1
Q
The following are all examples of what type of injury?
subarachnoid hemorrhage (SAH)
intraventricular hemorrhage
intracerberal hemorrhage
skull fractrues
epidural hematomas (EDH)
subdural hematomas (SDH)
cerebral contusion => intraparanchymal hemorrhage
focal and diffuse axonal injuries with cerebral edema
A
primary brain injury
2
Q
Secondary Brain Injury and the path to increased ICP
A
Chain of Cellular Events Following Tissue Damage
- glutamate neurotoxicity => increased swelling, ICP
- electrolyte imbalances
- mitocondrial dysfunction
- inflammatory responses
- apoptosis (cell death)
All contribute to brain swelling and increased ICP
Lack of oxygenated blood flow to the brain may also be due to
- systemic hypotension
- anoxia (seen in drowning victims)/hypoxia (seen in pt’s who have an event where they don’t breathe)
- vascualr damage
3
Q
What are the signs and symptoms of Psottraumatic Hydrochephalus?
A
- obtudation (decreased responsiveness)/decreased consciousness
- failure to improve or decreaseing status
- pyschomotor retardation
- memeory loss
- gait deterories (may have wide base)
- intontinence
- unusal symptoms including emotional disorder
4
Q
The following are all examples of what?
- DVT
- heterotropic ossification
- pressure ulcer
- seizures
- pnuemoia, respiratory issues
- chronic pain
- contractures
- decreased endurance
- muscle atrophy
- GI, GU (feeding tube, PEG)
- Cardiovascular
A
Secondary impairments and medical complications of brain injury
5
Q
Classificaiton of TBI Severity: Chart Review
A
6
Q
Impairments commonly associated with TBI: chart review
A
7
Q
TBI can result in what type of impairments that include these symptoms
Difficulties with interpretaiton and loss of ability to filter…
- touch
- pain
- Deep pressure
- temperature
- limb position
- fine discrimination
- visual input (not able to register what they are seeing => slwo to recognize objects => may present as unsteady)
- smell (cranial nerve dysfunction)
- auditory input
A
Sensory processing impairments
8
Q
What are the 8 levels of cognitive funciton for adults in the Ranchos Los Amigos Scale?
A
- Level I: No response
- Level II: generalized response
- level III: localized response
- Level IV: confused-agitated
- Level V: Confused-inappropriate
- Level VI: Confused-appropriate
- Level VII: Automatic-appropriate
- Level VIII: Purposeful-appropriate
9
Q
Characteristics of each of the Rancho Levels of Cognitive Funciton
A
- Levels 1-3: Low level patients -> Stimulation oriented approach
- stimulation must have structure (include rest periods)
- Levels 4-5: Agitated-Confused and Confused-Inappropriate => Structure Oriented Approach
- won’t be teaching anything new => work on keeping the patient calm and from hurting themselves/others
- if patient get’s worked up, remove the agitating stimulus
- Levels 6-8: Confused, Automatic, and Purposeful-Appropriate => decreased structure, increase task complexity
- level 6 = this is often where people are when starting to look at discharge to home setting with supervision
- as the level increases, you continue decreasing structure while making the tasks more complex
10
Q
Pyramid of Cognitive Recovery: Image review
A
11
Q
Characteristics of RLA scale Level 1 patients
A
- No response to stimuli: sound, sights, touch, or movement
- Appears to be in a deep sleep
- Total assistance
- Glasgow Coma Scale score: 3 out of 15 (3 is the lowest score on this scale and indicates unresposiveness)
12
Q
The following are characteristics of which level of Rancho Los Amigos?
- Total assistance
- Non-purposeful, slow, delayed and inconsistent responses to stimuli
- may be unable to localize or attend to voice
- Responses limited, same regardless of stimuli
- Gross body movements (won’t be able to pull away from painful stimuli)
- Physiologic changes: increased BP, HR
- Sweating
- Vocalization
- Chewing movements
- Periods of wakefulness
- Not following commands
A
Level II: Generalized Response
13
Q
The following are characteristics of which Rancho Scale Level?
- Responses are specific but inconsistent, delayed, and directly related to the type of stimuli presented
- Turns head towards sound
- Withdraws extremity from painful stimuli
- May make eye contact, look around
- May follow simple commands
- Look at me……Squeeze my hand
- Open your eyes……Close your eyes
- Stick out your tongue
- Does not remember new information
- Awake intermittently
A
Level III: Localized Response
14
Q
What is the biggest difference between Rancho Levels 2 and 3?
A
- Level 3 = may be able to follow commands
- even if they aren’t following commands, if you pinch them, they are able to draw their arm away instead of having generalized increased arousal (they have a localized response to stimuli)
15
Q
How does a PT Examine a Low Level Patient?
A
- Observation
- Determine level of alterness and response to commands
- assess cranial nerves
- sensory motor exam
- assess neruomuscular system
- try rolling the pt
- can do some neurodevelopmental training
- musculoskeletal system exam
- assess cardiovascular system
- assess integumentary system
- evaluate funcitonal abilities
- try sitting the pt up (can they hold their head up?)
- check for head-riding (if traciton is applied through the upper trap and the head does not come up => this involves the mid-brainstem and is not good)
16
Q
the folllowing are examples of what type of exam?
- Test each limb for withdrawal from painful stimulus
- Skin pinch/twist
- Nail bed pressure
- Assess response
- Reflexive (spinal cord level)
- UE: pinch flexor surface of arm, arm flexes, no abduction
- L/E: triple flexion (pinch flexor surface of leg and hip, knee flex + ankle DF)
- Purposeful withdrawal
- pinch flexor surface, arm flexes and abducts: moves away from stimulus
- Reflexive (spinal cord level)
A
Sensory and Motor Exam
17
Q
the following are examples of what type of exam?
- Resistance to PROM (spasticity, hypotonicity)
- Effect of body/head position on tone
- Presence of Abnormal Primitive Reflexes
- ATNR, STNR, TLR
- Babinski
- DTR’s/clonus
- Hoffman’s
A
Neuromuscular examination: Muscle Tone
18
Q
The following are examples of what type of exam?
- Level of assistance provided by PT with mobility tasks
- Patient’s active participation with mobility
- Once in a position, do something for treatment!
- Head/ body righting with rolling
- Head/trunk control in sitting, standing
A
Functional Exam
19
Q
What are the treatment goals of Ranchos Levels 1-3, Stimulation Orieted Program?
A
- increase awarness of enviornment/ increase attention span
- reinforce localized responses to stimuli and repsonse to one step commands
- maintain or increase joint ROM
- normalize muscle tone
- increase active movement
- achieve proper body alignment while progressing tolerance to upright positioning
- improve motor control and functional status
- increase endurance
20
Q
Which Ranchos Level is hallmarked by the following characteristics:
- heightened state of activity, agitation
- a response to patient’s internal state of confusion and discomfort
- decreased ability to process information, distractable, fatigure, sleep distrubances
- unable to recall new information
- may recognize family/friends
- can respond to simple commands with structure
- Overreacts: hitting behavior, yelling, foul language, restless
- short attention span, confabulation, no memory
A
Level IV: Confused and Agitated: Maximal Assisstance
- max assit = for structure and for safety and problem solving and sequencing to finish a task
- these patients need structure for safety
- Approach: Structure Oriented Program
21
Q
What are some team goals for treating Ranchos Level IV: confused-agitated?
A
- Decrease intensity, duration and frequency of agitation
- goal is basically to get the pt through this stage as quickly and safely as possible without them injurying themselves or anyone else
- Prevent injury
- Prevent inappropriate response patterning
- Increase attending behaviors to environmental stimuli
- Complete simple tasks with structure (giving the pt verbal cues)
- Facilitate appropriate behaviors
- Family education re patient behavior, team goals
- Facilitate automatic responses in ADL and mobility
22
Q
What are some treatment stratergies to meet goals for Level IV: confused-agitated?
A
- Decrease agitation, prevent injury
- Prevent inappropriate response patterning
- Improve ability to pay attention
- ID and remove sources of agitation
- Structure environment: consistent PT, schedule, treatment session structure, private room
- Reality orientation (where are you? what day is it? who is the president? Why are you here? what happened? => you are in the hospital, you have had an accident, you are here to get better)
- Have help readily available
- Calm with slow rocking, neutral warmth, etc.
- Fatigue hyperactive patients with gait, w/c mobility, ADL’s, etc.
- reassure the pt they are safe
- allow as much movement as is safe
- facilitate automatic, overlearned responses in ADL’s and mobility (i.e., repeated sit-to-stand, walking, washing hands, rolling, sitting up => consider using mobility and things the person has to do every day of their life)
23
Q
what are intervention stratergies that can be used when treating ranchos level IV: confused-agitated?
A
Structure, re-direction
- Skills should be directed to level of function and focus on cognitive endurance rather than progressing to new skills
- Consistency is very important
- Teaching new skills is unrealistic at this level
- Patient is likely to model the behavior of the caregiver
- Therapist must be flexible with treatment activities
- Family education regarding patient behavior and team goals is critical!
- Don’t reinforce inappropriate behaviors
- Consider how you might do the same task but work on the pt’s cognitive endurance (i.e., more repititions)
24
Q
Which rancho level is characterized by the following characteristics?
- Non-agitated
- Agitation and confused are now in response to EXTERNAL stimuli
- Responds to simple commands consistently with assistance
- Performs self-care/ ADL’s with MAXIMAL supervision/ step by step instruction and assist (STRUCTURE)
- Distractible, lacks ability to focus attention (minutes)
- Cannot learn new information
- Memory severely impaired, some immediate memory
- Verbalizations: confabulatory, inappropriate
- Perseverates on basic needs; hunger, thirst, sleep, going home
A
Level V: Confused-Inappropriate
- Approach: Structure Oriented Program
- pt’s can still get agitated if you overstimulate them and irritate and/or challening them too much
- when doing a transfer with this level of pt, they will need maximum supervision and step by step instruction from a cognitive standpoint
25
Which ranchos level has the following characteristics?
* Awake and aware! Now emerges from PTA (post traumatic amnesia), has some day to day recall.
* Goal Directed Behavior
* Moderate assistance/cues to structure tasks, ADL’s
* Purposeful interactions, converses on a simple, social level
* Carry-over with simple tasks
* Can remember main points but will confuse the details
* Can follow a schedule
* Knows month, year, and place
* Can pay attention for about 30 minutes but is easily distracted, difficulty multitasking
* Manage own bathroom needs (with supervison if they are safe enough with their mobility)
* More aware of physical problems than cognitive problems
* Focal injuries more apparent
Level VI: Confused Appropriate
* Approach: Structure Oriented Program
* oftentimes, this is the level that someone can go home from an acute care inpatient rehab into an outpatient program
26
The following are appropraite PT goals for which ranchos level?
* Decrease confusion from environment
* Increase cognitive abilities (i.e., tell the pt a short story and have them try to re-tell it to you)
* Increase frequency, rate, duration & quality of appropriate interactions with environment
* Incorporate increasing cognitive function into functional activity (i.e., when walking, tell a patient their room #, then have them stop and read room #'s on the way back)
Level V: Confused Inappropriate
27
The following are appropriate PT goals for which ranchos level?
* The goal is to maximize functional recovery & prepare the patient for discharge to home & the community
Level VI: Confused Appropriate
28
What are some intervention strategies for Levels V and VI?
* The same strategies as level IV should be considered
* Continue reality orientation
* Repetition
* Memory planner
* Use re-direction if patient gets argumentative
* Patient & family education
* Developmental, functional postures (i.e., with pt in prone on elbows, have them flip the pages of a book)
* Balance, coordination, strength, endurance, mobility
* Locomotor training (gait training, wheelchair mobility)
29
What are stratergies applied to the environment for Level V?
* Consistent (as you can't assume the pt being able to get out of bed at the hospital means they can do the same thing at home, you have to perform a home evaluation and structure your environment accordingly to make it consistent)
* Memory aids in visual range (i.e., a sign that says "paper towel" on a paper towel dispenser)
* Minimize distractions (as a treatment, you can vary the amount of distractions from none to increasing them)
* Same therapy staff
* Everyone orients patient to time, place, activity and staff names
* Bring in family pictures & other personal items
* Limit to 2-3 visitors at a time
30
The following are treatment interventions for which ranchos level?
* Pre-functional skills
* Head/neck/trunk control
* Balance
* Strengthening
* Simple, repetitive exercises
* Progress to more complex as ability to participate improves
* Early Functional Training
* 1 step activity
* Verbal, visual, tactile cues
* Do not anticipate carry-over of learning to new situations, practice in specific situation
* can perform activities in devlopmental postures (i.e., tall kneeling on a pad while boxing = function + head/neck/trunk control)
Level V: Confused Inappropriate
31
What are some guidelines for treating patients who are confused?
* Structure: repetition of relevant functional activity
* *doing the same thing,...*
* *at the same time, in the same place,...*
* *with the same person, in the same way*
* Increase complexity
* increase number of steps
* decrease cues
* practice with increased distractions
* Physical Therapy Treatments
* incorporate attention, orientation, and memory
* simple reason and problem solving
32
Which ranchos level has the following characteristics?
* Minimal assistance for daily living skills
* Appropriate and oriented
* Shallow recall
* Goes through daily routine “robot-like” with minimal to no confusion
* New learning is slow
* Impaired judgement, problem-solving and realistic planning for the future
* Needs assistance in decision making, encouragement to use compensatory strategies set up by ST and OT
Level VII: Automatic and Appropriate
* RX: Decrease structure, Increase challenge
33
Which ranchos level has the following characteristics?
* Stand-by assistance for daily living skills, reminders
* Recalls and integrates past and recent events
* Carry-over for new learning
* Independent function in home setting within constraints of focal deficits
* Low frustration and stress tolerance
* Impaired judgment in new situations
* Social, emotional, intellectual deficits may persist but functional for society
* School, Vocational Rehabilitation
Level VIII: Purposeful and Appropriate
* before this point, pt's were re-learning things they used to know and now they are learning new things (i.e., they can go to college)
34
Can you recall the ranchos levels, their recovery phase, and treatment approach?
