Introduction and Overview
My name is Erin Mattingly and I am excited to be back presenting another webinar for SpeechPathology.com. I do not have anything financial to disclose. I have not received any compensation from test, treatment or application developers or publishers. As for non-financial disclosures, I am the Professional Development Manager for ASHA SIG 2 Coordinating Committee, a member of the Academy of Certified Brain Injury Specialists Marketing Committee and a member of the American Neurologic Communication Disorders and Sciences Communications Committee. All opinions here are my own.
Mechanisms and Symptoms of ABI
First, we will start with the mechanisms and symptoms of acquired brain injury (ABI). ABI is a true health crisis in the United States. Statistics show that in 2013, there were 2.5 million people who sustained a traumatic brain injury (TBI) and an additional 795,000 who sustained a non-traumatic acquired brain injury (mostly likely, stroke). According to the Brain Injury Association of America, ABI is an injury to the brain occurring after birth that is not hereditary, congenital, degenerative or induced by birth trauma. There is the traumatic brain injury that is a result of, just to keep it very simple, a knock to the head, a fall or something that impacts the brain externally. There is stroke, such as bleeding or hemorrhage in the brain. There are also other neurological impairments such as anoxia and hypoxia (lack of oxygen to the brain), or diseases such as meningitis, brain tumors, cancer or epilepsy. ABI does not typically include degenerative disorders - things like amyotrophic lateral sclerosis (ALS) or Parkinson's - that impact cognition. They are their own entity.
Acute inpatient rehabilitation has multiple names. You might just hear “acute rehab” or “inpatient rehab.” In this setting, there is a great definition provided by the report of the Panel for Consensus Development Conference on the Rehabilitation of Persons with Traumatic Brain Injury. They did a nice job of summarizing acute inpatient rehab as an interdisciplinary approach that includes medical stabilization, physical rehab and cognitive and behavioral rehab. That is what we are going to focus on in this course. These folks are in the acute stage of their injuries. They are usually out of the intensive care unit, but this is well before they go into any sort of outpatient community re-entry, so they are still pretty sick.
I want to discuss the severity of acquired brain injury. There are many methods available to measure severity, but there are a few common ones that you might see when reviewing a patient's notes: the Rancho Los Amigos Scale, which is used for traumatic brain injury; the Glasgow Coma Scale, which is used for traumatic brain injury; and the National Institutes of Health (NIH) Stroke Scale, which is used for stroke. The reason these scales were developed was because they wanted to standardize the measurement of the severity of these types of injuries. You are usually going to see these scores and these levels decided upon in the emergency department or upon admission to your unit.
The Rancho Los Amigos Scale. The original scale was developed in 1972. It ranged from a score of Level I (“No Response: Total Assistance”) to Level VIII (“Purposeful and Appropriate: Stand-by Assistance”). This applies to both cognition and physical impairment. In 2005, the scale was actually revised. It now goes all the way up to Level X, which is more of a Modified Independent level. In general, what I have seen is that providers, doctors, etc. are primarily still using the eight-level scale because they are most familiar with it and have used it for a while.
The Glasgow Coma Scale. You are going to see this scale almost every time in the Emergency Department (ED). It looks at three prongs: eye opening, verbal response, and motor response. You obtain a total numerical score that helps standardize the severity level. Anything less than a score of 8 is considered severe. A score of 9 to 12 is a moderate traumatic brain injury, and somewhere in the 13 to 15 range is mild, with 15 being the best score possible.
The NIH Stroke Scale looks at the level of consciousness, receptive and expressive language, motor weakness, visual symptoms, and sensory loss. It is similar to those traumatic brain injury scales, in that it is a way of measuring the severity of stroke.
You will sometimes see in the patient’s notes - and I have seen this happen - that maybe a doctor has stated that a patient who survived a stroke is a “Rancho III.” That is really not an appropriate use of the scale, because the Rancho Scale and the Glasgow Coma Scale are only valid for traumatic brain injury, not for stroke. That is a great opportunity to do some education of staff.
Typical Symptoms of ABI
Below is a list of "typical" symptoms of ABI:
- Executive Functioning
- Problem Solving
- Physical Symptoms
With attention, you are looking at really basic levels of attention. When patients are emerging from coma, you are looking for localization to pain or any sort of focused attention on anything. If you do a trapezius squeeze to try to get that patient more alert or to demonstrate eye opening, and they reach out to touch your hand or try to push you away, that is a good sign that the patient is beginning to localize.
Regarding memory, you are going to see a lot of issues with declarative memory -- forming new memories. You will see that problem often with patients who are in post-traumatic amnesia. These are patients who are not oriented and are not laying down new memories. We will talk later about what type of treatment goals and evaluation goals are appropriate when a patient is in that state. Sometimes, but not as often, you might see some implicit memory difficulties. Those are routine procedural memory type tasks that you are automatically familiar with; for example, your morning routine, maybe self-feeding, and tasks like that.
Executive functioning is how you recognize a task needs to be completed or a problem needs to be solved. You plan how to complete that task, and then you actually implement your plan and evaluate your performance. Almost every patient with a traumatic brain injury or acquired injury is going to have some sort of executive functioning issue. However, you may not be able to tease out that it is even a problem until patients have progressed in their recovery because it is such a high-level function.
Problem solving includes simple things like math, all the way up to more complex reasoning and awareness.
As for language symptoms, you might see some aphasia in patients with stroke, and word finding problems in stroke and traumatic brain injury. Pragmatics can be locked in with language because it is a type of language; but I did just want to separate them out. I also wanted to note that it is important to differentiate between a language disorder and confusion, or something that is happening as the patient is emerging. Patients in the post-traumatic amnesia (PTA) period are quite confused. You have to differentiate between a true aphasia and confusion. It may sound like the patient is perhaps a Wernicke's aphasic, but actually, it is just a confusion-based language disorder at that period in time, and not a true language disorder.
Pragmatics is social skills. Here is a story that is still one of my favorites from when I was treating in an inpatient setting. I was running a group and this patient put his hands in his pants and he screamed out, “This I call pterodactyl!” Clearly, that was an example of confusion. It was confused language, but also not appropriate pragmatics. You are going to see a lot of pragmatic issues both in language and in actions.
Swallowing can definitely be impacted by attention, by level of consciousness, and of course, by cranial nerve involvement. Physical symptoms will vary depending on the site of injury. You might see hemiparesis, maybe a visual field cut, left inattention, or a subluxation in the shoulder. You might see oral-motor weakness because of cranial nerve involvement, and that ties into dysarthria, which is another possible symptom.
Impact of Medication
The impact of medication is a big issue and something to be aware of when you do an evaluation and treatment. You should know about some of these common medications that you will see in the charts.
Of course, there is pain medication, which can be extremely sedating and will make it more difficult to get a true impression of what the patient's cognitive-communication is really like. It is important to know if the patient is sedated. Usually, any nurse or the physician can tell you what medications the patient is taking. You can look in the chart and find out if the patient is actively on it or if he/she is in between doses; that is an important thing to know.
Neurostimulants may be given later on in recovery. You may see that patients are on Amantadine, or Aricept®, or Concerta® to try to stimulate the memory and attention components that have been damaged due to acquired brain injury. So, it is good to familiarize yourself with some of those. Some physicians are not as open to using neurostimulants. I have found that those who are, are really willing to talk about what you are seeing cognitively, in order to develop an idea about what neurostimulant to use. Typically, you primarily see neurologists and physical medicine and rehab (PM&R, or physiatry) doctors who are willing to prescribe those.
Blood pressure medications can also cause some issues. You are not necessarily going to see cognitive effects unless they are about to pass out, but most patients are on blood pressure meds as they are stabilizing.
Anti-epilepsy meds are used post-TBI in particular. You might see somebody on a dose of Keppra® in order to try to prevent any seizures as a result of the trauma.
It is worth mentioning that there are studies showing that, if you give too many sedating medications, it can really negatively impact recovery of the patient and impact long-term outcomes. Again, that can be an educational moment that you have with staff; however, there is a fine line between stabilizing a patient and trying to wake them up. You really need to use your judgment. Sedation can also be used as a form of chemical medical restraint to prevent further injury and stabilize a patient. It prevents patients from removing tubes and lines if they are vented or trached or have IVs, etc. Typically, the use of sedating medications as a restraint is done only in the early phases of recovery -- the very acute stages. Perhaps when the patient has had a craniotomy or when intracranial pressure is really high, you might want to sedate them just to protect them and allow easier healing. There are also more physical restraints such as wrist restraints, a locked Posey® belt, soft belts, mitts, or a Posey bed. The Posey bed and similar beds are netted, so that the patient can move around.
Post-traumatic amnesia (PTA) is an important topic. First, you are really only going to see this after a traumatic brain injury. A patient who has survived a stroke may have a memory issue or an orientation issue, but she is not considered to be in PTA. That is just worth mentioning.
PTA, defined, is a period of confusion and disorientation following a TBI and it can last for a few minutes, to days or months. The duration of PTA is directly correlated to the patient’s outcome. If you have a patient who is in PTA for five minutes, chances are they are going to recover to very limited symptoms; whereas, a patient who is in a coma, wakes up and is in PTA for months is going to have a poorer prognosis.
The big question for us is, “How does PTA impact my treatment and assessment?” People always talk about orientation and that is one of the first things that you really look at when you come in to assess a patient. Every neurologist and every doctor, nurse, everyone is going to ask, “What is the date? Where are you? What happened?” A patient who is in PTA is not oriented and cannot be oriented, because he is not laying down new memories. It is important to know that. For that reason, you do not want to have an orientation goal for this patient because there is really no treatment that is going to cause that patient to become oriented.
You also want to make sure that you are focusing on implicit tasks as opposed to declarative memory tasks. This is not the time to teach a patient compensatory strategies for dysarthria. You want to focus on more procedural, automatic tasks like I mentioned earlier; for example, steps to brushing your teeth or dressing, if the patient is safe for transfers and stable. That is really what you want to focus on with a disoriented patient.
Many facilities run orientation groups. There are pros and cons of these groups. There is really no evidence of efficacy for these groups because these patients are not forming new memories. You can repeat to them all day long what the date and day are and where they are, but that really is not going to help with the PTA. However, the groups do provide peer interaction and exposure to others with injury, so there is that social aspect which can be a benefit. But I think that goals related to orientation will not be easily met or treated based on being part of an orientation group.
Treatment and Goal Planning Frameworks
Treatment and goal planning frameworks should focus on making tasks functional. The typical medical model of rehabilitation has always been that you find out what the diagnosis is, and then you treat to that diagnosis. Because of our (unfortunately) insurance-driven system, you are trying to come up with quantitative goals that are measurable; ones that an insurance company can just look at and say, “Check, check, they are 90% here, 75% there.” You may find folks doing worksheets or deductive reasoning puzzles, which are not very functional. That is why I was really excited when I was asked to do this presentation because I think it is hard, sometimes, to come up with functional goals at that inpatient acute care level. I wanted to share some of my ideas, but also, these frameworks that can really help you build treatment and evaluation goals.
International Classification of Functioning, Disability and Health (ICF)
The first one is the International Classification of Functioning, Disability and Health (ICF). It was developed in 2001 by the World Health Organization, and it is a biopsychosocial model of disability based on the integration of the social and medical models of disability. It incorporates body functions and structures, the level of functioning or the activities that a patient can perform, the environmental factors, and a person's level of participation in society. As we move forward, we are going to talk though some goals that match up with the ICF framework and that provide a holistic, patient-centered approach.