Test 3: Moderate TBI

Question 1

what is a moderate TBI

Answer 1

middle GCS
moderate to high medical needs
some LOC
PTA at least 1 day and less than 7
marked confusion- Rancho level indicates

Question 2

what is a mild TBI

Answer 2

concussion

no LOC

<1 day PTA

no injury on image

Question 3

GCS for moderate TBI

Answer 3

9-12

Question 4

PTA for moderate TBI and score on O-log

Answer 4

1-7 days PTA

O-log score <25/30 for at least 1 day but less than 7

or

GOAT score of <75 for 1-7 days

Question 5

LOC for those with moderate TBI

Answer 5

30 min to 24 hours

Question 6

rancho levels IV-VI and meaning

Answer 6

IV = confused/agitated

V = confused/inappropriate

VI = confused/appropriate

Question 7

describe characteristics of pts with Rancho level IV (confused/agitated)

Answer 7

heightened activity

bizarre behavior

unable to cooperate directly with treatment

incoherent/inappropriate verbalization

lack of short and long term recall

may confabulate- create story that makes sense for them; not intentionally lying

limited ability to learn

Question 8

describe characteristics of pts with rancho level V (confused/inappropriate)

Answer 8

can consistently respond to commands

random response to complex commands

has attention to environment but lacks focused attention to task

confabulatory/inappropriate verbalization

impaired memory

inappropriate use of objects

can perform old tasks but trouble with performing new ones

**Like IV but without violence; more confusion and “why” than hostility

Question 9

describe characteristics of pts with rancho level VI (confused/appropriate)

Answer 9

can demonstrate goal behavior but need external input or direction

shows carry over for learned task

follow simple directions consistently

past memories are showing up more in depth than recent memories

may have wrong answer to questions, but is appropriate in answer

Question 10

things to consider when taking history/doing pt interview with moderate TBI pt

Answer 10

Behavior, arousal, consciousness limit

pts not good historians - often confused and confabulate

medical status not as dynamic as severe TBU but still consult RN

Question 11

cognitive screens/scales used for cognition with moderate TBI (if appropriate to test)

Answer 11

coma recovery scale (CRS)

moss attention rating scale (MARS)

rancho levels of consciousness scale

Question 12

describe MARS

Answer 12

measurs attention related behaviors after TBI

22 items

5 point rating scale

Question 13

selective vs divided attention

Answer 13

selective = requires pt to attend to a singular particular task (i.e. digit span task)

divided attention = examined by requiring pt to attend to 2 tasks simultaneously

Question 14

basic cognitive functions vs advanced

Answer 14

basic = attention, memory, and language

advanced = abstract thinking, problem solving, judgement, and reasoning

Question 15

how does attention require cognitive demand

Answer 15

difficulty paying attention = increases cognitive demand

leads to cognitive fatigue

fatigue leads to agitation and irritability

Question 16

how does executive function allow us to behave appropriately and pragmatically

Answer 16

poor judgement = poor choices

decreased filter for what is appropriate = say inappropriate things

presents as misbehavior

Question 17

recommended measure for looking at affect/behavior changes in moderate TBI pts

Answer 17

agitated behavior scale

Question 18

describe the agitated behavior scale

Answer 18

measures behavior aspects of agitation during acute phase from TBI

measures aggression, disinhibition, and lability

can also be used with dementia

14 items scored 1-4 (1 is not present behavior, 4 is extremely present)

min score = 14, max = 56

lower scores better

Question 19

scoring scale for agitated behavior scale

Answer 19

</= 21 - WNL

22-28 = mild agitation

29-35 = moderate agitation

36 or over = severe agitation

Question 20

outcome measures used for general neurological injury

Answer 20

6 MWT

10 MWT

Berg Balance Scale

Functional Gait Assessment

Activities Specific Balance Confidence Scale

5 time STS

Question 21

outcome measures recommended for inpatient rehab TBI pts

Answer 21

FAM+FIM

Barthel index

Disability rating scale

Question 22

outcome measures recommended for outpatient rehab TBI pts

Answer 22

high level mobility assessment

community balance and mobility scale

quality of life after brain injury

Question 23

interpretation of berg balance scale

Answer 23

45-56 = independent

<45 = fall risk (for stroke and older adults)

ceiling effect possible

Question 24

describe the berg balance scale

Answer 24

14 item

geriatric adult or neuro pt to assess fall risk

15-20 min to administer

0-4 pt scoring; 0 is lowest, 4 is highest level of function

Question 25

describe the Functional Assessment Measure (FAM + FIM)

Answer 25

12 items added to FIM; enhances utility for brain injury population rated on same 7 pt scale as FIM increased time to administer

Question 26

what are the 12 items added to FIM to create FIM+FAM

Answer 26

swallowing car transfer community access readign writing speech intelligibility emotional status adjustable to limitations employability orientation attention safety judgement

Question 27

describe the barthel index

Answer 27

assesses ability of individual with neuromuscular or musculoskeletal disorder to care for him/her self inpatient rehab activity domain - caring for yourself not specific to TBI/stroke evaluation of independence; measures changes in disability over time score measures functional independence; higher score = better function

Question 28

describe the disability rating scale

Answer 28

tracks recovery of individual from coma to community measures general functional changes ove rcourse of recovery for mod-severe TBI 30 pt scale observer rated evaluates 8 areas of functioning and 4 categories -consciousness -cognitive ability -dependence on others -employability high score = higher level of disability (29 highest, 0 min)

Question 29

outcome measures for gait

Answer 29

setting doesnt matter; outcome measures for gait are same no matter the setting diagnosis does not matter TUG 6MWT 10 MWT Dynamic gait index

Question 30

gait outcome measure for TBI pt

Answer 30

high level mobility assessment (HiMAT) community balance and mobility scales

Question 31

describe the HiMAT outcome measure

Answer 31

assesses high level performance in TBI may use orthoses must be able to ambulate 20 m independently w/o AD used in outpatient activity ICF domain 13 items performed at max speed (running, skipping, hopping, etc) total scores from 0-54 (each item 0-4) higher scores = better performance

Question 32

normative values for HiMAT 18-25 years old

Answer 32

males: 50-54 females: 44-54

Question 33

describe the community balance and mobility scale

Answer 33

detects high level balance and mobility deficits based on tasks that are commonly encountered in community environments similar to HiMAT but not specific to TBI allowed to wear orthotic cant use ambulation aids 13 challenging tasks with 6 tasks performed on both sides

Question 34

scoring for community balance and mobility scale

Answer 34

items scored from 0-5 and reflect progressing difficulty 0 = complete inability to perform 5 = most successful completion of item possible max score of 96 high score = high function

Question 35

intervention considerations for PTs with moderate TBI pt

Answer 35

distribute practice with frequent rest (mental fatigue leads to irritability, lowered attention, etc) self efficacy and executive function dual task performance for community reintegration aerobic conditioning (helps with deconditioning associated with prolonged stay in ICU/acute care)

Question 36

where to start with return to mobility for moderate TBI pts

Answer 36

upright interventions good for BP management, WBing, strength, building against gravity, prevention of contractures, and progression toward function for more alert pts: standing frame, BW support, or sabina lift

Question 37

examples of task oriented training

Answer 37

crossing street doing laundry folding towels cooking a meal taking the bus playing the guitar

Question 38

when is behavior management most often used

Answer 38

rancho IV TBU cant participate in new learning and pt is easily agitated reorientation is primary focus

Question 39

ways to manage behavior in pts

Answer 39

work on familiar activities (no new learning; dont overstimulate) coregulation of ANS (use your ANS to regulate theirs; open posture, calm voice, low stimulation) do no escalate with them consistent time/schedule; team effort nonviolent crisis intervention training

Question 40

what is a behavior modification plan

Answer 40

uses behavioral modification techniques such as positive reinforcement with an accompanied point or reward system developed with pt based on percieved goals for behavioral modificaiton must have capacity to learn (Rancho V and VI)

Question 41

describe management of cognitive/executive function as an intervention

Answer 41

focus of SLP and OT PT needs to reinforce use outcome measures (MMSE, MOCA, SLUMS) work on prioritization of tasks reinforce appropriate vs inappropriate behavior promote safety start simple then ass complex as they emerge through rancho stages (usually applicable to rancho VI and beyond) for PT, incorporate cognitive thought into mobility exercises (i.e. self reflection or mental walkthroughs)

Question 42

neuroprotective benefits of ecercises - pros

Answer 42

aerobic conditioning for cognitive benefit

Question 43

neuroprotective benefits of exercises - cons

Answer 43

TBI pts have decreased ability to perform aerobic exercise due to deconditioning due to prolonged ICU/acute care stays