TBI Flashcards
(93 cards)
1
Q
Who’s most likely to get TBI?
A
80% are men btwn 18-30y/o
2
Q
Leading causes of TBI (5)
A
- Falls (35%)
- MVA (23%)
- Unknown (21%)
- Struck by/against (16%)
- Assault (10%)
3
Q
Types of TBI (2)
A
- Penetrating
2. Closed
4
Q
What’s a closed TBI?
A
An injury to the brain caused by mvmt of the brain within the skill. AKA Closed Head Injury (CHI). e.g. falls, MVA, struck by/against
5
Q
What’s a penetrating TBI?
A
An injury to the brain caused by a foreign object entering the skull. eg GSW.
6
Q
What’s a coup-countercoup injury?
A
Due to sudden stop/impact - brain hits inside of skill in direction of impact (due to inertia) then bounces back other way & sides other side of skull. Damage occurs at both locations. e.g. whiplash - direct impact isn’t necessary
7
Q
Causes of Non-Traumatic Brain Injury (5)
A
- Drug overdoes
- Chronic substance abuse
- Carbon monoxide
- Enviro exposure (toxins)
- Anoxia *Most severe, affects whole brain
8
Q
Factors for TBI prognosis (6)
A
- Consciousness (level of arousal, length of coma, ability to follow commands)
- Autonomic functions (pulse, respiratory rate, temp, BP)
- Pupillary reactions
- Ocular mvmts
- Motor functions (reflexes, voluntary mvmt, postures)
- Posttraumatic amnesia (PTA)
9
Q
What’s posttraumatic amnesia?
A
The time after injury when day-to-day recall occurs in full orientation is present
10
Q
Posttraumatic amnesia scale/relation to prognosis (5 levels)
A
Mild - less than 1hr Moderate - 1 day Severe - 1 week Very severe - 1 month Extremely severe - more than a month
11
Q
TBI - what posturing might occur? (2) Prognosis?
A
- Decerebrate - UE/LE in extension. Associated with brainstem damage. Poorer prognosis.
- Decorticate - UE/LE is spastic flexion. Associated with cerebral hemisphere damage. Better prognosis. Risk for contractures.
12
Q
What is the Glasgow Coma Scale?
A
A clinical tool designed to assess coma & impaired consciousness & is one of the most commonly used severity scoring systems for TBI
13
Q
What are the 3 Glasgow Coma Scale factors?
A
- Eye opening (none - spontaneous), score 1-4
- Motor response (none - obeys commands), score 1-6
- Verbal response ( none - oriented), score 1-5
14
Q
What are the categories for the Glasgow Coma Scale? What are the corresponding scores?
A
Severe: 3-8 *Score of 8 or less generally categorized as coma
Moderate: 9-12
Mild: 13-15
15
Q
What’s the Rancho Los Amigos Scale of Cognitive Functioning? What’s the corresponding assistance level?
A
- No Response (D)
- Generalized Response (D) - delayed/slow, moaning
- Localized Response (D) - intermittent waking, react to specific stimulus, recognize some familiar ppl
- Confused, Agitated (Max A)
- Confused, Inappropriate, Non-agitated (Max A)
- Confused, Appropriate (Mod A)
- Automatic, Appropriate (Min A)
- Purposeful, Appropriate (Stand-by A)
16
Q
What are the types of amnesia?
A
- Retrograde Amnesia - forgotten events for a period of time prior to injury
- Anterograde Amnesia - period of time unable to form new memories
- Posttraumatic Amnesia - following injury, period of time pt is confused & appears unable to form new memories or remember what happened prior to the event
17
Q
Factors affecting TBI prognosis (7)
A
- Predictors
- Age
- Lifestyle
- Social support system
- Pre-morbid use of drugs/alcohol
- Education
- Length of time in coma/PTA
18
Q
OT Eval of TBI ct Includes (6)
A
- Interview/observation
- Clinical eval (ROM, tone, sensation, balance, mvmt)
- Cog/Perception/Vision
- Perf of mobility & functional activities
- Endurance & pain
- Behavior
19
Q
Typical (primary) OT goals include… (7)
A
ADLs Splinting Neuromuscular re-education Bed positioning & mobility Equipment needs Home eval Caregiver training
20
Q
Description of Rancho Level: No Response (1)
A
Coma
21
Q
Description of Rancho Level: Generalized Response (3)
A
(D) - delayed/slow, moaning, no awareness of enviro
22
Q
Description of Rancho Level: Localized Response (6)
A
(D) intermittent waking, react to specific stimulus, visual tracking, recognize some familiar ppl, follow simple directions, answer yes/no
23
Q
Description of Rancho Level: Confused, Agitated (6)
A
(Max A) frightened/doesn’t understand what’s happening, overreacts (via hitting screaming biting etc.), focus on basic needs (food, sleep, etc.), short attention span, difficulty following directions, work on simple ADLs
24
Q
Description of Rancho Level: Confused, Inappropriate, Non-agitated (5)
A
(Max A) Few min attention span, not Ox3, instruction to complete ADLs, poor memory, focus on basic needs/ADLs
25
Description of Rancho Level: Confused, Appropriate (5)
(Mod A) Still confused - can remember some important points, follow schedule w/ assistance, 30 min attention span, Basic ADLs, understand in hospital due to injury, doesn't understand gravity
26
Description of Rancho Level: Automatic, Appropriate (7)
(Min A) Follows schedule, can do ADLs, difficulty planning/gets frustrated with tasks, still doesn't understand gravity of cog deficits, poor safety awareness, stubborn, can talk about doing something but can't always do it
27
Description of Rancho Level: Purposeful, Appropriate (4)
(Stand-by A) Understand cog issues, increase in flexibility, Ready for driving/work eval, still some poor judgment
28
Behavior mgmt program for RLA 4 (3)
1. Provide enviro that motivates ct
2. Integrate family into rehab team
3. Maintain safe enviro
29
Behavior mgmt program for RLA 4 - interventions (7)
1. Model appropriate behavior
2. Speak slow, calm, simple
3. If ct wants to walk, walk!
4. Praise desired behavior
5. Don't reinforce undesirable behavior
6. Redirect ct's when they're agitated or perseverative
7. Decrease enviro stimuli
30
What are assessments for determining progress from coma to minimally conscious state (MCS) (5)
1. JFK Coma Recovery Scale
2. Wessex Head Injury Matrix
3. Coma-Near Coma Scale
4. Sensory Stimulation Assessment Measure
5. Western Neuro Sensory Stimulation Profile
31
What is the best predictor of functional outcome for TBI?
Post-Traumatic Amnesia (PTA)
32
What is Post-Traumatic Amnesia?
Length of time from the injury to the moment when the individual regains ongoing memory of daily events
PTA lasting longer than 4 weeks is associated with poor outcome & long-term disability
33
TBI Interventions for specific symptoms: Decerebrate rigidity (4)
UE/LE patterns of extension
1. Positioning
2. ROM
3. Neuromuscular blocks
4. Early casting
34
TBI Interventions for specific symptoms: Decorticate rigidity (4)
UE flexion & LE extension
1. Positioning
2. ROM
3. Neuromuscular blocks
4. Early casting
35
TBI Interventions for specific symptoms: Bruxism (What is it?) (2 interventions)
Persistent jaw clenching, teeth grinding, and/or temporomandibular dislocation or subluxation
1. Neuromuscular blocks
2. Oral orthotics
36
TBI Interventions for specific symptoms: Spasticity
1. Positioning
2. ROM
3. Weight bearing
4. Neuromuscular blocks
5. Inhibitive casting
6. Medications
7. Tendon release
8. Relaxation techniques
37
TBI Interventions for specific symptoms: Rigidity & Bradykinesia ("parkinsonism") (4)
1. Positioning
2. ROM
3. Functional activities
4. Meds
38
TBI Interventions for specific symptoms: Torticollis (What is it?) (5 interventions)
Dystonic posture of the neck; spasticity &/or contracture of the sternocleidomastoid, splenius muscles
1. Positioning
2. Modalities
3. ROM
4. Meds
5. Neuromuscular blocks
39
TBI Interventions for specific symptoms: Myoclonus (What is it?) (2 interventions)
Abrupt, shock-like involuntary jerks in large/small muscles when asleep or awake
1. Meds
2. Neuromuscular blocks
40
TBI Interventions for specific symptoms: Tremor (5)
1. Weighted devices
2. Weight bearing
3. Assistive devices
4. Meds
5. Neuromuscular blocks
41
TBI Interventions for specific symptoms: Dystonia (What is it?) (5 interventions)
Dynamic contraction/relaxation of muscles with slow, writhing, or repetitive twisting mvmts or sustained contortions, usually distal limbs
1. Positioning
2. ROM
3. Assistive devices
4. Meds
5. Neuromuscular blocks
42
TBI Interventions for specific symptoms: Athetosis (What is it?) (2 interventions)
Slow sinuous mvmt of face, tongue, or limb
1. Relation techniques
2. Taper offending meds
43
TBI Interventions for specific symptoms: Chorea (What is it?) (1 interventions)
Involuntary dance-like or jerky mvmts without rhythmic pattern, distal
1. Meds
44
TBI Interventions for specific symptoms: Hemiballismus (1)
1. Meds
45
TBI Interventions for specific symptoms: Tics (What is it?) (3 interventions)
Sudden stereotypic coordinated automatic mvmts or vocalizations while awake
1. Meds
2. Behavioral mgmt
3. Relaxation techniques
46
What are physical/motor signs post TBI? (12)
1. Decerebrate, decorticate, & motor rigidity
2. Abnormal muscle tone & spasticity
3. Primitive reflexes
4. Muscle weakness
5. Decreased functional endurance
6. Ataxia
7. Postural deficits
8. Loss of ROM
9. Sensation deficits (decreased or absent)
10. Decreased integration of total body mvmts (coordination)
11. Dysphagia
12. Difficulty with self-feeding
47
What are the most common cognitive deficits post TBI? (6)
1. Decreased attention & concentration
2. Impaired memory
3. Impaired initiation & termination of activities
4. Decreased safety awareness & judgement
5. Impulsivity
6. Difficulty w/ executive functions & abstract thinking
48
Visual deficits possible post TBI (10)
1. Accommodative dysfunction (causing blurred vision)
2. Convergence insufficiency (inability to maintain a single vision while fixating on an object)
3. Strabismus
4. Nystagmus
5. Hemianopia
6. Impairment of scanning & pursuits
7. Impaired saccades
8. Reduced blink rate
9. Ptosis
10. Lagophthalmos
49
Psychosocial Factors (5)
1. Alteration of self-concept
2. Altered social roles, isolation, inability to maintain relationships
3. Inability to live independently
4. Dealing with loss (go through stages of grief)
5. Affective changes (changes in mood)
50
Interventions used in behavior mgmt of TBI (6)
1. One-on-one coaching (ct's who may hurt themselves or others)
2. Psychotropic meds
3. Individually designed intervention guidelines
4. Ignoring comments
5. Redirecting inappropriate behavior
6. Modeling acceptable behavior
7. Provide consistent schedule
8. Goal sheets that provide visual cues for expectations
9. Providing visual & physical guidance
51
What does a one-on-one coach do?
Often provides 24/7 behavior mgmt
| Reinforce ct's behavior & redirect inappropriate or maladaptive behaviors
52
Environmental modifications to support behavior mgmt
1. Cubicle or net bed
2. Alarm system
3. Helmet
4. Walkie-talkies
5. Quiet/non-distracting environment
53
Eval of lower-level TBI ct's (7)
1. Level of arousal/cognition - Follow any commands?
2. Vision - ability to locate/track objects? Make eye contact?
3. Sensation - response to external stimuli?
4. Joint ROM - Any loss due to spasticity, etc.?
5. Motor control - Any purposeful mvmts?
6. Dysphagia - oral motor control? Mgmt of drool etc?
7. Emotion
54
Interventions for lower-level TBI ct's: general goal for those at Rancho Levels 1-3
Increase the individual's level of response & overall awareness of self & enviro
55
Interventions for lower-level TBI ct's: general guidelines for those at Rancho Levels 1-3 (2)
1. All stimulation should be broken down into simple steps & commands
2. Allow sufficient time for response
56
Interventions for lower-level TBI ct's: specific basic interventions for Rancho Levels 1-3 (7)
1. Sensory stimulation
2. Wheelchair positioning
3. Bed positioning
4. Casting or spinting
5. Mgmt of dysphagia
6. Emotional & behavioral mgmt
7. Family & caregiver education
57
Interventions for lower-level TBI ct's: Sensory stimulation intervention for Rancho Levels 1-3
Begins as soon as ct is medically stable - ICU
Introduce isolated sensory stimuli to heighten arousal
e.g. flashlight to elicit eye responses, familiar music to elicit autonomic responses, scents to elicit head turning or eye opening, kinesthetic input (therapist actively guides the client to perform simple mvmts, such as wiping their mouth)
* Idea is to reactivate highly processed neural pathways
Any response is noted
58
Interventions for lower-level TBI ct's: Wheelchair positioning facilitates what.... for Rancho Levels 1-3 (3)
1. Proper positioning allows ct to interact with immediate enviro - upright, midline posture
2. Facilitate head & neck control
3. Proper positioning helps prevent skin breakdown & joint contractures, facilitates normal muscle tone, increase sitting tolerance , enhance swallowing function, etc.
59
Interventions for lower-level TBI ct's: Components of proper wheelchair positioning intervention for Rancho Levels 1-3
1. Stable base of support at pelvis
2. Maintenance of trunk in midline
3. Facilitate head in upright, midline position
60
Interventions for lower-level TBI ct's: Wc positioning for the pelvis (4)
1. Solid seat to facilitate neutral to slightly anterior tilt
2. Lumbar support
3. Wedged seat (w/ downward tilt to back of chair) facilitate slight hip flexion & inhibit extensor tone
4. Seat belt to help maintain desired position - weight even across the buttocks
61
Interventions for lower-level TBI ct's: Wc positioning for the trunk (4)
1. Backsupport to maintain erect spine
2. Should be contoured to maintain curves of spine
3. Lateral trunk supports
4. Chest strap can be used to decrease kyphosis, facilitate shoulder retraction & adduction, & expand chest for breathing
62
Interventions for lower-level TBI ct's: Wc positioning for the LE & UE & interventions (1 each)
LE: Use WEDGES to correct or adduction or abduction at the hips
LE POSITION:want knees @ 90 degrees & aligned w/ hips
UE: ideal position = Use LAP TRAY to support UEs & encourage bilateral weight bearing & use.
UE POSITION: neutral scapulae, shoulders slight ext. rot. & abd., elbows in neutral w/ slight flex & forearm pronation
63
Interventions for lower-level TBI ct's: wc head support - difficulty, goal, intervention
At this level, ct's typically have little active control. Goal = obtain neutral-midline head position for optimal visual contact w/ the enviro. Intervention = dynamic head-positioning device, wc in slight backward tilt (10-15 degrees only). Helmet is necessary if there is a bone flap. Build sitting tolerance slowly & maintain a sitting schedule.
64
Interventions for lower-level TBI ct's: Bed positioning
Goals: Prevent pressure sores, facilitate normal tone, & prevent loss of pelvis & trunk ROM & mobility
For abnormal posturing/tone: Side-lying or semi-prone position - normalizes tone & provides sensory input.
Pillows, foam wedges, & splints may be a part of bed-positioning program
65
Interventions for lower-level TBI ct's: Splinting & casting - indications (3)
1. Spasticity interferes with functional mvmt & independence, 2. Joint ROM limitations are present, 3. soft tissue contractures are possible.
66
Interventions for lower-level TBI ct's: Splinting & casting - rationale (4)
1. Splints provide elongation/counteract spasticity/tone
2. Splinting the elbow, wrists, & hands maintains a functional position
3. Serial casting is used to increase ROM when contractures have developed
4. Splinting & casting also prevent skin breakdown
67
Interventions for lower-level TBI ct's: Splinting & casting - types (3)
1. Resting splint (or functional position splint) - worn when ct is not performing active mvmts or functional tasks - schedule is usually 2 hours on, 2 hours off
2. Cone splints - used in palm of hand to prevent finger nails from digging into skin
3. Antispasticity splint - like a resting splint but also abducts the fingers to decrease spasticity
68
Interventions for lower-level TBI ct's: Splinting & casting - Serial casting
Used when mod-severe spasticity cannot be managed by splints.
GOAL = increase ROM & decrease tone
Cast for 5-7 days - places muscle & tendons on prolonged stretch. Successive casts are designed to increase ROM until it is functional.
PRECAUTION = must be d/c if there is skin breakdown
69
Interventions for lower-level TBI ct's: Behavior & cognition
1. Important to track changes in arousal & awareness level - marks progress
2. Establish way to communicate - reliable yes/no system needs to be implemented (e.g. eye blinks, eye gaze, head nod, motor mvmts)
70
Interventions for lower-level TBI ct's: Family & caregiver education
1. Involving family helps them not feel helpless
2. Important for implementing ROM, position, & sensory stimulation programs since tx time is limited
3. Later on they can help with transfers, wc positioning, feeding programs, ADL retraining
4. Provide educational materials
71
Evaluation for intermediate-higher level ct w/ TBI (10)
```
Rancho Level 1-8
The ct is alert but is often confused, agitated, & inappropriate. Ability to follow simple 2-3-step directions, but easily distracted. Need min-mod cues.
Eval includes everything from before:
1. Physical status
2. Dysphagia
3. Psychosocial & behavioral factors
4. Vision
5. Sensation
6. Perception
PLUS
7. More extensive ADL/IADL (prob-solving, following multiple steps, safety awareness)
8. Work readiness
9. Driving
10. Ability to reintegrate into the community
```
72
Evaluation for intermediate-higher level ct w/ TBI: Typical cognitive assessments (5)
1. Allen Cognitive Level
2. Loewenstein Occupational Therapy Cognitive Assessment
3. The Rivermead Behavioral Assessment
4. Kohlman Eval of Living Skills (KELS)
5. Cognitive Assessment of Minnesota
73
Evaluation for intermediate-higher level ct w/ TBI: Typical ADL assessments (4)
1. Arnadottir OT-ADL Neurobehavioral Eval
2. Assessment of Motor & Process Skills (AMPS)
3. FIM
4. Klein-Bell Activities of Daily Living Scale
74
Evaluation for intermediate-higher level ct w/ TBI: Necessary components of a driving eval
1. Clinical assessment (visual, cognitive, perceptual, & physical status as it relates to driving)
2. On the road assessment
75
Interventions for higher-level TBI ct's: general approaches (2)
1. Rehabilitative model (regaining lost skills)
2. Compensatory model (adapt/modify to compensate for lost skills)
* Generally the rehabilitative model is used until the ct has plateaued, then compensatory strategies are implemented
76
Interventions for higher-level TBI ct's: Neuromuscular impairments - general approach (5)
1. Facilitate control of muscle groups (proximal - distal)
2. Encourage symmetric posture
3. Bilateral integration during activities
4. Encourage bilateral weight bearing
5. Introduce a normal sensory experience
77
Interventions for higher-level TBI ct's: Neuromuscular impairments - specific components/techniques (7)
1. Begin with pelvis - desire a slight anterior pelvic tilt
2. Next trunk - alignment, bilateral muscle use, weight shift in all directions
3. NDT
4. PNF
5. Myofascial release
6. Rood
7. PAMS
78
Interventions for higher-level TBI ct's: Ataxia
Rehabilitation methods not very effective
Weighting of body parts & use of resistive activities may improve control
AE such as weighted utensils & cups may help, but not often effective
79
Interventions for higher-level TBI ct's: Cognition
1. Use everyday/functional ADL/IADL tasks
2. e.g. using public transit works on: problem-solving, planning, organization, concentration, tolerance of frustration, sequencing, money mgmt, & categorization
80
Interventions for higher-level TBI ct's: Vision (3)
1. Diplopia - double vison - eye patch (or prism glasses or binasal occluders)
2. Vision exercises (intended to optimize, remediate, increase awareness, & compensate)
3. Enviro adaptations (color labels, large #s on phone, textures as cues)
81
Interventions for higher-level TBI ct's: Perception (4)
1. Figure-ground perception (Remediate [R] - practice - find socks in drawer, or Compensate [C] - arrange enviro, label, color code,etc.)
2. Aphasia (R - repeated conversation exercises & feedback; C - communication boards/technology)
3. Apraxia (R - hand over hand to relearn; C - follow steps)
4. Neglect (R - place items on neglected side, provide feedback; C - modify enviro/cater to unaffected side)
82
Interventions for higher-level TBI ct's: Behavior (5)
Twofold: Environmental & Interactive
ENVIRO:
1. Minimal sensory stimuli (no TVs, roommates, etc.)
2. One-to-one care (aid that remains w/ ct throughout day)
INTERACTIVE
3. Staff needs to be consistent (calm, concise)
4. Keep safe distance/awareness
5. Behavior mgmt program for ct's postacute
83
Interventions for higher-level TBI ct's: Dysphagia & self-feeding (4)
1. Begin in quiet enviro (room) progress to more social enviro
2. AE - rocker knife, plate guard, nonspill mug (intro one at a time if attention span is low)
3. Set down fork after each bite to ensure proper chewing
4. Altered consistencies to avoid aspiration
84
Interventions for higher-level TBI ct's: Functional mobility - General principles
1. Bilateral extremity use
2. Weight bearing
3. Tone normalization
4. Discourage compensatory strategies during acute phase - may become habitual & therefore lost potential for recovery
85
Interventions for higher-level TBI ct's: Bed mobility (4)
Training includes:
1. Rolling
2. Scooting up & down in bed
3. Bridging
4. Moving from supine to/from sitting & standing
86
Interventions for higher-level TBI ct's: wc mgmt (3)
1. mgmt of wc parts
2. propelling the wc on a variety on surfaces
3. possible need for custom wc if long-term use is suspect
87
Interventions for higher-level TBI ct's: Functional ambulation
Ambulation for purpose of participation in ADLs (use of UEs & LEs together to carry items, etc.), use of ambulatory device - compensatory aids include walker bags, baskets, wc carts, canes w/ built-in reachers, pouch belts (aka fanny packs), aprons during meal prep
88
Interventions for higher-level TBI ct's: Community Travel
Ability to respond to dynamic enviro (curbs, lights, signs, moving vehicles, etc.)
Possible powered scooter or wc
89
Interventions for higher-level TBI ct's: transfers (3)
1. Needs to be consistent due to memory deficits & poor carryover
2. Practice transferring both to L & R sides
3. Education family on proper techniques (body mechanics)
90
Interventions for higher-level TBI ct's: Home Mgmt (4)
1. Focus on activities ct performed prior to injury
2. Varies on level of ct (microwave meals vs stove)
3. Start simple & grade up
4. Family involvement as much as possible
91
Interventions for higher-level TBI ct's: Community Reintegration (2)
1. Practice trips into community to perform IADLs provide real life scenarios to practice/build new skills *necessary part of reintegration
2. Provide feedback based on observations of ct's strengths & weaknesses
92
Interventions for higher-level TBI ct's: Psychosocial Skills (10)
First year is the most difficult. GOAL = rebuild desired occupational & social roles
1. ID desired roles
2. ID activities that support those roles
3. ID rites of passage lost due to TBI (e.g. driver's license, graduation, employment, etc.)
4. Use of adaptation, compensation, & new learning to fulfill ID roles
5. Interpersonal skills
6. Self-expression
7. Social appropriateness
8. Time mgmt
9. Self-control
10. Group intervention
93
Discharge Planning includes
1. Home eval
2. Equipment eval & ordering
3. Family/caregiver education
4. Recommendations for a driver's training program
5. Recommendations for return to work/school
