Concorde Career College Physical Therapist Assistant PTA 150: Fundamentals of Treatment II Day 11 Traumatic Brain Injury (TBI) Concorde Career College

Concorde Career College Lesson Objectives Describe the pathophysiology of traumatic brain injury Describe physical neurological deficits associated with traumatic brain injury Identify clinical rating scales in their application in the treatment of traumatic brain injury Describe physical therapy treatment interventions for patients with traumatic brain injury Concorde Career College

Traumatic Brain Injury http://abcnews.go.com/video/playerIndex?id=3489 618 Concorde Career College

Traumatic Brain Injury Epidemiology 1.5 to 2 million Traumatic Brain Injuries in the United States each year 50,000 deaths 80 to 90,000 patients with residual cognitive, behavioral, and physical disorders Concorde Career College

What are ways in which the brain might be damaged? Page 1149 (O’Sullivan) Concorde Career College

Traumatic Brain Injury Causes of Injury Motor vehicle accidents Falls Violence Sports and recreation Concorde Career College

Concorde Career College Pathophysiology An external force to the skull that causes brain tissue damage Acceleration Force Deceleration Force Rotational Force Brain tissue can become compressed, torn or displaced Open head injury Skull fracture Meninges tear with brain exposure Closed head wound Concorde Career College

Types of Traumatic Brain Injury Focal/ Coup/ Local Injury Injury at the sight of impact under the skull Cerebral contusion Vascular lesion Laceration Hemorrhage Hematoma Brain swelling/Edema Concorde Career College

Types of Traumatic Brain Injury Coup – Contracoup Injury (Bouncing) Injury at the point of impact and an opposite site to the point of impact Flexion/extension (whiplash) can cause brain injury without direct impact Diffuse Axonal Injury Stretching, shearing, or tearing of the axons and small blood vessels within the brain Caused by acceleration, deceleration or rotational force Hi velocity injuries Concorde Career College

Types of Traumatic Brain Injury Secondary Brain Damage Physiological changes in the brain due to trauma Hypoxic ischemic injury Lack of oxygen to brain tissue Brain hemorrhage or hematoma between the skull and the dura mater (epidural) or within the brain (subdural) ↑ Intracranial Pressure Brain herniation Cardiovascular System, Respiratory System, Cerebral circulation Concorde Career College

TBI Medical Intervention Acute Stage Stabilize cardiovascular system, respiratory system, brain pressure & brain blood flow Assess severity of brain injury CAT Scan & MRI assesses structural & functional involvement X-ray assesses for skull fracture Cerebral angiography assesses for abnormalities in brain vessels and circulation Evoked Potential Electroencephalogram (EPEG) assesses for localized brain damage Positron Emission Tomography (PET) assesses cerebral metabolism function Concorde Career College

TBI Medical Intervention Surgical Intervention Monitor intracranial pressure Decompress skull Ongoing Medications Diuretics: ↓ intracranial pressure and fluid in the brain Anticonvulsants: Control seizures Antidepressants: Behavioral problems Electrolytes: Brain metabolism and healing Neurotransmitters: Serotonin (behavior & emotions) Catheter in brain Concorde Career College

Levels of Consciousness Coma A state of unconsciousness and the level of unresponsiveness to all internal and external stimulation Stupor A state of general unresponsiveness with only brief arousal occurring from repeated stimulation Obtunded Patient sleeps often and when aroused, exhibits decreased alertness and interest in the environment with delayed reactions Concorde Career College

Levels of Consciousness Delirium A state of consciousness that is characterized by disorientation, confusion, agitation and loudness Clouding of Consciousness (lethargic) A state of consciousness that is characterized by quiet behavior, confusion, poor attention and delayed responses Consciousness A state of alertness, awareness orientation and memory PTA Exam: the Complete Study Guide, Scott Giles, p. 100 Concorde Career College

TBI: Neuromuscular Impairments Abnormal tone Decorticate Postural Tone Rigid tone with upper extremities held in flexion and lower extremities in extension (lesion above brainstem) Decerebrate Postural Tone Rigid tone with upper extremities and lower extremities held in extension (lesion in brainstem) Flaccidity to Spasticity (low, moderate or severe tone) Concorde Career College

TBI: Neuromuscular Impairments Impaired motor function (depends on site of brain damage) Monoplegic, Hemiplegic, Tetraplegic, Quadriplegic Impaired reflex responses (mild to severe) Abnormal synergistic movement patterns Impaired balance and coordination responses Diminished muscle performance for ADL Strength, Power, Endurance Concorde Career College

TBI: Neuromuscular Impairments Cognitive Deficits Impaired in orientation to time, person and place Impaired reasons and problem solving abilities Attention Deficits Hyperactive, impulsive, distractive, ↓ concentration Behavior Problems Low frustration tolerance Depression Disinhibition: emotions, aggression, apathy, sexual Safety Awareness Concorde Career College

TBI: Neuromuscular Impairments Memory Deficits Retrograde Amnesia Inability to remember events prior to the injury Post Traumatic Amnesia The time between the injury and when the patient is able to remember recent events. The patient does not recall the injury circumstances. The patient cannot retain new information or hold recent memories. This affects their ability to learn new skills. Anterograde Memory Inability to create new memory Anterograde memory Effected by poor attention, distractibility and impaired perceptions can Concorde Career College

TBI: Neuromuscular Impairments Visual Problems Hemianopsia Cortical Blindness ↓ sensory perception and ability to process sensory information Touch, temperature, position, kinesthetic, pain Spatial orientation Concorde Career College

TBI: Neuromuscular Impairments Speech & Communication Express aphasia (Broca’s area) Unable to speak Unable to form intelligible words Receptive aphasia (AKA Wernicke’s aphasia) Unable to distinguish appropriate sounds Global aphasia Dysarthria Lack of control and coordination of speech muscles Concorde Career College

TBI: Neuromuscular Impairments Auditory Reading comprehension and written expression Swallowing Problems Dysphagia Concorde Career College

Medical Problems Related to Inactivity Soft tissue contractures Muscle atrophy Skin breakdown Deep vein thrombosis Infection/pneumonia Hypertrophic ossification Cardiovascular and respiratory disorders Indirect impairments Concorde Career College

Physical Therapy Examination Cognitive Function Vital Signs Muscle Control (tone, reflex patterns) Postural Control (sit, stand) and Balance Sensation Strength and Endurance Range of Motion Functional Mobility (bed mobility, transfers, wheelchair, gait) Medications Concorde Career College

Concorde Career College TBI Outcome Measures Glasgow Coma Scores Determines the patient’s level of arousal and cerebral cortex function Eye Opening, Verbal Responses, Motor responses Score between 13 - 15 indicate mild impairment Score between 9 -12 indicate moderate impairment Score below an 8 indicate severe impairment and comatose state Galveston Orientation & Amnesia Test (GOAT) Concorde Career College

Concorde Career College TBI Outcome Measures Rancho Los Amigos: Levels Of Cognitive Functioning (LOCF) Based upon patient’s level of consciousness and functional status The patient usually passes through all stages in the sequence progressions Patient brain recovery varies and not all patient achieve the purposeful conscious state of function Eight levels Concorde Career College

TBI Outcome Measures: (LOCF) Level 1: No Response Patient appears to be in a deep sleep and completely unresponsive to any stimulation Level 2: Generalized Response Patient exhibits a generalized, inconsistent , non- purposeful response. Physiological changes, gross body movements or localization Concorde Career College

TBI Outcome Measures: (LOCF) Level 3:Localized Response Patient exhibits an inconsistent, localized response May follow simple commands such as opening eyes or squeezing hand Level 4: Confused Agitation Patient exhibits a high state of unorganized activity; Bizarre behavior and non-purposeful relative to immediate environment; Does not discriminate among persons or objects Frequent incoherent verbalizations Decreased gross attention span Concorde Career College

TBI Outcome Measures: (LOCF) Level 5: Confused Inappropriate Consistent response to simple commands Highly distractible and lacks ability to focus attention to a specific task May be able to converse for short periods of time Memory impaired and unable to retain new information Concorde Career College

TBI Outcome Measures: (LOCF) Level 6: Confused Appropriate Goal directed behavior in structured situation Follows simple directions consistently Carryover for relearned tasks; No carryover new tasks Level 7: Automatic Appropriate Performs routine daily activities automatically Robot like with minimal to absent confusion Shallow recall of activities .Structured social interaction Beginning to show new learning carry over Concorde Career College

TBI Outcome Measures: (LOCF) Level 8: Purposeful and Appropriate Patient is responsive to environment Patient is able to demonstrate recall memories and integrate past and recent events Able to learn and needs no supervision once activities are learned Decreased tolerance to stress, and complex reasoning skills Concorde Career College

Concorde Career College TBI Outcome Measures Functional Individual Measurement (FIM) Assesses ADLs and functional mobility Functional Assessment Measurement (FAM) Assesses the patient’s ability to integrate and adjust into the community Disability Rating Scale (DRS) Patients are scored on a wide range of functional areas Score 0-29, 0 = no disability; 29 = extreme vegetative state Concorde Career College

In what setting might you be treating a patient after a TBI? Discussion Concorde Career College

TBI Treatment Guidelines Patient and family participation Consistency is key Same therapist, daily schedule, offer orientation (person, place, time) Goal directed, familiar, functional and recreational activities Focus on behavior modification activities May use positive reinforcement (rewards system) Feedback is important Concorde Career College

TBI Treatment Guidelines Initially, focus may be on endurance rather than challenging the patient to learn new skills May not have capacity to learn early on Mental fatigue can lead to irritability, ↓ attention, etc. Simple commands, calm voice Practice without overstimulation Do not expect carryover Therapeutic activities need to be safe and flexible, based on level of awareness and function Concorde Career College

TBI Treatment Guidelines Give the patient control, if appropriate As the patient advances Community & social reintegration will be important Involve that patient in decision making Encourage independence & cooperative work Concorde Career College

Physical Therapy Interventions Positioning Bed positioning to decrease abnormal posturing and primitive reflexes (O’Sullivan Table 22.7, page 908) Head in neutral, cone in hand if fingers flexed, hips & knees slightly flexed, roll behind hips if rotation, roll between legs if strong adduction, turn the patient every 2 hours Wheelchair positioning – head and pelvis should be in neutral, may require splinting or multipodus boot; reclining or tilt-in-space chair may be necessary as well Concorde Career College

Physical Therapy Interventions Sensory Stimulation Attempt to ↑ arousal & movement Systems are systematically stimulated Auditory, Olfactory, Gustatory, Visual, Tactile, Kinesthetic, Vestibular Must monitor closely for subtle changes in VS ROM Avoid forceful or aggressive movements Concorde Career College

Physical Therapy Interventions Managing Abnormal Tone & Spasticity PROM Strengthening the antagonist Proper positioning Serial casting Cryotherapy Remember that high tone can, at times, be beneficial for function (ie., LE tone can improve WBing for transfers) Concorde Career College

Physical Therapy Interventions Therapeutic Exercises Passive exs, stretching exs, active assistive exs, active exs, and strengthening exs Developmental Positioning and Mobility Retraining Prone, Sit, Quadruped, Kneeling, Plantigrade, Standing Neuromuscular Facilitation Techniques Strength and Endurance Training Concorde Career College

Physical Therapy Interventions Mobility Training Important pt is upright as soon as medically stable Sitting in chair, wheelchair or using a tilt table Bed mobility Transfer training May require co-tx with OT for initial transfers Sitting balance Standing balance Gait training Tilt Table, II Bars, Suspended Gait Device, TM, ADs Wheelchair Mobility Training Concorde Career College

Physical Therapy Interventions Balance, coordination and vestibular retraining Sensory integration Wheelchair and adaptive equipment assessment and application Concorde Career College

Concorde Career College Learning after a TBI Learning will depend on genetics, age, physical & mental health, severity of brain injury & quality of environmental stimuli Associated with neural plasticity Must properly assess memory Is the patient able to apply the same skill learned within a PT session to a separate setting? Concorde Career College

Concorde Career College Learning after a TBI Learning capabilities and information processing may change over time Therefore, need to adjust teaching style Needs to be a balance between challenging the patient without overwhelming & causing stress and frustration Concorde Career College

Concorde Career College Documentation Patient posture and the effect of reflexes upon posture and abnormal tone and movement patterns Patient response to stimulation, type of response and frequency of response Patient response to sensory stimulation and carry over into functional activities Attention span, orientation, ability to follow instructions Patient ability to learn and recall tasks Concorde Career College

Concorde Career College Documentation Patient safety awareness Physical or emotional fatigue Activity performed, patient participation, assistance level Patient ,family and rehabilitation team education and communication Concorde Career College

Who else may be involved with the care of a patient with a TBI? Patient & family, physician, SLP, OT/OTA, Rehab nurse, case manager/team coordinator, medical social worker, neuropsychologist Discussion Concorde Career College

Concorde Career College TBI Assess for Understanding: List the members of the multidisciplinary rehabilitation team that provide services to patient’s with a traumatic brain injury What physical therapy interventions would be applied to a medically stable patient post 7 days injury. The patient is bedbound, level 3 (Localized response) and exhibiting spasticity in the arms and legs. Concorde Career College

Concorde Career College TBI Assess for Understanding: What physical therapy interventions would be applied to a patient with Level 7 (Automatic Appropriate). The patient can sit up unsupported 1 minute, max assistance stand and transfers, strength fair trunk and lower extremities with mild hypertonus. Concorde Career College

Concorde Career College Questions Concorde Career College

Concorde Career College Resources Physical Rehabilitation, 5th ed., Susan B. O’Sullivan and Thomas J. Schmitz, 2007; F.A. Davis, Company. Chapter 22 PTA Exam The Complete Study Guide. Scott M. Giles, Scorebuilders. 2011, PTA Examination Review and Study Guide, Karen Ryan and Rebecca McKnight, International Educational Resources. 2010. Functional Neurorehabilitation through the Lifespan. Bertoti, D. F.A. Davis. 2004. page 160-161 Concorde Career College