1. Concorde Career College Physical Therapist Assistant
PTA 150: Fundamentals of Treatment II Day 11 Traumatic Brain Injury (TBI)
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2. 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
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3. Traumatic Brain Injury
618
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4. 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
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5. What are ways in which the brain might be damaged?
Page 1149 (O’Sullivan)
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6. Traumatic Brain Injury
Causes of Injury
Motor vehicle accidents
Falls
Violence
Sports and recreation
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7. 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
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8. 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
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9. 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
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10. 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
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11. 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
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12. 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
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13. 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
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14. 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
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15. 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)
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16. 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
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17. 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
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18. 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
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19. TBI: Neuromuscular Impairments
Visual Problems
Hemianopsia
Cortical Blindness
↓ sensory perception and ability to process sensory information
Touch, temperature, position, kinesthetic, pain
Spatial orientation
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20. 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
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21. TBI: Neuromuscular Impairments
Auditory
Reading comprehension and written expression
Swallowing Problems
Dysphagia
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22. 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
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23. 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
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24. 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 indicate mild impairment
Score between indicate moderate impairment
Score below an 8 indicate severe impairment and comatose state
Galveston Orientation & Amnesia Test (GOAT)
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25. 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
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26. 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
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27. 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
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28. 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
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29. 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
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30. 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
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31. 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
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32. In what setting might you be treating a patient after a TBI?
Discussion
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33. 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
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34. 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
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35. 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
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36. 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
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37. 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
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38. 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)
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39. 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
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40. 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
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41. Physical Therapy Interventions
Balance, coordination and vestibular retraining
Sensory integration
Wheelchair and adaptive equipment assessment and application
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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?
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43. 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
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44. 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
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45. 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
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46. 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
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47. 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.
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48. 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.
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49. Concorde Career College
Questions
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50. 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
Functional Neurorehabilitation through the Lifespan. Bertoti, D. F.A. Davis page
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