings can be done as usual CN 7 Most commonly injured in temporal bone fracture ○ Should be tested if facial asymmetry is evident CN 8 Basal skull fractures, CSF otorrhea ○ CSF otorrhea is the leakage of CSF in CEREBELLUM one of the ears, and also indication of basal skull fractures Testing for the cerebellar functions is also important in TBI to know if the injury has extended to the cerebellum Testings can only be done if pt can follow simple commands RLAs Level 1-4 are NOT CANDIDATES for cerebellar examination Non-equilibrium Tests Equilibrium Tests CN 9-12 Testings can be done as usual CRANIAL NERVES SENSORY TESTING Cranial nerve testing should also be done Pts who cannot follow commands, such as RLAs Level 1-4, Can be done on pts who can follow simple instructions and passive cranial nerve tests (reflexes) may be done are NOT in a state of confusion such as in the RLAs Level 6, Below are additional measures to be performed aside from 7, 8 the usual CN testing procedures: ○ Superficial ○ Deep ○ Combined Cortical CN 1 In addition to the usual assessment for CN1, such as the discernment of senses, the PT must take note of CSF rhinorrhea REFLEX TESTING Basal skull fractures, rhinorrhea (CSF) ○ CSF Rhinorrhea is the leakage of CSF in Can be done in all levels of RLA one nostril, especially when the head is ○ Superficial tilted forward (indicative of basal skull ○ Deep fracture) ○ Pathologic ○ In addition to leakage, pt may also subjectively report metallic taste in the mouth & sensation of drainage at the back of the mouth 9 M.C | M.D. | W.D. | K.E | J.K. | V.M.  ○ Social cognition ROM ASSESSMENT ○ Sphincter control ○ Transfer PROM ○ Locomotion ○ Passive ROM must be carefully done so as not to ○ Communication induce stretching pain on tight or contracted muscles and joints FIM for younger children: AROM WeeFIM (pediatric version of FIM) ○ Also assesses 18 domains of function ○ Used on 0-7 years of age MMT 6-minute walk test ○ For CV endurance and is helpful in determining the level If pt can follow instructions, usual MMT can be done of pt’s tolerance in sustaining activities, especially FMT during the early stages of PT treatment ○ Can be used if pt is not able to follow instructions or is unconscious PROGNOSIS ○ Done by observing and describing motor responses of the pt The table summarizes findings which can be categorized as whether poor or good indications in recovery POSTURAL ASSESSMENT Supine, standing or sitting Important to take note of the abnormal posturing such as decorticate or decerebrate postures GAIT ASSESSMENT Can be assessed if pt is able to ambulate Indep or dep, surfaces, distances and use of AD Gait deviations Phases of Gait FUNCTIONAL ASSESSMENT Level of independence POORER PROGNOSIS ○ Pt’s level of independence in performing ADLs GCS < 7 Endurance PTA > 2 weeks ○ CV endurance, especially those who are immobilized for Imaging results (CT Scan): poorer prognosis if there are long periods presence of large blood clots in the brain Balance Old age can be a factor for poor recovery d/t the body’s ○ Must be assessed in sitting and standing decreased ability to recover from an injury Tolerance For Pupillary light reflex: ○ Tolerance to upright position is important to determine ○ Pupillary dilatation is associated with a poor prognosis, even if pt is unresponsive however, constriction of only one pupil is an indication ○ Testing can be done by monitoring VS, particularly BP that the pt is nearing death d/t affectation of brainstem and HR responses in position changes which is responsible for automatic breathing ,and Outcome Measure Tools possible brain herniation ○ To assess pt’s function objectively For doll’s eye sign and caloric testing: ○ impaired (poor) d/t involvement of brainstem Rigid motor response and decerebrate posturing are FUNCTIONAL ASSESSMENT > OMT associated with poor outcomes since decerebrate posturing also indicates brainstem, specifically pontine affectation, and possible cerebellar tonsil herniation DISABILITY RATING SCALE STRATEGIES PER RLA LEVEL Assesses participation restriction domain of ICF Intended to assess changes “from coma to community” RLA LEVEL 1: NO RESPONSE An observer-rated, 30-point continuous scale that provides quantitative information to document the progress of patients with severe head injury from coma to community Coma reintegration. Disruption of connection from the brainstem to the cortex The higher the score, the more disabled ○ automatic functions are present in the brainstem Evaluates eight areas of functioning in four categories: PT approaches: 1. consciousness (eye opening, verbal response, motor ○ Watch for signs of consciousness or wakefulness response) ○ Examination will focus on passive procedures such as 2. cognitive ability (feeding, toileting, grooming) ocular inspection, palpation, testing for reflexes, passive 3. dependence on others range of motion and functional assessment esp on the 4. employability level of dependency and tolerance in upright positions. ○ PT must still talk to the pt even without any form of response. FUNCTIONAL INDEPENDENCE MEASURE 1. Level of Test the level of consciousness of pt Commonly used measure of functional mobility, ADL Conscious- They may appear unconscious but it is function, cognition, and communication. ness still important to know their responses to Usually administered in acute in-patient rehabilitation external stimuli setting ○ Calling by name measure level of disability and burden of care in individuals ○ Then, lightly touch the patient if did undergoing inpatient rehabilitation not respond useful for monitoring patient progress and evaluating ○ Then, apply noxious stimulation like outcomes sternal rub, applying pressure behind Areas to be assessed: the jaw or nail beds ○ Self-care Note the type of response they have to 10 M.C | M.D. | W.D. | K.E | J.K. | V.M.  external stimuli ○ Do they respond appropriately - e.g. swinging at you bc they don’t like what you’re doing ○ Do they just open their eyes, are they groaning ○ Also note if there was no response at all Oculovestibular reflex 2. Test for the respiratory/ breathing pattern ○ Done if doll’s eye is abnormal, this is Respiratory/ of the pt a stronger stimuli Breathing Depends if they are intubated and ○ Aka cold water calorics Pattern mechanically ventilated or breathing ○ Using syringe icy cold water is spontaneously on their own infused in one ear with the head in ○ Spontaneous: note the rate and the the bed at 30 degrees, done in both pattern (can indicate level of brain ears injury involved) ○ Brainstem intact c stronger stimulus: Normal: each breath at same Response: both eyes should interval and same size slowly and tonically move Cheyne-Stoke towards cold stimulus Crescendo-Decrescendo: breath Gag Reflex gets larger and larger, then ○ If pt is not intubated: using q-tip then smaller and smaller c some touch back of throat apneic pauses ○ If pt is intubated: grab ET tube and Erratic pattern: breaths are in jiggle back and forth varying size and varying intervals However, intubated pts for a between them while often suppress their gag reflex → not very reliable 3. Eye exam Eye exam ○ A stronger reflex that checks CN 9 & ○ Not so much of the reflex 10: cough reflex ○ More of “what did the eyes look like?” Suction the pt through the ET ○ First, note if the eyes are open or tube, so that the suction catheter closed can touch the carina → ○ If closed, gently passively open them stimulates very strong cough (if and check it doesn’t, there is dysfunction in Conjugate (looking in the same part of brainstem) direction) ○ Saline water can be infused down Disconjugate (both looking in the ET tube if suctioning does not different directions) elicit cough reflex → in intact pt, this Deviated to one side must stimulate cough reflex Abnormal spontaneous Lowest or most primitive brainstem reflex movements of the eyes → reflex to breathe Nystagmus - abnormal in a comatose pt; may be 5. Motor If pt is moving spontaneously → note that indicate an irritative lesion and Sensory they are moving spontaneously of the brain or seizure Responses If not → apply noxious stimulation then Bobbing of the eyes to Noxious observe the responses (start centrally c a Slowly roving Stimulation sternal rub, then each limb to look for Tells us whether NS is intact and asymmetries) at what level may be dysfunction ○ Sternal rub: ○ Second, it is also important to take appropriate response → fending note of the pupils off the hand, localizing where the Size - same or different size pain is coming from Shape - could be irregular Note cortical sensory responses (e.g. grimacing of the face) 4. Pupillary light reflex ○ Limbs: appropriate response → Brainstem ○ Equally or unequally responsive fending off the hand, localizing where Reflexes ○ Briskly or sluggishly responsive the pain is coming from ○ Conjugate or disconjugate response withdraw response (not quite so Corneal reflex bad response) ○ Brush the edge of the eye (not the iris); or ○ Brush the eyelashes or tickle inside of nose to elicit sensorimotor reflex ○ CN5 (afferent); CN7 (efferent) Oculocephalic reflex ○ Aka Doll’s eye maneuver ○ Done by passively opening both eyes flexion/decorticate posture and briskly moving head from side to where arms flex reflexively (not side so bad/good response) ○ Normal (conscious pt): eyes will move with head ○ Normal (comatose pt c intact brainstem): eyes will lag behind the head, and slowly catch up ○ If brainstem is not intact eyes will stay with the head as the head moves side to side ○ (-) Oculocephalic reflex extensor posturing where arms eyes do not move with head extend and turn out (fairly bad (they do not lag and catch up, lag response) and catch up) → use a stronger stimulation 11 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Unable to localize or attend to voice no response (worst response) ○ Nail bed pressure → if no response, it is the worst response Responses are minimal, delayed and inconsistent 6. Muscle Same in the conscious person Reflexes Check the tone of the limbs before and striking reflex Pathological ○ Check each side to note the degree Reflexes of response and noting symmetry/asymmetry Pathological Reflex ○ Plantar response - most common (scratch the plantar aspect of foot) → flexor response Breathes heavier and tenses up in response to pain Pathological reflex is an upgoing toe with fanning of toes Triple flexion (exaggerated response where the hip, knee, foot flex up) - reflexive movement that happens in the same way every time stimulus is applied Triple flexion response vs withdrawal response - repetitive nature that occurs in the same No verbal or non-verbal response, shows reflexive way and great toe goes up chewing (Babinski) along with flexion is more of pathological response “One is unable to test a patient when in Comatose” ← INCORRECT and DANGEROUS for the patient ○ No more important time to perform neurological assessment than in a coma pt, for a number of reasons: Establish diagnosis Level of injury Location of injury Prognosis for the pt “Look at the ball” To provide baseline for future comparison over Poor attention, fatigue, and unable to follow commands time RLA LEVEL 3: LOCALIZED RESPONSE RLA LEVEL 2: GENERALIZED RESPONSE Minimal conscious state Vegetative State Brainstem starts to recover but the connections to the Brainstem starts to recover but the connections to the cortex are still impaired cortex are still impaired PT Approaches: PT approaches: ○ Speak in calm and soothing voice ○ Must speak in a loud voice ○ Talk like they understand you, avoid complex ○ Different stimuli may produce similar responses such information and commands as breathing heavily, chewing or increased stiff ○ When touching the pt, explain to them what you are posturing when pain is applied or hearing a loud sound going to do ○ Give time for the pt to response (10 sec) before repeating command ○ Provide small amounts of stimulation (TV, Radio etc) ○ Provide plenty of rest due to easy fatiguability “Take the ball” Awake but not following commands “Touch the ball for me” Responses may be slow and inconsistent “Look over here” 12 M.C | M.D. | W.D. | K.E | J.K. | V.M.  “Look at the ceiling” or “Look down at the floor” Restless and language reflects confusion Follows verbal commands but may be inconsistent “Here is a cup, show me how you use a cup” Starting to recognize objects Completes simple tasks with structure “Look right at the cup for me” or “Look at the ball” Increased restlessness and agitation Still shows decreased arousal Emotions may change rapidly Localizes to pain and pulls away RLA LEVEL 4: CONFUSED AGITATED Characterized by behaviors like hitting, yelling, restlessness, foul language, confabulations PT Approaches ○ Make activities simple and familiar ○ Change activities frequently ○ Do not force patterns to do things and do not reason with them ○ Increase rest periods ○ Start with functional assessments first ○ Keep stimulation low (quiet room, soft lights, soothing sounds, limit talking) ○ Do not ask orientation information 13 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Severe agitation seen as foul language, hitting, and Confusion throwing “This leg tells me it’s a Thursday” Pt incorrectly says the state that he is in Tell a story at first then let pt recall Unable to attend and recall new information Poor day to day recall Decreased awareness or understanding of injury Maximum assistance with familiar tasks Distracted and unable to maintain attention to task Poor problem solving RLA LEVEL 5: CONFUSED INAPPROPRIATE ○ “What happens when you car breaks down?” - pt has some logical answers like “call my wife” but answers are inconsistent and speech is Post-traumatic Confusional State impaired (di maintindihan). PT Approaches: ○ Provide a step by step command Maximum Structure for basic tasks ○ Don’t assume they will remember what you tell them ○ Can identify the different suits of the cards and repeat instructions as needed ○ Avoid quizzing and change topic when discussion arise ○ Explain what to expect when you change the activity ○ Quiet place with less distractions Poor attention to task and does not recognize errors ○ Placed the diamonds on hearts, but doesnt know what’s wrong Disorientation - Incorrectly guessing the day “Feels like a thursday” Decreased initiation ○ Saliva drips and forgets the task at hand. Therapist needs to tell the pt to continue the task. 14 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Decreased problem solving ability ○ Therapist asks what pt will do if he forgets his Starting to demonstrate immediate memory lunch money. Pt answered to wait for the next ○ Therapist reads a story to pt. Pt can recall day important events in the story instantly Can start to name deficits and recognizes things are not the same ○ Pt states that changes in his lifestyle irritates him Requires step by step instruction Follows simple commands fairly consistent with assistance Decreased memory and needs assistance with RLA LEVEL 6: CONFUSED – APPROPRIATE compensation strategies ○ Pt has a planner to jot down notes and help him remember important things Emerged from Post traumatic amnesia PT Approaches: ○ Establish a routine Day to day recall is improving but still limited Uninsightful to how deficits impact return to pre-injury ○ Therapist asks what pt does during OT activities sessions but pt can’t remember ○ Pt believes that once he is cured, he will go ○ Pt writes down important stuff on paper so he back to his old self (pre-injury). And he can remember believes his condition won’t affect his job. Pt forgot recent events ○ Therapist asks what the pt will do when ge goes back to school. She asks if it’s better for pt to continue or repeat the grade. Pt answered repeat because he forgot all his lessons from the past 15 M.C | M.D. | W.D. | K.E | J.K. | V.M.  RATIO NOTES SUBJECTIVE Chief Complaint We seldom receive pt with neurologic conditions where pain is the main complaint (except if it’s shoulder pain syndrome, OA) Primary complaints are usually difficulties in performing specific tasks or movements; weakness, or naninigas cos of spasticity Requires less assistance for familiar tasks For TBI, you will see them look like CVA patients initially ○ The main difference is in cognition, where TBI usually has more severe affectation. more cognitive issues (memory problems, problem-solving, concentration, orientation) ○ They may not be aware of these changes or affectations and may believe they are acting normally. Ask the relatives for a point of reference of what is normal. Take note of all major psychological changes (may be due to the accident and damage or conscious change in attitude (like grateful that they are alive)) Mood issues, Behavioral problems - sometimes they are not aware Affectation in communication, social skills Demonstrates lability ○ Usually noticed by the relatives (e.g. before ○ Pt breaks down and cries before therapist can masungit / strict → after, they became more read him the story compliant, laid back) Cognition More on observation from family members E.g. TV - concentration - do they like changing the channel too much Prognosis Ask for the level of consciousness at the time of initial injury/when consciousness was lost A longer unconscious state generally has a poorer prognosis Sequence of recovery – sometimes not observed by relatives, but not a requirement to ask Eye opening - open eye but doesn’t been cognitive function is okay; no meaningful eye contact; blank stares OBJECTIVE OI For acute cases, familiarize yourself with all the attachments (be aware where the tubes are; are they fixed/ attached properly?) Should something fall off, ask the nurse to reattach, especially if it is an essential component or major part (minor attachments that we are familiar with may be Memory for new information still impaired returned by us). Requires moderate assistance for recall when you move a pt, we should be aware where the ○ Therapist reads the pt a story. Pt has a hard tubes are → are they fixed properly since they can be time in recalling the details of the story but removed? remembers them when you give him some tracheostomy tube- if the top of T is removed, you can assistance. attach it again but if the long part of T is removed (end of the tube attached to the trachea) → you should not attach it again (get a nurse) RLA LEVEL 7 AND 8: AUTOMATIC APPROPRIATE AND pneumatic compressions and arm & leg restraints PURPOSEFUL APPROPRIATE ○ IPC are smaller → we can attach and detach since it is only sleeve Allows them to do as much as possible on their own before ○ Arm leg restraints - attached to the rail providing assistance ○ Needles, chest sleeve, NGT - ask help from Encourage them to use compensatory strategies nurse STRATEGIES FOR RLA LEVELS RLA 1: Essentially no response (Talk to them even when there is no response (always do this regardless of level) ○ Ask their name even if they can’t response; Still talk to the pt even if they don’t have a response 16 M.C | M.D. | W.D. | K.E | J.K. | V.M.  Engage the caregiver as well - talk to (less than 30 mins) bc the more you both pt and caregiver - alternate prolong it, the more they’ll be agitated between them ○ can give instructions to parent (parent can give ○ Spontaneous eye opening; no meaningful eye instructions to the pt while you observe) → contact able to follow commands for 3/5 trials ○ Vestibular, tactile, auditory, visual (apply if ○ no distractions or other sounds (should be the there is eye opening) - apply those feedback pt and PT + the person the pt is familiar with) para magising yung pt ○ lighting should not be too bright Voice needs to be loud since it is an ○ girls hair’ must be tied up since pt can grab it auditory stimulus ○ all things from the body like ID lace, earrings, watches must be removed since it can be RLA 2: Slight response to stimuli (like painful stimulus grabbed and them moving it away) ○ PT aid - both of u should be introduced bc they ○ Slight response but reflex response may get triggered if someone new shows up (generalized response) ○ DOCUMENTATION - document whatever you ○ Whatever stimulus u do (either pain, light saw touch, etc), they’ll have the same react (reflex if no ROM → ROM not assessed response) 2ndary to restlessness and agitation) E.g. Glabellar response more of a FMT: (R) LE able to kick or tap reflex response and not deliberate forcefully the floor (QUALITATIVE IN response NATURE) ○ talk to pt still for stimuli → "sir hawak ko po those tests that are not assessed will kanang kamay niyo, ito po yung kanang kamay be documented as: not assessed niyo (itaas)" 2ndary to combative state narrate how you do the exercise and ○ IMPORTANT: if initially calm, do FA what you are touching immediately ○ if they hit us, it can be used for FMT RLA 3: Awake but low cognitive function (don't expect Docu: FMT able to lift UE (example them to respond easily; simple commands and give attempt to hit the PT) - shows pt has them time to do it) (less stimulation and stimuli strength compared to RLA 1 and 2) ○ Pt is able to grasp objects (example pt was ○ still low cognitive function so do not expect able to pull PT’s hair) them to respond easily or be awake all of the time RLA 5: Pt is confused. Be brief in the explanations and ○ speak loud but in a calm voice simplify them, and give a more complete proper ○ talk to them like they understand you; explanation to the caregiver (environmental stimuli ○ give simple instructions – e.g. raise your hand; compared to RLA 1 and 2) “taas kamay” - 2-3 words ○ No agitated state but they still have emotional ○ give more time for them to respond to your lability command (2-3 words only) ○ Less violent - safer to be around Allot 10 secs before you repeat the ○ Can give two step commands - grasp and command release hand (FMT assessment) If they have conscious when u “pakipisil po ang kamay ko at assessed, give them enough time to bitawan” for 2-step command respond (opening and closing of hand for Has stimulation but not as FMT) bombarded as RLA 1,2 ○ Still (