TBI_lecture_Callum_Baker.pdf

Traumatic Brain Injury Callum Baker PhD AEP Case Jeremy from Utah • • • • • • • Think about how the TBI changed Jeremy’s life and how he has changed since the TBI. Think about how the life of Jeremy’s family members have changes What impairments do you see? What were Jeremy’s goals following hi...

Traumatic Brain Injury Callum Baker PhD AEP Case Jeremy from Utah • • • • • • • Think about how the TBI changed Jeremy’s life and how he has changed since the TBI. Think about how the life of Jeremy’s family members have changes What impairments do you see? What were Jeremy’s goals following his injury? What do the family think helped with Jeremy’s recovery? What complication could arise from having the family so involved? How do you see an AEP helping Jeremy? Demographics of Persons with a TBI • • • The incidence of TBI peaks in the 15-35 years age group TBI by gender: 3.4 males to 1 female (largely thought to be related to risk-taking behaviour among young males) 2/3 mod-severe TBI caused by MVA • • • About 50% of the adult and paediatric NSW BIRP populations have 1 or more challenging behaviours following TBI Mental Health, Drug and ETOH are common comorbidities both pre and post TBI Employment rates post TBI average 29% and there is a marked and consistent post injury shift from full-time to part-time employment. TBI - Pathophysiology Primary injury • Initial application of force to the skull that disrupts white/grey matter and blood vessels in the brain. (Osmosis.org) Pathophysiology Secondary Injury Events occurring following the primary injury that cause further injury: edema, build-up of neurotoxins • Intracranial haemorrhage (bleeding inside the skull) • Brain swelling • Increased intracranial pressure (pressure inside the skull) • Brain damage associated with lack of oxygen • Infection inside the skull, common with penetrating trauma • Chemical changes leading to cell death • Increased fluid inside the skull (hydrocephalus) McKee CA, Lukens JR. Emerging Roles for the Immune System in Traumatic Brain Injury. Front Immunol. 2016;7:556. Pathophysiology Location and severity of injury dictates functional changes in TBI: Frontal lobe damage: • Speech problems • inattentiveness Parietal lobe damage • Sensory deficits Severity • • • • • Graded on degree of neurological deficit resulting from injury (not severity of injury per se) GCS <8 = severe 9-12 = moderate 13-15 = mild • Duration of post-traumatic amnesia Period of time the brain is unable to lay day-to-day memory. Best indicator of functional and cognitive deficits after TBI 10%–15% of mild TBI survivors have persisting symptoms and impairments Clinical Presentation Seizures (penetrating TBIs) • Early seizures (within the first few weeks of injury) • Later seizures (within 2 years) • Require medication (side effects) • Lifestyle implications Hypertonia and spasticity (brainstem/cerebellum or midbrain TBIs) • High muscle tone/muscle stretch reflex • Spasticity: • • • • “Velocity dependent increase in resistance when a joint is passively moved through ROM” Often prevents/interferes with ADLs Medications Measurement of spasticity • Poor muscle co-ordination/co-contraction • Spastic dystonia • Contractures Hypotonia Heterotopic ossification Balance disorders Case Sean from New Orleans • • • • What symptoms do you observe? What would you imagine is the impact of Sean’s disabilities on his day-to-day life? What medications are discussed and what are the short term and long-term effect? What exercises do you see and how are the related to his disabilities? Clinical Presentation Musculoskeletal injuries • Msk injuries associated with cause of TBI (MVA or fall) • Need to be treated alongside TBI Hypotonia (cerebellum) • Less common than spasticity • Low muscle tone Heterotopic ossification • ectopic growth of bony tissue in tissue planes around major joints • Surgery/pharmacological intervention Balance disorders • High prevalence • Diverse presentation and root cause Case Joey from New York • What symptoms do you observe? • What are Joey and the therapist working on? • What is the function of the strap on Joeys R leg? • How would the anti-gravity treddy/pool help? Clinical Presentation “The importance of these behavioral, psychiatric, speech, and sensory consequences cannot be underestimated because they may be the primary reason for failure of successful community reintegration after brain Injury” Anthony Lequerica, PhD Riggio S. Traumatic Brain Injury and Its Neurobehavioral Sequelae. Neurologic Clinics. 2011;29(1):35-47. Clinical Presentation Neurocognitive function, sensory function, speech, and communication • psychiatric disturbance (depression, anxiety, mood disorders) • Extremely common • Sensory changes (heightened sensitivity, difficulty filtering sensory input, sensory loss) • Other: Sleep disturbances, chronic pain, and headaches Clinical Presentation Neurocognitive function, sensory function, speech, and communication • Cognitive problems • Memory impairment, difficulty with new learning, attention and concentration; reduced speed and flexibility of thought processing; impaired problem-solving skills • Problems in planning, organizing, and making decisions • Language problems – dysphasia, problems finding words, and impaired reading and writing skills • Impaired judgement and safety awareness Clinical Presentation Neurocognitive function, sensory function, speech, and communication • Personality/behavior changes • Impaired social and coping skills, reduced self-esteem • Altered emotional control; poor frustration tolerance and anger management; denial, and self-centeredness • Reduced insight, disinhibition, impulsivity • Psychiatric disorders – anxiety, depression, post-traumatic stress disorder, psychosis • Apathy, amotivational states Psychosocial Complications Common lifestyle consequences • Unemployment and financial hardship • Inadequate academic achievement • Lack of transportation alternatives • Inadequate recreational opportunities • Difficulties in maintaining interpersonal relationships, marital breakdown • Loss of pre-injury roles; loss of independence “Staff need to be trained to detect these signals that clients with TBI are often sending. It is apparent that psychosocial factors contribute to a rising obstacle level to community adjustment.” Morton MV, Wehman P. Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations. Brain Inj. 1995;9(1):81-92. AEPs need to be aware of changes and refer when appropriate. Rehabilitation for People with TBIs Rehabilitation is effectively using an interdisciplinary approach • Multidisciplinary • Neurologist/OT/Speechie/PT/NDIS service providers • Close involvement of family/carers • Patient centered Rehab focus is on issues such as retraining in ADLs, pain management, cognitive and behavioral therapies, and pharmacological management. Social burden of TBI is significant, family and carers need education, support, counselling. Thomas C, Evaluation of a Multidisciplinary Transitional and Community Rehabilitation Intervention for Adults with Severe Acquired Brain Injury: A Case Series Exploring Community Integration2018. Goals of Rehabilitation Reduce impairment • • • • Spasticity Hypotonia Balance disorders Cognitive Improve activity/participation • Capacity to carry out ADLs • • Task specific skills Functional capacity Goals of Rehabilitation Factors that influence recovery • Severity of injury • Age at TBI • Time between injury and rehab commencement • Duration AND intensity of rehab intervention • Support system (family care, QoC, community resources) n=68 with moderate-to-severe TBI. high (4-hour/day) or control (2-hour/day) for 5/7. 20 days post TBI commenced therapy. Zhu XL, Poon WS, Chan CCH, Chan SSH. Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Injury. 2007;21(7):681-90. Exercise Advice and PALs 1. Devine JM, Wong B, Gervino E, Pascual-Leone A, Alexander MP. Independent, CommunityBased Aerobic Exercise Training for People With Moderate-to-Severe Traumatic Brain Injury. Arch Phys Med Rehabil. 2016;97(8):1392-7. Independent Exercise advice and Safety/Efficacy 1. Driver S, Woolsey A. Evaluation of a Physical Activity Behavior Change Program for Individuals With a Brain Injury. Arch Phys Med Rehabil. 2016;97(9 Suppl):S194-200. Aex and Exercise Capacity 1. Bateman A, Culpan FJ, Pickering AD, Powell JH, Scott OM, Greenwood RJ. The effect of aerobic training on rehabilitation outcomes after recent severe brain injury: A randomized controlled evaluation. Archives of Physical Medicine and Rehabilitation. 2001;82(2):174-82. Circuit training (Aex + functional strength) and Exercise Capacity/Walking Efficiency 1. Jankowski LW, Sullivan SJ. Aerobic and neuromuscular training: effect on the capacity, efficiency, and fatigability of patients with traumatic brain injuries. Archives of physical medicine and rehabilitation. 1990;71(7):500-4. Circuit training (Aex + functional strength) and weight/BF%/CRF 1. Bhambhani Y, Rowland G, Farag M. Effects of circuit training on body composition and peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 2005;86(2):268-76. Weight Supported Treadmill and CRF 1. Mossberg KA, Orlander EE, Norcross JL. Cardiorespiratory capacity after weight-supported treadmill training in patients with traumatic brain injury. Phys Ther. 2008;88(1):77-87. PRT and 1-RM/Function OMs 1. Morris S, Dodd KJ, Morris M, Matyas T. Community-based progressive resistance strength training in traumatic brain injury: A multiple, single-system, trial. Advances in Physiotherapy. 2009;11(4):218-26. Aex and Ambulatory Status 1. Lorenz LS, Charrette AL, O'Neil-Pirozzi TM, Doucett JM, Fong J. Healthy body, healthy mind: A mixed methods study of outcomes, barriers and supports for exercise by people who have chronic moderate-to- Exercise and Depressive Symptoms 1. Perry SA, Coetzer R, Saville CWN. The effectiveness of physical exercise as an intervention to reduce depressive symptoms following traumatic brain injury: A meta-analysis and systematic review. Neuropsychological Rehabilitation. 2020;30(3):564-78. Exercise and Balance Exercise and Cognitive Recovery 1. Morris T, Gomes Osman J, Tormos Muñoz JM, Costa Miserachs D, Pascual Leone A. The role of physical exercise in cognitive recovery after traumatic brain injury: A&nbsp;systematic review. Restorative Neurology and Neuroscience. 2016;34:977-88. Exercise Goals • Increase PALs • Consistency/habit forming is more important than mode/intensity etc. • People with TBI of minor severity → follow same PA guidelines as health adults (150min per week of MICT/75min vigorous, 2*PRT) • People with TBI or moderate+ severity → ExRx tailored to: • Type and severity of impairment • personal interests • support levels • ExRx to meet personalised functional outcomes (I.e. step over curb with confidence and increase walking speed) Exercise Considerations • • Risk of another TBI (Falls risk, lack of spatial awareness etc) Likely working within a rehab team; ensure knowledge of: medical, mobility, communication, behavioural and cognitive needs for an individual patient Patience and adaptive communication methods may be needed • • • Attention and understanding of instructions may be impaired Hypotonia/spasticity • • Wrist straps, Velcro fasteners, etc. may be needed to facilitate use of exercise equipment when hand function is impaired Altered joint function and form • Affected side may have reduce ROM, strength, tone. Exercise Considerations • Reduced fitness, strength and mobility are common (compounded by sedentary lifestyle) • • • • • Concomitant disease? Higher CVA risk post TBI Early onset fatigue (prior to reaching exercise max) Effect of fatigue on rest of the client's day Rehab environment • Distractions • Family/Carer involvement • Working with Neurologists and medico specialists Exercise Considerations - Medications • Medications • Anti-anxiety/anti-depressants medication to lessen feelings of nervousness and fear May cause fatigue and may require longer cooldown post exercise • Anticoagulants to prevent blood clots and improve blood flow May increase likelihood of brusing • Anticonvulsants to prevent seizures • Diuretics to help remove fluid that can increase pressure inside the brain • Muscle relaxants to reduce muscle spasms and to relax constricted muscles May cause bradycardia, hypotension, weakness • Stimulants to increase alertness and attention Exercise Pre-Screening Assessment • Sensory deficits • CVD • Psychological factor Function Outcome Measures • 60sec STS • Timed up and Go • Berg Balance • 5 x STS Measuring CRF and Aerobic Capacity Mode: • suited to individuals' capability • • Balance considerations Sensorimotor impairments (spasticity) • Focus on large muscle groups Testing Protocol • Modify existing tests if needed • • E.g., reduce power/speed increases between sets E.g., reduce RPM of bike tests • Submax testing protocols may be more appropriate RPE may not be valid • • Use objective measurements (HR/VO2/watts etc.) • TBI USUALLY does not impair acute cardiovascular/respiratory response to exercise*** Field tests may be more appropriate than lab based testing • E.g., 6MWT vs gas exchange VO2maxtest Measuring Strength and Anthropometry Mode: • Machines Vs free weights • Body weight tests • Hand grip dynamometers Considerations during exercise testing • Spasticity • Bilateral deficits • Joint morphology • Motivation • Cognition deficits • • • • • • Anthropometry BMI WC WC:HR Weight DXA/Skinfolds ExRx for TBI – Aex F: 3-5/7 I: 60-80% of VO2peak/Watt max/HRmax (use values from ExTest) T: 20-60minutes (rest incorporated as needed) T: modality of choosing and relevant to ADL where possible Use aids/modify equipment as needed ExRx for TBI – Circuit Training • resistance exercise to enhance muscular strength and endurance of the major muscle groups • balance training* • shorter duration of 20 minutes at the aerobic station may be used to avoid undue fatigue and increase compliance Duration: 50 mins WU/CD inclusive *separate sessions may also be useful ExRx for TBI – Strength Training Morris paper forms guidelines for PRT in TBI • Consider 1-RM as correct form not if weight was moved • Potential to use rest between sets for other exercise training 1. Morris S, Dodd KJ, Morris M, Matyas T. Community-based progressive resistance strength training in traumatic brain injury: A multiple, single-system, trial. Advances in Physiotherapy. 2009;11(4):218-26. ExRx – Balance Poor clinical guidance regarding balance exercise in TBI (does not mean balance training does not work) • Incorporate into circuit training • Task/deficit specific • Progress difficulty over time • Use of technology Examples • Staggered Stance (Eye Tracking) • Marching in Place • Single Step Forward/Backward • Single Step Side to Side • Swing One Leg Forward and Back • Swing One Leg Side to Side • Walking with Side-to-side Head Motion. Learning Outcomes for week 2 • Recount basic details regarding traumatic brain injury • Describe recent evidence regarding the effectiveness of exercise interventions in managing TBI • Be familiar with the diversity of presentations in TBI • Understand the importance of goal setting for TBI • Understand the considerations and contraindications to exercise in TBI • Understand Complications that arise in TBI • Understand and be able to apply functional scales used in TBI management • Appreciate the definition and nature of spasticity and its prevalence and impact across neuromuscular disorders