Traumatic brain injury Fazan zaffar kashoo

INTRODUCTION Definition: Traumatic brain injury (TBI, also called intracranial injury) occurs when an external force traumatically injures the brain. Epidemiology: 1.5 -2 million /year Motor vehicle accidents accounts for more than half 9-10 billion $ annual economic impact.

Pathophysiology Focal injury: coup-contercoup injury Diffuse axonal injury: shearing and retraction of damaged axons. Hypoxic-ischemic injury: lack of oxygenated blood flow. Increased intracranial pressure: epidural subdural hemorrhage (4-15 mm Hg)

diagnosis CT scan. MRI scan.

Complications after TBI Neuromuscular impairment: Abnormal tone Primitive posturing Decorticate (UL Flex –LL exten above superior colliculus ) and decerebrate rigidity (UL, LL exten between Superior colliculus and vestibular nucleus) All sensations impaired Monoplegia, hemiplegia, tetraplegia Cordination timing and sequence of movement

Complications after TBI Cognitive impairment Altered level of consciousness- Glasgow coma scale Coma- cant arose Stupor- can arose with difficulty Obtunded- arose easily Memory deficit: post traumatic amnesia- time of injury and person makes new memories. Types of memories: declarative and procedural Declarative memory: conscious recollection of task to do activity Procedural memory: unconscious performance of activity

Complications after TBI Communication impairment: aphasia Visual-perceptual impairment: spatial neglect, left right discrimination neglect, Swallowing impairment: dysphagia Indirect impairment: soft tissue contractures Ulcer DVT Decreased bone density Muscle atrophy Infection Pneumonia

Clinical rating scale Glasgow coma Scale: 3-15 score Galveston orientation and amnesia test: measure of Post traumatic Amnesia Rancho los Amigos level of cognitive functioning: cognitive and behavioral recovery of patient. Glasgow outcome Scale: outcome measure of after TBI FIM: functional independence measure.

Prognosis and goal setting Initial severity of injury Duration of coma Length of PTA Coma less than one week – good recovery PTA less the 12 weeks – good recovery

Medical management Stabilization of cardio-vascular and respiratory system. Stabilize the vital signs. CT scan. ICP monitoring (4-12 mm Hg) Below 20mm Hg. 30 degree head position and sedatives.

Rehabilitation team Physician Speech language pathologist Occupational therapist Rehabilitation nurse Case manager Medical social worker. Neuropsychologist Physiotherapist

examination Information from the medical records Posture Eyes closed or open Track visual and auditory stimulus Can speak Active movements Reaction to tactile stimulus Change in vital signs with external stimulus Examine tone with ashworth scale.

INTERVENTION AT HOSPITAL Preventing indirect impairment Positioning Head neural position, neck movement (stable ICP) Trunk scapula mobilization Upper extremity cone in hand, wedge between fingers Lower extremity: hip rotation prevention with roll PROM Respiratory Care: Arousal through sensatory stimulus: auditory, gustatory, visual, tactile, kinesthetic and vestibular. Early transition to sitting position.

INTERVENTION AT REHAB CENTRE Learn new skills Locomotion training with body weight support Constraint induced movement therapy Prone on elbow, quadruped,bridging etc. Sitting on therapy ball Serial casting