8th Floor Inservice

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Acquired Brain Injury: Acquired Brain Injury: Caring for the Minimally Caring for the Minimally Responsive Responsive Kristen Arvidson, Beth Hanson, Kristen Arvidson, Beth Hanson, Chris Kaltenburg Chris Kaltenburg Erin Riley, Julie Szabo, Chrissie Erin Riley, Julie Szabo, Chrissie Stone Stone

Transcript of 8th Floor Inservice

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Acquired Brain Injury:Acquired Brain Injury:Caring for the Minimally ResponsiveCaring for the Minimally Responsive

Kristen Arvidson, Beth Hanson, Chris KaltenburgKristen Arvidson, Beth Hanson, Chris Kaltenburg

Erin Riley, Julie Szabo, Chrissie StoneErin Riley, Julie Szabo, Chrissie Stone

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OutlineOutline

Overview of Minimally Conscious StateOverview of Minimally Conscious State JFK Coma Recovery ScaleJFK Coma Recovery Scale Serial CastingSerial Casting Goal SettingGoal Setting Case StudyCase Study

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Altered Levels of ConsciousnessAltered Levels of Consciousness

ComaComa

Vegetative StateVegetative State

Minimally Conscious StateMinimally Conscious State

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ComaComa

No eye opening even with vigorous No eye opening even with vigorous stimulationstimulation

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Vegetative StateVegetative State

Only vegetative functions are present:Only vegetative functions are present:– Respiratory rate, heart rate, primitive reflexesRespiratory rate, heart rate, primitive reflexes

Complete absence of awareness of Complete absence of awareness of environment or selfenvironment or self

Sleep wake cycles presentSleep wake cycles present

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Minimally Conscious State Minimally Conscious State (MCS)(MCS)

Aspen Neurobehavioral ConferenceAspen Neurobehavioral Conference– Comprised of international experts in the fields Comprised of international experts in the fields

of bioethics, neurology, neuropsychology, of bioethics, neurology, neuropsychology, neurosurgery, physiatry, nursing and allied neurosurgery, physiatry, nursing and allied healthhealth

– Developed guidelines for diagnosis, prognosis Developed guidelines for diagnosis, prognosis and management of MCSand management of MCS

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Minimally Conscious StateMinimally Conscious State

““The minimally conscious state is a condition The minimally conscious state is a condition of severely altered consciousness in which of severely altered consciousness in which minimal but definite behavioral evidence of minimal but definite behavioral evidence of

self or environmental awareness is self or environmental awareness is demonstrated.”demonstrated.”

Gianco et al 2002Gianco et al 2002Aspen Neurobehavioral ConferenceAspen Neurobehavioral Conference

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Evidence for diagnosis of MCSEvidence for diagnosis of MCS

Follow simple commandsFollow simple commands Gestures or verbal yes/no responseGestures or verbal yes/no response Intelligible verbalizationIntelligible verbalization Purposeful behaviorPurposeful behavior

– Tracking, sustained visual fixation, Tracking, sustained visual fixation, reaching/holding objects that shows awareness reaching/holding objects that shows awareness of size/shape position in space, contingent of size/shape position in space, contingent laughing/crying to situationlaughing/crying to situation

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Criteria for Emergence from MCSCriteria for Emergence from MCS

Functional CommunicationFunctional Communication– Accurate yes/no response to six out of six Accurate yes/no response to six out of six

situational orientation questionssituational orientation questions» ““Am I clapping now?” Am I clapping now?”

Functional Object UseFunctional Object Use– Using two different objects generally Using two different objects generally

appropriately on two different occasionsappropriately on two different occasions

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Coma Recovery ScalesComa Recovery Scales

There are different standardized evaluation There are different standardized evaluation tools medical practitioners use to diagnoses tools medical practitioners use to diagnoses the symptoms of TBIthe symptoms of TBI– Glasgow Coma ScaleGlasgow Coma Scale– Ranchos Los AmigosRanchos Los Amigos– JFK Coma Recovery ScaleJFK Coma Recovery Scale– Coma/Near Coma ScaleComa/Near Coma Scale

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

The coma recovery scale consists of 25 items The coma recovery scale consists of 25 items representing various levels of neurologic representing various levels of neurologic responsivenessresponsiveness

Developed to monitor the recovery of minimally Developed to monitor the recovery of minimally responsive adolescents and adultsresponsive adolescents and adults

Levels of responsiveness:Levels of responsiveness:– GeneralizedGeneralized– LocalizedLocalized– Emergent Emergent – Cognitively mediatedCognitively mediated

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

Designed to evaluate the sensory modalities of:Designed to evaluate the sensory modalities of:– Arousal/attentionArousal/attention– Auditory functionAuditory function– Visual functionVisual function– Motor functionMotor function– Oromotor/verbal abilityOromotor/verbal ability– communicationcommunication

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

Lowest item within each subscale represents Lowest item within each subscale represents reflexive activity while the highest scores reflexive activity while the highest scores represent cognitively mediated behaviorsrepresent cognitively mediated behaviors

Score from 0-23Score from 0-23

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

Auditory functionAuditory function 0 – no response to loud stimuli0 – no response to loud stimuli 1 – auditory startle1 – auditory startle 2- localization to command2- localization to command 3-reproducible movement to command3-reproducible movement to command 4-consistent movement to command4-consistent movement to command

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

Motor functionMotor function– 0-no response to noxious stimuli0-no response to noxious stimuli– 1-abnormal posturing (stereotyped flexion/ 1-abnormal posturing (stereotyped flexion/

extension)extension)– 2-flexion withdrawal2-flexion withdrawal– 3-localization to noxious stimuli3-localization to noxious stimuli– 4-object manipulation4-object manipulation– 5-automatic motor response5-automatic motor response– 6-functional object use6-functional object use

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

Visual FunctionVisual Function 0-no response0-no response 1-visual startle1-visual startle 2-fixation2-fixation 3-visual pursuit3-visual pursuit 4- object localization/reaching4- object localization/reaching 5-object recognition5-object recognition

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

Oromotor/verbal functionOromotor/verbal function– 0-no oral movement0-no oral movement– 1-oral reflexive movement1-oral reflexive movement– 2-vocalization/oral movement2-vocalization/oral movement– 3-intelligible verbalization3-intelligible verbalization

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

CommunicationCommunication– 0-no verbal/nonverbal communication0-no verbal/nonverbal communication– 1-nonfunctional: intentional1-nonfunctional: intentional– 2-functional accurate2-functional accurate

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JFK Coma Recovery ScaleJFK Coma Recovery Scale

ArousalArousal– 0-unarousable0-unarousable– 1-eye opening with stimulation1-eye opening with stimulation– 2-eye opening without stimulation2-eye opening without stimulation– 3-attention3-attention

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Serial CastingSerial Casting

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Benefits and Goals to Serial Benefits and Goals to Serial castingcasting

Provide constant stretch to reduce soft tissue Provide constant stretch to reduce soft tissue contracture/increase ROMcontracture/increase ROM

Increase proprioceptive input to the extremity through Increase proprioceptive input to the extremity through static positioning and added weight of the cast static positioning and added weight of the cast

Passive- To gain ROM for hygiene, fit of clothing or Passive- To gain ROM for hygiene, fit of clothing or permanent splint or orthosispermanent splint or orthosis

Active- To allow potential active range of motion/strength Active- To allow potential active range of motion/strength for functional gains for ADL’s, transfers /ambulationfor functional gains for ADL’s, transfers /ambulation

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IndicationsIndications

Soft tissue contracture/loss in Soft tissue contracture/loss in ROMROM

Potential for loss of ROM due Potential for loss of ROM due to hypertonic muscle tone, to hypertonic muscle tone, posturing or immobility in a posturing or immobility in a reduced ROM.reduced ROM.

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ContraindicationsContraindications

Edema – uncontrolledEdema – uncontrolled

Unhealed fracturesUnhealed fractures

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PrecautionsPrecautions

Circulation problemsCirculation problems Skin integritySkin integrity SensationSensation Mild edemaMild edema Medical instability Medical instability Need for accessibilityNeed for accessibility Restless/agitatedRestless/agitated

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Discontinuation CriteriaDiscontinuation Criteria

Skin breakdownSkin breakdown Circulation dysfunctionCirculation dysfunction Minimal gains on ROM: >5 degrees Minimal gains on ROM: >5 degrees

through 2 cast changesthrough 2 cast changes Cast or procedure not tolerated by patientCast or procedure not tolerated by patient

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Goal Setting for the Minimally Goal Setting for the Minimally Responsive PatientResponsive Patient

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Setting Goals for the Minimally Setting Goals for the Minimally Responsive PatientResponsive Patient

Overall, given cognitive Overall, given cognitive and physical and physical limitations, progress is limitations, progress is likely to be very slow.likely to be very slow.

Consider breaking typical goals into Consider breaking typical goals into component parts and consider family component parts and consider family member’s ability to participate in patient tasks.member’s ability to participate in patient tasks.

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Mobility GoalsMobility Goals

LTG:LTG:– Begin by determining Mod-Max-D transfer.Begin by determining Mod-Max-D transfer.– Ex. Pt will be Max A for supine-sit transfer.Ex. Pt will be Max A for supine-sit transfer.

STG:STG:– Based on your assessment, can patient contribute Based on your assessment, can patient contribute

to any portion of movement?to any portion of movement?

-Control tone, track with eyes, chin tuck, etc-Control tone, track with eyes, chin tuck, etc

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Mobility GoalsMobility Goals STG:STG:– Ex. Pt will Ex. Pt will rollroll to the left with to the left with Max AMax A using using

Max Cueing with Max Cueing with patient initiating rollpatient initiating roll by by tracking his eyestracking his eyes to the Left on 1/5 trials. to the Left on 1/5 trials.

-Ex. Pt will transfer -Ex. Pt will transfer squat pivotsquat pivot from bed-w/c from bed-w/c Max AMax A with Max Cues with patient able to with Max Cues with patient able to decrease extensor tonedecrease extensor tone on 2/5 trials. on 2/5 trials.

-Ex. Pt’s mother will demonstrate-Ex. Pt’s mother will demonstrate understanding understanding of of STNR STNR and and A ptA pt in controlling reflex during in controlling reflex during Max A roll.Max A roll.

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Activity ToleranceActivity Tolerance

LTG: LTG: – Ex. Pt will be able to tolerate Ex. Pt will be able to tolerate

OOB 6 hoursOOB 6 hours to participate to participate in therapeutic activities.in therapeutic activities.

STG: STG: – Ex. Pt will tolerate Ex. Pt will tolerate OOB OOB

2hours/ 2x/day2hours/ 2x/day to improve pt to improve pt hemodynamic responses.hemodynamic responses.

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ROM GoalsROM Goals

LTG: LTG: – PROM for functional positions, ie w/c positioningPROM for functional positions, ie w/c positioning– Ex. Pt will have Ex. Pt will have 90 degrees90 degrees B knee flex for B knee flex for w/cw/c

positioningpositioning

STG:STG:– PROM in increments of LTG goalPROM in increments of LTG goal– Ex. Pt will increase ankle DF PROM by Ex. Pt will increase ankle DF PROM by 5 degrees5 degrees to to

progress towards optimal progress towards optimal neutral positioningneutral positioning for for effective effective WB transfersWB transfers..

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Balance GoalsBalance Goals

LTG:LTG:– Patient able to participate in all or component Patient able to participate in all or component

of functional taskof functional task– Ex. Pt able to Ex. Pt able to maintain head in neutralmaintain head in neutral during during

all components of sitting activity.all components of sitting activity. STG: STG:

– Ex. Pt able to Ex. Pt able to maintain headmaintain head in neutral once in neutral once assistedassisted to neutral position during Max A to neutral position during Max A supported sittingsupported sitting for 10 seconds. for 10 seconds.

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Oh my Gosh, I don’t have a clue.Oh my Gosh, I don’t have a clue.

Task STG LTG

Activity Tolerance

OOB 2 hours/2x/day

OOB 6 hours

ROM Pt tolerate PROM ROM for w/c positioning

Bed Mobility Pt participate in some component of Max A supine-sit

Max A supine-sit

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Case StudyCase Study

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Case StudyCase Study

18 yo male s/p MVA in Jan ’0718 yo male s/p MVA in Jan ’07 GCS 3 at sceneGCS 3 at scene CT scan: intraparenchymal frontal CT scan: intraparenchymal frontal

hemorrhagehemorrhage C2 fx, ruptured spleen, R femoral fxC2 fx, ruptured spleen, R femoral fx Underwent R frontal craniotomy, R LE Underwent R frontal craniotomy, R LE

ORIF, trach, PEGORIF, trach, PEG

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Case StudyCase Study

Repeat head CTs: diffuse axonal injury, R Repeat head CTs: diffuse axonal injury, R frontal, R basal ganglia, L thalamic bleedsfrontal, R basal ganglia, L thalamic bleeds

DysautonomiaDysautonomia L hip: lytic bone lesion, ?oncologyL hip: lytic bone lesion, ?oncology Orders: C-collar 8-12 weeksOrders: C-collar 8-12 weeks

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EvaluationEvaluation

Minimally responsive programMinimally responsive program Spontaneous R sided mvmtSpontaneous R sided mvmt Hypertonicity B LE’s with clonusHypertonicity B LE’s with clonus PROM limited R hip/knee/anklePROM limited R hip/knee/ankle Dependent for all mobilityDependent for all mobility Inconsistent periods of alertnessInconsistent periods of alertness

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Long Term GoalsLong Term Goals

Tolerance: >/= 6 hours OOB upright in Tolerance: >/= 6 hours OOB upright in W/CW/C

Functional Mobility: Mod A in all areasFunctional Mobility: Mod A in all areas Wheelchair level initiallyWheelchair level initially ROM: achieve/maintain functional rangesROM: achieve/maintain functional ranges

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11stst Month: Treatment Month: Treatment

• Dependent transfersDependent transfers• Tilt tableTilt table• Sitting balanceSitting balance• Tracking activitiesTracking activities• PROMPROM• Serial CastingSerial Casting• PositioningPositioning• Family EducationFamily Education

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11stst Month: Outcomes Month: Outcomes

Heterotrophic OssificationHeterotrophic Ossification Decannulated, non-verbalDecannulated, non-verbal Following simple 1-step commandsFollowing simple 1-step commands PusherPusher Motor restlessnessMotor restlessness Improved all aspects of mobilityImproved all aspects of mobility

– Mod A bed mob, Max/1 + Min/1 transferMod A bed mob, Max/1 + Min/1 transfer

– Initiating standing frame activitiesInitiating standing frame activities

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22ndnd Month: Treatment Month: Treatment

• Bed mobility, TransfersBed mobility, Transfers

• Sit->stand with B assistance, mirrorSit->stand with B assistance, mirror

• Ambulation with LitegaitAmbulation with Litegait

• PROMPROM

• Positioning – L LE contracturesPositioning – L LE contractures

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22ndnd Month: Outcomes Month: Outcomes

VerbalizingVerbalizing Pain, Pain, PainPain, Pain, Pain Attention, Restlessness, PerseverationAttention, Restlessness, Perseveration Decreased pushingDecreased pushing Continuing gains, new limitationsContinuing gains, new limitations

– Min A bed mob, mod/max A transfers, Min A bed mob, mod/max A transfers, dependent ambulation x 20’dependent ambulation x 20’

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33rdrd Month: Treatment Month: Treatment

• Continued functional mobilityContinued functional mobility

• Sitting/Standing balanceSitting/Standing balance

• PROMPROM

• Ambulation with KAFO, Atlas walker, Ambulation with KAFO, Atlas walker, Assist x 2Assist x 2

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33rdrd Month: Outcomes Month: Outcomes

Continued painContinued pain Anxiety, PerseverationAnxiety, Perseveration Decreased restlessnessDecreased restlessness D/C C-collarD/C C-collar Standard W/C for mobilityStandard W/C for mobility

– S bed mob, Min/mod transfer, Max amb.S bed mob, Min/mod transfer, Max amb.

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44thth Month: Treatment Month: Treatment

• Increasing independence with functionIncreasing independence with function

• PROMPROM

• Restraint reductionRestraint reduction

• Problem solvingProblem solving

• Gait with KAFO, LBQCGait with KAFO, LBQC

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44thth Month: Outcomes Month: Outcomes

D/C to subacute rehabD/C to subacute rehab (S) bed mobility without rails(S) bed mobility without rails Min A transfer stand pivotMin A transfer stand pivot Mod A ambulation household distanceMod A ambulation household distance (S) W/C mobility(S) W/C mobility Increasing social appropriateness, emerging Increasing social appropriateness, emerging

personalitypersonality

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Questions?Questions?