Week 4

Question 1

Definition of TBI

Answer 1

nondegenerative, noncongenital insult to the brain from an external force mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical and psychosocial functions with an associated diminished or altered state of consciousness

Question 2

what is the most common cause of death under the age of 35 in most developed countries

Answer 2

TBI

Question 3

What is the most common cause of accidental death

Answer 3

TBI

Question 4

TBI is most commonly the result of

Answer 4

road accidents
industrial and sporting accidents
attempted suicides
interpersonal violence

Question 5

M vs F TBI

Answer 5

males outnumber females 2:1

Question 6

What is the second leading type of ABI in australia

Answer 6

TBI, following stroke

Question 7

Mild compared to moderate or severe TBIs

Answer 7

20% moderate or severe

80% mild

Question 8

increasing number of elderly people sustaining TBI’s, why?

Answer 8

falls

Question 9

Risk factors of TBI

Answer 9

young adults : 66%
M>F
Fall: 40%
Transport (MVA: 33%
Assault 25%
substance abuse
risk taking behaviour
psychiatric disorder
limited educational attainment 
unstable work history

Question 10

sequelae =

Answer 10

complications

Question 11

complications associated with TBI include

Answer 11

dependant on severity
physical and cognitive impairments - vary as a consequence of the lesion severity and location as well as the nature of brain damage and complications

can have devastating impact on lifestyle/future aspirations, creating general health and social problems causing disruption for family members and marital strain, affecting role relationships and fostering economic hardship
Individuals confront their disability for decades in a society which most commonly associates disability with the elderly or those with congenital intellectual disabilities

Question 12

Common health issues in TBI include

Answer 12

seizures (early and late) 
Somatic complaints
- headaches
dizziness
- pain
- sleep disturbances 

Post concussion syndrome 
Mental health issues 
- depression 
- anxiety 
- schizophrenia

Question 13

What are ways to prevent TBIs

Answer 13

protective laws and recommendations have resulted in a reduced incidence (and reduced severity) of TBI
use of helmets by cyclists, motorcyclists
protective headache in sport
automobile seatbelts
automobile child restraints/rearfacing car seats
enforcement of drink driving laws
falls prevention strategies for those at risk of falls

Question 14

MOI for TBI

Answer 14

neuropathological evidence suggests that there are several mechanisms of brain injury, some operating at the moment of impact and others as a consequence of secondary complications

Question 15

Types of MOIs

Answer 15

direct - blunt/penetrating

indirect

Question 16

Direct MOI is

Answer 16

direct blow to the head

Question 17

indirect MOI is

Answer 17

impact from other parts of the body

Question 18

Blunt direct MOI is

Answer 18

acceleration-deceleration injury commonly resulting in multiple body injuries and widespread brain damage; may cause scalp injuries, skull deformation +/- fractures and depressed fractures +/- perforated dura mater and brain

Question 19

penetrating direct MOI

Answer 19

open head injury in which the dura mater is breached; may be caused by external objects or bone fragments from a skull fracture

Question 20

Primary brain damage involves

Answer 20

occurs at the time of injury

effects are largely immediate

Question 21

Neuropathic processes of primary brain damage

Answer 21

hypoxia
hypotension
cerebral metabolic flow uncoupling
impairments of CV autoregulation - important for maintaining ICP

Question 22

Secondary brain damage cause

Answer 22

primary injury initiates cascade of neuropathological processes resulting in more severe and widespread brain damage

Question 23

Neuropathic processes involved in secondary brain damage

Answer 23

excitotoxicity
impaired calcium homeostasis
oxygen free radicals
inflammatory processes

Question 24

intracranial mechanisms in primary and secondary brain damage

Answer 24

primary

• diffuse
• -diffuse axonal injury
• focal
• • laceration
• • contusion
• -haemorrhage (subdural, epidural, subarachnoid, intraventricular)

Secondary

• brain swelling (vasogenic oedema, cytotoxic oedema )
• cerebral blood vessel constriction

Question 25

Extracranial mechanisms

Answer 25

hypoxia | hypotension

Question 26

predictors of outcome for TBI include

Answer 26

period of confusion (PTA) - immediate loss or impairment of consciousness indices of severity of predictors of outcome -depth of coma -duration of coma - length of post-traumatic amnesia (PTA) depth of coma provides the best clinical picture of a patient's current neurological status Duration of coma and length of PTA appear to be better predictors of functional outcomes

Question 27

Depth of coma

Answer 27

the GCS defines severity of a TBI within 48h of injury most widely used measure of severity of coma - severe =GCS less than or equal to 8 Moderate = 9-12 Mild =13-15

Question 28

If a patient is intubated and therefore cannot give a verbal response for a GCS, what do you do

Answer 28

add the suffix T indicates intubation therefore maximum score = 10T minimum score = 2T

Question 29

Duration of coma is determined by

Answer 29

different definitions , they include - time from injury to spontaneous eye opening the following of commands and scoring >/=8 on GCS Severity of trauma using the duration of coma are ``` Severe= >6h Moderate = 20m - 6h Mild = <20m ```

Question 30

Length of PTA

Answer 30

PTA is the period of impaired consciousness that extends from the initial injury until continuous memory for ongoing events is restored Criteria for classification of severity using duration of PTA = extremely severe = >4 weeks Very severe= 1-4 weeks Severe= 1-7 days Moderate =1-24h Mild =<1hour

Question 31

Recovery from TBI includes

Answer 31

most exhibit a range of ongoing sensorimotor, cognitive and behavioural sequelae, which vary widely in their nature and severity mechanism of recovery poorly understood considerable variability in patterns of recovery

Question 32

types of recovery

Answer 32

spontaneous recovery - resolution of temporary physiological changes regenerative neuronal changes - limited potential, especially with severe injuries neuroplasticity/cortical reorganisation - capacity decreases with severe injuries - presence of intact tissue enables reorganisation

Question 33

Recovery from mild TBI

Answer 33

expected to recover quickly, how ever some will have psychological consequences that require management most people experiencing mild TBI recover fully within days to months, but a small percentage (1-20%) continue to experience symptoms three months after injury

Question 34

Recovery from moderate - severe TBI

Answer 34

negatively accelerating curve, with recovery being most rapid in the first 3-6 months may continue for several years

Question 35

Rehabilitation includes

Answer 35

acute care stabilisation recovery after TBI often exceeds expectations rehabilitation routinely offered to patients who have some level of responsiveness to maximise potential for recovery

Question 36

Physiotherapy assessment of the TBI patient

Answer 36

for patients with TBI, the standard neurological subjective/objective assessment should be performed assessment may need to be modified based on patient's presentation (eg. cognitive deficit, concurrent injuries)

Question 37

Cranial nerves

Answer 37

all cranial nerves should be assessed by the MDT (with physio to focus on CN III< IV, VI and others if they have not been assessed)

Question 38

Shoulder pain

Answer 38

prevalence of 62% limited evidence in TBI population implement assessment and management strategies with demonstrated efficacy in stroke patients

Question 39

Remember decordicate | decerebrate

Answer 39

slide 31

Question 40

common variations to standard neurological assessment with regards to extracranial injuries

Answer 40

fractures soft tissue injuries effect on outcome controversial important in determining mortality and functional outcomes contraindications, precautions and considerations for physio management

Question 41

Acute medical management includes

Answer 41

``` ventilation evacuation of space occupying haematoma management of scalp lacerations and skull fractures correction of hypovolaemia provision of anticonvulsants monitoring of - ICP BP CPP -cerebral perfusion pressure -provision of brain protective agents ```

Question 42

Physiotherapy management of a patient with TBI

Answer 42

physiotherapy can hold a major role in the management of a patient following a TBI. Management is as indicated based on the patient's presentation (based on assessment) physios are generally responsible for - providing respiratory care (improve respiratory function ; prevent/manage respiratory complications) Optimising MSK integrity (prevent/minimise /manage secondary adaptive changes in soft tissue) Promoting the restoration of motor function

Question 43

Evidence for physio management

Answer 43

no verifiable evidence of the efficacy of sensory stimulation programs More intensive rehab programmes lead to early functional skills - no ceiling effect identified for more intensive therapy improvement in PROM after serial casts or orthosis reduced spasticity after serial casts or orthosis no verifiable clinical improvement after night splints in functional position improvement in CV fitness after strength training

Question 44

further evidence regarding physio management

Answer 44

There is good evidence for the efficacy of intensive task oriented training programmes • Gait training with partial weight bearing is not superior to physiotherapeutic gait training • Proof of efficacy for functional arm training • Overall, it is important to analyse the immediate primary concerns of the patient through the process of clinical reasoning and to select and modify treatment methods appropriately

Question 45

Benefits of CV training in these patients

Answer 45

Improves cardiovascular fitness • Improves general health • Reduces depression • No evidence for transfer of the improvements to the functional level • Evidence demonstrates that fitness often ignored in rehabilitation, particularly for patients with a FIM >4 for locomotion • The treadmill is not ideally suited to functional gait training but it is superior to conventional gait training in terms of endurance and fitness

Question 46

Functional training in patients with TBI

Answer 46

* Efficacy for upper limb and lower limb functional training • Evidence for CIMT in later/ chronic stage of TBI * Influenced by patient compliance, criteria to participate in CIMT and strength and lack of evidence for acute management of TBI * In contrast to stroke research, no proof of superiority for treadmill training with partial body weight support.• Practice walking on different surfaces, uneven ground, up and down slopes and over obstacles. * Practice walking with selective head control but without loss of postural stability, walking under different lighting conditions and walking in crowds.

Question 47

Treatment considerations for acute sever TBI

Answer 47

• Respiratory treatment should be provided with the patient in a maximally sedated state (bolus sedation) • Treat when ICP is low (<20mmHg if possible) • Maintain neck strictly midline throughout treatment as rotation will block CSF drainage and venous blood low with consequent increase in ICP • Nurse with head 30°to optimise cerebral oedema drainage • MHI can be used but with caution as it can increase ICP. • If ICP is high, small rapid volume breaths will reduce ICP by removal of CO2 to allow intermittent MHI breaths If positioning is required, perform slowly • Turning may be better tolerated following a bolus of sedation • Manual respiratory techniques can be performed with caution, ensuring obs are monitored closely • Pre-oxygenate prior to suctioning • Lightening of sedation required prior to mobilisation/ training

Question 48

management of impairments includes

Answer 48

* Joint flexibility/ tone/ spasticity: PROM exs, positioning, stretching, serial casting, botulinum toxin * Shoulder pain: PROM exs, positioning, electrical stimulation, specific retraining of shoulder motor function * Respiratory: positioning, MHI, manual techniques to facilitate inspiratory effort

Question 49

Management of activity limitations includes

Answer 49

* Bridging * Supine to side-lying (rolling) * Side-lying to sitting over edge of bed • Sitting to standing * Standing to sitting * Sitting balance * Standing balance * Gait * Tilt table, physiotherapeutic functional retraining, aid prescription (e.g. wheelchair)