Traumatic Brain Injury Flashcards
(36 cards)
1
Q
What is TBI?
A
Brain injury caused by an impact to the head resulting in an acceleration or deceleration of the brain within the skullll
2
Q
What are the two main types of TBI?
A
Focal & diffuse
3
Q
What are the characteristics of focal TBI?
A
- Produce contusions & haematomas
- Subsequent deficits based on location, size & progression
- Commonly in frontal lobes & anterior & inferior temporal regions
4
Q
What are the characteristics of diffuse TBI?
A
- Result of stretch & shearing to axons
- Most commonly in BG, cerebellum, corpus callosum & midbrain
- Higher mortality & morbidity than focal
- More likely paediatrics than adults
5
Q
What does initial medical management of TBI involve?
A
- Check GCS score at scene
- Preventing hypoxia & hypotension & treating any operable intracranial lesions (as primary brain injury cannot be reversed)
- Patient may require intubation, sedation & paralysis, intravenous fluids
6
Q
What values are MAP and CPP maintained above in the management of primary TBI?
A
MAP > 90mmHg
CPP > 70mmHg
7
Q
When is surgery considered for TBI?
A
If SDH >5mm or ICH >20ml with a mid-line shift
8
Q
What are TBI outcomes inversely proportional to?
A
Percentage of time ICP >20mmHg
9
Q
What are the common causes of TBI?
A
- Falls (28%)
- MVA (20%)
- Struck by/against events (19%)
- Assaults (11%)
10
Q
What are the rates of falls?
A
- Highest for children 0-4 years & adults 75+ years
- Risk increases with age, women > men
- 2/3 of those who fall will fall again within 6 months
11
Q
What are the common primary motor impairments in TBI?
A
- Loss of strength
- Loss of dexterity
- Loss of sensation
- Spasticity
12
Q
What are the common non-motor impairments in TBI?
A
Language:
- Receptive/expressive aphasia
- Commonly have both at the same time
Perceptual-cognitive:
- Information processing
- Attention
- Memory
Behavioural:
- Lability (uncontrolled emotions)
- Disinhibition (no social filter)
- Apathy (difficulty initiating/finishing anything, looks like laziness)
- Decreased planning
13
Q
What are the characteristics of expressive aphasia?
A
- Inability to express language
- Comprehension preserved, expression affected
- Little impact on motor training
14
Q
What are the characteristics of receptive aphasia?
A
- Inability to understand language
- Comprehension, reading and writing affected
- May have significant impact on motor training
15
Q
What are the strategies for training patients with aphasia?
A
- Liaise with speech pathologist
- Establish some form of communication
- Don’t exclude the patient or finish the patient’s
sentences during conversation - Keep sentences short & simple
- Provide time for the patient to answer
- Use eye contact, gestures and demonstrations
- Don’t shout
16
Q
What are the characteristics of loss of information processing?
A
- Slowness in response to cognitive demands
- Reduced ability to perform two tasks at once
17
Q
What are the characteristics of loss of attention?
A
- Sustained
- Selective
- Spatial
18
Q
What are the types of loss of memory?
A
- Short term memory loss
- Post-traumatic amnesia (PTA)
19
Q
What did Madigan et al 2000 find regarding loss of information processing in TBI patients
A
- Compared TBI patients with control
- Provided subjects with 2 serial addition tasks (one auditory, one visual)
- Greater time required to complete auditory tasks for both groups
- TBI patients were slower than controls in both conditions
- At preferred speed TBI patients had greater accuracy
- CIs: Give patients time to process instructions &
complete the task, provide written/verbal instructions & photos/diagrams
20
Q
What are the strategies for motor training when a patient has loss of information processing?
A
- Give patients time (slow down)
- Ensure patient is on task
- Provide written information
- Increase arousal before completing more
difficult cognitive tasks
21
Q
What is the impact of loss of attention on motor training?
A
- Mental fatigue after several repetitions
- Distracted after several repetitions
- Inability to attend to stimuli on one side of the
body or the environment
22
Q
What did Whyte et al 1994 find regarding loss of attention in TBI?
A
- 4 TBI patients
- Video taped patients completing 3 tasks with varying degrees of structure over 3 sessions
- Deliberate, random distractions implemented
throughout task - Measured time on/off task
- All patients improved
- The more structured the task, the greater the
time spent on task - The greater the complexity the less time spent on
task - The greater the number of distractions the less
time spent on task
23
Q
What are the clinical implications of the study by Whyte et al 1994 regarding loss of attention?
A
- Attention and time on task improves with practice, so can be trained
To increase motor practice:
- Increase structure of the task
- Reduce complexity of the task
- Reduce distractions
24
Q
What did Robertson et al 1996 find regarding loss of attention in TBI?
A
- Trained patients with left neglect under 5
conditions (control, PROM exercises left hand, visual anchor to left, auditory anchor to left, AROM left fingers and knee) - Greatest improvement on the letter cancellation
test was under the AROM condition - Some improvement with the visual and auditory
anchor - No change with PROM
- CIS: Train active movements ASAP
25
What are the strategies for motor training for patients with loss of spatial attention?
- Increase awareness and arousal
- Encourage visual scanning
- Encourage searching
- Encourage active movements of the affected side
- Use markers to anchor vision
- Use rehearsal and self cueing
26
What are the strategies for motor training for patients with loss of selective & sustained attention?
- Reorient the patient often
- Use feedback and visual cues
- Increase the structure of training
- Minimise distractions
- Set goals to sustain attention
27
What did Wilson et al 2001 find regarding short term memory loss?
- Patients with difficulty remembering ADLs randomly allocated to pager system for 7 weeks
- Significant improvement in remembering ADLs
at end of 7 weeks with use of pager
- 75% of the first group retained improvement
after they stopped using the pager
- CIs: Devices that alert patients to complete practice
may be a useful adjunct to therapy
28
What are the strategies for motor training patients with short term memory loss?
- Simplify information
- Reduce the amount of information
- Reduce distractions
- Ensure understanding
- Link new information with already known information
- Encourage questions
- Label the environment
- Use reminders
- Use internal mnemonic strategies
29
What are the types of memory?
Declarative:
- Data based memory (factual)
- Affected in PTA, e.g. won't remember therapist from the day before
Procedural:
- Rule based memory
- Related to skill learning
- Intact in PTA, e.g. will remember skills learnt the day before
30
What are the strategies for motor training patients with PTA?
- As for short term memory loss plus
- Keep the structure of practice the same (i.e. same order of exercises)
- Use trickery and bribery
- Reorient the patient continually to the task
- Keep instructions short
31
What is the impact of behavioural impairments on physio?
- Reduces the amount of practice achieved
- Decreases the retention of learnt skills
- Creates stress for staff and family
32
What did Eames & Wood 1985 find regarding behavioural modification in disinhibition?
- TBI patients > 1 year post injury with severe
disinhibition resulting in unacceptable behaviour (e.g. walking around naked)
- Implemented behavioural modification & tokens to extinguish inappropriate behaviours
- Reduced supervision for 66% of patients & 50% continued to improve after cessation of intervention
33
What did Burke et al 1991 find regarding TBI patients with behavioural impairments?
- TBI patients were provided with written check-
lists for problem solving, planning or apathy
- Resulted in a progressive reduction in the
prompting required to complete the task & increase in the number of tasks completed
34
What are the clinical implications of the studies regarding behavioural impairments?
- Behavioural impairments can be successfully
treated by combining rehabilitation &
behavioural modification
- Providing structured written information may
reduce prompting required and increase the amount of practice performed
35
What are the interventions for behavioural impairments?
- Positive reinforcement
- Extinction
- Fogging and broken record (repeating instructions)
- Time out on the spot
- Non-contingent reinforcement (telling them they're great all the time)
- Token systems
- Contracts
- Checklists
- Graph results
- Train what patient wants to do
- Provide structure and direction
- Complete home visits & set goals
36
What are the outcome measures used for perceptual-cognitive & behavioural impairments?
Performed by OT or neuropsych
- Westmead PTA scale
- Rivermead Behavioural Memory test
- Rivermead Perceptual Assessment Battery
- Behavioural Inattention test
- Recording number of inappropriate behaviours
per session
