What is a traumatic brain injury (TBI)?
Brain injury caused by impact to the head resulting in acceleration or deceleration of the brain within the skull
What is the difference between a focal and a diffuse TBI (3/3)?
Focal
- produces contusions and haematomas
- subsequent deficits based on location, size and progression
- common areas injured include frontal lobes, ant and inf temporal lobes, occipital. Due to the brain ‘bouncing’ against the skull.
Diffused axonal injury
- stretch and shearing of axons most commonly in the BG
- higher mobility and morbidity than focal injuries due to widespread damage
- Children more likely to suffer from diffused injuries
What is the general medical management for TBI? (2)
TBI medical management
- Primary brain injury cannot be reversed = initial management is to prevent hypoxia and hypotension, and treat operable intracranial lesions
- May require intubation, sedation and paralysis, IV - to reduce metabolic requirements and maintain BP
What are MAP and CPP and what should they be maintained at following TBI?
MAP = mean arterial pressure (>90mmHg) CPP = cerebral perfusion pressure (>70mmHg)
If ICP is >20mmHg for a long time, is this likely to result in better or worse outcomes?
Worse.
Who are falls most likely to occur in?
Children 0-4
Adults >75 (2/3 will fall again in 6m)
What are the common sensorimotor impairments following TBI?
Sensorimotor impairments
- Loss of strength
- Loss of dexterity
- Loss of sensation
- Spasticity
- Contracture
(i. e. same as stroke, just different cause)
Common non-motor impairments after TBI?
Non-motor impairments
- Language impairments (receptive and expressive aphasia)
- Perceptual-cognitive
- – information processing (slow to respond; dual tasks)
- – attention
- sustained (can’t maintain)
- selective (distracted by everything)
- spatial (completely ignore everything on one side) - – memory
- short term memory loss
- post traumatic amnesia (can’t lay down new memories)
Common behavioural impairments after TBI?
Behavioural impairments
- lability = uncontrollable emotions
- disinhibitions = inappropriate behaviour
- apathy (independent of depression)
- inattention (to one side of the world)
Physiotherapy considerations in ICU (6)
Consider
- stability of ICP and BP
- respiratory status
- attachments
- orthopaedic injuries
- post traumatic amnesia
- behavioural issues
How is contracture managed for TBI? (5)
Preventing contracture
- task practice
- resting splints
- serial casting
- positioning
- medical management (e.g. baclofen for spasticity)
Strategies for training patients with aphasia (6)
Aphasia training
- Speech pathologist
- Establish a form of communication
- Don’t finish their sentences
- Short and simple sentences
- Provide time to answer
- Eye contact, gestures and demos
How do you address motor impairments in TBI? (2)
Motor impairments
- Like with stroke patients
- Spasticity is a greater problem in TBI due to paralysis and early onset spasticity
Important joint considerations in TBI (high risk)
Upper limb
- shoulder abductors and ERs
- elbow supination
- wrist extension
- hand web space, thumb flexors and abductors
Lower limb
- hip extension and IR
- ankle DF
Interventions for behavioural impairments (general - 4, behaviour management - 7)
General
- checklists
- graph results
- train what the patient wants
- provide structure and direction (and set goals)
Behaviour management
- Positive reinforcement
- Extinction
- Fogging and broken record
- Non-contingent reinforcement (despite how bad, choose a bit they did well)
- Token systems
- Contracts
- Time out (on the spot)
What are 2 perceptual-cognitive and behavioural measures?
Westmead PTA
Rivermead Behavioural Memory test
Research on information processing in TBI?
22 TBI vs 20 control with serial addition tasks (visual and auditory)
= slower with both (but better accuracy when preferred speed)
Research on attention? (3)
ATTENTION
Structured = better
Complex = worse
More distractions = worse
Research on neglect?
Letter cancellation exercise
- Train using AROM (on affected side)
- Some improvement with visual/auditory anchor
Strategies for loss of attention (4)
Attention
- Encourage scanning, searching, AROM
- Use markers, feedback and cues
- Increase awareness and arousal
- more structured, simple tasks
Short term memory loss reasearch
Use devices to alert to ADLs etc
pager study - many retained improvement
Strategies for memory loss
Memory loss
- short and simple
- link information to previously known
- understanding
- reminders
Strategies with post-traumatic amnesia
Techs
- As for short term loss
- same structure
- trickery and bribery
- reorient
Research on behavioural impairments (2)
Severe disinhibition
- behaviour modification and tokens
= less supervision (66%) and continued improvement (50%)
Written checklists for problems, plans or apathy
= less prompting needed
