Objectives (continued)

Transcription

Physical Therapy Management for Patients
with Disorders of Consciousness
1/22/2013
Objectives
Physical Therapy Management for
Patients with Disorders of Consciousness
• Upon completion of this course, attendants will
be able to:
– Describe disorders of consciousness including the
Vegetative State, Minimally Conscious State, and
Coma.
– Understand the common neurologic and medical
complications associated with Severe Traumatic Brain
Injury.
– Identify the components of a thorough Physical
Therapy evaluation including Special Tests and the
most commonly used Outcomes Measures including
the CRS-R, GCS, and DRS.
Combined Sections Meeting
San Diego, CA Jan 21-24 2013
Natalie Sibley, PT, NCS
Bryn Mawr Rehab, Malvern, PA
Carolyn Tassini, PT, DPT, NCS
MossRehab, Elkins Park, PA
Objectives (continued)
– Recognize the common physical, cognitive, and
functional impairments seen as a result of severe
traumatic brain injury.
– Identify appropriate Physical Therapy interventions
along with the specialized equipment utilized and
prescribed for this population.
– Write objective and functional therapeutic goals for
this population.
– Identify commonly used medications and their impact
on Physical Therapy.
Outline
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Incidence and etiology
Neuromedical complications with severe TBI
PT examination
Examination of consciousness
PT goal setting
PT interventions for patients with severe TBI
Commonly used medications and their impact on
PT
• Outcome tools for patients with severe TBI
Introduction to TBI
CDC, 2006
Combined Sections meeting 2013
San Diego, CA January 21-24, 2013
1
Overview
1/22/2013
TBI Incidence by Age and Gender
• Differentiate between head injury (HI) and TBI
• Variation by geographic location
• Variation by age, gender, race
Risk of TBI and Age
Incidence by Severity
• Mild TBI = 131 cases per 100,000 people
• Moderate= 15 cases per 100,000 people
• Severe= 14 cases per 100,000 people
Causes of TBI
TBI Morbidity
• Accounts for 40% of all deaths from acute
injuries in US
• Financial cost estimated at $4 billion per year
• NIH estimates that 2.5-6.5 million Americans
live with TBI-related disabilities
2
TBI morbidity
• Mild head injury (80% of injuries)
• 10% with disabilities
• Moderate head injury (10% of injuries)
• Severe head injury (10% of injuries)
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TBI Mortality
• Highest mortality rate in persons 15-24 yrs
(32.8 cases per 100,000 people)
• Elderly (65 yrs+) = 31.4 cases per 100,000
people
• Mortality rate by severity:
– Severe =33%
– Moderate = 2.5%
• 1:20 receives proper rehabilitation (NHIF)
Probability for Recovery
at 3 Months Post-Injury (Adult)
at 6 Months Post-Injury (Adult)
at 3 Months Post-Injury (Pediatric)
at 6 Months Post-Injury (Pediatric)
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Outcomes
• N=140
• Studied patients in VS at one month
– At one year:
• 51% dead; 11% vegetative; 26% severe disability; 10%
moderate or good recovery
• 83% of patients who regained consciousness did at 3
mos
• 93% at 6 months
Prognostic Factors
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Age*
GCS*
Pupillary response and size*
Presence of major extracranial injury*
Medical complications
– Hyperthermia
– Elevated ICP
– Hypoxia
Braakman, 1988
“Severe” TBI defined
• Referring to patients with disorders of
consciousness (DOC) including:
– Coma
– Vegetative state (VS)
– Minimally Conscious state (MCS)
• Rancho Level I – III
• Rancho Los Amigos Level of Cognitive Functioning Scale
• GCS 3 - 8
• Glasgow Coma Scale
Vegetative State
(VS)
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Spontaneous eye opening
Sleep/wake cycle
No awareness of environment or internal stimuli
No purposeful movement
No evidence of sustained, reproducible,
purposeful or voluntary behavioral responses
• No cortical function, but there may be brain stem
reflexes
• Rancho II
Coma
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No evidence of arousal and awareness
Eyes closed
No sleep-wake cycle
GCS < 9 ; Rancho I
Rarely last longer than a few weeks
An unarousable, unresponsive state, regardless of
duration, in which eyes are continuously closed
• Not obeying commands, not uttering words, not
opening eyes
Vegetative State
(VS)
– Vegetative state
• Persistent
– One month or longer after injury
• Permanent
– 3 months or longer if anoxic injury
– 12 months or longer if traumatic injury
– Requires serial evaluation
– Often misdiagnosed
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Minimally Conscious State
(MCS)
(MCS)
Evidence of awareness of self or environment indicating cortical function
Inconsistent but meaningful interaction with the environment
Intentional communication*
Intelligible verbalization*
Localization to noxious stimulation*
Object manipulation*
Automatic motor response*
Consistent or reproducible movement to command*
Object recognition or localization (reaching)*
Visual pursuit or visual fixation*
Non-stereotypical movements
Rancho III
• “Severely altered consciousness in which the
patient does not meet the criteria for coma or
the vegetative state because there is
inconsistent but reproducible or sustained
behavioral evidence of self or environmental
awareness” (Aspen WP 2001)
http://www.tbims.org/combi/crs/CRS%20form.pdf
(MCS)
• 20% with severe TBI are unresponsive at least
1 month and may go through period of
inconsistent awareness (Whyte 1995)
• Individualized Quantitative Assessments can
be used to identify evidence of awareness as
opposed to random movement (Whyte 1999)
• CRS-R can be used to identify MCS
Common Complications in
Severe TBI Population
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Elevated Intracranial Pressure (ICP)
Hydrocephalus
Sympathetic Storming
Seizures
Critical Illness Polyneuropathy (CIP)
Fractures
Heterotopic Ossification (HO)
Common Complications in
patients with DOC
Elevated Intracranial Pressure
• Definition: Pressure exerted by the cranium on brain tissue, CSF,
and brain blood volume
– Can lead to decreased cerebral blood flow and brain ischemia
– Most frequent cause of death/disability following severe TBI
– Normal = 5-15 mmHg
• Incidence
– >50% of patients with severe TBI and intracranial mass evacuated
– 30-80% in patients without mass lesions (Hlatky, 2003)
• American Association of Neurological Surgeons
– Monitor ICP in all salvageable pts w/ GCS 3-8 and an abnormal CT
– ICP monitoring indicated if 2 of 3 are present:
• Age >40 years
• Unilateral or bilateral motor posturing
• SBP <90 mmHg
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• Concern with elevated ICP is compromised
cerebral perfusion pressure (CPP)
– CPP is an important determinant of cerebral blood
flow
• CPP = MAP - ICP
– CPP will be decreased by:
• Elevated ICP
• Hypotension
• Signs and Symptoms of elevated ICP
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Headache
Altered MS
Nausea & vomiting
Papilledema
Visual loss
Diplopia
Cushings Triad: HTN, bradycardia, irregular
respirations
Blumenfeld, 2002
• Impact on treatment
– Monitoring
• EVD must be closed to mobilize
• Bolt- patients will remain on bedrest
• Prognosis
– Severity of elevated ICP is related to poorer outcomes
post severe TBI (Sahuquillo 2008, Hlatky 2003)
• 77% of patients with ICP <15mmHg had favorable outcome
vs 43% of patients with ICP >15mmHg (Hlatky, 2003)
• Normal ICP compared to ICP which could not be decreased
to 20mmHg (Miller, 1981)
– Exercise and ICP (Brimioulle, 1997)
• PROM showed trend to decrease ICP in pts w/ normal or
higher ICP
• Active exercise showed ICP and CPP unchanged
• Isometric ex increased ICP and CPP w/ normal ICP,
unchanged in higher ICP
– Use caution with casting in patients with elevated ICP
(Zafonte, 2004)
– Mortality increased 18 to 92%
– Frequency of good outcomes decreased from 74 to 3%
– May also result in secondary injury
• Cerebral ischemia
• Distortion and compression of brainstem
Hydrocephalus
• Definition: Excess CSF in the intracranial cavity which
may be caused by:
– An excess of CSF production
– Obstruction of flow at any point in ventricles or
subarachnoid space
– A decrease in re-absorption
• Incidence: Post-traumatic hydrocephalus (PTH) varies
from 0.75% to 10.7% in severe TBI (Mazzini,2003)
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–
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45% of patients developed PTH
11% of patients required surgery
developed within first 3 mos post injury
ventriculomegaly developing slowly over period of 6 mos
Hydrocephalus
• Signs and symptoms
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Magnetic gait*
Incontinence*
Cognitive changes*
Decreased level of
consciousness
Headache
Nausea
Vomiting
Papilledema
Decreased vision
Sixth nerve palsies
(similar to those of elevated
ICP)
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Hydrocephalus
– Monitor patients for change in status or signs and
symptoms of hydrocephalus and report to MD
– Patients already treated with shunting should be
observed for change in status as this may reflect
shunt malfunction, obstruction, or overshunting
• Definition: Autonomic instability following TBI
– “Dysfunction of autonomic centers in the
diencephalon or their connections to cortical,
subcortical, and brainstem loci that mediate
autonomic function.”
– Also known as
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Paroxysmal sympathetic storms
Diencephalic seizures
Midbrain dysregulatory syndromes
Paroxysymal autonomic instability with dystonia (PAID)
– May persist weeks to months in pts w/ low response
state (Blackman, 2004)
• Incidence:
– 15-33% of pts w/ severe TBI suffer storming (Lemke, 2007)
• Signs and Symptoms
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Intermittent agitation
Diaphoresis
Hyperthermia
Hypertension
Tachycardia
Tachypnea
Extensor posturing
Pupillary dilatation
• Medical treatment
– Medication management
– Minimize complications
– Noxious stimuli may trigger storming in predisposed
patients
– Monitor VS response to treatment
– Increased tone and posturing may result in skin
breakdown or contractures
Seizures
• Definition: An episode of abnormally
synchronized and high-frequency firing of
neurons in the brain
• Incidence: 5-10% of pts with TBI experience
new onset seizures (Asikainen, 1999)
– Early Post-Traumatic seizures associated with
depressed skull fracture and intracranial
hematoma
Seizures
• Type of seizures
– Partial (focal, local) seizures
• Simple partial
• Complex partial
• Partial seizures evolving to secondarily generalized seizures
– Generalized seizures
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Absence seizures
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic-clonic (grand mal) seizures
Atonic seizures
– Unclassified epileptic seizures
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Seizures
• Signs and Symptoms
– Vary depending type and location of seizure
– May include
• Motor
– Myoclonic jerks
– Sustained contractions
• Autonomic signs or symptoms
• Somatosensory or special sensory symptoms
Seizures
– Increased fall risk
– Medication side effects
– Post-ictal state
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Paresis (Todd’s paresis)
Lethargy
Confusion
Amnesia
Headache
Critical Illness Polyneuropathy
– Distal generally more affected vs. proximal
• May affect limb, trunk, respiratory muscles
– Usually motor and sensory
– Usually symmetric
• Impact of spasticity and CIP on each other not well
described.
– LMN vs. UMN signs
• Diminished/absent reflexes
• Increased muscle wasting
– Most evident in tibialis anterior, quadriceps, suprascapular
Seizures
• Prognosis (Asikainen, 1999)
– Epilepsy slightly worsens functional and social
outcome
– Employment is equivalent patients with TBI w/o
seizures
– Proper anti-epileptic treatment helps improve
chance of employment
• Definition: Axon-loss neuropathy affecting patients who are
significantly medically compromised
– Closely related myopathy also exists
– No clear consensus yet on subtypes, combination with myopathy
– Other related names include
• Critical care neuropathy
• ICU-acquired neuropathy
• “Critical illness neuromuscular abnormalities” (CINMA) (Stevens, 2007)
• Incidence in this population: not described
– 50% to 70% of patients with sepsis and multiple organ failure
•
(Bolton, 2000)
– Associated with long or complicated acute care/ICU stays
– Also correlated with time on vent, steroid use, neuromuscular
blockade
– Expect longer course for recovery of strength
• Peripheral nerve healing ~1-3 mm/day
– Use of e-stim or aggressive strengthening is
controversial
• One study in rats suggested this may interfere with reinnervation of neuropathy (Tam, 2001)
• Cochrane review investigating exercises in neuropathy
included three studies, concluded that evidence was
limited. (White, 2004)
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Fractures
• Fractures and peripheral nerve injuries
• Prognosis/outcomes
– Mild to moderate cases with good outcomes
– Severe cases with mixed outcomes (deSeze, 2000)
• 19 patients with CIP and tetraplegia or tetraparesis
• 2 died; 11 completely recovered; 4 with tetraplegia; 2
with tetraparesis
– present in 40-60% of head injured patients (Kushwaha, 1998)
• Up to 11% of orthopedic injuries undiagnosed until rehab
admission (O'Dell, 1998)
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Life saving measures more important than orthopedic concerns
Patients unable to complain or express concerns
Patients not moving
Symptoms may be confused for other medical issues. ie DVT
• Lower extremity injuries more common than Upper
extremity
– LE fractures 50-75% (Kushwaha, 1998)
– Peripheral nerve injuries more common in LE (Kushwaha, 1998)
Fractures
• Consider undiagnosed fractures
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Pain
Swelling
Deformity
Bruising
• Maintain Orthopedic precautions
• Weight bearing
• Range of motion
• Intervention may be impacted by patients
status
• i.e. agitated patient attempting to remove
splint, pulling at collar
• Communication with ortho/trauma service
regarding complications
Heterotopic Ossification
• Definition: Presence of bone in a location where
bone does not normally exist
– Myositisossificans now generally regarded as a
subtype of H.O.
• Incidence in this TBI
– “Clinically relevant” H.O. varies between 8-22% in
individuals with TBI
• (van Kampen 2011)
– Length of coma and ventilation, surgical fixation of
fractures, autonomic dysregulation, spasticity strongly
associated with increased H.O. risk.
• (van Kampen 2011, Hendricks 2007)
• Location: Most common
location in TBI is hip, followed
by shoulders, elbows, knees.
– Develops in as little as 3 weeks,
or may onset months post
– may not be discovered until
months post.
– Stiffness, limited ROM, edema,
erythema, pain
– These signs can be difficult to
discern in this population
– Must be differentiated from
DVT, local infection, local
trauma/fracture
– PT seen as an adjunctive role in prevention of H.O.
formation
– Relationship of ROM activities to H.O. very
controversial
– “Gentle exercise within pain-free ROM” is consensus
guideline, not supported by literature or evidence
• May need to premedicate for pain
– Early rabbit studies indicated that aggressive ROM
could worsen H.O., but not clinically proven (VandenBossche,
2005)
– CPM may increase ROM
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• Impact on Treatment (con’t)
– Review by Cullen (2007) indicates that “there is
limited evidence that forceful manipulation under
general anesthesia increases ROM in patients with
H.O. following brain injury”
– Emerging evidence for pulse low intensity
electromagnetic field therapy (Aubut 2011)
– May need medical assistance for spasticity
management
• Treatment: Limited literature both medical and PT
management
– Medication/Medical:
• NSAID, Diphosphates, Cox-2 inhibitors may prevent and/or decrease
severity
• Diphosphates (disodium etidronate) - early phase
• NSAIDs – early and intermediate phase
– Indomethacin- has shown efficacy s/p THA
• Radiation
– Further management dependent on impact on function or
symptoms
• Surgical resection with significant recurrence
– Overall 19.8% in recent review (Chalidis, 2007)
– Recurrence increased with increased coma duration
– Also dependent on location, observation periods
• Surgical Treatment
– goals: mobility, decrease spasms, hygiene,
positioning
– Recommended 1.5 years post TBI
• but must balance risk/benefit
– Post-operatively
• early gentle joint mobilization and prophylaxis
– Recurrence rate varies
• clinically insignificant seen in 82-100%
• clinically significant HO 17%-85%
• Prognosis
– Positive prognosis:
• High level neurologic function is best single predictor of a
good surgical result and lowest rate of recurrence
• Patients with selective limb control, primary HO resections,
and HO associated with trauma
• Continuously passive ROM exercises have better outcomes
post-op
– Poorer outcomes:
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Immature HO or long delays until surgery
Lack of selective limb control
Involvement of multiple joints
Previous recurrence of HO
Physical Therapy Examination
• Examination consists of:
Physical Therapy
Examination
– History
– Review of systems
– Tests and Measures
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PT Examination
• Goals of your exam
– Describe movement dysfunction and how it
impacts functional independence
PT Examination
• Use neuroanatomy and pathophysiology to guide
examination
– Consider location of lesion/injury on imaging studies
• Left temporo-parietal lobe injury:
– suspect language and right motor control deficits
– may modify communication style
• Relevant to meaningful tasks
– Identify impairments
– Test hypotheses formulated from history and
systems review
– Develop prognosis
• Zygomatic fracture:
– anticipate vestibular involvement
• Occipital lobe fracture or bleed
– anticipate vision deficits
• Frontal lobe injury
– anticipate behavioral issues
– Impulsivity, initiation, inhibition, self monitoring
PT Examination
• Pathophysiology
– Anoxia/hypoxia
• Basal ganglia, cerebellum, hippocampus, cortex
– Diffuse axonal injury (DAI)
• Hallmark of TBI
• Often responsible for discrepancy between imaging studies
and clinical presentation
• White matter, cranial nerves
– Coup/contrecoup
– Hemorrhagic insult
– Ischemic insult
Patient/Client History
• Demographics
– Age, sex
• Social history
– Activity pattern, interests, hobbies
• Employment (job/school/play)
– Prior work and/or education level
• Living environment and options for home setup
– Support available at home
– Entrance to home or first floor setup
• Growth and development
– Handedness
• General health status
– Pre-morbid health conditions
• Cardiopulmonary
• Orthopedic
• Musculoskeletal
– Exercise pattern and history
• History of current condition
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Time since injury
Course since injury
Complicating factors
Medical interventions
• Medications
– Be aware of secondary or side effects of medications
• i.e. lethargy, confusion, tachycardia
• Clinical tests
– Blood tests (lab values)
– Diagnostic imaging
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Review of Systems
• Cardiopulmonary
– Respiratory rate, HR, BP, edema
– Cardiac status: HR, heart rhythm, BP
• Integumentary
– Pressure sores, abrasions, post-surgical incisions, scars
• Musculoskeletal
– Gross A/PROM, strength, restrictions related to fractures, orthopedic
precautions, height, weight
• Neuromuscular
– Gross coordination of movements, motor function (motor control and
learning)
• Communication, Affect, Cognition, Language and Learning Style
– Consciousness
– Verbal vs. non-verbal, tactile cues, demonstration
– Ability to make needs known
PT Examination
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Arousal, attention, cognition
Aerobic Capacity
Peripheral Nerve Integrity/ Sensory
Vision/vestibular
Motor function, motor control, motor learning
Muscle Performance
Reflex Integrity
Pain
Posture
Gait/locomotion
Balance
Work, community, leisure re-integration
Tests and Measures for Patients
with Severe Brain Injury
• Standardized assessments
– Often will not be able to be used in this
population
– Inability to follow commands, communicate
• General principles
– Describe what is observed as objectively as
possible
– Consider both spontaneous and elicited behavior
Tests and Measures
• Observation is key to examination
– What does the patient do at rest?
• Positioning, movement, gaze, verbalization
– What reactions do you see during Nursing care
• Be aware of the different stimuli introduced and note
responses
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Auditory
Visual
Tactile
Combination
• Be aware of patient’s care schedule
– Nursing care sessions may result in overstimulation or fatigue
Tests and Measures
• Arousal
– Arousal is actually an internal state of readiness that is
unable to be directly measured
– Very frequently impacted by severe TBI and secondary
issues
– Indirectly assess arousal through eye opening
– Can be problematic with eye injuries, or subset of
patients who tend to keep eyes closed even when
aroused
– Document spontaneous eye opening, or with
stimulation
Tests and Measures
• Attention
– Internal process that we are attempting to evaluate
– Includes many different aspects
– Attention is generally assessed with regard to
engagement in a task or activity in other populations
• Often unable to be performed in this population.
– Ability to attend to an object presented
– If patient unable to physically interact, consider visual
attention
• Ability to sustain and/or track visually
• Consider attention to both left and right
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Tests and Measures
• Cognition
– Unable to be evaluated formally
– Describe any evidence of higher-order cognitive
processing
• Command following, communication
– Differentiate reflexive behavior from behavior
which requires processing
• Reaching for objects
• Purposeful object use
• Non-reflexive responses to stimuli
Tests and Measures
• Ventilation, Respiration, and Circulation
– HR, BP, SaO2, need for supplemental 02
– Auscultation
– Respiration
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– Monitor response to interventions
Tests and Measures
• Cranial nerve exam
– Facial expression – CN VII
• Elicit grimacing if no spontaneous expression
– Hearing – CN VIII
• Try to assess right and left
• If no response, assess auditory startle
– Gag reflex – CN IX, X
– Tongue protrusion – CN XII
Tests and Measures
• Range of Motion
– Assess and document key areas
• Areas with current significant limitations
• Areas most at risk for loss of ROM
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Ankles: dorsiflexion, eversion
Hips: extension, internal rotation
Shoulders: flexion, abduction, external rotation
Pelvis: anterior tilt
Trunk: extension
Scapulae: upward rotation, general mobility
Cervical: throughout
Rate
Pattern
Muscle use
Cough
Tests and Measures
• Muscle performance
– Description of observed movements
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Quality/smoothness
Speed/timing
Isolated control vs. synergistic/patterned
Spontaneous and elicited
– Type of stimulation to elicit
– May be observed during postural control challenges
– Tone/spasticity assessment
• Modified Ashworth Scale
• Tardieu scale
Tests and Measures
• Peripheral Nerve Integrity
– DTR’s
– Sensation
• Response or lack of response to tactile stimuli
• Localizing vs withdrawal
– Muscle atrophy
• EMG’s to supplement clinical findings
• Consider Critical Illness Polyneuropathy (CIP)
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Tests and Measures
• Neuromotor development and Sensory
Integration
– Decorticate or decerebrate posturing
– Primitive reflexes
• ATNR, STNR
• Pain
– Can be difficult to assess
• Facial expression/grimacing may not be reliable
• Heart rate and other physical signs may be confounded
– Assess response to noxious stimulusgroaning/moaning, flexion withdrawal, localizing,
facial expressions
1/22/2013
Tests and Measures
• Reflex integrity
– Can help identify LMN involvement
– Grasp reflex
• May confound assessment if not recognized
– VOR (doll’s eye)
– DTRs
– Spasticity
• Sensory integrity
– As in cranial nerve assessment
– Evidence of sensation throughout
– Reaction to deep pressure throughout
Tests and Measures
• Posture
– Description of resting position
– Include head/neck, eyes, trunk
– May include supine or seated in wheelchair
– Examine in supine, supported and unsupported sitting
Role of PT in Evaluating
Consciousness
• Assess fixed vs flexible deformity
• Postural control and righting reactions
– Note righting and protective reactions to
displacement
Evaluating Consciousness:
The Challenge
• Patients can remain vegetative or minimally
conscious for prolonged periods
• Routine assessment of cognitive abilities
depends on voluntary engagement of the
patient and consistency of performance
• Variable behavior/arousal is the hallmark of
minimally conscious state and is present in
vegetative patients
Evaluating Consciousness
The Assessment Challenge
• Observed behaviors may be volitional,
spontaneous, reflexive
• Clinical observations and conclusions are
biased by “extremes”
• Observation alone does not provide accurate
information
• Errors in classification as VS vs MCS range
from 15-43% (Tresch, 1991; Childs, 1993; Andrews, 1996)
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Examination of
Consciousness
• Standardized behavioral scales
– Glasgow Coma Scale (GCS)
– Full Outline of UnResponsiveness Scale (FOUR)
– JFK- Coma Recovery Scale –Revised (CRS-R)
– Rancho Los Amigos Level of Cognitive Funcrtioning
Scale (RLCFS)
• Patient specific measures
Glasgow Coma Scale
(GCS)
• Brief measure of brain injury severity
• Assesses the function of the cerebral cortex and the upper
brainstem, the reticular activating system
– eye-opening response - arousal mechanism of the brainstem
– verbal response - integration of cerebral cortex and brainstem
– motor response - integrity of cerebral cortex and spinal cord
• International use in ERs and trauma units
• Total score usually documented
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•
Mild = 13-15
Moderate = 9-12
Severe = 3-8
3-4 = very severe
(Teasdale, 1974) (Zuercher M, et al 2009) (Matis G &Birbilis T, 2008)
Glasgow Coma Scale
(GCS)
• Important instrument in clinical decision making
Glasgow Coma Scale
Eye Opening
– Surgery, follow up CT scanning, intubation, monitoring of ICP
• Limitations:
– brainstem reflexes and eye movements are not considered
– Not sensitive to mild brain injury deficits
Best Motor Response
• Predicts recovery outcome in moderate to severe brain
injury
• Strong predictor of:
– hospital mortality, length of coma (LOC) and posttraumatic
amnesia (PTA), Glasgow Outcome Score (GOS) at 6 months,
long-term abilities after TBI
(Teasdale, 1974) (Zuercher M, et al 2009) (Matis G &Birbilis T, 2008)
Rancho Los Amigos Level of
Cognitive Functioning Scale
• Commonly used tool used to describe a patients level of
cognitive function across the continuum of recovery after TBI
• Correlates with 24 hour CGS scores, length of coma, and
duration of posttraumatic amnesia.
• Limited as a predictor of long term outcome or to monitor
progress within levels
• Every patient does not go through all levels.
• Inter-rater reliability = 0.89 (Gouvier 1987)
• Includes 8 levels ranging from “No Response” to “Purposeful
and Appropriate Responses”
Verbal Response
Spontaneous
E4
To Speech
E3
Eyes closed by
To Pain
E2
Swelling =
None
E1
C
Obeys
M6
Localizes
M5
Withdrawals
M4
Abnormal Flexion (decorticate)
M3
Abnormal Extension (decerebrate)
M2
None
M1
Oriented
V5
Endotracheal
Confused conversation
V4
tube or
Inappropriate words
V3
Tracheostomy =
Incomprehensible sounds
V2
T
None
V1
Rancho Level
• I - No Response
• II – Generalized Response
• III – Localized Response
• IV – Confused Agitated
• V – Confused Inappropriate
• VI – Confused Appropriate
• VII – Automatic Appropriate
• VIII – Purposeful
Appropriate
Cognitive deficit limiting function
•
•
•
•
•
•
•
•
Arousal
Awareness of environment
Consistency of awareness
Filtering and Attention
Attention
Memory
Executive Functioning
Abstract Thinking
15
1/22/2013
• Level I - No Response
• Level II - Generalized Response
– Generalized reflex response to painful stimuli
– Responds to external stimuli with
– Patient appears to be in a deep sleep and is
completely unresponsive to any stimuli
• physiological changes
• generalized gross body movement
• non-purposeful vocalization
• Role of PT
– Provide orienting information in simple language
with pauses to allow processing time
– In some facilities, PT role at this stage is limited to
periodic consultation.
– Responses noted above may be same regardless of type and location
of stimulation
– Responses may be significantly delayed
– Patient reacts inconsistently and non-purposefully to stimuli in a
nonspecific manner
• Role of PT
– try to increase patient’s awareness of the environment by providing
information using the modalities to which the patient is responsive
• Level III - Localized Response
–
–
–
–
–
–
–
–
–
–
–
Withdrawal or vocalization to painful stimuli
Turns toward or away from auditory stimuli
Blinks when strong light crosses visual field
Follows moving object passed within visual field
Responds to discomfort by pulling tubes or restraints
Responds inconsistently to simple commands
Responses directly related to type of stimulus
Reacts specifically but inconsistently to stimuli
Responses directly related to type of stimulus provided
May follow simple commands in an inconsistent, delayed manner
May respond to some persons (especially family and friends) but not to
others.
• Role of PT
JFK Coma Recovery Scale – Revised
(CRS-R)
•
•
•
•
•
•
Original scale 1991 (Giacino, et al)
Revised 2004 (Giacino, Kalmar & Whyte)
Developed to characterize and monitor patients at Rancho Levels I –IV
Discriminate MCS from VS
Used widely in clinical and research settings
Reliable and Valid
–
–
–
–
Inter-rater reliability (0.84)
Test-retest reliability (0.94)
Concurrent validity (0.97) with the CRS
Concurrent validity (0.90) with the Disability Rating Scale (DRS)
• Differential diagnosis of DOC and tracks recovery (Giacino, 2004; Giacino, 2006)
• Recommended to assess DOC with only minor reservations (Seel et al, 2010)
• www.tbims.org/combi/crs/index.html
– Try to build on responses observed
JFK Coma Recovery Scale – Revised
(CRS-R)
• 23 Items with 6 subscales
– Auditory Function
– Visual Function
– Motor Function
– Oromotor/Verbal Function
– Communication
– Arousal
• Hierarchical: lowest item is reflexive, highest
item is cognitively-mediated
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1/22/2013
CRS-R
Administration Overview
• Conduct 1 minute baseline observation
–
–
–
–
Determine level of arousal
Facilitate selection of appropriate commands
Differentiate volitional from random/coincidental movement
Resting position of extremities, eye opening status, spontaneous visual fixation or
tracking, spontaneous movement
• Administer Arousal Facilitation Protocol (AFP)
– May administer protocol any time
– Purpose is to increase the length of time arousal is sustained
– Deep pressure, vestibular
• Administer CRS-R items in sequence
– Score elicited responses only
– Do not score responses that occur after 10 seconds
– score best response within each subscale
CRS-R
Auditory Function Scale
• Score = 4 = Consistent Movement to Command
– Clearly discernible & accurate responses occur on all 4 trials
– Functional significance:
•
•
•
•
Capable of sustained environmental interaction
Signals readiness for active rehabilitation
Able to tolerate more complex cognitive assessment
Denotes MCS
• Score = 3 = Reproducible Movement to Command
– 3 clearly discernible, accurate responses occur over the 4 trials
• Retain capacity for cortically based processing and cognitively mediated
behavior
• Clearest indication of recovery of consciousness
• Denotes MCS
(Giacino lecture, 2003; www.tbims.org/combi/crs/CRS%20Syllabus.pdf)
CRS-R
Auditory Function Scale
• Score = 2 = Localization to Sound
– Head/eyes orient toward location of stimulus in >/= one direction, both trials
• Retains capacity for detection and gross discrimination of location of sound
• Score = 1 = Auditory Startle
– Eyelid flutter or blink occurs immediately following stimulus on at least 2 trials
• Retains capacity to detect sound
• Score = 0 = None
– No discernible auditory response
– Functional Significance:
• Arousal dysfunction, sedation
• Hearing loss
CRS-R
Visual Function Scale
• Score = 5 = Object Recognition
– 3 to 4 clearly discernible, accurate responses occur over 4 trials
• Retains capacity to follow commands and discriminate visual stimuli
• Indicative of MCS
• Score = 4 = Object localization: Reaching
– Limb must move toward object on 3 of 4 trials
• Retains capacity to detect, locate and apprehend stimuli in the
immediate environment
CRS-R
• Score = 3 = Visual Pursuit
– Eyes follow movement of mirror without loss of fixation to 45° of
midline in at least one field
• Retains capacity for visual exploration of environment
• Indicative of emergence from VS
• Denotes MCS
• Score = 2 = Fixation
– Eyes change from initial fixation point and re-fixate on new target
– Two episodes of fixation are required
– Functional Significance
• Retains capacity to detect and locate visual stimuli
• Denotes MCS
CRS-R
• Score = 1 = Visual Startle
– Eyelid flutter or blink immediately following visual threat
• Retains capacity to detect movement
– No discernible visual response
•
•
•
•
Arousal dysfunction
Sedation
Visual impairment
Cortical blindness
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CRS-R
Motor Function Scale
• Score = 6 = Functional Object Use
– Limb movement is generally compatible with specific function of each object
across all 4 trials
– Functional significance
CRS-R
• Score = 4 = Object Manipulation
– On at least 3 of 4 trials wrist must rotate, fingers must extend and object must
be grasped and held for 5 seconds
– Ball cannot be held by means of grasp reflex or flexor hypertonus
• Retains basic capacity for instrumental ADL’s
• Indicative of emergence from MCS
• retains capacity for exploratory sensorimotor behavior
• Score = 5 = Automatic Motor Response
– 2 episodes of automatic motor behavior are observed, each episode can be
differentiated from a reflexive response
– Patient performs a familiar gesture when demonstrated
– Patient performs the oral movement pattern when presented a spoon or a
straw
– Functional Significance
• Score = 3 = Localization to Noxious Stimulation
– Non-stimulated limb must locate and make contact with stimulated body part
at the point of stimulation on at least 2 trials
• Retains awareness of body schema
• Capable of self-defensive behavior
• Denotes MCS
• Maintains access to over-learned behavioral routines
• Indicative of minimally conscious state (MCS)
CRS-R
• Score = 2 = Flexion Withdraw
– Isolated flexion withdraw occurs in at lest 1 limb, away from point of
stimulation
CRS-R
Oromotor/Verbal Function Scale
• Score = 3 = Intelligible Verbalization
– 2 different words, each consisting of at least consonant-vowelconsonant (“Mom” not “Ma”)
– Intelligible, but not necessarily appropriate
– Writing or alphabet board acceptable
• Retains capacity for active movement (maybe unable to initiate or regulate)
• Score = 1 = Abnormal Posturing
– Slow, stereotyped flexion or extension of the upper and/or lower extremities
immediately after stimulation is applied
• Unable to initiate or regulate movement secondary to loss of competing extensor tone
• Score = 0 = None/Flaccid
• Retains capacity for expressive language
• Score = 2 = Vocalization/Oral Movement
– At least one episode of non-reflexive oral movement and/or
vocalization occur spontaneously or in response to sensory stimulation
– No discernible motor response
• Movement not possible
• Speech apparatus functional
CRS-R
Oromotor/Verbal Function Scale
• Score = 1 = Oral Reflexive Movement
– Clamping of jaws, tongue pumping and/or chewing
movement occurs following introduction of tongue blade
into mouth
• Loss of inhibition and regulation of primitive reflexive oromotor
activity (incompatible with speech)
CRS-R
Communication Scale
•
– Accurate responses to all 6 questions situational orientation questions from protocol
– verbal, motor, or gestural means of communication
•
•
•
•
• No evidence of capacity for verbal communication
Immediate memory intact
Language comprehension and expression reliable
Denotes emergence from MCS
Score = 1 = Non-Functional: Intentional
– Clearly discernible responses to at least 2 of the 6 questions
– No discernible vocalization or oromotor activity
Score = 2 = Functional: Accurate
•
•
•
Suggests re-emergence of capacity for interactive communication
Indicative of MCS
Score = 0 = None
– No discernible verbal or non-verbal communicative responses occur at any time
18
CRS-R
Arousal Scale
• Score = 3 = Attention
– No more than 3 occasions across the length of evaluation in
which patient does not respond to a verbal prompt
• Retains basic capacity to direct attention and sustain attentional focus
• Score = 2 = Eye Opening without Stimulation
– Eyes remain open across the length of examination without the
need for tactile, pressure, or noxious stimulation
• Sleep/wake cycle is re-established
1/22/2013
CRS-R
Arousal Scale
• Score = 1 = Eye Opening with Stimulation
– Tactile, pressure or noxious stimulation must be applied at least
once during the examination in order for the patient to sustain
eye opening
– Length of time eyes remain open is not considered in scoring
• Score = 0 = Unarousable
– No spontaneous or elicited eye opening at any time during the
assessment
• Persistent disturbance of wakefulness
• Sedation
• Chemical paralysis
Full Outline of UnResponsiveness
(FOUR)
• Evaluates visual functioning, command
following, brainstem reflexes, breathing
patterns, evidence of brain herniation (Wijdicks, 2005)
– Developed to address limitations of GCS, but not
widely used
– Does not depend on verbal response
– Able to identify locked-in syndrome
• Adequate reliability, validity.
• Predicts recovery at 3 months
Review of
Disorders of Consciousness Scales
• The CRS-R may be used to assess DOC with
minor reservations
• The SMART, WNSSP, SSAM, WHIM, and DOCS
may be used with moderate reservations
• The CNC may be used with major reservations
• The FOUR is not recommended at this time
because of a lack of content validity, lack of
standardization, and/or unproven reliability
(Seel et al, 2010)
Coma/Near-Coma Scale
(CNC)
• Description: 11-item measure of
sensory/perceptual functioning, primitive
responses in patients with DOC (Rappaport, 1982)
• Sensitive to changes in severe TBI
• Predicts recovery of consciousness one year
after injury (Rappaport, 2005)
• Five categories of Awareness/Responsivity
– No Coma, Near Coma, Moderate Coma, Marked
Coma, Extreme Coma
Patient-Specific Measures
• Purpose: Evaluate clinically meaningful questions
– Is the person under-aroused?
– Can the person see?
– Is the person demonstrating “purposeful behaviors”?
• Tracking, pulling at tubes, reaching for caregiver, pushing
away noxious stimuli
– Can the person follow commands?
– Is the person’s behavior changing over time or with
medications?
19
• Stimuli (e.g., specific commands) and responses (e.g.,
particular movements) are operationalized
• Uses patient specific behaviors
• Selection of measure depends on clinical question
• Patient measures (“Protocols”) developed by the
interdisciplinary team
• Pilot data may be collected for inter-rater
reliability/feasibility of protocol
• Data collection continues until the clinical question is
answered
• Data analyses are reported to the treatment team and
family
1/22/2013
• Stimuli (e.g., specific commands) and
responses (e.g., particular movements) are
operationalized
• Pilot data may be collected for inter-rater
reliability/feasibility of protocol
• Data collection continues until the clinical
question is answered
• Data analyses are reported to the treatment
team and family
Arousal data
Examples of Patient-Specific Measures
• Arousal
– Time sampling of degree of eye-opening across
therapy session
• Therapists record level of eye opening every 5 min
– 0 = closed,
– 0.5 = half-open
– 1.0 = open
• Average score reflects arousal
• Average across days, time
• Evaluates progress, medication effects
Verbal command only, RR = 55%, Acc = 65%
Examples of Patient-Specific Measures
• Command following
– Identify spontaneously generated behaviors
– Evaluate patient’s ability to perform behavior “to
command”
– Example: A patient is able to follow command for
“thumbs up” and “thumbs down” with verbal and
gestural command. His ability to follow a verbal
command only is unclear.
– Protocol will clarify command following and
language comprehension.
Thumb up Thumb
down
NR
Total
Thumb up 17
6
31
54
Thumb
down
15
22
17
54
32
28
48
108
Verbal plus gesture, RR = 83%, Acc = 86%
Thumb
up
Thumb
down
NR
Total
Thumb
up
42
4
8
54
Thumb
down
8
36
10
54
50
40
18
108
20
Changes in Command Following
Over Time
Conclusions
• Patient is able to follow verbal commands
• Patient benefits from gestural cues, suggesting
impaired language comprehension
• Command following has improved over time
1.0
0.9
0.8
0.7
Value
1/22/2013
RESPONSE RATE
0.6
ACCURACY
0.5
0.4
0.3
0.2
5728
5732
5736 5740
DATE
5744
5748
Summary
• Correct diagnosis of level of consciousness is
important for patient care and services
– Misdiagnosis rate very high (15-43%)
• Use of standardized tools such as CRS-R and
patient specific measures have been found to
be best for diagnosing consciousness.
Goal Setting for patients with DOC
• Focus on prevention of secondary
complications- contractures, skin breakdown,
pulmonary
• Ongoing assessment of function and cognitive
changes
• Maximize abilities as recovery occurs
• Family education and training
• Identification of appropriate level of care
Sample Goals for Low Level
BI Patients
• Command follow:
“Pt will demo yes/no response via thumbs up/down to biographical information in
4/6 trials.”
• Head or trunk control:
“Pt will maintain head in neutral after positioning, with visual and verbal cues for
30 seconds.”
• Endurance:
“Pt will tolerate tilt table for with VSS at 60 degrees x 20 minutes.”
• ADLs:
“Pt will assist in grooming with suction toothbrush by demonstrating intact grasp
and mouth opening after presentation with verbal cues.”
• Tracking:
“Pt will track a picture of a family member when it is moved to the right and left
of midline, 3 out of 5 times, in supported sitting.”
Physical Therapy
Interventions
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1/22/2013
Interventions for Patients
with Severe TBI
• Focus of goals
– Prevention of secondary impairments
– Ongoing assessment of abilities
– Family/caregiver education and instruction
– Maximizing abilities as natural recovery occurs
– Identification of appropriate next level of care
Therapeutic objectives for individuals
with severe disability
• Mobility goals that will improve quality of life
for pt and caregiver as well as reduce risk for
secondary complications
• Developing a communication system
• Being able to control eye and head movement
to orient towards stimuli of interest improves
quality of life for patient and caregiver.
• Caregiver training and education
Interventions for Patients
with Severe TBI
• Ongoing assessment
– Each session is an assessment of current abilities
• Remember, inconsistency is a hallmark of these
patients
• Even small changes very important
– Positive changes improve prognosis
– Negative changes give concern for medical issues
• Therapist consistency is crucial
Body Structures and Function
•
•
•
•
•
•
Arousal
Range of Motion
Strength and motor control
Muscle tone/spasticity
Postural control
Endurance
– Independent of setting
Body Structures and Function:
Arousal
• Goals of interventions include
– Increase arousal & attention
– Increase reactive, adaptive, or meaningful responses
• Types of Sensory Stimulation
–
–
–
–
–
–
–
Vestibular
Proprioceptive/Kinesthetic
Auditory
Visual
Olfactory
Gustatory
Tactile
PT Interventions for Low Arousal:
Sensory Stimulation
• Vestibular
–
–
–
–
–
–
–
–
Stimulated using motion and gravity
Incorporate rocking, rolling, spinning into treatment
Tracking with and without head movement
Supine to/from sit
Elicit balance/righting reactions
Large ball
Large bolster
Rocker board
22
Vestibular Stimulation
• Cerebellum and proprioceptors in muscles,
tendons and joints work to regulate posture,
equilibrium, muscle tone and orientation of body
and head in space
• Found to have positive effect on arousal,
exploratory behavior, visual fixation ability,
occular pursuit activities, and motor function
• Vestibular stimulation is the most important form
of stimulation for acquisition of visual alertness
and awareness in children
(Ottenbacher 1983)
Sensory Stimulation
• Auditory
–
–
–
–
–
–
–
–
–
1/22/2013
Sensory Stimulation
• Proprioceptive& Kinesthetic
–
–
–
–
–
–
Weightbearing& joint compression
Facilitating normal alignment (NPT, lumbar lordosis)
ROM activities
Positional changes
Tilt table
Prone over wedge, sidelying over a wedge with WB
through UE
– Motomed®
– Erigo®
Sensory Stimulation
• Visual
Pleasant and unpleasant sounds
Familiar and unfamiliar sounds
Use normal tone of voice when addressing patient
Assume he/she understands what you say
Visualization
Familiar music
Modulate your voice for the activity
Orient patient frequently
Loud noise, music, or clapping to increase arousal
– Present personal or familiar items, pictures
– Mirror image
– Assess awareness of surroundings using “blink to
threat”
– Encourage families to bring in pictures of
meaningful people and possessions
– Facilitate tracking
– observe righting responses via eye gaze during
therapy
Sensory Stimulation
Sensory Stimulation
• Olfactory
– noxious or pleasant odors
– Incorporate cologne or perfume into treatment
sessions
• Gustatory
– Stimulated using pleasant or sour tastes
– Incorporate tooth brushing with suction
toothbrush into ADL sessions
• Tactile
– Incorporate ice or different textures into session
– Sternal rub
– Pressure to nail bed
– Deep pressure using a therapy ball
– face, hands, feet, usually greatest response
– Refer to arousal facilitation protocol of CRS-R
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1/22/2013
Evidence for Sensory Stimulation
• Termed “Coma Stim” or “Intense Multisensory
Stimulation” (IMS) programs
– Started 1950’s at Institute of Achievement for Human
Potential (Lombardi, 2008)
– “In comatose patients, although the problem is
primarily cerebral, there is a condition of
environmental deprivation that could lead to
widespread impairment of intellectual and perceptual
processes accompanied by changes in cerebral
electrical activity”
– Sensory deprivation leads to physical deterioration of
the brain in animals and humans (Bragin, 1992)
• When possible, observe patients & perform
neurological assessments in the standing position
– In one preliminary study, patients (3 VS, 5 MCS)
showed consistent improvements in the highest
ranked behaviors (p=0.008) and total number of
behaviors (p=0.013) observed in the standing position
using the Wessex Head Injury Matrix (WHIM)
compared to lying in bed
• Results suggest that positional changes may have
an impact on behaviors demonstrated by patients
in the VS and MCS
(Elliot et al, 2005)
Sensory Stimulation
• Clinical Applications:
– Make team aware of stimuli meaningful to the patient
• Information boards with pictures of family members, friends, favorite sayings, topics of
interest, favorite music, tv show, hobbies, etc.
– Encourage visitors to talk to the patient about important or familiar events
– Request family members to provide meaningful objects
• e.g. favorite hat, football, stuffed animal, etc
– Be aware of sensory input intrinsic to each examination procedure or
intervention applied to patient and observe responses
– Incorporating sensory input into treatment may improve interaction with
environment and provide a more “normal” sensory experience
– Interventions may include:
•
•
•
•
Noxious stimuli to facilitate response
Muscle vibration
Muscle tapping
Visual stimuli
•
Systematic review by Lombardi et al, 2008 found there is no reliable evidence to
support, or rule out, the effectiveness of multisensory programs in patients in coma or
vegetative state
•
Article by Gerber, 2005 encouraged researching the possibility of implementing
structured coma stimulation programs as early as 72 hours post injury in the intensive
care unit
•
Sosnowski and Ustik, 1994 found that an individualized coma stimulation program in
the early stages of recovery from brain injury is paramount in stimulating the reticular
activating system and promoting brain reorganization
•
Altering the environment by providing meaningful yet novel sensory stimulation may
enhance plasticity and lead to reorganization of structures that support cognitive
processes (Davis AE, 2000)
•
Although the efficacy of coma stimulation has not been established – patients who are
not conscious can be mobilized providing an opportunity to examine head righting,
head control, trunk control and provide stimulation to increase arousal and provide an
avenue for interaction
• Several studies have reported positive effects of providing
sensory stimulation programs for patients in coma (Johnson 1993,
Kater 1989, Mitchell 1990)
• Wood (1991) argues bombardment with undifferentiated
stimulation results in decreased ability to process
information. He recommends creating a quiet environment
and providing selective input.
• Multimodal stimulation produced greater behavioral
changes than unimodal stimulation, and the use of
personally salient stimuli in multimodal stimulation
produced the greatest changes of all (Wilson SL, et al 1996)
• Sensory stimulation for coma arousal is not included as an
intervention in the Guide to Physical Therapist Practice.
ROM
• Goal: to maintain or increase PROM
– Allow for proper postural alignment, including:
• Neutral alignment of head, trunk, pelvis, upper and lower extremities
– Preparation for sitting, standing, gait, functional use of
extremities
• Passive stretching
– Helps to prevent loss of ROM in acute setting
– Appears to provide short-term decrease in spasticity (Zafonte, 2004)
– Recent review inconclusive as to effects of stretching on
spasticity (Bovend'Eerdt, 2008)
– ROM can be a skilled intervention in this compromised
population, not maintenance
24
1/22/2013
ROM
• Goal : maintain functional ROM of extremities
• Prevention of secondary impairments
• Splinting/bracing/casting/bivalves
– Serial casting is the only intervention with evidence
suggesting that it can change spasticity over long term
(Zafonte, 2004) (Hellweg S and Johannes S, 2008)
– Serial casting shown to increase ROM or prevent
further loss of ROM(Hellweg S and Johannes S, 2008)
• Superior to positioning for elbow contractures in TBI
patients (Moseley, 2008)
– Reduced spasticity noted in serial casting
– Effects on ROM and spasticity appeared short-lived
Increased Muscle Tone/Spasticity
• Oral Medications (Rekand T, 2010)
–
–
–
–
–
Baclofen
Tizanidine
Dantrolene
Diazepam
Gapapentin
• Injections (Esquenazi A, et al, 2012)
– Chemodenervation with botulinum toxin A
– Chmical neurolysis with phenol
•
•
•
•
Intrathecal Baclofen Pump (Rekand T, 2010)
Rhizotomy (Rekand T, 2010)
Tendon Lengthening and Soft Tissue Release (Rekand T, 2010)
Serial casting
– evidence suggesting that it can change spasticity over long term (Zafonte, 2004)
(Hellweg S and Johannes S, 2008)
Postural Control
• Postural Control
– Sitting
•
•
•
•
•
Interaction w/ environment
Cardiopulmonary benefits
Considerations: ROM, Integumentary status, VS response
Facilitation of automatic postural reactions
Proprioceptive feedback may be provided through tactile
cues to the
– Trunk
– Upper extremities
– Lower extremities
– Provide challenges
• Rapid displacement of center of mass
ROM
• Positioning: bed and wheelchair
–
–
–
–
Focus on: Skin protection, Tone inhibition, ROM preservation
Pictures, training
Positioning devices
If developing an imbalance of tone that might cause contracture, use
positioning to minimize chance of contracture
– Bed positioning recommendations in supine and sidelying
• Identify 2 or 3 positions that will minimize integumentary compromise given
the neuromusculoskeletal status and medical precautions
– Customized wheelchairs
• Tilt in space wheelchair, headrest, contoured back, contoured cushion, upper
extremity support, legrests
• Neutral alignment of head, trunk, pelvis, upper and lower extremities
• Increased time OOB
• Greater interaction with environment, staff, and family
Strength/Motor Control
• Strength
– Indirect strength training achieved through
positioning
• Maintain static positions
• Therapeutic transitions
– Address muscle activation, strength, coordination,
motor planning
– Provide opportunities for patient to practice
purposeful movements
Endurance/Upright Tolerance
• Endurance/Cardiopulmonary
– Upright tolerance
• Gradually raise head of bed
• Sitting
– Wheelchair, unsupported edge of bed/mat, perched sitting
• Standing
– Tilt table, standing frame
– Moveo™, Erigo®
– Some ICU beds may reverse trendelenberg and allow for
standing/upright progression
25
1/22/2013
Endurance/Upright Tolerance
• Tilt Table
– Allows for graded progressive standing of patients in VS/MCS
– Benefits
•
•
•
•
•
•
•
•
•
Load vertebrae
Pressure relief
Improved respiratory function
Improved alertness and orientation (Symons 2008, Elliott 2005)
Prolonged stretch for ankles, knees, hips
Inhibition of flexor patterns
Bone Mass Density
Improved circulation
Improved renal function
– Considerations
• VS response to upright posture
• Wounds
• WB status related to orthopedic issues
Family Training and Education
• Course of rehabilitation
– Plan of care
– Behavioral and cognitive challenges
• PROM and sensory/environmental stimulation
– Alternating time with TV or radio on/off
– Soft voices if patient “storming” or showing agitation
• Positioning
– WC and Bed
Activity
• Transfers
– Utilize lift devices as needed
– Functional transfers including low pivot and sit to stand
• Provide opportunity to stimulate and assess spontaneous muscle
activation
• Gait training
–
–
–
–
LiteGait®
Lokomat®
Platform walker
Up n Go Walker®
• Strong evidence exists that intensive task-orientated
rehabilitation programmes lead to earlier and better
functional abilities (Hellweg S and Johannes S, 2008)
Prevention of Secondary Complications
• Pulmonary
– Relax increased tone around thoracic area
– Mobilize rib cage
– Reposition for postural drainage
• Prone, sidelying over wedge
– Prevent positioning in upper cervical extension
• can cause aspiration pneumonia
• Integumentary Integrity
– Weight shifts, skin checks, positioning
Pharmacology in TBI –
DOC and Arousal
•
– another dopamine-enhancing agent, postsynaptic D2 dopamine receptor agonist
– has been examined less extensively
– associated with a greater rate of transition from persistent VS (PVS) to MCS in a retrospective
chart review
• The acute phase of recovery from severe traumatic brain
injury is characterized by a brief period of neuronal
excitability followed by a longer period of hypoexcitability,
involving depletion of multiple neurotransmitters, including
dopamine.
• Amantadine may promote dopaminergic activity by
facilitating presynaptic release and blocking reuptake
postsynaptically.
• The favorable neurobehavioral effects of amantadine may
reflect enhanced neurotransmission in the dopaminedependent circuits that are responsible for mediating
arousal, drive, and attentional functions.
(Chew E &Zafonte D, 2009)
(Giacino JT, et al 2012)
Amphetamines (Adderall) and methylphenidate (Ritalin)
– Increase dopamine and norepinephrine availability
– Few studies and no conclusive evidence support the use of neurostimulants to enhance
emergence from states of impaired consciousness
•
Amantadine
Amantadine (Symmetrel)
– Anti-parkinsonian, antiviral agent
– increases pre- and postsynaptic dopamine availability, is also a weak NMDA receptor
antagonist
– Growing body of evidence supports its use in impaired consciousness due to TBI
•
Zolpidem (Ambien)
•
Bromocriptine (Parlodel)
– acts as an agonist on a subtype of GABA-A receptors
– A number of case reports exist on its use as an “awakening” agent in patients in PVS or MCS
26
1/22/2013
Amantadine
• More rapid recovery
• Affected functionally meaningful behaviors:
–
–
–
–
consistent responses to commands
intelligible speech
reliable yes-or-no communication
functional-object use
• The benefits consistent regardless of the interval since injury or
whether patients were in a VS or MCS at enrollment
• Gains were generally well maintained but the rate of recovery
attenuated after treatment
• Exposure did not increase the risk of adverse medical, neurologic,
or behavioral events, including seizure
Attention
• Methylphenidate (Ritalin)
– Despite limitations, reasonable strength of evidence exists to support its use for various
aspects of attention, processing speed, concentration, and sustained attention in the
acute and subacute phases of recovery
• Cholinesterase inhibitors (Physostigmine, Donepezil or
Aricept)
– Compelling evidence is lacking,
– Preliminary evidence for improving attention encourages further investigation
– A double-blind, placebo controlled study found improvement in scores on one measure
of attentional processes in the physostigmine group
– One randomized crossover trial demonstrated attention and memory benefits following
TBI with Donepezil, which were sustained after the washout period
– Another case series reported subjective improvement and improvement in processing
speed, verbal memory, and divided attention in 8 of 10 subjects treated with Donepezil
(Giacino JT, et al 2012)
Memory
Identification of
Next Level of Care
• Memory disturbance remains a primary concern of patients
with severe TBI and their families.
• Attempts have been made to enhance memory via the
cholinergic and adrenergic systems
• Further investigation into the role of cholinergic augmentation
with cholinesterase inhibitors for those with impaired
memory following TBI is warranted
• Use of neurostimulants for this purpose has met with mixed
results
• No clear conclusion regarding agents to improve memory can
be made at this time
• Post acute care disposition frequently dictated
by physical therapist
Evidence to Support
Post Acute Rehabilitation
• Strong evidence exists that more intensive rehabilitation
programmes lead to earlier functional abilities (Hellweg S and Johannes S, 2008)
• Postacute rehabilitation effective in improving functional outcome
after TBI, including persons with stable neurologic recovery at 12 or
more months post injury (High WM et al 2006)
– Improvements
•
•
•
•
•
on measures of overall disability
independence
home competency
productivity
gains were maintained at follow-up
– For the group beginning postacute rehabilitation < 6 months post
injury independence continued to improve after discharge
– Community integration and home competency also continued to
improve even after discharge
– Complete understanding of patients’ current
functioning and prognosis is essential to make
proper recommendations
• In rehab, LOS significantly longer, but
discharge planning by the team is important
from the start
– Consider family goals and resources
Negative Prognostic Indicators
• Predictors of poor outcome 6 months postTBI:
– low GCS overall
– Low GCS on admission
– low motor score on GCS
– presence of midline shift on CT scan
– presence of subdural hematoma
(Husson E, et al 2010)
27
1/22/2013
Positive Prognostic Indicators
Negative Prognostic Indicators
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•
•
•
•
Prolonged coma (> 1 week)
Prolonged PTA (>2 weeks)
Coexisting injury
Secondary injury
Delayed access to trauma care
Presence of DAI
Presence of hypoxic or anoxic injury
Little or no change in GCS or RLCFS (within 4 weeks)
Positive brain injury imaging findings several weeks
after injury
•
•
•
•
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•
•
•
•
•
Early or rapid improvement in cognitive and/or motor skills
Young Age
Higher IQ
Higher educational achievement
No history of drug abuse
No previous TBI
Stable work history
Access to and continuity of rehab
Specialized care for TBI
Access to case management
Consistent communication between professionals and
patient/family
• Patient/Family acceptance and understanding of TBI
(Review by McCulloch and Crea, 2002)
(Review by McCulloch and Crea, 2002)
Glasgow Outcome Scale
(GOS)
PHYSICAL THERAPY
OUTCOME MEASURES
• Commonly used before other scales were developed as a brief
descriptive outcome scale
• Replaced by the DRS
• Still seen occasionally in the literature investigating early acute
medical predictors of gross outcome.
• The five categories of the original scale are:
– Dead
– Vegetative = Unable to interact with environment; unresponsive
– severely disabled = Able to follow commands; unable to live
independently
– moderately disabled = Able to live independently; unable to return to
work or school
– good recovery = Able to return to work or school
(www.tbims.org/combi/gos/index.html)
The Disability Rating Scale
(DRS)
• Developed and tested with individuals with moderate and severe TBI in an
inpatient rehabilitation setting
• The scale is intended to measure accurately general functional changes
over the course of recovery
• Addresses impairment, disability and handicap
– The first three items of the DRS (Eye Opening, Communication Ability and
Motor Response) are a modification of the GCS and reflect impairment ratings
– Cognitive ability for "Feeding," "Toileting" and "Grooming" reflect level of
disability
– The Level of Functioning and Employability items reflects handicap
• The maximum score is 29 (extreme vegetative state)
• Limitations
– relative insensitivity at the low end of the scale (mild TBI)
– inability to reflect more subtle but sometimes significant changes
(www.tbims.org/combi/drs/index.html)
28
1/22/2013
Take Home Message
• Formalized rehabilitation is an important part of the
rehab process.
• Observation is key…as is documentation of these
changes!
• Use of objective tools can support care and change.
• Medical and pharmacologic issues must be considered
with this population.
• Prevention of secondary complications is important for
future function.
• Recognize your part as an important part of the rehab
team.
Thank you from the
Brain Injury Special Interest Group
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