Traumatic Brain Injury
an acquired injury - the condition does not refer to brain dysfunction secondary to
congenital or degenerative disease.
An external physical force -> brain insult and impaired functioning of the brain, resulting
in impaired function of one or any number of the following:
-cognition
-perception
-behavior
-physical
-psychological
TBI prognosis
Tremendously variable, (D) on severity, symptoms present upon initial trauma and
subsequent progress; ranges from complete recovery, to lifelong mild-severe disability,
to death.
TBI Susceptibility
Infant - 4 years (abuse, falls, MVA)
15-19 (and early 20s) (risky behavior, sports)
Elderly (falls)
Causes:
Accidental falls
MVA (motor vehicle accidents)
Violence & trauma
Substance abuse
More common in males
230,000 TBI survivors annually in US; 5.3 million Americans
currently living w/ TBI
Open TBI
Meninges torn, brain tissue exposed, penetrating or crushing injuries
Closed TBI
Soft brain tissue forcefully in contact with hard skull - a blow to the brain, as in a MVA-
acceleration and deceleration of brain tissue
Primary TBI
Occurs at the time of trauma
Hemorrhage and infarction
Herniation of brain tissue
Secondary TBI
Brain swelling and intracranial pressure -> hypoxic damage and axonal injury; post-
traumatic aneurysms
Diffuse TBI
More severe
Damage to long axons that run through brain stem and communicate with cortex
-rotational force of brain on more stable brainstem
-if axonal damage is mild, coma will resolve quickly
-if axonal rupture occurs -> persistent vegetative state
-Possible symptoms include:
ataxia
diplopia
dysarthria
impulsivity, irritability
apathy, poor initiative
decreased mental processing speed & efficiency
impaired attention
impaired abstract reasoning, planning, prob. solving
Focal TBI
Can be less severe
More localized
Brain forcefully hits interior of bony skull
examples: contusion, laceration, hematoma
-Location of trauma dictates symptoms:
Pre-frontal & anterior temporal areas -> imp'd memory, emotion, motivation
Orbitofrontal area -> impulsivity
Frontolateral cortex -> impulsivity, hemiparesis, imp'd attention and mental flexibility
Mild TBI - Concussion:
Trauma to the head with only a brief change in mental status
Characterized by either loss of memory for < 24 hours, or loss of consciousness < 30
min, &/or post-injury seizure
> 1 million in US annually
Symptoms can include: headache, dizziness, nausea, irritability, fatigue, and trouble
with information processing, memory, concentration
Most recover completely from symptoms in <3 months
10% experience symptoms > 1 year
Second Impact Syndrome:
Occurs when one experiences a concussion before complete recovery from a previous
concussion. Can be serious:
Loss of consciousness
Rapid progression to severe disability &/or fatal
-> importance of pursuing complete recovery of a concussion prior to engaging in
activity that could lead to a second concussion (ie returning to sports too early)
Chronic Traumatic Encephalopathy:
Multiple concussions over period of years.
First i.d. in boxers; other impact sports as well
Decreased memory
Impaired judgement
Behavioral problems (impulsive, aggressive, depressed)
Glascow Coma Scale (GCS):
Most commonly used
Quick Standardized Assessment
Used in early & acute stages
Can give a picture of severity of brain injury
3 functions assessed:
Open eyes (1-4)
Motor response demonstrated (1-6)
Verbal responses/ quality of them (1-5)
-> Add three sections, and the total = scored
Lowest level = 1
<8 = coma, severe level TBI
9-12 = mod TBI
13-15 = mild TBI
GCS & Prognosis
90% of clients with GCS <8 = in a coma
if initial score is < 8 x 6 hours
-> 50 % death
-> 50% survive w/ mod - severe disability
Post-traumatic amnesia:
< 1 hour = mild impairment
1 - 24 hours = moderate
1 - 7 days = severe
> 7 days = very severe
Post-traumatic amnesia
What can the person remember after injury occurred
Rancho Los Amigos Levels of Cognitive Functioning (RLA)
I: Unresponsive to stimuli
II: Generalized response (non-specific)
III: Localized response (inaccurate but related to stimuli)
IV: Confused - severe w/agitation, aggression
V: Confused - inappropriate
VI: Confused - appropriate, requires cueing
VII: Automatic-appropriate, rote responses, no higher skill
VIII: Purposeful-appropriate (w/ standby (A)) to familiar task
IX: Purposeful-appropriate (some cueing for prob. solving)
X: Purposeful & appropriate (Mod (I))
True learning can occur at what stage in the RLA?
Stage 8 (VIII)
Symptoms of TBI
A wide variety and combination of symptoms possible, all of varying intensity levels (D)
on severity of injury: UMN symptoms (abnormalities in reflexes & tone), cranial nerve
damage, hemiplegia/paresis (or mono-(one extremity) or (B) ), cognitive, perceptual,
sensory.
In addition:
25 - 61% of TBI clients have depression
TBI clients are at increased risk for substance abuse
TBI client has 3x increased risk of another TBI
Increased risk of homelessness and incarceration
Behavior
Behavioral changes and abnormalities are common, and, often most challenging
symptomatology for clients, families, friends and medical staff to address.
Disinhibition - excessive demonstration of behaviors
Social and interpersonal skills compromised
Irritability, anger, rage
Emotional lability
Wandering
Perseveration
Restlessness
Uncooperative
Lack of motivation
Violent
Impulsive
Intervention for TBI
Involvement of family, significant others key.
Compensatory vs. restorative approaches: (D) on -
-stage of recovery
-individual client circumstances
Intervention stages
Acute/Medical - first days and weeks s/p
Rehabilitation - inpt. & outpt, weeks - months
Survivorship - life-long; includes community re-integration
(more successful given post-acute rehab)
Intervention: Positioning
Acute: -similar principles to CVA
-medical management: elevation of head and neck may be necessary to manage ICP
Manage tone: -similar principles to CVA
-serial casting for progressive restoration of contractures (LLPS)
Intervention: Sensory stimulation
For the severe TBI client, low levels RLA.
Goal = increase arousal and awareness, interaction, and hence neurological recovery,
for client whom is only in a state of minimal consciousness.
-tactile: touch, pressure, temperature, PROM
-kinesthetic, proprioceptive, vestibular: motion
-olfactory: pleasant and noxious
-auditory: calming (music, soft voice)
stimulating (noises, for arousal)
-visual: encourage attention, tracking
Research evidence for sensory stimulation programs mixed -
is effective for some but not all TBI patients.
Stimulation Continued
Stimulation should be meaningful to encourage recovery, vs. becoming habitual (ex: TV
on for news to encourage orientation, but do not leave TV on all day so as to just
become background noise.)
Protocols vary: 2x/day - 12x/day; 30 - 90 minute sessions.
Clinician needs to wait for delayed response in patient.
Monitor effect: observe for overt & subtle responses - physiological signs: BP, HR,
respiration, muscle tone
Multimodal vs. unimodal: target one sensation at a time vs. stimulating two or more
senses simultaneously; strong evidence for clinical effectiveness of bimodal and
multimodal
Intervention: Cognition & Visual perception
(Same tx learned in previous classes)
Lack of insight is rather common w/ TBI-can impede progress.
Self-generated learning
Self-generated learning
A stumbling block to learning and memory with TBI clients appears to be initial
acquisition of new information. One possible solution is to encourage self-generated
learning: new learning is more easily recalled by persons with TBI when info comes
from within self vs. reading new info or having it presented.
Example of self-generated learning
Provide written or verbal directions
Leave directions incomplete
See if client can come up with info to fill in blanks. (More apt to remember it)
Ex:
Learning to make an omelet -
Provided information:
"Scramble two eggs in a bowl.
Pour into hot pan on stove.
Let cook three minutes. Flip."
Self-generated information:
"Scramble two _______in a bowl.
_____ into hot pan on stove.
Let cook______ minutes. Flip."
(Client needs to fill-in the blanks, generating the information)
There is evidence for improved carryover of recall of information in self-generated
circumstances.
Intervention: Community Re-integration
Social communication deficits -> isolation (impulsiveness, decreased initiation, ego
centric)
-Social skills training programs can benefit (overtly teach proper behavior such as how
to greet, etc.)
-Holistic programs emphasizing cognitive and interpersonal skills training
-Prevent self-injurious and anti-social behavior
Return to work (RTW): social, cognitive, behavioral, and personality traits can be more
of a hindrance to employment than physical deficits - cognitive rehabilitation does
increase chances of RTW
Intervention: Follow-up programs
Follow-up programs:
- creative models to fill gap / ensure carryover of formal rehab, especially w/ shortened
LOS
-"booster" sessions provide support and keep clients 'on-track'
-Ex: Brain Injury Wellness Program @ Kessler
Powered by TCPDF (www.tcpdf.org)
