TBI (Part 2)

Question 1

TBI Rehab Team

Answer 1

• Medical team = physician, resident, physicians assistant, nurse practitioner, nurse, nursing assistant
• neuropsychologist
• Therapy team = OT, COTA, PT, PTA, SLP
• Social worker/case manager
• recreational therapist
• respiratory therapist

Question 2

Course of Rehab

Answer 2

• ICU/acute care;
• inpatient rehab program (May depend on cognitive recovery)
  
  • Patient receive services from a multi-disciplinary team
  • three hours of therapy each day
• Long-term care facility
  
  • After acute care; before inpatient rehab; or skip inpatient rehab
• Outpatient rehab
• Community-based programs
  
  • Vocational re-entry; exercise programs

Question 3

When to start therapy

Answer 3

• No set standard (patient dependent)
• Team decision
• Two primary reasons
  
  • Normalization of ICP (< 20 mmHg, patient dependent)
  • hemodynamic stability

Question 4

Strategies to Maximize Outcomes

Answer 4

• Structured organizational system
  
  • Daily log/journal;
  • calendar;
  • areas for important documentation (HEP, medication list)
    
    • at higher RLFCS levels, patient can fill it out on their own

Question 5

Galveston Orientation and Amnesia Test (GOAT)

Answer 5

• Formally assesses PTA
  
  • memories before and after the injury
  • 100 points
    
    • 76-100 = normal
    • <76 = still in PTA
  • Pediatric version: Children’s Orientation and Amnesia Test (COAT)
• rarely assessed by PT*

Question 6

Glasgow Outcome Scale (GOS)

Answer 6

• assessed generalized outcomes
• interview with patient/family
  
  • death
  • vegetative
  • severely disabled
  • moderately disabled
  • good recovery

Question 7

Rancho Level I-III: Chart Review

Answer 7

• ventilator
• ICP monitoring
• WTB restrictions
• ROM restrictions
• Open Wounds
• External fixations
• presence of other external supports

Question 8

Levels of Consciousness: Coma

Answer 8

• completely unresponsive
• eyes are typically closed (no sleep cycle)
• GCS <9; Rancho Level I

Question 9

Levels of Consciousness: Vegetative State

Answer 9

• patient is awake, but not aware
• spontaneous eye opening
• restoration of sleep/wake cycle
• lack of awareness of self and environment
• Rancho I or II

Question 10

Vegetative State: Characteristics

Answer 10

• may startle to visual or auditory stimuli (inconsistently)
• not able to follow commands or communicate
• reflexive smiling, yawning, crying, chewing
• MAY demonstrate generalized response to stimuli (Rancho Level II)

Question 11

Persist at Vegetative State

Answer 11

• > 12 months post trauma

- >3 months post anoxia (poor px)

Question 12

Minimally Conscious State (MCS)

Answer 12

• awake and partially aware
• be able to do one of the following
  
  • follow commands
  • communicates yes/no
  • verbalize intellectually
  • demonstrate purposeful behavior
• Rancho level II or III

Question 13

Emergence from MCS

Answer 13

• demonstrate one or both of the following
  
  • and yes/no to 6/6 situational questions on 2 seperate occasions
  • functional object use for 2 different objects

Question 14

Assessing Levels of Consciousness: Levels I-III

Answer 14

• distraction free environment
• motor movements that aren’t reflexive (blinking, open/close hand)
• movements have to be within patient’s ability

Question 15

JFK Coma Recovery Scale-Revised (CRS-R)

Answer 15

• assess people in a coma or coma emergent
• 23 items: 6 subgroups
  
  • audio, oromotor, visual, motor, communication, and arousal
  • 23 points
• differentiates between levels of coma (VS, MCS)

Question 16

Rehab Goals: Levels I-III

Answer 16

• increase alertness and level of function
• minimize risk of secondary impairments
• manage abnormal tone
• tolerate upright positions
• improve motor control
• improve or retain joint integrity and ROM
• provide education to family and caregiver

Question 17

Early Mobility

Answer 17

• monitor vitals closely
• getting them to different positions
  
  • sitting on edge of bed, sitting up, getting into chair, standing frame
• goal = increase alertness with stimuli in different environment

Question 18

Sensory Stimulation Program

Answer 18

• goal: increase level of alertness, arousal, and awareness
• informal or formal
• nondistracting environment
• give patient time to respond
• olfactory ad gustatory are first triggered
• document environment include patient position

Question 19

Informal Sensory Stimulation Program

Answer 19

• for patients making changes readily

- different therapists provide different stimuli

Question 20

Formalized Sensory Stimulation Program

Answer 20

• each team member provides consistent sensory stimuli
• results are docmented
  
  • used to track progress, update insurance companies, help support families
• 4-6x/day
• discontinued once patient shows consistent responses (emergence from MCS)

Question 21

Skin Management

Answer 21

• beware of ulcers
• prevent skin issues
  
  • turning schedule
  • speciality bed
  • wheelchair seating and positioning
• provide family education

Question 22

ROM/Tone

Answer 22

• ROM should be assessed at IE
• prevent any ROM deficits
• address ROM impairments first

Question 23

Contracture Prevention/Management

Answer 23

• position devices
• educate patient and family
• stretching/WTB
• serial casting

Question 24

Serial Casting

Answer 24

• most common areas
  
  • prevent elbow flexion contracture
  • prevent ankle PF contracture
• improves transient ROM

Question 25

Rancho Levels I-III interactions

Answer 25

- treat with respect - explain what and why you are doing something - frequently orient patient - give time to respond - PT model behavior for patient and family - dont overstimulate

Question 26

Rancho Level IV: Optimizing the Environment

Answer 26

- allow freedom of movement - floor bed; padded walls - non-distracting environment - helmets, abdominal binders, G-tube - carefully choose when family members can watch tx session - have help easily available

Question 27

Rancho Level IV: Activity Selection

Answer 27

- shorter tx sessions - provide a lot of rest breaks - activities that allow the patient to move - repetitive and automatic task can help ease agitation - have many activities - change activity often

Question 28

Rancho Level IV: Patient Interaction

Answer 28

- be careful of nonverbal communication - be respectful - be flexible and let the patient have control - provide frequent re-orientation

Question 29

Rancho Level IV: Medical Management

Answer 29

- behavioral intervention first | - medication are last resort and used if PT, other team members, and/or family isn’t safe

Question 30

Rancho Level IV: Patient Exam

Answer 30

- frequent observation based - functional skills; use of UE and LE - can’t formally assess using: - outcome measures for balance/gait - thorough impairment testing - document: - command following - attention to the environment - ability to recognize familiar people, objects, photos to help with orientation

Question 31

Agitated Behavior Scale

Answer 31

- 14 items | - scoring = 14-56 (higher score = more impaired)

Question 32

Rancho Level IV: Goals

Answer 32

- no functional goals - no new learning - improve endurance - improve activity tolerance - decrease agitation - family edu and support - help patient learn to control his/her own behavior - prevent agitation through environmental modification and graded stimuli

Question 33

Rancho Level IV: interactions

Answer 33

- redirect patient to ew task, or face - show verbal and nonverbal communication that you support - use team members to help with behavior - behavioral modification plan can be help is in level IV for a while