Examination of Moderate TBI

• Physical therapists treating patients with moderate to severe TBI

  • Must manage three core problem areas: physical, cognitive, and behavioral
  • Many patients have been involved in some type of accident that has led to multiple trauma
• Patients with TBI


  • Have cognitive and behavioral impairments that pose barriers to the examination process which may include disorientation, confusion, physical aggression, memory deficits, and limited attention span
  • It may be difficult to gather data using standardized tests and measures and physical therapists must utilize observational skills as the patient moves to gain insight to the extent of the body structure/function impairments and activity restrictions

  
• Cognitive abilities


  Affect the capacity to relearn motor skills, including orientation, attention span, memory, insight, safety awareness, and alertness
• This module will focus on assessment of cognitive and behavioral sequela of TBI
• You will see examples of patients at different Ranchos Los Amigos Levels of Cognitive Functioning

  
• Prognosis after moderate to severe TBI will also be discussed
• TBI can impact


  • Attention, memory, initiation, judgment, and speed of processing
• Physical therapy assessment


  1. Careful examination of the domains of cognitive function

  2. Treatment is based on these findings
• Attention assessment


  • Observing the patient's ability to stay focused on the task at hand, during the therapy evaluation
  • Observing the patient in situations where there are distractions to determine if selective attention is impaired
  • Divided attention is intact if the patient can talk while carrying out a task
  • Sustained attention is measured by the length of time the patient can stay on task, during their work with the therapist
• Memory loss


  • Questions should be asked to assess the patient's ability to retrieve old memories and acquire new ones
  • Retrograde amnesia is identified by questioning about the period leading up to the injury, the time of the injury, and immediately after the injury
  • Anterograde amnesia is assessed by asking about events from the previous therapy session
  • Post-traumatic amnesia is the inability to lay down memories reliably from one day to the next, including orientation to time, person, place, and situation

  
• Duration of post-traumatic amnesia


  A key indicator of injury severity and prognosis, defined as the time from injury to regaining continuous memory for ongoing events

  
• Moss Attention Rating Scale


  An observational tool used to measure attention-related behaviors after TBI

  
• Personality and behavioral changes after TBI

  • Have a significant impact on the person's sense of self and can be quite debilitating for both the patient and their family and friends
  • Most difficult for individuals with mild TBI as they are cognizant of the changes and the impact on their friends and family
  • Physical therapists should acknowledge these changes and recognize the need to modify therapy based on mood and negative behaviors
• Common behaviors that occur after TBI

  • Agitation
  • Confusion
  • Perseveration
  • Impulsivity
  • Disinhibition
  • Confabulation
  • Inability to self-reflect
  • Apathy
  • Depression
  • Lack of initiation
• Agitated behaviors


  Restlessness, inability to focus or maintain attention, irritability, and combativeness
• Confusion


  Inability of patients to recall minute-to-minute, hour-to-hour, or day-to-day events in their life
• Perseveration


  A person's repetition of certain behaviors, either actions or verbalizations
• Impulsivity


  A tendency to act without thinking
• Disinhibition


  An inability to stop oneself from acting on one's thoughts
• Confabulation


  The creation of false memories
• Inability to self-reflect


  Due to a lack of insight into the effects of ones behavior on others
• Apathy


  Lethargy, a bland affect, an absence of agitation, and low motivation
• Lack of initiation


  The inability to determine how to carry out an activity
• Agitated Behavior Scale


  Measures behavioral aspects of agitation during the acute phase of recovery from TBI including aspects of aggression, disinhibition, and lability
• Level of consciousness


  • Best observed in the awake patient before and during interaction to look for signs of drowsiness or by observing the response of the sleeping or unconscious patient to stimulation
  • Can be alert, lethargic, delirious, obtunded, stupor, or coma
• Disorders of consciousness


  • Coma: complete loss of the arousal system, unable to be awakened with reflex and postural response motor function, and no sleep/wake cycles
  • Vegetative state: loss of awareness to self and environment, sleep/wake cycles, with motor function response to noxious stimuli only
  • Minimally conscious state: partial preservation of conscious awareness including inconsistent localized responses to noxious stimulation or sound, verbalization, purposeful behavior such as holding objects and visual pursuit
• Coma Recovery Scale-Revised


  A standardized neurobehavioral assessment measure designed for use in patients with disorders of consciousness
• Ranchos Los Amigos Levels of Cognitive Functioning


  • A common scale used to characterize cognitive and behavioral functioning after TBI
  • Establishes the language rehabilitation professionals use to communicate regarding the management of the patient with TBI
  • Each level describes behaviors representing various aspects of cognitive/emotional function, including responsiveness, irritability, attention, ability to follow directions, appropriateness, verbalizations, and self-directed behaviors

  
• Ranchos Los Amigos Level I


  No response. The patient is in a coma and appears to be in a deep sleep. The patient is completely unresponsive to any stimuli. The patient has no sleep/wake cycles.
• Ranchos Los Amigos Level II


  Generalized response and the patient requires total assistance for cognitive activities. The patient is in a vegetative state. The patient reacts inconsistently and nonpurposefully to stimuli in a nonspecific manner. Responses are limited, often the same regardless of the stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalizations.

  
• Ranchos Los Amigos Level III


  Localized response, and the patient requires total assistance for cognitive activities. The patient is in a minimally conscious state. The patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. The patient may follow simple commands such as closing eyes or squeezing hand in an inconsistent delayed manner.

  
• Patients that emerge from coma after a moderate to severe TBI progress through the vegetative state to a gradual reemergence of responsiveness and severe confusion, abnormal behavior, and memory disruption
• Post-traumatic amnesia


  Disrupts memories prior to the accident as well as the formation of new memories, including the day-to-day activities within the hospital setting

  
• Ranchos Los Amigos Level IV


  Confused and agitated and requires total assistance for cognitive activities
• Patient


  • Reacts specifically but inconsistently to stimuli
  • Responses are directly related to the type of stimulus presented
  • May follow simple commands such as closing eyes or squeezing hand in an inconsistent delayed manner

  
• Post-traumatic amnesia


  1. Emerging from minimally conscious state

  2. Disrupts memories prior to the accident as well as the formation of new memories

  3. As post-traumatic amnesia clears, the patient is left to deal with a myriad of deficits in multiple systems – sensory, motor, behavioral, and cognitive

  
• RLA-LOCF Level IV


  • Confused and agitated, requires maximal assistance with cognitive activities
  • In a post-traumatic amnesia state
  • Heightened state of activity
  • Bizarre and nonpurposeful behavior
  • Unable to discriminate among persons or objects
  • Unable to directly cooperate with treatment efforts
  • Incoherent and/or inappropriate verbalizations, confabulation may be present
  • Very brief and selective attention, lacks short- and long-term recall

  
• RLA-LOCF Level V


  • Confused and inappropriate, requires maximal assistance with cognitive activities
  • Able to respond to simple commands somewhat consistently
  • Responses become nonpurposeful, random, or fragmented with increasing complexity
  • Highly distractable, unable to focus attention
  • Able to hold a conversation at a social automatic level for short periods
  • Inappropriate and confabulatory verbalizations
  • Severe memory impairments, inappropriate use of objects
  • Able to perform previously learned tasks with structure, unable to learn new information

  
• RLA-LOCF Level VI


  • Confused and appropriate, requires moderate assistance with cognitive activities
  • Demonstrating goal-directed behavior but requires prompts and guidance
  • Consistently able to follow simple instructions and retain learning for previously familiar tasks
  • Increased awareness of self, situation, and environment but unaware of impairments and safety concerns
  • Long-term memories more detailed than short-term memories

  
• RLA-LOCF Level VII


  • Automatic and appropriate, requires minimal assistance with routine cognitive activities
  • Posttraumatic amnesia has cleared
  • Displaying appropriate behaviors and oriented in specific environments
  • Can manage daily routine automatically but often robot-like
  • Confusion minimal to absent, starting to remember activities
  • Demonstrating new learning at a slower pace
  • Beginning to participate in structured social or recreational activities
  • Judgment continues to be impaired