Traumatic Brain Injury - Lecture Notes PDF

PT 351 PT IN NEUROLOGY (1) Traumatic Brain Injury PART 2 Dr. Ali Bani Ahmed PT, DPT, CPT, CKTP, CES, CDNP, PhD  Recovery stages 1. Coma: 1. State of unconsciousness in which there is neither arousal or awareness 2. Eye remains closed,...

PT 351 PT IN NEUROLOGY (1) Traumatic Brain Injury PART 2 Dr. Ali Bani Ahmed PT, DPT, CPT, CKTP, CES, CDNP, PhD  Recovery stages 1. Coma: 1. State of unconsciousness in which there is neither arousal or awareness 2. Eye remains closed, no sleep awake cycle 2. Unresponsiveness vigilance/ vegetative state: 1. Marked by return of sleep/ awake cycle and normalization of vegetative function (respiratory, digestion, BP control) 2. They may open eyes occasionally, move their limbs as a reflex to noise or pain, but completely lack awareness and cognitive function. 3. Persistent vegetative state determined if patient remains in vegetative state > 1 year after TBI  Recovery stages 3. Mute responsiveness/ minimally responsiveness: 1. State in which patient is not vegetative and does show signs, even if intermittent, of fluctuating awareness. 4. Confusion state : 1. Mainly disturbance of attention mechanisms 2. All cognitive operations are affected 3. Unable to form new memories 4. May demonstrate either hyper or hypoarousal  Recovery stages 5. Emerging independence: 1. Confusion is clearing 2. Some memory is possible 3. Significant cognitive problems and limited insight remains 4. Frequently uninhibited social behavior  Recovery stages 6. Intellectual/ social competence: 1. Increasing independence, although cognitive difficulties (problem solving, reasoning) persists. Patient can platue at any stage or regress under conditions of stress or repetitive brain injury  Severity Classification scales 1. Glasgow Coma Scale (GCS) Use eye opening, motor response and verbal response 2. Rancho Los Amigos Level of Cognitive Functioning (LOCF)  Describe the general level of cognitive and behavioral status.  Does not address specific cognitive deficit.  Based on 8 levels of cognitive and behavioral functions. 3. Glasgow Outcome Scale (GOS) - Expanded from the original scale to 8 categories scale. - Used mainly in research.  Severity Classification scales Glasgow Coma Scale (GCS) Use eye opening, motor response and verbal response performed in 4 steps 1. Check 2. Observe 3. Stimulate 4. Rate Score 3-8 severe head injury Score 9-12 moderate head injury Score 13-15 mild head injury  Common Classification Severity GCS LOC PTA Mild 13–15 7 days GCS = Glasgow Coma Scale LOC = Loss of consciousness PTA = Posttraumatic amnesia Loss of memory of events immediately following the injury. A typical question to ask to assess for PTA is, “What is the first thing you remember after your injury?” If the first memory occurred more than 24 hours after the injury, the patient has suffered a moderate TBI.  Severity Classification scales (Rancho Los Amigos Level of Cognitive Functioning (LOCF) )  Severity Classification scales (Rancho Los Amigos Level of Cognitive Functioning (LOCF) ) (Rancho Los Amigos Level of Cognitive Functioning (LOCF) Level 1 (No response): patient does not response to external stimuli and appears asleep Level 2 (generalized response): patient responds to external stimuli with unspecific inconsistent and non- purposeful manner with stereotyped limited responses Level 3 (localized response): patient responds specifically and inconsistently with delays to stimuli but may follow simple commands for motor action (e.g. follow command like open your eyes, squeeze hand). (Rancho Los Amigos Level of Cognitive Functioning (LOCF) Level 4 (confused agitated): patient exhibit bizarre, non-purposeful inappropriate behavior. Patient has no short term or long term recall, attention is short, verbalization is incomprehensive/inappropriate; confabulation is present. Level 5 ( confused, inappropriate, non-agitated): patient gives random or fragmented responses to complex or unstructured stimuli. Simple commands are followed constantly, memory and attention are impaired, forming new information still unretained. (Rancho Los Amigos Level of Cognitive Functioning (LOCF) Level 6 (confused appropriate): patient gives appropriate goal directed responses depended on external input; recent memory problems persists Level 7 (automatic appropriate); patient performs appropriately in familiar settings, performs daily routine automatically frequently like robot. but abstract thinking ability is decreased. Level 8 (Purposeful appropriate); shows carry over into a new setting and needs no supervision once activity has been learned.  TBI Recovery and independence The Functional Assessment Measure (FAM) has been proposed as a measure of disability in post-acute Traumatic Brain Injury (TBI) outpatients It is comprised of the 18 items of The Functional Independence Measure (FIM), scored in terms of dependence, and of 12 newly designed items, scored in terms of dependence (7 items) or performance (5 items) FIM+FAM  FIM+FAM Functional Independence Measure (FIM) 18-item rating scale, is the most widely used outcome measurement scale in medical rehabilitation. Functional Assessment Measure (FAM) Developed to supplement FIM with more cognitively oriented items. Because of the relative insensitivity of the FIM to cognitive and behavioral deficits Functional Assessment Measure | RehabMeasures Database (sralab.org)  SELF CARE ITEMS FIM+FAM 1. Feeding COMMUNICATION ITEMS 2. Grooming 17. Comprehension-Audio/Visual 3. Bathing 18. Expression-Verbal, Non- 4. Dressing Upper Body Verbal 5. Dressing Lower Body 19. Reading* 6. Toileting 20. Writing* 7. Swallowing* 21. Speech Intelligibility* SPHINCTER CONTROL PSYCHOSOCIAL ADJUSTMENT 8. Bladder Manageme nt 22. Social Interaction 9. Bowel Management 23. Emotional Status* MOBILITY ITEMS (Type of 24. Adjustment to Limitations* Transfer) 25. Employability* 10. Bed, Chair, Wheelchair COGNITIVE FUNCTION 11. Toilet 26. Problem Solvin g 12. Tub or Shower 27. Memory 13. Car Transfer* 28. Orientation* LOCOMOTION 29. Attention* 14. Walking/Wheelchair 30. Safety Judgement* 15. Stairs 16. Community Access* *FAM items  FIM+FAM Scale 7 Complete Independence (timely, safely) NO HELPER 6 Modified Independence (extra time, devices) 5 Supervision/set up (coaxing, prompting) 4 Minimal Assist (performs 75% +) 3 Moderate Assist (performs 50%+) HELPER 2 Maximal Assist (performs 25% +) 1 Total Assist (performs