Concorde Career College Physical Therapist Assistant

Concorde Career CollegePhysical Therapist Assistant

PTA 150: Fundamentals of Treatment IIDay 11

Traumatic Brain Injury (TBI)

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


Traumatic Brain Injury

http://abcnews.go.com/video/playerIndex?id=3489618



Epidemiology1.5 to 2 million Traumatic

Brain Injuries in the United States each year

50,000 deaths80 to 90,000 patients with

residual cognitive, behavioral, and physical disorders


What are ways in which the brain might be

damaged?



Causes of InjuryMotor vehicle accidentsFallsViolenceSports and recreation


Pathophysiology

An external force to the skull that causes brain tissue damage Acceleration ForceDeceleration ForceRotational Force

Brain tissue can become compressed, torn or displaced

Open head injurySkull fractureMeninges tear with brain exposure

Closed head wound Concorde Career College

Types of Traumatic Brain Injury

Focal/ Coup/ Local InjuryInjury at the sight of impact under the skull

Cerebral contusionVascular lesionLacerationHemorrhageHematomaBrain swelling/Edema



Coup – Contracoup Injury (Bouncing)Injury at the point of impact and an opposite site to

the point of impactFlexion/extension (whiplash) can cause brain

injury without direct impact

Diffuse Axonal InjuryStretching, shearing, or tearing of the axons and

small blood vessels within the brainCaused by acceleration, deceleration or rotational

force



Secondary Brain DamagePhysiological changes in the brain due to traumaHypoxic ischemic injury

Lack of oxygen to brain tissueBrain hemorrhage or hematoma between the skull

and the dura mater (epidural) or within the brain (subdural)

↑ Intracranial PressureBrain herniation


TBI Medical InterventionAcute Stage

Stabilize cardiovascular system, respiratory system, brain pressure & brain blood flow

Assess severity of brain injuryCAT Scan & MRI assesses structural & functional

involvement X-ray assesses for skull fractureCerebral angiography assesses for abnormalities in

brain vessels and circulationEvoked Potential Electroencephalogram (EPEG)

assesses for localized brain damagePositron Emission Tomography (PET) assesses

cerebral metabolism functionConcorde Career College

TBI Medical Intervention

Surgical InterventionMonitor intracranial pressureDecompress skull

Ongoing MedicationsDiuretics: ↓ intracranial pressure and fluid in the brainAnticonvulsants: Control seizuresAntidepressants: Behavioral problemsElectrolytes: Brain metabolism and healingNeurotransmitters: Serotonin (behavior & emotions)


Levels of Consciousness

ComaA state of unconsciousness and the level of

unresponsiveness to all internal and external stimulation

StuporA state of general unresponsiveness with only brief

arousal occurring from repeated stimulationObtunded

Patient sleeps often and when aroused, exhibits decreased alertness and interest in the environment with delayed reactions


Levels of Consciousness

DeliriumA state of consciousness that is characterized by

disorientation, confusion, agitation and loudnessClouding of Consciousness (lethargic)

A state of consciousness that is characterized by quiet behavior, confusion, poor attention and delayed responses

ConsciousnessA state of alertness, awareness orientation and

memory


TBI: Neuromuscular Impairments

Abnormal toneDecorticate 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)



Impaired motor function (depends on site of brain damage)Monoplegic, Hemiplegic, Tetraplegic, Quadriplegic

Impaired reflex responses (mild to severe)Abnormal synergistic movement patternsImpaired balance and coordination responsesDiminished muscle performance for ADL

Strength, Power, Endurance



Cognitive DeficitsImpaired in orientation to time, person and place Impaired reasons and problem solving abilities

Attention DeficitsHyperactive, impulsive, distractive, ↓ concentration

Behavior ProblemsLow frustration toleranceDepressionDisinhibition: emotions, aggression, apathy, sexual



Memory DeficitsRetrograde Amnesia

• Inability to remember events prior to the injuryPost 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



Visual ProblemsHemianopsiaCortical Blindness

↓ sensory perception and ability to process sensory informationTouch, temperature, position, kinesthetic, painSpatial orientation



Speech & CommunicationExpress aphasia (Broca’s area)

• Unable to speak • Unable to form intelligible words

Receptive aphasia (AKA Wernicke’s aphasia)• Unable to distinguish appropriate sounds

Global aphasiaDysarthria

• Lack of control and coordination of speech muscles



Auditory Reading comprehension and written expressionSwallowing Problems

Dysphagia


Medical Problems Related to Inactivity

Soft tissue contracturesMuscle atrophySkin breakdownDeep vein thrombosisInfection/pneumoniaHypertrophic ossificationCardiovascular and respiratory disorders


Physical Therapy Examination

Cognitive FunctionVital SignsMuscle Control (tone, reflex patterns)Postural Control (sit, stand) and BalanceSensationStrength and EnduranceRange of MotionFunctional Mobility (bed mobility, transfers,

wheelchair, gait)Medications


TBI Outcome Measures

Glasgow Coma ScoresDetermines the patient’s level of arousal and

cerebral cortex functionEye Opening, Verbal Responses, Motor responses

Score between 13 - 15 indicate mild impairmentScore between 9 -12 indicate moderate impairmentScore below an 8 indicate severe impairment and

comatose state

Galveston Orientation & Amnesia Test (GOAT)Concorde Career College


Rancho Los Amigos: Levels Of Cognitive Functioning (LOCF)Based upon patient’s level of consciousness and

functional statusThe patient usually passes through all stages in the

sequence progressions• Patient brain recovery varies and not all patient achieve

the purposeful conscious state of functionEight levels


TBI Outcome Measures: (LOCF)

Level 1: No ResponsePatient appears to be in a deep sleep and

completely unresponsive to any stimulationLevel 2: Generalized Response

Patient exhibits a generalized, inconsistent , non-purposeful response.• Physiological changes, gross body movements or

localization



Level 3:Localized Response• Patient exhibits an inconsistent, localized response• May follow simple commands such as opening eyes or

squeezing handLevel 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



Level 5: Confused InappropriateConsistent response to simple commandsHighly 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



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



Level 8: Purposeful and AppropriatePatient is responsive to environmentPatient is able to demonstrate recall memories and

integrate past and recent eventsAble to learn and needs no supervision once

activities are learnedDecreased tolerance to stress, and complex

reasoning skills



Functional Individual Measurement (FIM)Assesses ADLs and functional mobility

Functional Assessment Measurement (FAM)Assesses the patient’s ability to integrate and adjust

into the communityDisability Rating Scale (DRS)

Patients are scored on a wide range of functional areas

Score 0-29, 0 = no disability; 29 = extreme vegetative state


In what setting might you be treating a

patient after a TBI?

Discussion


TBI Treatment Guidelines

Patient and family participationConsistency is key

Same therapist, daily schedule, offer orientation (person, place, time)

Goal directed, familiar, functional and recreational activities

Focus on behavior modification activitiesMay use positive reinforcement (rewards system)

Feedback is important



Initially, focus may be on endurance rather than challenging the patient to learn new skillsMay not have capacity to learn early onMental fatigue can lead to irritability, ↓ attention, etc.

Simple commands, calm voicePractice without overstimulation

Do not expect carryoverTherapeutic activities need to be safe and flexible,

based on level of awareness and function



Give the patient control, if appropriateAs the patient advances

Community & social reintegration will be importantInvolve that patient in decision makingEncourage independence & cooperative work


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



Sensory StimulationAttempt to ↑ arousal & movementSystems are systematically stimulated

• Auditory, Olfactory, Gustatory, Visual, Tactile, Kinesthetic, Vestibular

Must monitor closely for subtle changes in VSROM

Avoid forceful or aggressive movements



Managing Abnormal Tone & SpasticityPROMStrengthening the antagonistProper positioningSerial castingCryotherapyRemember that high tone can, at times, be beneficial

for function (ie., LE tone can improve WBing for transfers)



Therapeutic ExercisesPassive exs, stretching exs, active assistive exs,

active exs, and strengthening exsDevelopmental Positioning and Mobility Retraining

• Prone, Sit, Quadruped, Kneeling, Plantigrade, StandingNeuromuscular Facilitation TechniquesStrength and Endurance Training



Mobility TrainingImportant pt is upright as soon as medically stable

• Sitting in chair, wheelchair or using a tilt tableBed mobilityTransfer training

• May require co-tx with OT for initial transfersSitting balanceStanding balanceGait training

• Tilt Table, II Bars, Suspended Gait Device, TM, ADsWheelchair Mobility Training



Balance, coordination and vestibular retrainingSensory integrationWheelchair and adaptive equipment assessment

and application


Learning after a TBI

Learning will depend on genetics, age, physical & mental health, severity of brain injury & quality of environmental stimuli

Associated with neural plasticityMust properly assess memory

Is the patient able to apply the same skill learned within a PT session to a separate setting?


Learning after a TBI

Learning capabilities and information processing may change over timeTherefore, need to adjust teaching styleNeeds to be a balance between challenging the

patient without overwhelming & causing stress and frustration


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


Documentation

Patient safety awarenessPhysical or emotional fatigueActivity performed, patient participation, assistance

levelPatient ,family and rehabilitation team education

and communication


Who else may be involved with the care of

a patient with a TBI?

Discussion


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.


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.


Questions


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


Documents

Concorde Career College Physical Therapist Assistant