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
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
Altered Levels of ConsciousnessAltered Levels of Consciousness
ComaComa
Vegetative StateVegetative State
Minimally Conscious StateMinimally Conscious State
ComaComa
No eye opening even with vigorous No eye opening even with vigorous stimulationstimulation
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
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
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
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
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
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
JFK Coma Recovery ScaleJFK Coma Recovery Scale
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
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
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
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
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
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
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
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
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
Serial CastingSerial Casting
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
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.
ContraindicationsContraindications
Edema – uncontrolledEdema – uncontrolled
Unhealed fracturesUnhealed fractures
PrecautionsPrecautions
Circulation problemsCirculation problems Skin integritySkin integrity SensationSensation Mild edemaMild edema Medical instability Medical instability Need for accessibilityNeed for accessibility Restless/agitatedRestless/agitated
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
Goal Setting for the Minimally Goal Setting for the Minimally Responsive PatientResponsive Patient
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.
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
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.
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.
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..
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.
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
Case StudyCase Study
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
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
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
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
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
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
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
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’
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
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.
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
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
Questions?Questions?