Chapter 2: Trauma

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Chapter 2: Trauma
2015-03-10 20:20:22
NPTE: Chapter 2
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  1. Traumatic Brain Injury: Etiology
    • MOI: contact forces to skull and rotational acceleration forces
    • Causes varying degrees of injury to brain
  2. TBI: Pathophysiology
    • Primary brain damage
    • Secondary brain damage
    • Concussion
  3. Traumatic Brain Injury: Pathophysiology = Primary Brain Damage
    • Diffuse axonal injury: disruption and tearing of axons and small blood vessels from shearing-strain of angular acceleration → results in neuronal death and petechial hemorrhages 
    • Focal injury: contusions, lacerations, mass effect from hemorrhage, and edema (hematoma)
    • Coup-countracoup injury: injury at point of impact and opposite point of impact
    • Closed or open injury: with fracture of skull
  4. Traumatic Brain Injury: Pathophysiology = Secondary Brain Damage
    • Hypoxic-ischemic injury: results form systemic problems (respiratory or cardiovascular) that compromise cerebral circulation
    • Swelling/edema: can result in mass effect → increased intracranial pressure, brain herniation (uncal, central, or tonsillar), and death
    • Electrolyte imbalance and mass release of damaging neurotransmitters 
  5. Traumatic Brain Injury: Concussion
    • Loss of consciousness (temporary or permanent) resulting from injury or blow to head
    • Impaired functioning of brainstem reticular activating system (RAS)
    • May see changes in HR, RR, BP
  6. Glasgow Coma Scale (GCS)
    Allows classification into mild (score 13-15), moderate (score 9-12), or severe (<8) head injury (coma)
  7. Rancho Los Amigos Levels of Cognitive Functioning (LOCF)
    Delineates 8 general cognitive and behavioral levels
  8. Rappaport's Disability Rating Scale (DRS)
    Classifies levels of disability using ride range of functional behaviors
  9. Glasgow Outcome Scale (GOS)
    • Expands original scale
    • Includes major disability categories for outcome assessment
  10. High Level Mobility Assessment Tool (HI-MAT)
    Provides measurement of high-level function mobility skills
  11. Recover Stages from Diffuse Axonal Injury
    • Coma
    • Unresponsive vigilance/vegetative state
    • Mute responsiveness/minimally responsive
    • Confusional state
    • Emerging independence 
    • Intellectual/social competence

    Pt can plateau at any stage or regress under conditions of stress or repetitive brain injury
  12. Coma
    • A state of unconsciousness in which there is neither arousal nor awareness
    • Eyes remain closed
    • No sleep/wake cycles
  13. Unresponsive Vigilance/Vegetative State
    • Marked by return of sleep/wake cycles and normalization of vegetative functions (respiration, digestion, BP control) 
    • Persistent vegetative state determined if pt remains in vegetative state > 1 year after TBI
  14. Mute Responsiveness/Minimally Responsive
    Pt is not vegetative and shows signs (even if intermittent) of fluctuating awareness
  15. Confusional State
    • Mainly a disturbance of attention mechanisms
    • All cognitive operations are affected
    • Pt is unable to form new memories
    • May demonstrate either hypoarousal or hyperarousal
  16. Emerging Independence
    • Confusion is clearing
    • Some memory is possible 
    • Significant cognitive problems and limited insight remain
    • Frequently uninhibited social behaviors
  17. Intellectual/Social Competence
    • Increasing independence 
    • Cognitive difficulties (problem solving, reasoning) persist along with behavioral and social problems (enhancement of premorbid traits, mood swings)
  18. TBI: Examination
    • Generalized signs of increased intracranial pressure
    • Level of consciousness (CGS)
    • Cognitive functioning (LOCF)
    • Disorders of learning, attention, memory and complex info processing
    • CN function
    • Behavior changes 
    • Speech/communication
    • Sensory deficits
    • Motor function (paresis, apraxia (dyspraxia), reflexive behaviors, balance deficits, ataxia, and incoordination (cerebellar damage common)) 
    • Functional mobility skills (FMS), ADLs
    • Level of general deconditioning (from prolonged hospitalization)
  19. TBI: PT Goals, Outcomes, and Interventions for LOCF I-III
    • Maintain ROM
    • Prevent contracture development (PROM, positioning, splinting, casting) 
    • Skin integrity (decubitus ulcers)
    • Maintain respiratory status and prevent complications (postural drainage, percussion, vibration, suctioning)
    • Sensory stimulation for arousal and to elicit movement (environmental and direct stimulation (auditory, visual, olfactory, gustatory, tactile)) 
    • Promote early return of FMS = upright positioning for improved arousal, proper body alignment
  20. TBI: PT Goals, Outcomes and Interventions for LOCF IV-VI (Mid-Level Recovery)
    • Provide structure, prevent overstimulation for confused, agitated patient (closed, reduced stimulus environment; daily schedules; memory logs; relaxation techniques)
    • Provide consistency
    • Engage pt in task-specific training (limit activities to familiar, well-liked ones; offer options; break down complex tasks)
    • Provide verbal or physical assistance
    • Control rate of instruction
    • Provide frequent orientation to time, place, your name, and task
    • Emphasize safety, behavioral management techniques
    • Model calm, focused behavior
  21. TBI: PT Goals, Outcomes, and Interventions for LOCF VII-VIII (High-Level Recovery)
    Allow for increasing independence (wean pt from structure (closed → open environment, involve pt in decision making)

    • Assist in behavioral, cognitive, emotional reintegration 
    • Promote independence in functional tasks
    • Improve postural control, symmetry, and balance
    • Encourage active lifestyle
    • Improve cardiovascular endurance
  22. Spinal Cord Injury: Etiology
    Partial or complete disruption of SC → paralysis, sensory loss, altered autonomic and reflex activities 

    • Traumatic causes: MVA (most common), jumps and falls, diving, gunshot wounds
    • MOI: flexion (most common lumbar injury), flex-rot (most common cervical injury), compression, hyperextension
    • Areas of greatest frequency of injury: C5, C7, T12, and L1 
    • Nontraumatic causes: disc prolapse, vascular insult, infections
  23. SCI: Pathophysiology
    • Primary injury, interruption of blood supply
    • Secondary sequelae = ischemia, edema, demyelination, and necrosis of axons → progresses to scar tissue formation
  24. SCI: Classification
    • Level of Injury (UMN injury)
    • Degree of Injury
  25. SCI: Level of Injury
    • Lesion level indicates most distal uninvolved nerve root segment with normal function
    • Muscles must have a grade of at least 3+/5 or fair+ function
    • Tetraplegia (quadriplegia): injury occurs between C1 and C8 → involves all 4 extremities and trunk
    • Paraplegia: injury occurs between T1 and T12-L1 → involves both LE's and trunk
  26. SCI: Decree of Injury
    • Complete: no sensory of motor function below level of lesion
    • Incomplete: preservation of sensory or motor function below level of injury (spotty sensation, some muscle function (<3+/5)
  27. American Spinal Injury Association (ASIA) Impairment Scale
    • A: complete, no motor or sensory function is preserved in sacral segments S4-5
    • B: incomplete = sensory but not motor function is preserved below neurological level and includes sacral segments S4-5
    • C: incomplete = motor function preserved below neurological level and most key muscles below neurological level have muscle grade of <3
    • D: incomplete = motor function preserved below neurological level and most key muscles below neurological level have muscle grade of >3
    • E: normal motor and sensory function
  28. Central Cord Syndrome
    • Cavitation of central cord in cervical section
    • Loss of more ventral horn and centrally located cervical tracts/arm function 
    • Loss of spinothalamic tracts with B loss of pain and temp
    • Preservation of more peripherally located lumbar and sacral tracts/leg function
    • Preservation of proprioception and discriminatory sensation 
    • Typically caused by hyperextension injuries to c-spine
  29. Brown-Sequard Syndrome
    • Hemisection of SC typically caused by penetration wounds (knife or gunshot)
    • Ipsilateral loss of dorsal columns → tactile discrimination, pressure, vibration, proprioception
    • Ipsilateral loss of corticospinal tracts → motor function loss and spastic paralysis below level of lesion
    • Contralateral loss of spinothalamic tract → pain and temp loss below level of lesion; at lesion level, B loss of pain and temp
  30. Anterior Cord Syndrome
    • Loss of anterior cord
    • Loss of lateral corticospinal tracts → B loss of motor function, spastic paralysis below level of lesion 
    • Loss of spinothalamic tracts → B loss of pain and temp
    • Preservation of dorsal columns → proprioception, kinesthesia, vibratory sense 
    • Typically caused by flexion injuries of c-spine
  31. Posterior Cord Syndrome
    • Loss of dorsal columns bilaterally
    • B loss of proprioception, vibration, pressure, stereognosis, 2-point discrimination
    • Preservation of motor function, pain and light touch
  32. Cauda Equina Injury
    • LMN Lesion (injury to lumbar and sacral roots of peripheral nerves)
    • Loss of long nerve roots at/below L1
    • Variable nerve root damage (motor and sensory signs)
    • Incomplete lesions common
    • Flaccid paralysis with no spinal reflex activity
    • Flaccid paralysis of bladder and bowel 
    • Potential for nerve regeneration → often incomplete, slows and stops after about 1 year
  33. Sacral Sparing
    • Sparing tracts to sacral segments
    • With preservation of perianal sensation, rectal sphincter tone, or active toe flexion
  34. SCI: Examination
    • Vital signs
    • Respiratory function = activation of diaphragm, respiratory muscles, intercostals, chest expansion, breathing pattern, cough, vital capacity
    • Skin condition/integrity
    • Muscle tone and DTR's
    • Sensation/SC level of injury (check to see if sensory level corresponds to motor level innervation)
    • Muscle strength (lowest segmental level of innervation includes muscle strength present at fair+ grade (3+/5) → use caution with MMT in acute phase with spinal immobilization) 
    • Functional status
  35. Respiratory Failure (with SCI)
    Occurs in lesions above C4 (phrenic nerve → C3-5 innervates diaphragm)
  36. SCI: PT Goals, Outcomes, and Intervetnions
    • Monitor changes associated with recovery (spinal shock, spasticity/spasms, autonomic dysreflexia, heterotopic bone formation, DVT)
    • Improve respiratory capacity
    • Maintain ROM, prevent contracture (MAINTAIN TENODESIS GRASP)
    • Maintain skin integrity
    • Improve strength
    • Reorient pt to vertical position 
    • Promote early return of FMS and ADLs
    • Improve sitting tolerance, postural control, symmetry, and balance 
    • Appropriate WC prescription
    • Promote WC skills/independence 
    • Locomotor training
    • Improve cardiovascular endurance
  37. Spinal Shock
    • Transient period of reflex depression and flaccidity
    • May last several hours → 24 weeks
  38. Spasticity/Spasms with SCI
    • Determine location and degree of tone
    • Examine for nociceptive stimuli that may trigger increased tone (blocked catheter, tight clothing, body position, environmental temp, infection, decubitus ulcers)
  39. Autonomic Dysreflexia (Hyperreflexia)
    • Emergency situation → elevate head, check and empty catheter first 
    • Noxious stimulus precipitates a pathological autonomic reflex 
    • Examine for irritating stimuli 

    • Symptoms:
    • Bradycardia
    • Headache
    • Diaphoresis (sweating)
    • Flushing
    • Diplopia
    • Confusions
  40. Heterotopic Bone Formation (Ectopic Bone)
    • Abnormal bone growth in soft tissues
    • Examine for early changes (soft tissue swelling, pain, erythemia)
    • Generally near large joint
    • Late changes = calcification, initial signs of ankylosis
  41. SCI: Reorient Pt to Vertical Position
    • Tilt table
    • WC
    • Use of abdominal binder
    • Elastic LE wraps to decrease venous pooling
    • Examine for orthostatic hypotension (lightheadedness, syncope, mental or visual blurring, sense of weakness)
  42. SCI: High Cervical Lesions (C1-4)
    • Electric WC with tilt-in space seating or reclining seat back
    • Microswitch or puff and sip controls
    • Portable respirator may be attached
  43. SCI: Cervical Lesions, Shoulder Function, Elbow Flexion (C5)
    • Use manual chair with propulsion aids (i.e. projections)
    • Independent for short distances on smooth flat surfaces
    • May choose electric WC for distances and energy conservation
  44. SCI: Cervical Lesions, Radial Wrist Extensors (C6)
    • Manual WC with friction surface hand rims
    • Independent
  45. SCI: Cervical Lesions, Triceps (C7)
    Same as C6 but with increased propulsion
  46. SCI: Patients with Hand Function (C8-T1 and below)
    • Manual WC 
    • Standard hand rims
  47. Locomotor Training with Complete Injuries: Midthoracic Lesions (T6-9)
    • Supervised ambulation for short distances 
    • Requires B KAFOs and crutches
    • Swing-to gait pattern
    • May prefer standing devices/WCs for physiological standing
  48. Locomotor Training with Complete Injuries: High Lumbar Lesions (T12-L3)
    • Can be independent in ambulation on all surfaces and stairs
    • Swing through or 4-point gait pattern 
    • B KAFOs and crutches
    • Pts may also use reciprocating gait orthoses with walker w/ or w/o FES system
    • Typically independent household ambulators 
    • WC for community ambulation
  49. Locomotor Training with Complete Injuries: Low Lumbar Lesions (L4-5)
    • Can be independent with B AFOs and crutches/canes
    • Typically independent community ambulatories
    • May still use WC for activities with high-endurance requirements
  50. Cardiovascular Endurance Precautions with SCI
    • Individuals with tetraplegia and high-lsion paraplegia = experience blunted tachycardia, lack of pressure response, and very low VO2 peak
    • Substantially higher variability of most responses
  51. Absolute Contraindications to Exercise Testing and Training of Individuals with SCI
    • Autonomic dysreflexia
    • Severe/infected skin on WB surfaces
    • Symptomatic hypotension
    • UTI
    • Unstable fracture
    • Uncontrolled hot and humid environments
    • Insufficient ROM to perform task
  52. Treadmill Training using Body Weight Support (SCI)
    • Indications: incomplete injuries (ASIA B, C, and D)
    • Promotes SC learning/activation of spinal locomotor loops
    • Use body harness to support weight 
    • High frequency (4days/week), moderate duration (20-30 min), typically 8-12 weeks
    • Progression: decrease BWS, increased speed, eliminate manual assistance