Y-220 Traumatic Brian Injury Handouts (PDF)

11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence...

11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Rancho Los Amigos Scale- Revised Level Clinical Examination Assist level I No Response Total II Generalized Response Total III Localized Response Total IV Confused and Agitated Maximal Assist V Confused and inappropriate, nonagitated Maximal Assist VI Confused and appropriate Moderate Assist VII Automatic and appropriate Minimal Assist VIII Purposeful, appropriate Stand-by assist IX Purposeful, appropriate Stand-by assist X Purposeful, appropriate Modified independence Capizzi et al. 2019 Program in Physical Therapy 27 27 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Program in Physical Therapy 28 28 14  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Program in Physical Therapy 29 29 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Program in Physical Therapy 30 30 15  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Program in Physical Therapy 31 31 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Disorders of Consciousness Rancho I-III Giacino et al 2002 Program in Physical Therapy 32 32 16  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Disorders of Consciousne ss Rancho I- III How to determine level of consciousness? 33 https://www.sralab.org/rehabilitation-measures/coma-recovery-scale-revised 33 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations 34 34 17  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Importance of determining level of consciousness Assure appropriate determination between vegetative and minimally conscious state: When the CRS-R was used 41% of patients that were previously thought to be the vegetative state, where found to be minimally conscious Program in Physical Therapy Schnakers et al. 2009 35 35 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Level Clinical Examination Assist level I No Response Total II Generalized Response Total III Localized Response Total IV Confused and Agitated Maximal Assist Post- V Confused and inappropriate, nonagitated Maximal Assist traumatic VI Confused and appropriate Moderate Assist Agitation VII Automatic and appropriate Minimal Assist VIII Purposeful, appropriate Stand-by assist Rancho Level IV IX Purposeful, appropriate Stand-by assist Confused-Agitated X Purposeful, appropriate Modified independence Capizzi et al. 2019 36 36 18  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Post-traumatic Agitation Definition: Excessive behavior occurring within the context of an alternated state of consciousness and diminished cognitive function Program in Physical Therapy Capizzi et al. 2019 37 37 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Agitated Behavioral Scale Observational Scale of 14 behaviors 0-4 scale Post- 1. Short attention span, easy distractibility, inability to concentrate. traumatic 2. Impulsive, impatient, low tolerance for pain or frustration. 3. Uncooperative, resistant to care, demanding. Agitation 4. Violent and or threatening violence toward people or property. 5. Explosive and/or unpredictable anger. Objective Measure 6. Rocking, rubbing, moaning or other self-stimulating behavior. 7. Pulling at tubes, restraints, etc. 8. Wandering from treatment areas. Score Interpretation 9. Restlessness, pacing, excessive movement. 10. Repetitive behaviors, motor and/or verbal. ≥36 Severely agitated 11. Rapid, loud or excessive talking. 29-35 moderately agitated 12. Sudden changes of mood. 13. Easily initiated or excessive crying and/or laughter. 22-28 mildly agitated 14. Self-abusiveness, physical and/or verbal. 4 weeks are unlikely to make a good recovery – Coma < 2 weeks is rarely associated with severe disability. Age at injury – Older age is associated with poorer prognosis – > 65 years old rarely associated with a good recovery Iaccarino et al. 2015 Program in Physical Therapy 62 62 31  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Neuroimaging Bilateral Brainstem lesion on MRI is not associated with CT findings of Epidural hematoma, a positive recovery subdural, or subarachnoid hemorrhage, cisternal effacement or significant midline shift are associate with worse outcomes Laccarino et al. 2015 Program in Physical Therapy 63 63 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Motor Recover and TBI Majority of motor recovery occurs in the first 6 months – Some studies report 85% of recovery occur within this time frame. Shorter Duration of loss of consciousness and mild initial deficits are associated with faster recovery Iaccarino et al. 2015 Maas et al 2008 Program in Physical Therapy 64 64 32  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Prognosis in Disorders of Consciousness Minimally Conscious state has a more favorable prognosis than vegetative state Traumatic causes have a better prognosis than acquired TBI 20% of patients in a vegetative state admitted to inpatient rehabilitation were functionally independent and had return to work at 1,2 and 5 years post injury Capizzi et al. Program in Physical Therapy 65 65 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Factors that affect ADL independence in older adults with TBI Personal – Age-older age associated with poorer outcomes – # of co-morbidities Injury-related – Severity- worse functional outcomes in the short-term – Medical complications- Increase complications associated with worse outcomes up to 12 months of injury Environmental – Social support – Access to rehabilitation services Lecours et al 2012 Program in Physical Therapy 66 66 33  11/17/2024 Knowledge Check A 23 year old patient had a TBI 6 weeks ago. They are currently in a coma. Their imaging showed a subdural hematoma. They had a GCS of 3 during the first 24 hours. Which of the following characteristics of this patient are associated with positive outcomes Program in Physical Therapy 67 67 Medical and Surgical Management Program in Physical Therapy 68 68 34  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Craniotomy Decompressive bone flap is removed and replaced after performing decompression procedure Capizzi et al. 2019 Program in Physical Therapy 69 69 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Craniectomy Decompressive bone flap is removed and left out until swelling is resolved Replacement is called cranioplasty Program in Physical Therapy Jeyaraj 2019 70 70 35  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Precautions If a person has a craniectomy, they will need to wear a custom helmet when out of bed. Check with medical team and providers: For both craniectomy and craniotomy – HOB may need to be elevated – May have lifting restrictions – May have activity limitations Capizzi et al. 2019 Program in Physical Therapy 71 71 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Intubation/tracheostomy Program in Physical Therapy Jeyaraj 2019 72 72 36  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Acute care/ICU management Neurosurgery to be consults if there is intracranial damage Monitoring and maintaining intracranial pressure [ICP] – Repeat imagining – Real time monitoring Extraventricular drain Intraparenchymal catheter Or combination of both Capizzi et al. 2019 –Under normal conditions ICP is between 5-10 mmHG or 7-15 mmHg Katz et al. 2021 ICP therapy to lower pressure starts when ICP>20mmHG Munakomi and Das 2024 Program in Physical Therapy 73 73 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Cerebral Perfusion Pressure [CPP] CPP= Mean Arterial Pressure [MAP]- Intracranial Pressure [ICP] –CCP Target Range: 60-70 mmHg Carney et al. 2017 MAP= DBP + 1/3( SBP=DBP) –MAP normal range: 70-100 mmHg Mount and Das 2023 Program in Physical Therapy 74 74 37  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Monitoring Intracranial Pressure [ICP] Kukreti et al. 2014 Program in Physical Therapy 75 75 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Post-Traumatic Hydrocephalus Incidence: More prevalent in moderate to severe TBI 70% of patients develop ventriculomegaly Can be due to atrophy 3.7-45% develop Post-traumatic hydrocephalus Presentation: 3 common symptoms Change in gait Change in cognition Urinary incontinence Jasey and Dabaghian Program in Physical Therapy Brain injury Medicine 2021 76 76 38  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Post-Traumatic Hydrocephalus Jasey and Dabaghian Program in Physical Therapy Brain injury Medicine 2021 77 77 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Post-Traumatic Hydrocephalus Perform a spinal tap Shunt placement Program in Physical Therapy 78 78 39  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Post-Traumatic Seizures Incidence varies depending on the type of injury, age, and when the seizure occurs. – 1 out of 10 people hospitalized with TBI will have a seizure – 2.6-33% Recommend anti seizure medication be used to prevent EARLY post-traumatic seizures (Within the first 7 days of injury) Has NOT been shown to be effective in preventing LATE post- traumatic seizures The Brain Trauma Foundation 2000 Program in Physical Therapy 79 79 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Paroxysmal Sympathetic Hyperactivity [PSH] Also known as: – Sympathetic Storming – Paroxysmal autonomic instability – Dystonia syndrome Occurs in 15-33% of patients with severe TBI Increased sympathetic activity – Increased heart rate – Increased respiratory rate – Increased blood pressure – Diaphoresis – Hyperthermia – Increased dystonia, posturing, spasticity Capizzi et al. 2019 Program in Physical Therapy Zheng et al 2020 80 80 40  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Paroxysmal Sympathetic Hyperactivity [PSH] Triggers: – Trauma to autoregulatory centers with subsequent catecholamine surges – Stimuli: Sepsis Fractures HO Pressure ulcers Underlying spasticity Pain Constipation, Urinary Retention Medical Treatment: opioids, beta-blockers, bromocriptine, intrathecal baclofen Zheng et al 2020 Program in Physical Therapy 81 81 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Heterotopic Ossification Definition: – Formation of new bone within tissues where bone growth does not normally occur (soft tissue) The Why? – HO is often missed in the acute stages of injury secondary to immobility and other medical complications. – HO can cause significant problems and challenges for functional mobility. Meriggi and Weppner 2019 Program in Physical Therapy 82 82 41  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Heterotopic Ossification Meriggi and Weppner 2019 Program in Physical Therapy 83 83 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Heterotopic Ossification Meriggi and Weppner 2019 Program in Physical Therapy 84 84 42  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Additional Medical and Rehab Considerations Sleep Dysregulation is common Urinary dysfunction Pain Management CN injuries Contracture management Fatigue Swallowing deficits Development of psychiatric Spasticity management disorders DVT Prophylaxis Alcohol and drug abuse – Occurs in 10-18% Program in Physical Therapy 85 85 Check Your Knowledge A patient has recently arrived at inpatient rehabilitation after a severe brain injury (diffused axonal injury). When the PT goes to evaluate them, they are having pain in the left hip, it is difficult to flex greater than 70 degrees and it doesn’t change in supine, sideline or in sitting. What is the MOST likely cause? Program in Physical Therapy 86 86 43  11/17/2024 Rehabilitation Considerations Program in Physical Therapy 87 87 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Acute Care/ ICU interventions Effects of Positioning and Exercise on Intracranial Pressure in a Neurosurgical Intensive Care Unit – Conclusion and Discussion. Physical therapy can be used safely in patients with normal or increased ICP provided that Valsalva-like maneuvers are avoided. Brimioulle et al. 1997 Physical Therapist Treatment of Patients in the Neurological Intensive Care Unit: Description of Practice Conclusions: “. Physical therapy was performed safely in the NICU. Patients who required invasive support received less frequent physical therapy.” Program in Physical Therapy Sottile et al. 2015 88 88 44  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Physical Therapist Treatment of Patients in the Neurological Intensive Care Unit: Description of Practice Sottile et al. 2015 Program in Physical Therapy 89 89 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Physical Therapist Treatment of Patients in the Neurological Intensive Care Unit: Description of Practice Sottile et al. 2015 Program in Physical Therapy 90 90 45  11/17/2024 Etiology and Incidence and Lab, imaging and diagnostic Clinical Course and Medical and Surgical Rehabilitation Common Presentations Risk Factors Prevalence test Prognosis Management Considerations Paroxysmal Sympathetic Hyperactivity [PSH] About 72% of the time PSH is caused by unavoidable, non-noxious stimuli Episodes can last a few minutes to 2 hours. Typically resolves in the first 2 weeks Acute Care/ICU and Inpatient Rehab Typically seen in patients with GCS