TBI

Question 1

What is a traumatic brain injury?

Answer 1

Alteration in brain function, or other evidence of brain pathology

Question 2

What is the leading cause of TBI?

Answer 2

TBI is leading cause of injury-related death
Falls (32%)
MVA (19%) are second

Question 3

Who is most at risk for a TBI?

Answer 3

Children and young adults

most common in children 0-4 years old

Question 4

What is the mechanism of injury for primary injury?

Answer 4

Brain tissue contacts object (bony skull or external object , bullet)
Rapid acceleration/deceleration

Question 5

What are the 2 was rapid acceleration/deceleration create a primary brain injury?

Answer 5

Cause sheer, tensile, and compression forces

Causes diffuse axonal injury (DAI), tissue tearing, hemorrhages

Question 6

Where do you see TBI related blast injury?

Answer 6

Military conflicts, explosive devices produce shock waves

Question 7

What is the mechanism of injury during a secondary injury part of a TBI?

Answer 7

Results of chain of cellular events that follow tissue damage
Hypoxemia, hypotension, ischemia, edema, elevated ICP, hematomas
Develop over hours and days

Question 8

What are some common impairments seen with TBI (7)?

Answer 8

WIDE spectrum
Neuromuscular - paresis, abnormal tone, motor function
Cognitive - arousal, attention, concentration, memory
Neurobehavioral - Agitation, aggression, disinibition, apathy, impulsivity
Communication
Swallowing
Dysautonomia
Seizures

Question 9

Are cognitive and behavioral or physical limitations more disabling?

Answer 9

Cognitive and behavioral

Question 10

What are the 3 categories in the Glasgow Coma Scale?

Answer 10

Eye opening (1-4)
Best Motor Response (1-6)
Verbal Response (1-5)

Question 11

How does the scoring system of the Glasgow Coma Scale work?

Answer 11

Scored 3-15
Score 8 or less = severe
9-12 moderate
13-15 mild

Question 12

What are some other ways you can determine the severity of a TBI?

Answer 12

Measure loss of consciousness
Alteration of consciousness
Post traumatic Amnesia

Question 13

What is post-traumatice amnesia and how can it be used as a predictor for recovery?

Answer 13

Length of time between injury and time at which the patient is able to consistently remember ongoing events
0-1 day mild
>1 and 7 days Moderate
>7 Days Severe

Question 14

What needs to be done at the scene of the accident after a TBI?

Answer 14

Stabilize cardiovascular and respiratory systems to maintain sufficient blood flow and O2 to the brain

Question 15

What happens early on at the hospital after a TBI?

Answer 15

Minimize secondary brain injury by optimizing cerebral blood flow, stabilize vitals, perform complete exam, identify and treat non neurological injures
May need intubation
Imaging and possible surgeries for hematomas

Question 16

What is normal ICP per NIH?

Answer 16

1-20 mmHg

Question 17

How can you treat elevated ICP (5)?

Answer 17

Sedating medications
Moderate head-up positioning
Hypothermia
Surgical decompression (bone flap removal)
Induced coma may be necessary

Question 18

Where’s the best place to monitor ICP?

Answer 18

External ventricular drain with subdural bolt or fiberoptic catheter

Question 19

Name 2 things you want to do before seeing the patient with a TBI in the acute phase.

Answer 19

Complete medical record review

Get an update on status from nursing

Question 20

What are some things your going to want to look at with a patient with a TBI?

Answer 20

Arousal, attention, cognition
Integument integrity
Sensory integrity
Motor function
ROM
Reflex integrity
Ventilation and respiration

Question 21

What are some scales you can use to measure arousal, attension, and cognition and what’s the most important one?

Answer 21

Coma recovery scale-Revised (CRS-R) - (23 item measures auditory, visual, motor, oromotor, communcaion and arousal)
Disorders of Consciousness scale (DOCS) - 23 items assess social knowledge, taste/swallowing, olfactory, proprioception, tactile sensation, auditory function, and visual function
Rancho Los Amigos Levels of Cognitive Functioning (LOCF) best one

Question 22

What are the 8 stages of the Rango Los Amigos Level of Cognitive Functioning?

Answer 22

1 - No response
2 - Generalized response
3 - Localized Response
4 - Confused-Agitated
5 - Confused-Inappropriate
6 - Confused-Appropriate
7 - Automatic-Appropriate
8 - Purposeful-Appropirate

Question 23

What are some goals in the acute phase after a TBI? (8)

Answer 23

Increase physical function and level of alertness
Reduce risk of secondary impairments
Manage the effects of tone
Improve postural control
Increase tolerance of activities and positions
Improve or maintain joint mobility and integrity
Educate family and caregivers
Coordinate with team members to provide care

Question 24

What are some interventions for preventing secondary impairments in the acute phase?

Answer 24

Proper positioning in bed/wheelchair
Passive ROM
Special boots or splints
Turning to prevent skin breakdown (every 2 hours)
Socialized air mattress
Serial casting (contracture)

Question 25

True/False It is important to move into a sitting position as soon as medically stable.

Answer 25

TRUE | Use tilt table for early weight-bearing

Question 26

During an examination of a patient with a TBI what is important for the physical therapists to be?

Answer 26

Be creative and Observant | -Standardized tests and measures may be difficult or inaccurate due to cognitive and behavioral impairments

Question 27

What are some things the PT should know?

Answer 27

Patient able to follow commands? (1-step, mutli-step) Is the patient oriented to person, place, and time? Does the patient recognize family members? Does the patient demonstrate any insight into what has happened?

Question 28

Name some outcome measures for TBI Attention and Cognition.

Answer 28

The Moss Attention Rating Scale (MARS) Test of Everyday Attention and Trail Making Test Part B (used by neuropsychology) Galveston Orientation and Amnesia Test (GOAT), often used b SLP

Question 29

Name some outcome measures for TBI Balance

Answer 29

BERG Balance Scale (when used with FIM may prdict length of stay, falls and functional gains) Community Balance and Mobility Scale (CB&M) - reliable and valid (specific to TBI) High-Level Mobility Assessment Tool (HiMAT) - measures higher level of performance patients with TBI

Question 30

What is a good outcome measure for global function after a TBI?

Answer 30

FIM - functional mobility, ADL function, cognition, and communication - Designed to measure level of disability and burden of care during inpatient rehab - Useful for monitoring patient progress - Valid and Reliable after TBI

Question 31

Describe the FIM

Answer 31

Has 18 items -13 motor -5 cognitive Scores range from 18-126 (each task has a 7 point scale)

Question 32

How does the scoring system work for the FIM?

Answer 32

No Helper - 7 or 6 (6 uses an assistive device Helper Modified Dependence - 5-3 (5 just needs supervision, 4 min assist, 3 mod assist) Helper Complete Dependence - 1-2 (2 max assist, 1 total assist)

Question 33

Name some functional and outcome measures for locomotor skills after TBI?

Answer 33

``` Observational gait (stance and swing phase) Gait speed (10 meter walk test) Endurance (6 MWT) Dual Task Performance Functional Gait Assessment (FGA) Dynamic Gait Index (DGI) ```

Question 34

Name some motor re-learning strategies after TBI.

Answer 34

Plan sessions ahead of time Practice should be distributed with frequent rest periods Explicit or augmented feedback may be better then intrinsic FOCUS on FUNCTION and work toward Active Movement as soon as able

Question 35

Do you want to use restorative or compensatory interventions with TBI injuries?

Answer 35

Probably both Restorative rehab will result in greater functional independence Compensatory will ensure safety

Question 36

What type of interventions with large amounts of practice can induce neuroplastic changes and restore function?

Answer 36

Task Specific Interventions

Question 37

What 3 things about interventions make them the most beneficial?

Answer 37

Specific to function/task Meaningful to patient Challenging to systems

Question 38

Name some strategies for treating confused or agitated patients (6)?

Answer 38

Consistency - All team members be consistent, establish routine Expect No Carryover - Teaching new skills unrealistic (use charts, graphs, memory aids) Model Calm Behavior Expect egocentricity - patient may not see others points of view Flexibility/Options Safety

Question 39

What type of TBI is a concussion known as?

Answer 39

mTBI | Mild TBI

Question 40

What characteristics be in a person with a concussion? (GCS score, etc)

Answer 40

13-15 GCS score Varying degrees of loss of consciousness (0-30 min) PTA Altered mental state for up to 24 hours

Question 41

What are some symptoms of a mild TBI?

Answer 41

``` Blurred vision and nausea are the 2 biggest ones Cognitive deficits Postural control and balance impairments Light Sensitivity Sleep Disturbance Ringing in the ears ```

Question 42

How long does it take for most people to recover from a mild TBI?

Answer 42

Fully recover in 3 months

Question 43

What percentage of people may experience postconcussive syndrome?

Answer 43

10-20%

Question 44

How do you want to return to activity after mild TBI?

Answer 44

1: No activity - (cognitive & physical rest until symptoms resolve) 2: Light aerobic exercise 3: Sport-specific exercise 4: Noncontact training drills 5: Full-contact practice 6: Return to play

Question 45

How long does each step of recovery take after mTBI?

Answer 45

``` 24 hours (1 week to return to full active duty or sport activity) ```

Question 46

What needs to be done if symptoms of mTBI return during a stage of recovery?

Answer 46

Wait 24 hours (rest) | Go back to previous stage

Question 47

Name some interventions for mTBI.

Answer 47

Vestibular - BPPV & Gaze stabilization exercises High-level task oriented balance and gait training Patient Education

Question 48

What is one of the most important thing to educate a patient about for a mTBI?

Answer 48

Dangers of Second Impact Syndrome