Download PTA 150 Day 11 TBI

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Physical Therapist Assistant
PTA 150: Fundamentals of Treatment II
Day 11
Traumatic Brain Injury (TBI)
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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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Traumatic Brain Injury
 http://abcnews.go.com/video/playerIndex?id=3489
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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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What are ways in
which the brain might
be damaged?
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Traumatic Brain Injury
 Causes of Injury
 Motor vehicle accidents
 Falls
 Violence
 Sports and recreation
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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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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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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
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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
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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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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)
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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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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
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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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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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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
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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
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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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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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TBI: Neuromuscular
Impairments
 Auditory
 Reading comprehension and written expression
 Swallowing Problems
 Dysphagia
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Medical Problems Related to
Inactivity
 Soft tissue contractures
 Muscle atrophy
 Skin breakdown
 Deep vein thrombosis
 Infection/pneumonia
 Hypertrophic ossification
 Cardiovascular and respiratory disorders
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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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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)
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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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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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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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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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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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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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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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In what setting might
you be treating a
patient after a TBI?
Discussion
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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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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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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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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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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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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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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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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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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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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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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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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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Who else may be
involved with the care
of a patient with a
TBI?
Discussion
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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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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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Questions
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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
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