Concorde Career College Physical Therapist Assistant

1. Concorde Career CollegePhysical Therapist Assistant PTA 150: Fundamentals of Treatment IIDay 11Traumatic Brain Injury (TBI) Concorde Career College

2. Lesson Objectives • Describe the pathophysiology of traumatic brain injury • Describe physical neurological deficits associated with traumatic brain injury • Identify clinical rating scales in their application in the treatment of traumatic brain injury • Describe physical therapy treatment interventions for patients with traumatic brain injury Concorde Career College

3. Traumatic Brain Injury • http://abcnews.go.com/video/playerIndex?id=3489618 Concorde Career College

4. Traumatic Brain Injury • Epidemiology • 1.5 to 2 million Traumatic Brain Injuries in the United States each year • 50,000 deaths • 80 to 90,000 patients with residual cognitive, behavioral, and physical disorders Concorde Career College

5. What are ways in which the brain might be damaged? Concorde Career College

6. Traumatic Brain Injury • Causes of Injury • Motor vehicle accidents • Falls • Violence • Sports and recreation Concorde Career College

7. Pathophysiology • An external force to the skull that causes brain tissue damage • Acceleration Force • Deceleration Force • Rotational Force • Brain tissue can become compressed, torn or displaced • Open head injury • Skull fracture • Meninges tear with brain exposure • Closed head wound Concorde Career College

8. Types of Traumatic Brain Injury Focal/ Coup/ Local Injury • Injury at the sight of impact under the skull • Cerebral contusion • Vascular lesion • Laceration • Hemorrhage • Hematoma • Brain swelling/Edema Concorde Career College

9. Types of Traumatic Brain Injury Coup – Contracoup Injury (Bouncing) • Injury at the point of impact and an opposite site to the point of impact • Flexion/extension (whiplash) can cause brain injury without direct impact Diffuse Axonal Injury • Stretching, shearing, or tearing of the axons and small blood vessels within the brain • Caused by acceleration, deceleration or rotational force Concorde Career College

10. Types of Traumatic Brain Injury Secondary Brain Damage • Physiological changes in the brain due to trauma • Hypoxic ischemic injury • Lack of oxygen to brain tissue • Brain hemorrhage or hematoma between the skull and the dura mater (epidural) or within the brain (subdural) • ↑ Intracranial Pressure • Brain herniation Concorde Career College

11. TBI Medical InterventionAcute Stage • Stabilize cardiovascular system, respiratory system, brain pressure & brain blood flow • Assess severity of brain injury • CAT Scan & MRI assesses structural & functional involvement • X-ray assesses for skull fracture • Cerebral angiography assesses for abnormalities in brain vessels and circulation • Evoked Potential Electroencephalogram (EPEG) assesses for localized brain damage • Positron Emission Tomography (PET) assesses cerebral metabolism function Concorde Career College

12. TBI Medical Intervention • Surgical Intervention • Monitor intracranial pressure • Decompress skull • Ongoing Medications • Diuretics: ↓ intracranial pressure and fluid in the brain • Anticonvulsants: Control seizures • Antidepressants: Behavioral problems • Electrolytes: Brain metabolism and healing • Neurotransmitters: Serotonin (behavior & emotions) Concorde Career College

13. Levels of Consciousness • Coma • A state of unconsciousness and the level of unresponsiveness to all internal and external stimulation • Stupor • A state of general unresponsiveness with only brief arousal occurring from repeated stimulation • Obtunded • Patient sleeps often and when aroused, exhibits decreased alertness and interest in the environment with delayed reactions Concorde Career College

14. Levels of Consciousness • Delirium • A state of consciousness that is characterized by disorientation, confusion, agitation and loudness • Clouding of Consciousness (lethargic) • A state of consciousness that is characterized by quiet behavior, confusion, poor attention and delayed responses • Consciousness • A state of alertness, awareness orientation and memory Concorde Career College

15. TBI: Neuromuscular Impairments • Abnormal tone • Decorticate Postural Tone • Rigid tone with upper extremities held in flexion and lower extremities in extension (lesion above brainstem) • Decerebrate Postural Tone • Rigid tone with upper extremities and lower extremities held in extension (lesion in brainstem) • Flaccidity to Spasticity (low, moderate or severe tone) Concorde Career College

16. TBI: Neuromuscular Impairments • Impaired motor function (depends on site of brain damage) • Monoplegic, Hemiplegic, Tetraplegic, Quadriplegic • Impaired reflex responses (mild to severe) • Abnormal synergistic movement patterns • Impaired balance and coordination responses • Diminished muscle performance for ADL • Strength, Power, Endurance Concorde Career College

17. TBI: Neuromuscular Impairments • Cognitive Deficits • Impaired in orientation to time, person and place • Impaired reasons and problem solving abilities • Attention Deficits • Hyperactive, impulsive, distractive, ↓ concentration • Behavior Problems • Low frustration tolerance • Depression • Disinhibition: emotions, aggression, apathy, sexual Concorde Career College

18. TBI: Neuromuscular Impairments • Memory Deficits • Retrograde Amnesia • Inability to remember events prior to the injury • Post Traumatic Amnesia • The time between the injury and when the patient is able to remember recent events. The patient does not recall the injury circumstances. • The patient cannot retain new information or hold recent memories. This affects their ability to learn new skills. • Anterograde Memory • Inability to create new memory Concorde Career College

19. TBI: Neuromuscular Impairments • Visual Problems • Hemianopsia • Cortical Blindness • ↓ sensory perception and ability to process sensory information • Touch, temperature, position, kinesthetic, pain • Spatial orientation Concorde Career College

20. TBI: Neuromuscular Impairments • Speech & Communication • Express aphasia (Broca’s area) • Unable to speak • Unable to form intelligible words • Receptive aphasia (AKA Wernicke’s aphasia) • Unable to distinguish appropriate sounds • Global aphasia • Dysarthria • Lack of control and coordination of speech muscles Concorde Career College

21. TBI: Neuromuscular Impairments • Auditory • Reading comprehension and written expression • Swallowing Problems • Dysphagia Concorde Career College

22. Medical Problems Related to Inactivity • Soft tissue contractures • Muscle atrophy • Skin breakdown • Deep vein thrombosis • Infection/pneumonia • Hypertrophic ossification • Cardiovascular and respiratory disorders Concorde Career College

23. Physical Therapy Examination • Cognitive Function • Vital Signs • Muscle Control (tone, reflex patterns) • Postural Control (sit, stand) and Balance • Sensation • Strength and Endurance • Range of Motion • Functional Mobility (bed mobility, transfers, wheelchair, gait) • Medications Concorde Career College

24. TBI Outcome Measures Glasgow Coma Scores • Determines the patient’s level of arousal and cerebral cortex function • Eye Opening, Verbal Responses, Motor responses • Score between 13 - 15 indicate mild impairment • Score between 9 -12 indicate moderate impairment • Score below an 8 indicate severe impairment and comatose state Galveston Orientation & Amnesia Test (GOAT) Concorde Career College

25. TBI Outcome Measures • Rancho Los Amigos: Levels Of Cognitive Functioning (LOCF) • Based upon patient’s level of consciousness and functional status • The patient usually passes through all stages in the sequence progressions • Patient brain recovery varies and not all patient achieve the purposeful conscious state of function • Eight levels Concorde Career College

26. TBI Outcome Measures: (LOCF) • Level 1: No Response • Patient appears to be in a deep sleep and completely unresponsive to any stimulation • Level 2: Generalized Response • Patient exhibits a generalized, inconsistent , non-purposeful response. • Physiological changes, gross body movements or localization Concorde Career College

27. TBI Outcome Measures: (LOCF) • Level 3:Localized Response • Patient exhibits an inconsistent, localized response • May follow simple commands such as opening eyes or squeezing hand • Level 4: Confused Agitation • Patient exhibits a high state of unorganized activity; • Bizarre behavior and non-purposeful relative to immediate environment; • Does not discriminate among persons or objects • Frequent incoherent verbalizations • Decreased gross attention span Concorde Career College

28. TBI Outcome Measures: (LOCF) • Level 5: Confused Inappropriate • Consistent response to simple commands • Highly distractible and lacks ability to focus attention to a specific task • May be able to converse for short periods of time • Memory impaired and unable to retain new information Concorde Career College

29. TBI Outcome Measures: (LOCF) • Level 6: Confused Appropriate • Goal directed behavior in structured situation • Follows simple directions consistently • Carryover for relearned tasks; No carryover new tasks • Level 7: Automatic Appropriate • Performs routine daily activities automatically • Robot like with minimal to absent confusion • Shallow recall of activities .Structured social interaction • Beginning to show new learning carry over Concorde Career College

30. TBI Outcome Measures: (LOCF) • Level 8: Purposeful and Appropriate • Patient is responsive to environment • Patient is able to demonstrate recall memories and integrate past and recent events • Able to learn and needs no supervision once activities are learned • Decreased tolerance to stress, and complex reasoning skills Concorde Career College

31. TBI Outcome Measures • Functional Individual Measurement (FIM) • Assesses ADLs and functional mobility • Functional Assessment Measurement (FAM) • Assesses the patient’s ability to integrate and adjust into the community • Disability Rating Scale (DRS) • Patients are scored on a wide range of functional areas • Score 0-29, 0 = no disability; 29 = extreme vegetative state Concorde Career College

32. In what setting might you be treating a patient after a TBI? Discussion Concorde Career College

33. TBI Treatment Guidelines • Patient and family participation • Consistency is key • Same therapist, daily schedule, offer orientation (person, place, time) • Goal directed, familiar, functional and recreational activities • Focus on behavior modification activities • May use positive reinforcement (rewards system) • Feedback is important Concorde Career College

34. TBI Treatment Guidelines • Initially, focus may be on endurance rather than challenging the patient to learn new skills • May not have capacity to learn early on • Mental fatigue can lead to irritability, ↓ attention, etc. • Simple commands, calm voice • Practice without overstimulation • Do not expect carryover • Therapeutic activities need to be safe and flexible, based on level of awareness and function Concorde Career College

35. TBI Treatment Guidelines • Give the patient control, if appropriate • As the patient advances • Community & social reintegration will be important • Involve that patient in decision making • Encourage independence & cooperative work Concorde Career College

36. Physical Therapy Interventions • Positioning • Bed positioning to decrease abnormal posturing and primitive reflexes (O’Sullivan Table 22.7, page 908) • Head in neutral, cone in hand if fingers flexed, hips & knees slightly flexed, roll behind hips if rotation, roll between legs if strong adduction, turn the patient every 2 hours • Wheelchair positioning – head and pelvis should be in neutral, may require splinting or multipodus boot; reclining or tilt-in-space chair may be necessary as well Concorde Career College

37. Physical Therapy Interventions • Sensory Stimulation • Attempt to ↑ arousal & movement • Systems are systematically stimulated • Auditory, Olfactory, Gustatory, Visual, Tactile, Kinesthetic, Vestibular • Must monitor closely for subtle changes in VS • ROM • Avoid forceful or aggressive movements Concorde Career College

38. Physical Therapy Interventions • Managing Abnormal Tone & Spasticity • PROM • Strengthening the antagonist • Proper positioning • Serial casting • Cryotherapy • Remember that high tone can, at times, be beneficial for function (ie., LE tone can improve WBing for transfers) Concorde Career College

39. Physical Therapy Interventions • Therapeutic Exercises • Passive exs, stretching exs, active assistive exs, active exs, and strengthening exs • Developmental Positioning and Mobility Retraining • Prone, Sit, Quadruped, Kneeling, Plantigrade, Standing • Neuromuscular Facilitation Techniques • Strength and Endurance Training Concorde Career College

40. Physical Therapy Interventions • Mobility Training • Important pt is upright as soon as medically stable • Sitting in chair, wheelchair or using a tilt table • Bed mobility • Transfer training • May require co-tx with OT for initial transfers • Sitting balance • Standing balance • Gait training • Tilt Table, II Bars, Suspended Gait Device, TM, ADs • Wheelchair Mobility Training Concorde Career College

41. Physical Therapy Interventions • Balance, coordination and vestibular retraining • Sensory integration • Wheelchair and adaptive equipment assessment and application Concorde Career College

42. Learning after a TBI • Learning will depend on genetics, age, physical & mental health, severity of brain injury & quality of environmental stimuli • Associated with neural plasticity • Must properly assess memory • Is the patient able to apply the same skill learned within a PT session to a separate setting? Concorde Career College

43. Learning after a TBI • Learning capabilities and information processing may change over time • Therefore, need to adjust teaching style • Needs to be a balance between challenging the patient without overwhelming & causing stress and frustration Concorde Career College

44. Documentation • Patient posture and the effect of reflexes upon posture and abnormal tone and movement patterns • Patient response to stimulation, type of response and frequency of response • Patient response to sensory stimulation and carry over into functional activities • Attention span, orientation, ability to follow instructions • Patient ability to learn and recall tasks Concorde Career College

45. Documentation • Patient safety awareness • Physical or emotional fatigue • Activity performed, patient participation, assistance level • Patient ,family and rehabilitation team education and communication Concorde Career College

46. Who else may be involved with the care of a patient with a TBI? Discussion Concorde Career College

47. TBI • Assess for Understanding: • List the members of the multidisciplinary rehabilitation team that provide services to patient’s with a traumatic brain injury • What physical therapy interventions would be applied to a medically stable patient post 7 days injury. The patient is bedbound, level 3 (Localized response) and exhibiting spasticity in the arms and legs. Concorde Career College

48. TBI • Assess for Understanding: • What physical therapy interventions would be applied to a patient with Level 7 (Automatic Appropriate). The patient can sit up unsupported 1 minute, max assistance stand and transfers, strength fair trunk and lower extremities with mild hypertonus. Concorde Career College

49. Questions Concorde Career College

50. Resources • Physical Rehabilitation, 5th ed., Susan B. O’Sullivan and Thomas J. Schmitz, 2007; F.A. Davis, Company. Chapter 22 • PTA Exam The Complete Study Guide. Scott M. Giles, Scorebuilders. 2011, • PTA Examination Review and Study Guide, Karen Ryan and Rebecca McKnight, International Educational Resources. 2010. • Functional Neurorehabilitation through the Lifespan. Bertoti, D. F.A. Davis. 2004. page 160-161 Concorde Career College