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5/8/2018
1
Preparing a Patient with TBI for Intensive Rehabilitation
Brooke Murtaugh, OTD, OTR/L, CBISTOccupational Therapist
Certified Brain Injury Specialist/TrainerBrain Injury Program Manager
Madonna Rehabilitation HospitalsLincoln/Omaha, NE
COI
• No Conflicts of Interest.
Objectives
• Attendees will:
– Identify appropriate TBI patient for specialized rehabilitation program.
– Describe interventions required in acute care to prepare TBI patient for intensive rehabilitation.
– Describe outcomes achieved by TBI patients post rehabilitation.
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Traumatic Brain Injury
• Center for Disease Control
– “Injury to the head arising from blunt or penetrating trauma or from the acceleration/deceleration forces resulting in one or more of the following: decreased level of consciousness, amnesia, objective neurologic or neuropsychological abnormalities….”
• Brain Injury Medicine (2013).
Types of Brain Injury
• Traumatic Brain Injury
• Focal Injuries
• Polar/Inertial Injuries
• Diffuse Axonal Injuries (DAI)
• Non‐Traumatic
• Hypoxic/Anoxic Injuries (HAI)
• Encephalopathy
• Meningitis
Severity of TBI
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Levels of Consciousness
• Consciousness is a continuum of states
– Brain Death
– Coma
– Unresponsive Wakefulness (previously Vegetative State)
– Minimally Consciousness State
– Emergence from Minimally Conscious State
Disorders of Consciousness• Coma
• Unresponsive Wakefulness
• Minimally Conscious State
• Emergence from MCS
– Functional Object Use
– Functional Communication
– Following Commands
• CRS‐R to assess level of consciousness.
Deficits Post Severe TBI
• Disorders of Consciousness
• Motor Impairments– Hemiplegia– Hypertonicity– Movement Disorders– Motor Planning Deficits
• Vision Impairments• Sleep Disorders• Feeding and Swallowing• Neurogenic bowel and
bladder
• Cognitive Impairments– Attention– Agitation– Impulsivity– Awareness of environment– Memory– Insight– Problem Solving– Executive Functioning
• Neuro‐behavioral sequelae
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Rancho Los Amigos• Classification of Cognitive Recovery
RLA
• Provides common language for professionals and families
• Describes common patterns of recovery
• Gives families perspective
• Can be used by anyone
RLA
• Patients vacillate between levels
• It is a subjective measure
• It is not predictive
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Why Rehabilitation After TBI?• Improve function
– Achieve optimal outcomes
• Reduce Deficits
• Prevent secondary complications
• Reduce burden of care
• Reduce risk/need for long term care
• Re‐integrate back into community
• Manage long term chronicity of BI
Who Should Be Referred to Rehab?• Brookeism…..Everyone!
– No evidence of brain death• Manara, 2016 reported on 5 cases of DBI where WLST was considered and discussed.
• Neurocritical Care Society reports 3% of pts with DBI go on to make a good neurological recovery.
• Increasing studies on timing of WLST after DBI.
• Study by Vedantam, 2017
– N=218
– 15% of TBI with favorable outcome followed commands beyond 2 weeks post injury
– Conclusion: Caution against early WLST
• Harvey, et. Al. (2018). DBI Consensus Statement
Who Should Be Referred to Rehab?
• Medically stable
– Trached
– Peg
– Off of consistent sedation or paralytics
• Rancho II‐III or higher
• Family is supportive of rehabilitation, long term support and QOL.
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TBI Continuum of Care
• Acute Care
• Long Term Acute Care
• Acute Rehabilitation
• Skilled Rehabilitation
• Outpatient
In The Meantime…
Preparing for Rehab
• Early Mobilization
– Medically safe
– Early therapy referrals
• Turning schedule
– Decrease risk for pressure injuries
• Coma Stimulation
• Environmental Adaptations
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Treatment Approach• RLA I‐III
– Attention to environment
– Positioning and bed mobility
– Sensory Stimulation
– Communication
– Nutrition
– Skin health
– Vent/trach weaning
– Family education
Attention to Environment
• Lights on, shades open when pt is to be up and alert for tx.
• Lights low, shades closed for rest periods
• TV and radio or music on preferred stations for short periods of time
• Talk to patient about activity when bathing, suctioning, administering meds, walking in room for any reason…etc
• Provide frequent reorientation to situation and surroundings. Frequently re‐introduce yourself.
• Be upbeat, animated, positive.
• Teach family. Encourage them to bring in a few familiar objects, review photos..
Sensory StimulusSensory Systems
– High contrast visual stimulation
– Oral sensory stimulation
• Oral input of strong tastes
• Proprioceptive/Vestibular Input
– Organizing and arousing to the brain
– Releases seratonin and norepinepherine that assists in neurological arousal and organization
• Interventions
– Bed mobility
– Sitting e.o.b
– Sitting schedule in w/c
– Lateral wt shift
– WB BUE for inc prop input
– Auditory stimulation• Radio/TV
– Familiar music/TV shows
– Family voices
– Simple commands
– Tactile stimulation• Noxious stimulus
• Various Tactile Inputs
• Rough, soft, sharp, dull
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Communication
• Talk to patient.
• Encourage motoric response to command.
• Use high and low tech AAC available
• Try new things every day. Just because the pt couldn’t follow commands one day, doesn’t mean they won’t the next.
Skin Health
• Frequent repositioning
– 2 hour turning schedule
– Tilt in Space wheelchairs
– Don’t forget the occiput
• Appropriate bowel and bladder management
• Be aware of orthotic use.
• Use favorite lotions and cosmetics
– Olfactory Stimulation
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Vision
• Eye Health
– CN IV & VI
• Impaired lid closure
• Corneal Exposure/Corneal Ulcer– Opthalmology Referral
Vision
• Promote Visual Tracking
• Facilitate Visual Attention
• Initiate spot patching and alternating spot patching for ocular mal‐alignment
Paroxysmal Sympathetic Hyperactivity
• “Central Storming” “Dysautonomia”
• Due to lack of cortical inhibition, abnormal brainstem function develops.
– Increased heart rate
– Increased respiratory rate
– Increased blood pressure
– Increased muscle tone
– Fever/sweating
– Brainstem posturing
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Family Education
• Teach family all the cares they are capable of doing such as positioning, wheelchair rides, oral cares, skin care, orienting patient…etc. give them ideas for interaction. Use them to get an idea of the patient’s daily routine so you can try to cater to the patient’s preferences.
What Does Brain Injury Specialty Rehabilitation Look Like?
BISP• Multi‐disciplinary care.
• Physiatrist involved.
• Experience with spectrum of brain injury.
– Volumes
• Dedicated team
– Experts, not generalists
• Behavioral programming
• Understands and/or provides continuum of care.
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BISP• CBIS staff
• Appropriate resources
– Therapy space
– 1:1 staffing PRN
– Individual rooms
– Access to needed consultations and specialists
– Neuro‐vision education/programming
– Family housing/accommodations
– Access to long‐term resources
– Recreational programming
• Emphasis on Education
Day In The Life• ADLs with OT in am
• Daily visits with physiatrist
• PT, SLP and OT interspersed throughout the day.
• 3‐4 hours of therapy 5 days/week
• NP services
• Team and patient/family meetings
• Goal focused interventions
• Consistent schedule, consistent team
• Community/Recreational outings
• Home visits
Brain Injury Outcomes
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Gains Post TBI
• Sandhaug et al., (2015) Outcome post moderate to severe TBI.
– 24 months post injury
– N=68
– 85% lived at home
– 70% lived independently
• 30% required some level of assistance at home
– FIM and GOSE
Gains Post TBI
• McLafferty, 2016
– Moderate to severe TBI
– Patients underwent IP Rehabilitation
• 98% improved FIM in mobility
• 93% improved FIM in self cares
• 84% improved FIM in communication/cognition
• 65% improved in continence
– Longer LOS demonstrated increased positive response to rehabilitation.
Gains Post TBI
• Lu et. Al, 2018 looked at 5 year post moderate‐severe TBI long term outcomes through FIM evaluation.
– 82.6% of pt demo stable and/or improved recovery for motor skills.
– 54.6% demonstrated stable and/or improved recovery in cognitive domains.
– Conclusion: good recovery 5 years post TBI was most common trajectory.
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Brain Injury as Chronic Disease
• Long Term Consequences of TBI:
– Increased risk for substance abuse, PTSD, suicide, incarceration, homelessness, disability, unemployment.
– Research looking at increased risk of early onset dementia and other progressive neurological disorders.
– Severe TBI
• DVT, pneumonia, pressure injuries, contractures
Case Study
Sidney
Sidney
• 23 yr old female from Downs, KS
• Psychology Major
• MVA
– December 18, 2014
– Diffuse Axonal Injury
– Respiratory Failure
– No other injuries
– Wesley Trauma Center
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Wesley Medical Center
Admit to Madonna
MRSH
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MRH
MRH
Rehabilitation Interventions• Vent weaning
• Standing Frame
• Sitting Balance
• Casting
• Botox injections B UE
• Neuro developmental techniques
• Lokomat
• Splinting
• Standing Balance
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Rehabilitation Interventions
• Self Cares
• Transfers
• Communication
• Feeding/Swallowing
• Recreation therapy
• Community Outings
• Family Education/Training
MRH
June 2015
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Madonna RDP
Madonna RDP
Madonna RDP
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Goal!!!!!!!
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Sidney Today
• Continues with vision rehabilitation, speech therapy, and therapeutic learning center.
• Rides and shows horses as much as she can.
• Plans to return to KU in the fall to complete her psychology degree.
Questions?
References• Cancelliere et al. (2014) Systematic review of return to work after mild traumatic brain injury: Results of the international
collaboration on mild traumatic brain injury prognosis. Archives of Physical Medicine and Rehabilitation 95(3): 201‐209.
• Harvey, D. et. Al. (2018). Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations. British Journal of Anesthesia; doi: 10.1016/j.bja.2017.11.007.
• Lu, J, et. Al. (2018). Trajectory of functional independent measurements during first 5‐years following moderate and severe traumatic brain injury. Journal of Neurotrauma; doi. 10.1089/neu.2017.5299.
• Manara, A., Thomas, I., & Harding, R. (2016). A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injury. Journal of Intensive Care Society; 17(4): 295‐301.
• Odgaard, L., Johnsen, S., Pedersen, A., & Nielsen, J. (2016). Return to work after severe traumatic brain injury: a nationwide follow‐up study. Journal of Head Trauma and Rehabilitation.
• Sandhaug,, M., Andelic, N., Langhammer, B., Mygland, A. (2015). Functional level during the first 2 years after moderate and severe traumatic brain injury. Brain Injury: 29(12): 1431‐1438.
• Suter, P., Harvey, L. (2010). Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury. Boca Raton, FL: CRC Press.
• Vedantam, A., Robertson, C., & Gopinath, S. (2017). Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury. Journal of Neurosurg; DOI: 10.3171/2017.3.JNS162720.
• Walker, W. et al. (2006). Occupational categories and return to work after traumatic brain injury: a multicenter study. Achieves of Physical Medicine and Rehabilitation; 87; 1576‐1582.
• Zasler, D.I. Katz, & R. D. Zafonte (Eds.), Brain Injury Medicine. New York, NY: Demos Medical Publishing.