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TRAUMATIC BRAIN INJURY

I. General Medical Background
A. Definition Traumatic Brain Injury (TBI) can be defined as any head injury with evidence of brain involvement. The term Traumatic Brain Injury (TBI) is increasingly endorsed as a general term for all injuries to the brain caused by trauma. This term is referred because it clearly denotes that injury to the brain is the major cause of morbidity and mortality and that injury is caused by e!ternal forces. " number of terms are also used to refer to traumatic injuries to the brain. # $raniocerebral trauma o %&uivalent in meaning to TBI o 'ess commonly used # (ead injury ) head trauma o $ommonly used but less referable because they do not clearly denote that there is injury to the brain. o "lthough these terms do im ly that the brain is injured* this im lication is not always true because it is ossible for a atient to have a head injury without a brain injury* and vice versa. TBI is one subset of "c&uired Brain Injuries ("BI) "BI are any injury to the brain ac&uired after birth. The other subset is +on#traumatic Brain Injury. # These are not caused by trauma to the brain. # %!am les are, o -troke o Brain tumors o Infection o .oisoning o (y o!ia o Ischemia o -ubstance abuse B. Classification Ty e as to -everity based on Glasgow $oma -cale (G$-) score. a. Mild (G$- /0#/1) b. Moderate (G$- 2#/3) c. -evere (G$- 0#4) Glasgow Coma Scale (GCS)
Acti it!
#!e $%ening (#)
- ontaneous To loud voice To ain +il 5 0 3 / 9 1 5 0 3 /

Sco"e

Best moto" "es%onse (M)

6beys 'ocali7es 8ithdraws (fle!ion) "bnormal fle!ion osturing %!tension osturing +il

&e"'al "es%onse (&)

1 6riented 5 $onfused* disoriented 0 Ina ro riate words 3 Incom rehensible sounds / +il N$T#( G$-:%;M;<. .atients scoring 0 or 5 have an 41 ercent chance of dying or remaining vegetative* while scores above // indicate only a 1 to /= ercent likelihood of death or vegetative state and 41 ercent chance of moderate disability or good recovery.

3
Intermediate scores correlate with ro ortional chances of recovery.

Ty es as to .rimary Injury, a. $losed # >enotes that the dura mater remains intact. # >ue to an im act on the head by a blunt object or vice#versa. # -ubcategories, o $oncussion # (ead injury with a transient loss of brain function but no structural damage. # ?sually due to a violent shaking of the head. o $ontusion # (ead injury with structural damage of the surfaces of the brain. # ?sually due to a blunt#force trauma. # 'ocal brain damage 6ccurs at the direct site of im act only. # $ou #contrecou injuries 6ccurs at both the direct (cou ) site and o osite (contrecou ) the site of im act. >ue to @bouncingA of the brain within the skull. # .olar brain damage $ou #contrecou injuries which include laceration of the bottom surface of the brain. 'aceration of the bottom surface of the brain is due to the brain moving over the shar rotrusions that e!ist on the base of the skull. # Most commonly involves the underside of the frontal and tem oral lobes. # 'ess commonly involves the underside of the occi ital lobes. o >iffuse "!onal Injury (>"I) # (ead injury with widely scattered shearing of subcortical a!ons within their myelin sheaths that is not isolated to any one location* but causes a dramatic cumulative effect. # May occur in isolation or associated with local* cou # contrecou * or olar damage. # ?sually results from rotational forces or severe deceleration* such as in head#on collisions. b. 6 en # >enotes that the dura mater is o ened. # >ue to any injury as long as the dura mater has been o ened. c. .enetrating # >enotes that a foreign object enetrated the dura mater and entered the brain. # -ubcategories, o -tab # .iercing of a shar object (i.e.* knife* screwdriver). o Missile # .iercing of a distantly#fired object (i.e.* bullet* arrow). Ty es as to -econdary Injury, Bollowing severe brain injury* any of the following conditions may cons ire to decrease the energy su ly to the brain* causing secondary injury. a. (y o!ic#Ischemic Injury ((II) # " major athological rocess seen in atients with TBI. # $auses swelling in the brain that restricts the flow of blood#borne o!ygen* glucose* and other nutrients. # "rterial hy o!emia* a more diffuse form of (II* may also cause

0 secondary injury. o This may be caused by other injuries to the body that further reduce the amount of o!ygen entering the bloodstream through the lungs* such as, # "irway obstruction # Myocardial infarction # .ericardial effusion # "rrhythmia # $ongestive heart failure # .ulmonary embolus # .neumothora! # "rterial hy otension may also contribute to (II. o 6ften the result of massive blood loss. 'ate#occurring Intracranial (ematomas # $an transform a seemingly mild injury into a life#threatening situation within hours. # 6ften associated with atients who @talk and die.A o These atients are coherent for a eriod of time after the initial injury but who later la se into a coma and die. o >ue to com ression of the brain by an e! anding hematoma. o 6ccurs only in a ortion of TBI atients. # Most often* atients are in a coma from the initial injury and the hematoma may go undetected and untreated* causing an unavoidable death. # $lassifications, o "s to -ite, # % idural 6utside the dura mater # -ubdural Between the dura mater and the brain surface # Intracerebral 8ithin the brain itself o "s to Time "fter Injury in which they develo , # "cute 8ithin 0 days # -ubacute "fter 0 days but within 3#0 weeks # $hronic More than 3#0 weeks Increased Intracranial .ressure (I$.) # +ormally is 1#/= mm(g. # 8ith mild increase, o "ssociated with increased morbidity in survivors. # 8ith severe increase, o May result in brain herniation which causes im ingement of herniated structure and surrounding tissue on the inner walls of the skull or on other tissue. # 8ill result in loss of function of the im inged nervous structures. Intracranial Infection $erebral "rtery <asos asm Tumors 6bstructive (ydroce halus .ost#traumatic % ile sy +eurochemical $hanges # -uch as "utodestructive $ellular .henomena which accom anies >"I.

b.

c.

d. e. f. g. h. i.

5 o Involves surges in levels of e!citatory neurotransmitters. # -ets u a cascade of intracellular events that im ede neuronal function and may go on to destroy neurons. # Cenders cells to become e!tremely sensitive to other insults (i.e.* hy o!ia). Ty es as to "ffectation, a. Bocal # $onfined to one area of the brain. # -uch as due to contusion or intracranial hemorrhage)hematoma. b. >iffuse # Involving more than one area of the brain. # -uch as due to >"I and secondary injuries. Ty es as to Trauma <elocity, a. (igh#velocity im act # -uch as gunshot wounds or motor vehicle accidents. b. 'ow#velocity im act # -uch as a blow to the head or falling from a height 9 feet or less. C. #%i)emiolog! 8orldwide (/229 data), 6f all ty es of injury* those to the brain are among the most likely to result in death or ermanent disability. The leading cause of death and disability. Traumatic brain injury is the leading cause of sei7ure disorders. $losed head injury with or without skull fracture constitutes the majority of cases. ?nited -tates (/229 data), "nnually, # 6ne million "mericans are treated and released from hos ital emergency de artments as a result of TBI. # 30=*=== eo le are hos itali7ed and survive. # 4=*=== eo le are estimated to be discharged from the hos ital with some TBI#related disability. # 1=*=== eo le die. "n estimated 1.0 million "mericans are living today with disability related to traumatic brain injury. Most studies indicate that males are far more likely to incur a TBI as females. The highest rate of injury occurs in between the ages of /1#35 years. .ersons under the age of 1 or over the age of D1 are also at higher risk. %uro e (/229 data), In the %uro ean ?nion* brain injury accounts for one million hos ital admissions er year. D. #tiolog! Motor vehicle crashes account for 1=E of all TBIs. This includes autos* trucks* motorcycles* bicycles* and edestrians hit by vehicles. The leading causes of TBI vary by age. Balls are the leading cause of TBI among ersons aged 91 years and older. Trans ortation is the leading cause of TBI among ersons under the age of 91 years. %stimates suggest that s orts related brain injury accounts for close to 0==*=== injuries each year. 8inter s orts such as skiing and ice#skating accounting for close to

1 3=*=== brain injuries. #. *at+o%+!siolog! , *at+omec+anics The athomechanics of TBI were reviously described under @Ty es as to .rimary InjuryA. The atho hysiology of the secondary injuries due to TBI was reviously described under @Ty es as to -econdary InjuryA. -. Clinical Manifestation(s) -ym toms, a. 'oss of consciousness b. -igns of increased I$. c. Brainstem damage d. 'ocali7ing sym toms >irect Im airments a. $ognitive im airments # "ltered levels of consciousness F in acceleration#deceleration injuries and some focal injuries # .ost#traumatic amnesia # 6rientation and memory deficits b. +euromuscular im airments # "bnormal tone # -ensory deficits # Motor control deficits c. <isual F .erce tual im airments # <isual F if damage occurs to cranial nerves and occi ital lobe # .erce tual F usually with damage to rimary somatosensory areas ( arietal lobes) d. -wallowing im airments # >ys hagia F may be due to cranial nerve damage* motor control im airments* a ra!ia* and oor ostural control e. Behavioral deficits # The most enduring and socially disabling of any of the im airments commonly seen after TBI # ?sually determines a roach of the team to the atient f. $ommunication im airments # -uch as a hasias and dysarthrias +ature of Cesidual >isabilities, a. .ermanent neuromuscular deficit b. -ei7ures c. $ognitive and behavioral roblems Cesolution of neurologic signs may continue as long as 0 years ost#trauma. G. Com%lication(s) -e&uelae of (ead Injuries a. -econdary injuries b. Infection F meningitis* abscess c. %!tradural infection d. Meningitis e. Brain abscess f. Bocal cerebral lesions Indirect Im airments >ue to com le! nature of TBI and often rolonged bed rest* such as, # $ontractures # Mobility deficits # -kin breakdown # (eteroto ic ossification # >ecreased endurance # Infection

9 # .neumonia # Im aired s eech (if with tracheostomy) # ><T Many of these im airments are avoidable* or at least can be minimi7ed* if a roactive treatment a roach is ado ted. .. Diagnosis $T -can MCI .ositron emission tomogra hy (.%T) scan -tandard %MG)+$< %lectroence halograms (%%G) and %voked .otentials $linical Cating -cales a. Glasgow $oma -cale (G$-) b. Glasgow 6utcome -cale (G6-)
S C $ R #
/ 3 0 5 1

CAT#G$RY

D#-INITI$N

>eath .<- ( ersistent vegetative state) -evere disability Moderate disability Good recovery

>irect result of Trauma ?nres onsive* may sometimes o en eyes* no cortical function* doesnAt follow commands and doesnAt s eak understandable words. >e endent for daily su ort Travel by ublic trans ortation* work in sheltered worksho s* ">' inde endent* residual neurological deficits Cesume normal life* Minor residual deficits

>isadvantages of G6-, o +ot sensitive in measuring rogress in the Cehab o >oesnAt rovide measurement of functional disabilities o $ognitive and behavioral dysfunctions are not addressed s ecifically c. Canchos 'os "migos 'evels of $ognitive Bunctioning # 6utlines a redictable se&uence of cognitive and behavioral recovery in atients with TBI.
/ # & # /
I II III I< < <I <II <III +o res onse Generali7ed res onse 'ocali7ed res onse $onfused res onse $onfused Ina ro riate $onfused " ro riate "utomatic " .ur oseful " ro riate ro riate

NAM#

D#SCRI*TI$N

" ears to be in dee slee G no res onse to any stimulation " ears to be resting &uietlyG makes gross movements in res onse to no!ious stimulation Make s ontaneous* ur oseful movementsG may follow commands inconsistently $onfused* amnestic and inattentive* may be aggressive +ot agitatedG $onfused and amnestic 'acks initiative and roblem solvingG functional with structure and su er vision Bollows daily routinesG needs su ervision for home and community skillsG inde endent in self#care within hysical ability Inde endent in home and community skills* May have cognitive deficits

?sing this scheme* rehabilitation a roach may be classified as to, o 'ow#'evel Ces onse 'evels # 'evels I* II* and III # 'evel I usually in an acute care hos ital setting # 'evels II and III usually in a rehabilitation hos ital setting o Mid#'evel Ces onse 'evels # 'evels I<* <* and <I # .atient is usually still receiving in atient rehabilitation # In late level <I* atient may be discharged to day treatment

D (out atient) rehabilitation setting o (igh#'evel Ces onse 'evels # 'evels <II and <III # In early level <II* atient may be discharged to day treatment (out atient) rehabilitation setting # .atient is now usually receiving out atient rehabilitation d. Ca a ortAs >isability Cating -cale (>C-) # $overs a wide range of functional areas and are used to clarify levels of disability ranging from death to no disability. o It is used serially to document rogress over time. # Many variations of this scale have been develo ed* usually s ecific for articular occu ations)functional needs. I. Diffe"ential Diagnosis ?sually* Traumatic Brain Injuries are differentially diagnosed from, a. +on#traumatic Brain Injury b. $erebral .alsy J. *"ognosis Majority of survivors of severe TBI emerge from coma and achieve remarkable rogress toward regaining their re#injury functional abilities. In most cases* however* the erson is left with a combination of hysical and cognitive im airments. These* in turn interact to roduce a broad array of disabilities and handica that may ersist for many months or years after the injury. Bor a given erson* the s ecific atterns of deficit are a conse&uence of the severity of the injury* nature of brain damage* and medical com lications varying greatly from one brain#injured atient to the ne!t. .rognostic Bactors, a. .atientAs age b. %!tracranial injuries c. "vailability of family su ort .rognosis in severe head injuries
CRIT#R IA
G$- -core $T -can "ge .u illary light refle! >ollAs %ye -ign $aloric testing with ice water Motor res onse to no!ious stimuli -omato#sensory evoked otentials .ost#traumatic "mnesia 'ength

*$$R#R
HD 'arge blood clot* massive bihemis heric swelling 6ld age .u ils remain dilated Im aired %yes do not deviate >ecerebrate rigidity >eficient I 3 weeks ID +ormal

B#TT#R

Jouth .u ils contract Intact %yes deviate to irrigated side 'ocali7es definitive gestures +ormal H 3 weeks

II.

Medical Management
A. *+a"macologic .harmacologic management is s ecific as to the action of the harmacologic agent. -ome e!am les are the following, a. %lavil # .ur ose, "nti#de ressantG 'evel II)III to heighten arousalG with higher levels to decrease agitation # $ontraindications, "rrhythmiasG ?rinary retention # -ide effects, $hange in B.* change in blood sugar* sweating* dry mouth* weakness* fatigue* tingling* tremors* ata!ia* arrhythmias* initial sedation* breast enlargement or testicular swelling. b. Tofrani # .ur ose, "ntide ressant # $ontraindications, Myocardial infarction

4 -ide effects, $hange in B.* confusional states* numbness* tingling* ata!ia* tremors* dry mouth* blurred vision* change in blood sugar c. Citalin # .ur ose, -timulation to heighten alertness # $ontraindications, (y ertension* history of drug de endency # -ide effects, "ta!ia* insomnia* cardiac arrhythmia* nausea* anore!ia* blurred vision* skin rash d. .henobarbital # .ur ose, "nticonvulsant (sei7ure revention) # $ontraindications, -evere trauma* severe hy otension* uncontrolled diabetes* drug de endence # -ide effects, 'ethargy* sedation* skin rash* ata!ia* nystagmus* osteomalacia* habit#forming. e. Tegretol # .ur ose, "nticonvulsant tem oral lobe # $ontraindications, liver abnormalities # -ide effects, $B$ abnormalities* rash* cardiac effects (arrhythmia* edema* $(B)* sedation f. >antrium # .ur ose, $ontrol of s asticity # $ontraindications, 'iver abnormalities # -ide effects, >rowsiness* di77iness* weakness* fatigue* diarrhea* otential for he atoto!icity (with greater than 4== mg daily) g. 'ioresal (Baclofen) # .ur ose, $ontrol of s asticityG general $+- de ressants # $ontraindications, >iabetes* e ile sy (should be monitored) # -ide effects, transient drowsiness* di77iness* fatigue* fre&uent urge to urinate* consti ation* nausea* im aired renal function h. <alium # .ur ose, $ontrol of s asticity # $ontraindications, $hildren under 9 months of age # -ide effects, >rowsiness* fatigue* ata!ia* headaches* confusion* de ression* blurred vision or double vision* skin rashes* urinary incontinence* consti ation B. Me)ical , S0"gical %arly medical management focuses on, a. >etermination of the severity of injury b. .reservation of life c. .revention of further damage Initially* the following rocess is observed, a. 'evel of consciousness ('6$) determined by G$-#neurologic e!am b. Cadiogra hic e!am of the skull and cervical s ine c. I$. monitoring via catheter in lateral ventricle # If I$. is over main value of 31 mm(g* decrease it # If I$. is below 31 mm(g value for 35 hours consistent* system can be discontinued. C. Re+a'ilitation Goal, Ceturning the atient to society at the highest ossible level of function 6ther members of the rehabilitation team are involved in the management of TBI cases. Their roles are the following, a. .atient and Bamily # "s sources of information about the atient # "s sources of direct social* moral* and functional su ort b. .hysiatrist and 6ther .hysicians # .hysiatrists rescribe medication in relation to rehabilitative goals # +eurologists rovide further diagnosis and rognosis c. - eech#language .athologist #

2 # d. %!amines* evaluates* and treats communication* swallowing* and cognitive im airments 6ccu ational Thera ist # %!amines* evaluates* and treats ability to erform both basic and instrumental ">'s* visual) erce tual im airments* u er e!tremity function* sensory integration # May often collaborate with s eech#language athologist in addressing cognitive im airments Cehabilitation +urse # Ces onsible for dis ensing medications and closely monitoring of their effects # Initiates bowel)bladder retraining rogram # Monitors daily the vital signs and status of integumentary system # ?sually given the task of following through with the rehabilitation teamAs treatment lan throughout the day (i.e.* turning schedules* etc.) $ase Manager)Team $oordinator # Cuns team meetings # -chedules family meetings # "cts as liaison for third# arty ayers # -ets u follow#u and discharge services Medical -ocial 8orker # .rovides su ort through education and counseling for both atient and family +euro sychologist # "ssesses baseline cognitive functioning # "ssists team in develo ing a behavioral management rogram # "ssumes role of team leader if behavioral im airments are severe Ces iratory Thera ist # In cases where atient needs ventilatory) ulmonary su ort Cecreational Thera ist # "ssists in either returning to revious enjoyable activities or identifying new enjoyable activities

e.

f.

g. h.

i. j.

III.

.hysical Thera y %!amination* %valuation K >iagnosis

A. *oints of #m%+asis in #1amination Major focus is on, $ommunication "bility* "ffect* $ognition* 'anguage* and 'earning -tyle +eurologic "ssessment Musculoskeletal "ssessment Bunctional "ssessment 6ther things to assess "ll subjective data "ll other objective data (only when affected) The following may be used as a guide in e!amining TBI atients, a. .atient)$lient (istory # General >emogra hics # -ocial (istory # %m loyment)8ork (Lob)-chool).lay) # Growth and >evelo ment F s ecifically if TBI occurred at a very young age # General (ealth -tatus (-elf#Ce ort* Bamily Ce ort* $aregiver Ce ort) # -ocial (ealth (abits (.ast and $urrent) # Bamily (istory # Medical)-urgical (istory # $urrent $ondition(s))$hief $om laint(s) # Bunctional -tatus and "ctivity 'evel # Medications

/= # 6ther $linical Tests b. -ystems Ceview # "natomical and .hysiological -tatus of, o $ardiovascular).ulmonary -ystem o Integumentary -ystem o Musculoskeletal -ystem o +euromuscular -ystem # $ommunication "bility* "ffect* $ognition* 'anguage* and 'earning -tyle c. Tests and Measures # "nthro ometric characteristics # "rousal* attention* and cognition # "ssistive and ada tive devices # $irculation (arterial* venous* lym hatic) # $ranial and eri heral nerve integrity # %nvironmental* home* and work (job)school) lay) barriers # Integumentary integrity # Motor function (motor control and motor learning) # +euromotor develo ment and sensory integration # 6rthotic* rotective* and su ortive devices # .ain # .osture # Cange of motion (including muscle length) # Cefle! integrity # -elf#care and home management (including ">' and I">') # <entilation and res iration)gas e!change d. 6ther Tests and Measures F only when indicated by the atientAs case # "erobic ca acity # %rgonomics and body mechanics # Gait* locomotion* and balance # Loint integrity and mobility # Muscle erformance (including strength* ower* and endurance) # .rosthetic re&uirements # -ensory integrity # 8ork (job)school) lay)* community* and leisure integration or reintegration (including I">') B. *"o'lem /ist "s a .T* always consider that hysical return of function may not mirror a return in behavioral and cognitive functions. Thus* the behavioral#cognitive a roach to a atient may be standardi7ed at each s ecific Canchos 'os "migos 'evels of $ognitive Bunction* but the a roach to the other (neuromuscular* visual# erce tual* swallowing* communication) functions will differ in each atient. %ven the cognitive levels may e!hibit variations* es ecially when moving from one level to another. "n e!am le would be a atient entering stage < but still has eriods where stage I< behaviors may demonstrate* es ecially during stressful situations. %ach atient will demonstrate with different .T roblems. It will be u to the attending .T to determine the resence and riority of these roblems in each atient. ?sing the Canchos 'os "migos 'evels of $ognitive Bunction* the following roblems may be a ro riate as er level, a. 'ow#'evels # 'ow arousal levels are the main roblem # Cisk of com lications are the other roblem

// b. Mid#'evels # "s arousal is now higher* this ceases to become the main roblem # In level I<* oor endurance is the focus # In levels < and <I* im aired safety in functional skills and ">'s is the focus c. (igh#'evels # In both levels <II and <III* im aired safety in community* work and leisure activities is now the focus "s a general guide only* the following .T roblems may be seen in a atient with TBI, a. Im aired level of alertness (consciousness) b. Im aired hysical functions* such as, # "bnormal tone # Im aired motor control # Im aired motor erformance # Im aired motor function # Im aired range of motion # Im aired gait* locomotion* and)or balance # Im aired eri heral nerve integrity # Im aired sensation # Im aired refle! integrity # Im aired joint integrity and mobility # Im aired osture) ostural control # Im aired ventilation* res iration)gas e!change and)or aerobic ca acity)endurance # Im aired integumentary integrity # Im aired circulation and anthro ometric dimensions c. Cisk(s) for any of the following, # -keletal deminerali7ation # 'oss of balance and falling # $ardiovascular) ulmonary disorders # Integumentary disorders C. *+!sical T+e"a%! Diagnosis If urely TBI without associated injuries* usual diagnostic classification is, Im aired arousal* range of motion* and motor control associated with coma* near coma* or vegetative state (owever* TBI cases usually have associated injuries and may necessitate classification under other diagnostic labels or classification in both this and another diagnostic label(s). 6ther injuries which may be associated with TBI are the following, # 6 en wounds # Bractures* o en and)or closed o -kull o 'ong bones o Cibs # - inal cord injury # .eri heral nerve damage # Internal organ injuries # -oft tissue injury

I&.

.hysical Thera y .rognosis (including .lan of $are) K Intervention

A. *lan of Ca"e The e! ected range of number of visits (sessions) er e isode of care for TBI cases may vary from 1 to 3=. This range re resents the lower and u er limits of the number of .T visits re&uired to achieve antici ated goals and e! ected outcomes. It is antici ated that 4=E of atients who are classified into this attern will

/3 achieve the antici ated goals and e! ected outcomes within 1 to 3= visits during a single continuous e isode of care. Bre&uency of visits and duration of the e isode of care should be determined by the .T to ma!imi7e effectiveness of care and efficiency of service delivery. " general goal for .T of TBI cases may be summed u as follows, 6ver the course of 0 months* atient)client will demonstrate o timal arousal* range of motion* and motor control and the minimi7ation of secondary im airments. ?sing the Canchos 'os "migos 'evels of $ognitive Bunction* the following goals may be a ro riate as er level, a. 'ow#'evels # Bor levels I* II* III, o Major Goals, Im rove the atientAs level of alertness and maintain)im rove hysical function. # %m hasis is on interaction with the atient to im rove level of alertness. o Increase hysical function and level of alertness o Ceduce risk of secondary com lications o Im rove motor control o Manage the effects of abnormal tone o Im rove ostural control o Increase tolerance to activities and ositions o Im rove)Maintain functional joint integrity and mobility o %ducate family and caregivers on atientAs diagnosis* .T interventions* goals* and outcomes o $oordinate care between all team members b. Mid#'evels # Bor level I< o Major Goal, Maintain the atientAs functional ca abilities in re aration for functional skills retraining. # %m hasis is on range of motion* strength* and endurance. o Im rove atientAs endurance o Maintain joint mobility and integrity o Ceduce risk of secondary im airments o Increase tolerance to activities o %ducate family on atientAs diagnosis* rognosis* .T interventions* and outcomes o $oordinate care between all team members # Bor levels < and <I o Major Goal, Ma!imi7e the atientAs functional mobility skills in re aration for return to community and home. # %m hasis is on im rovements in motor control* strength* endurance* balance* and* most im ortantly* safety. o Increase erformance of functional mobility and ">'s o Im rove gait* mobility* and balance o Increase motor control and ostural control o Ceduce risk of secondary im airments o Increase strength and endurance o Im rove safety with functional mobility tasks and ">'s o %ducate atient and family on atientAs diagnosis* rognosis* .T interventions* and outcomes o Im rove tolerance to activities o $oordinate care between all team members

/0 c. (igh#'evels # Bor levels <II and <III o Major Goal, "ssist the atient in integrating the cognitive* hysical* and emotional skills that are necessary to function in the real world. # %m hasis is on judgment* roblem#solving* and lanning. o %ducate atient and family on atientAs diagnosis* rognosis* .T interventions* and outcomes o Im rove safety of atient and family o Increase ability to erform hysical tasks related to ">'s* community and work reintegration* and leisure activities o Im rove functional mobility o Im rove motor control* balance* and ostural control o Increase self#management of sym toms o Increase strength and endurance o >ecrease level of su ervision and assistance in task erformance B. Inte" entions General $onsiderations in "cute Management Bre&uent osition changes will assist ulmonary hygiene and skin integrity .ostural drainage* ercussion* and vibration may be used to kee the atientAs lungs clear .C6M should be erformed regularly but may not be enough to revent develo ment of deformities 6ther Management $onsiderations, ?se of s lints or ro hylactic short leg casts and assive standing on a tilt table to im rove atientAs tolerance to u right ositioning Bunctional mobility training may begin when the atientAs medical status is stable to increase atientAs active movement ca abilities Management based on 'evel of $ognitive Bunction, a. 'ow#'evels # Increase atientAs level of interaction with the environment by encouragement of "C6M and res onse to stimulation o Intervention, .C6M # Guidelines, > %arly aggressive .C6M. > ?se caution in stretching due to atientAs decreased level of consciousness. > .atient laced in side lying for shoulder C6M to allow the sca ula to move and revent jamming the glenohumeral joint. > -tretching should be done in slow* controlled fashion. > Cotation seems to be effective in rela!ing the atient with significant s asticity. o Intervention, -ensory stimulation # Guidelines, > ?sed for arousal and to elicit movementG rovides stimulation in a controlled* multisensory manner with a balance of stimulation and restG reticular activating system maybe stimulated causing a general increase in arousal. > -timulation is most effectively administered for short treatment session (/1#0= minutes) and it is im ortant to resent stimuli in an orderly manner via one or two modalities one at a time to revent over stimulation. > >uring this ty e of treatment* the atient must be closely monitored for subtle res onses (e.g. changes in (C* B.*

/5 rate of res iration and dia horesis). > <arious motor res onses (e.g. eye movement* facial grimacing* and changes in osture* head turning or vocali7ation) should be recorded. > +ote, 'atency F the time delay between stimulus and res onse $onsistency F how many times out a given number of stimulus resentation does the atient res ond the same Intensity F the res onse ro ortionate to the stimulus >uration F brief forms of stimuli should result in brief forms of res onse. # "uditory stimulation > Most obvious lace to begin > +ormal conversational tones should be used and .T should begin by identifying him)herself and e! laining what is to be done > Intermittent use of T< or radio may be thera eutic but constant background noise is undesirable. > (abituation to background noise is likely to occur and it rovides com etition for meaningful stimuli. # <isual stimulation > .rovided by use of familiar objects (e.g. ictures of families and friends) > Im ortant to systematically stimulate all areas of visual fields. > <isual attentiveness (how long the atient can maintain visual attention on an object) and visual training should be documented. # 6lfactory -timulation > $an be rovided by lacing scents under the atientAs nose for /=#/1 sec during &uiet breathing. > .atients with tracheotomy are not likely to res ond because they donAt breathe through their noses. > Bavorable results most likely if using atientAs own favorite scents. # Gustatory stimulation > Involves the a lication of a cotton swab di ed in a flavored solution to the li s and gums* or may involve the use of flavored ice chi s* o sicles* etc. # Tactile -timulation > .rovided during most functional activities e.g. turning* bathing* dressing* etc.G might involve using atientAs own hands e.g. face washing. # <estibular -timulation > .rovided by neck C6M* rolling on a mat* rocking or ulling the atient on a wheelchair. o Intervention, .ositioning # Goals, > .rovide normal sensory e! eriences* thereby facilitating normal movement. > .rovide su ort for body alignment* thereby reventing deformities and skin breakdown. > "llow mobility. > Im rove cosmesis.

/1 b. Mid#'evels # 'evel I< o Goals, # Maintenance or im rovement of joint C6M # .revention of further hysical deconditioning # Im roved res onses to sim le commands # .revention of agitated outburst via the use of a highly structured environment. o Tasks and activities (e.g. rolling* coming to sit* transfers* wheelchair* ro ulsion and gait). # 8hen distraction occurs* the .T must redirect the atientAs attention first back to the .T* and then back to the task at hand. # .rovide a &uiet environment and limit the overall length of a session to within the atientAs fatigue limits* then gradually increase as the atientAs tolerance allows. # .rom t and fre&uent raise should be rovided when the atient does concentrate on a given task. o Cemember, # 8hen the atient is confused* hel decrease confusion by letting the same erson be seen by the atient at the same time and at the same lace everyday. # %! ect no carryover F the use of charts and gra hs may be useful to hel the atient rogress each day. # Model calm behavior F it is im ortant for the .T to assume a calm and focused affect. # %! ect egocentricity F at this oint* the atient cannot be e! ected to see anotherAs oint of view* including the .TAs. # 6ffer o tions F treat the atient at an a ro riate age levelG give control to the atient when it is a ro riate. # Be re ared with numerous activities F if the atient canAt be redirected to the selected task* it is a ro riate to attem t to engage him)her in another. # 'evel < and <I o Best for relearned activities o Instructions should be brief and sim le and evaluation is concise so as not to fatigue the atient unnecessarily. o Goals, # Increase the atientAs artici ation for the rogram # Increase or maintain C6M # Increase hysical conditioning o Cemember, # Treat the focal motor deficits that e!ist e.g. hemi aresis* .+I* etc. # Maintain structure # %m hasi7e safety # Mee instructions to a minimum # ?se hysical ro s to im rove com liance c. (igh#'evels # Interventions are directed toward safe functioning in home* community* work* and leisure activities* such as, o Bunctional Training in -elf#care and (ome Management (including ">' and I">') o Bunctional Training in 8ork (Lob)-chool).lay)* $ommunity* and 'eisure Integration and Ceintegration (including I">'* 8ork (ardening* and 8ork $onditioning) Issues that cross all levels

/9 a. C6M F must be continued at all levels of rehabilitation # 6ral medications for s asticity* nerve or motor oint blocks may be rescribed by hysicians rior to .T # -erial casting and ositioning systems for the bed and)or wheelchair atients as a lied by .T # If conservative measure fails F mani ulation under anesthesia or surgical tendon release may be done by hysicians rior to .T b. Mobility F im ortant to encourage active mobility "-". # %arly rolling for low#level atients # -u ervised wheelchair ro ulsion for mid#level atients # "ssisted ambulation for any atient that a ears to have the hysical ability to walk