ACUTE HEAD INJURY

Submited By : Manjiwan
Garcha
 CONTENTS
• INTRODUCTION
• CAUSES
• MECHANISM
• TYPES OF HEAD INJURIES
 INTRODUCTION
• 50-99% OF MODERATE HEAD TRAUMA
VICTIMS HAVE PERMANENT INJURY.
• MOTOR VEHICLE ACCIDENT IS THE
PRIMARY CAUSE ADULT.
• FALLS FOR ELDERLY AND CHILDREN
.
 CAUSES

MOTOR VEHICLE ACCIDENTS

FIREARM-RELATED INJURIES
FALLS
ASSAULTS
SPORTS-RELATED INJURIES
RECREATIONAL ACCIDENTS
 MECHANISM
BLUNT INJURY
HIGH VELOCITY
LOW VELOCITY

PENTRATING INJURY
GUN SHOT
SHARP INSTRUMENTS
 CLASSIFICATION OF HEAD
INJURY
• SCALP INJURY: MINOR INJURY RESULTING IN
LACERATION, ABRASION & HEMATOMA

• SKULL INJURY: MAY OCCUR WITH OR

WITHOUT DAMAGE TO BRAIN.

• BRAIN INJURY
 SCALP INJURY
• CONTUSIONS
• LACERATIONS
• SIGNIFICANT HEMORRHAGE
 SCALP LACERATIONS
• RICH BLOOD SUPPLY
• HYPOVOLEMIC SHOCK
• OFTEN DEEPER BRAIN INJURY
• DIRECT PRESSURE TO CONTROL
BLEEDING
• DO NOT APPLY EXCESSIVE PRESSURE
 SKULL INJURY

• LINEAR
• DEPRESSED
• OPEN
• IMPALED
OBJECT
 SKULL FRACTURES
• LINEAR SKULL FRACTURE: IS A BREAK IN THE
CONTINUITY OF THE BONE, APPEAR AS THIN
LINES ON X-RAY.

• DEPRESSED SKULL FRACTURE - THE BROKEN

PIECE OF SKULL BONE IS PRESSED TOWARDS OR
EMBEDDED IN THE BRAIN.

• COMMINUTED AND COMPOUND SKULL

FRACTURE - THE SCALP IS CUT AND THE SKULL
IS SPLINTERED, MULTIPLE FRACTURE
FRAGMENTS.
Skull Fractures
• BASILAR SKULL FRACTURE
• THE SKULL FRACTURE IS LOCATED AT THE BASE OF
THE SKULL AND MAY INCLUDE THE OPENING AT
THE BASE OF THE SKULL
• DIASTATIC SKULL FRACTURE

SKULL FRACTURES THAT SEPARATE THE CRANIAL

SUTURES IN CHILDREN PRIOR TO THE CLOSING OF
THE CRANIAL FISSURES
CRIBIFORM PLATE FRACTURE

IF THE CRIBIFORM PLATE IS FRACTURED, CEREBRAL

SPINAL FLUID CAN LEAK FROM THE BRAIN AREA OUT
THE NOSE.

CAN CAUSE DAMAGE TO THE NERVES AND BLOOD

VESSELS THAT PASS THROUGH THE OPENING AT THE
BASE OF THE SKULL
 SKULL FRACTURES
• SIGNIFICANT FORCE CAUSES THE SKULL
FRACTURE.
• INJURIES FROM BULLETS, BLASTS,BLUNT FORCE,
OTHER PENETRATING OBJECTS.
• RISK OF INFECTION, IF OPEN SKULL FRACTURE.
• X-RAY OR CT
• DEFORMITY
 SKULL FRACTURES
• RACCOON EYES
• INDICATES
MAXILOFACIAL
FRACTURES
AROUND EYES
• ECCHYMOSIS
(BLACK EYES)
• EYE BULGES OUT
(EXOPTHALMOS)
• EYE SINKS IN
(ENOPTHALMOS)
 SKULL FRACTURES
• BATTLE’S SIGN
• ASSOCIATED WITH BASILAR
SKULL FRACTURE
• BLOOD ACCUMULATION BEHIND
ONE OR BOTH EARS (FORMS
BRUISING 12-24 HOURS LATER
• HEMOTYMPANUM - BLOOD IN THE
TYMPANIC CAVITY OF THE
MIDDLE EAR.

• CSF DRAINAGE FROM EARS OR

NOSE
 BRAIN INJURIES
• CONCUSSIONS

• CONTUSIONS

• INTRACRANIAL
BLEEDING

• CEREBRAL EDEMA
 CONCUSION
• CONCUSSIONS RESULT FROM DIRECT BLOWS
TO THE HEAD, GUNSHOT WOUNDS, VIOLENT
SHAKING OF THE HEAD, OR THROUGH A
WHIPLASH TYPE OF INJURY.
 CONCUSSION
• MILD TRAUMATIC
BRAIN INJURY
(MTBI), MILD HEAD
INJURY (MHI)
• TEMPORARY LOSS
OF BRAIN FUNCTION
• MAY RESULT IN LOSS
OF CONSCIOUSNESS
• CONFUSION
• AMNESIA
• DIZZYNESS
• WEAKNESS
 CONCUSSION
• COUP- SAME SIDE
INJURY

• CONTER-COUP-
OPPOSITE SIDE INJURY
 CONTUSION

• A CONTUSION IS A BLEEDING BRUISE TO THE

BRAIN CAUSED BY A DIRECT IMPACT TO THE
HEAD.
 CONTUSION
• CONTUSIONS MAY OCCUR AS THE
BRAIN SCRAPES THE INSIDE OF THE
SKULL
• A FORM OF TRAUMATIC BRAIN
INJURY, IS A BRUISE OF THE BRAIN
TISSUE
• COMMONLY OCCUR IN COUP OR
COUNTRE-COUP INJURIES

BLEEDING, PERMANENT INJURY,

SWELLING, AMNESIA,
UNCONSCIOUSNESS
 INTRACRANIAL BLEEDING
• EPIDURAL HEMATOMA

• SUBDURAL HEMATOMA

• INTRACEREBRAL HEMORRHAGE
 EPIDURAL HEMATOMA
• HEMATOMA BETWEEN THE DURA MATER AND
THE SKULL
• MOST OFTEN ARTERIAL BLEEDING
• DEVELOPS RAPIDLY
• RAPID DETERIORATION OF NEUROLOGIC
FUNCTIONS
• LUCID PHASE
• RETURN TO CONSCIOUSNESS AFTER LOSS OF
CONSIOUSNESS
 SUBDURAL HEMATOMA
• OCCURS BETWEEN THE DURA AND ARACHNOID
• USUALLY VENOUS IN NATURE
• DEVELOPS SLOWLY
• PROGRESSIVE LOSS OF NEUROLOGICAL
FUNCTION
• PATIENTS MAY NOT REMEMBER BLUNT TRAUMA
INTRACRANIAL HEMORRHAGE
• BLEEDING OCCURS WITHIN THE BRAIN ITSELF

• CAUSED BY TEARING, SHEARING OF BLOOD

VESSELS

• SPINAL TAPS CONTRAINDICATED DUE TO

INCREASED SWELLING
 HEAD INJURY OUTCOME
HIGH POTENTIAL FOR POOR OUTCOME

DEATHS OCCUR AT THREE POINTS IN TIME AFTER

INJURY:

IMMEDIATELY AFTER THE INJURY

WITHIN 2 HOURS AFTER INJURY
3 WEEKS AFTER INJURY
 BRAIN INJURY
RESPONSE TO INJURY
• SWELLING OF BRAIN
• VASODILATATION WITH INCREASED BLOOD
VOLUME
• INCREASED ICP
• DECREASED BLOOD FLOW TO BRAIN
• PERFUSION DECREASES
• CEREBRAL ISCHEMIA (HYPOXIA)

Head Trauma - 34
 PATHOPHYSIOLOGY
• PRIMARY BRAIN • SECONDARY BRAIN
INJURY INJURY

• DIRECT TRAUMA • HYPOXIA,

• INVOLVES BLEEDING, HYPERCAPNEA,
TEARING, SHEARING, HYPOTENSION,
NEURON DAMAGE HYPERGLYCEMIA,
HYPOGLYCEMIA,
INCREASED
INTRACRANIAL
PRESSURE,
SWELLING, SEIZURES
 SIGNS & SYMPTOMS
OF BRAIN INJURY
• ALTERED MENTAL STATUS VOMITING WITHOUT
• ALTERED ORIENTATION NAUSEA
• ALTERATION IN BDOY TEMPERATURE
PERSONALITY CHANGES
CHANGES IN PUPIL
• AMNESIA REACTIVITY
• RETROGRADE – DECORTING POSTURE
PRIOR TO DISEASE
• ANTEGRADE – AFTER
THE ONSET
• CUSHING’S TRIAD
• INCREASED BP
• BRADYCARDIA
• ERRATIC RESPIRATIONS
 SIGN AND SYMPTOMS:
• DILATED PUPILS
• CHANGES IN BEHAVIOUR, SUCH AS IRRITABILITY
OR CONFUSION
• TROUBLE WALKING OR SPEAKING
• DRAINAGE OF BLOODY OR CLEAR FLUIDS FROM
EARS OR NOSE
• VOMITING
• SEIZURES
• WEAKNESS OR NUMBNESS IN THE ARMS OR LEGS
 DIAGNOSTIC TESTS
• CT OR MRI: DATA ON STRUCTURAL CAUSES SUCH
AS TUMOR OR HEMMORHAGE.
• LP: INFECTION OR BLEEDING (CLOUDY OR
BLOODY)
• EEG: STRUCTURAL OR METABOLIC, SEIZURE
ACTIVITY
• LAB TESTS: LFTS, KIDNEY FUNCTION, GLUCOSE
LEVELS, TOXICOLOGY, ABGS
 GLASGOW COMA SCALE
• PREDICTS MORTALITY
• MEASURES LEVEL OF CONSCIOUSNESS
• MOTOR COMPONENT MOST SENSITIVE SUBSET
• INDICATES IMPROVEMENT OR DETERIORATION
• GCS OF 9-15 INDICATES MILD TO MODERATE
INJURY
• GCS OF 3-8 INDICATES SEVERE HEAD INJURY
 GLASGOW COMA SCALE
Suspect severe brain injury GCS <9

*Decorticate posturing to pain

**Decerebrate posturing to pain
OUTCOME
 EXTREMITY POSTURING
DECORTICATE
• ARMS FLEXED
AND LEGS
EXTENDED

DECEREBRATE
• ARMS EXTENDED
AND LEGS
EXTENDED
 PUPIL ASSESSMENT
• SIZE
• LIGHT RESPONSE
• EQUAL
• COMPARE
 PUPILS

Both dilated Anisocoria

• Nonreactive: brainstem
• Reactive: often reversible

Unilaterally dilated
• Reactive: ICP increasing
Eyelid closure • Nonreactive (altered LOC):
• Slow: cranial nerve III increased ICP
• Fluttering: often hysteria • Nonreactive (normal LOC): not
from head injury
 COMPLICATIONS

• COMA
• CHRONIC HEADACHES
• LOSS OF OR CHANGE IN SENSATION, HEARING,
VISION, TASTE, OR SMELL
• PARALYSIS
• SEIZURES
• SPEECH AND LANGUAGE PROBLEMS
• DEATH
 INITIAL MANAGEMENT

• A: AIRWAY CONTROL INCLUDING CERVICAL

SPINE IMMOBILISATION WITH A STIFF
COLLAR.
• B: BREATHING
• C: CIRCULATION
• D: DYSFUNCTION OR DISABILITY
• E: EXTERNAL EXAMINATION
 CONTUSION

• A CONTUSION IS A BLEEDING BRUISE TO THE

BRAIN CAUSED BY A DIRECT IMPACT TO THE
HEAD.
 TREATMENT
• PREVENT SECONDARY INJURY
• AIRWAY-OXYGEN AND INTUBATION IF GCS
<8
• TREAT SHOCK-NORMOTENSIVE
• HYPERVENTILATION IS ONLY INDICATED IF
PATIENT SHOWS SIGNS OF IMPENDING
HERNIATION
• CONTROL BLEEDING FROM OTHER
INJURIES
• RAPID TRANSPORT IF POSSIBLE
 TREATMENT
• CONTINUAL ASSESSMENT-PUPILS & GCS
• TREAT SEIZURES-INCREASED OXYGEN
CONSUMPTION OF THE BRAIN
• WATCH FOR RESPIRATORY PATTERN
CHANGES-MAY INDICATE YOUR PATIENT
IS WORSENING.
 FRACTURE SKULL BASE
• WITH CSF LEAKS
NO ACUTE SURGERY REQUIRED FOR CSF LEAK
FOR FIRST 72 HRS OBSERVATION (ELEVATION OF
HEAD)

IF LEAK PERSISTS

TEMPORARY CSF DIVERSION (LUMBAR

DRAINAGE OR VENTRICULOSTOMY)

STILL LEAK PERSISTS SURGERY TO BE DONE

• EXPLORATION OF FLOOR OF FRONTAL FOSSA
WITH CLOSURE OF DURAL DEFECT
 EDH
• ABSOLUTE INDICATIONS OF SURGERY (REGARDLESS
OF GCS)
1. > 30 ML VOL OF HEMATOMA
2. > 15 ML THICKNESS OF BLOOD CLOT
• IF GCS <8 = IMMEDIATE SURGERY
• IF GCS > 8 = AS SOON AS POSSIBLE
• IF SIZE LESS THAN ABOVE BUT GCS <8 = SURGERY
• IF SIZE LESS THAN ABOVE BUT GCS >8
=NONOPERATIVE MANAGEMENT CAN BE DONE
• MEAN TIME OF EDH FOR REEXPANSION IS 8 HRS -36
HRS.
 SDH
• ABSOLUTE INDICATION OF SURGERY
1. > 10 MM THICKNESS OF BLOT CLOT
• IF SIZE LESS THAN ABOVE BUT GCS <8 ALONG WITH
1. GCS DECREASED BY 2 FROM TIME OF INJURY TO
ADMISSION
2. PT. WITH ASYMMETRIC OR FIXED DILATED
PUPILS
3.ICP >20 MM OF HG
• IF SIZE LESS THAN ABOVE AND GCS >8 = NON
OPERATIVE TREATMENT.
• SURGERY SHOULD BE WITHIN FIRST 4 HRS
• CRANIOTOMY WITH OR WITHOUT BONE FLAP
REMOVAL
 POSTERIOR FOSSA LESIONS
• NO MONITORING POSSIBLE BECAUSE OF LOCATION

• GUIDELINES FOR EVACUATION

1. > 3CM CLOT ON CT SCAN
2. ANY SIZE OF CLOT WITH SDH OR EDH
 PENETRATING BRAIN INJURY
• MENINGITIS AND ABSCESS MOST COMMON
COMPLICATIONS FOLLOWED BY SEIZURES

• IF GROSSLY CONTAMINATED WOUND THEN

CRANIOTOMY AND DEBRIDEMENT REQUIRED

• SMALL CLEAN WOUNDS WITH NO SCALP

DEVITALIZATION CAN BE MANAGED
CONSERVATIVELY

• IF OPEN SINUS SUSPECTED REPAIR SHOULD BE

DONE

• IF DURAL INJURY SUSPECTED REPAIR SHOULD BE

DONE.
 DECOMPRESSIVE CRANIECTOMY
• USED IN PATIENTS WITHOUT FOCAL LESION AND
RAISED ICP WHO ARE REFRACTORY TO MAXIMUM
MEDICAL MANAGEMENT

• THE OPERATION INVOLVES REMOVING A LARGE

SECTION OF SKULL AND OPENING THE DURA,
ALLOWING THE SWOLLEN BRAIN TO EXPAND
UNDERNEATH THE SCALP

• THE BONE FLAP IS STORED AND CAN BE REPLACED 3–

6 MONTHS LATER WHEN THE PATIENT HAS MADE A
GOOD NEUROLOGICAL RECOVERY AND THE BRAIN
SWELLING HAS RESOLVED
LONG TERM SEQUELAE OF HEAD
INJURY
• NEUROREHABILITATION

• NEUROPSYCHOLOGY – AFTER MINOR HEAD INJURIES

SUCH AS HEADACHE, DIZZINESS, IMPAIRED SHORT
TERM MEMORY, CONCENTRATION ETC.

• SEIZURES –PROPHYLACTIC ANTICONVULSANTS CANT

PREVENT LONG TERM SEIZURES

• DELAYED CSF LEAK

• CONCUSSION

• UP TO 80% MAY HAVE SYMPTOMS AT 3 MONTHS

• 15% MAY HAVE SYMPTOMS AT 1 YEAR
• PERSISTENCE OF THESE SYMPTOMS IS TERMED
POSTCONCUSSIVE SYNDROME
• 85-90% RECOVER AFTER 1 YEAR
PHENEAS GAGE – MOST POPULAR
PATIENT IN NEUROSURGERY
 REHABILITATION ANAGEMENT FOR
TBI
• THE REHABILITATION OF TRAUMATIC BRAIN
INJURY IS A INTERDISCIPILINARY TEAM
APPROACH
• COMMUNICATION AND OPEN MINDNESS IS
IMPORTANT KEY FOR TEAM
• TEAM MEMBERS INCLUDES
• PATIENT AND FAMILY
• PHYSICIAN
• SPEECH THERAPIST
• PHYSIO AND OCCUPATIONAL THERAPIST
• REHAB NURSE
• SOCIAL WORKER etc
 DIRECT AND IDIRECT IMPAIRMENTS
TBI IS ASSOCIATED WITH A WIDE VARIETY OF
IMPAIRMENTS,BOTH DIRECT OR INDIRECT
FUNCTIONAL LIMITATIONS AND DISABILITIES THAT
MAY LEADS HANDICAP.
DIRECTS IMPAIRMENTS
COGNITIVE DEFICITS
NEUROMUSCULAR DEFICITS
VISUAL DEFICITS
SWALLOWING DIFICULTIES
BEHAVIOUR CHANGES
COMMUNICATION DEFICITS
COGNITIVE IMPAIRMENTS
• ALTERED LEVEL OF CONSCIOUSNESS
• POST TRAMATIC AMNESIA
• IMPAIRED SAFETY AWARNESS
• PROBLEM SOLVING
NEUROMUSCULAR DEFICITS
ABNORMAL TONE
SENSORY LOSS
MOTOR CONTROL DEFICITS
LOSS OF BALANCE/ATAXIA/NYSTAGMUS
PARESIS/PARALYSIS
 INDIRECT IMPAIRMENTS
• CONTRACTURES
• MOBILITY DEFICITS
• HETROTROPHIC OSSIFICATION
• DECREASED ENDURANCE
• INFECTION
• PNEUMONIA
• DEEP VEIN THROMBOSIS
• LOSS OF SPEECH DUE TO TRACHEOTOMY
 RLA SCALE
• Level I - No Response.
• Patient does not respond to external stimuli and appears
asleep.
• Level II - Generalized Response.
• Patient reacts to external stimuli in nonspecific, inconsistent,
and nonpurposeful manner with stereotypic and limited
responses.
• Level III - Localized Response.
• Patient responds specifically and inconsistently with delays to
stimuli, but may follow simple commands for motor action
• Level IV - Confused, Agitated Response.
• Patient exhibits bizarre, nonpurposeful, incoherent or
inappropriate behaviors, has no short- term recall, attention
is short and nonselective.

• Level V - Confused, Inappropriate, Nonagitated Response.

• Patient gives random, fragmented, and nonpurposeful
responses to complex or unstructured stimuli - Simple
commands are followed consistently, memory and selective
attention are impaired, and new information is not retained.
• Level VI - Confused, Appropriate Response.
• Patient gives context appropriate, goal-directed responses,
dependent upon external input for direction. There is
carry-over for relearned, but not for new tasks, and recent
memory problems persist
• Level VII - Automatic, Appropriate Response.
• Patient behaves appropriately in familiar settings, performs
daily routines automatically, and shows carry-over for
new learning at lower than normal rates. Patient initiates
social interactions, but judgment remains impaired.
•
• Level VIII - Purposeful, Appropriate Response.
• Patient oriented and responds to the environment but
abstract reasoning abilities are decreased relative to
premorbid levels
 RLA I,II AND III
• GOALS OF PHYSIOTHERAPY

• IMPROVING AROUSAL THROUGH SENSORY

INTERVENTION
• PREVENTING SECONDARY IMPAIRMENTS
• MANAGING THE EFFECTS OF TONE AND
SPASTICITY
• EARLY MOBILIZATION
• DOCUMNETATION
• PATIENT AND FAMILY EDUCATION
 IMPROVING LEVEL OF ALERTNESS

• SENSORY STIMULATION IS AN INTERVENTION

USTED TO INCREASE THE LEVEL OF AROUSAL AND
ELICIT MOVEMENT

• SENSORY STIMULATION IN BALANCED MANNER

COULD STIMULATE THE RETICULAR ACTIVATING
SYTEM CAUSING INCREASED AROUSAL

• 15-30 MIN WITH ONE OR TWO STIMULI

• AUDITORY STIMULATION
• NORMAL CONVERSATIONAL TONE USED TO
EXPLAING THE PROCEDURES AND
INSTRUCTIONS
• INTERMITTENT USE OF RADIO AND TV
• AVOID CONTINUOUS BACKGROUND NOISE
WHILE DOING THE PASSIVE MOVEMENTS EXPALIN THE
PROCEDURE AND PROVIDE ORIENTATION

EXPLAINING AND DEMOSTRATE THE TREATMENT

TECHNIQUE WILL PROVIDE
TACTILE,AUDITORY,PAINFUL ,PROPRIOCEPTIVE AND
VISULA STIMULATION
EARLY MOBILIZATION SUCH AS SITTING ON THE EDGE
OF THE CHAIR,WHEEL CHAIR TRANSFER AND TILT
TABLE STANDING INCREASE THE LEVEL OF
ALERTNESS
THERAPIST ENCOURAGE PATIENT TO ATTEMT TO
INITIATE OR VISULALY FOLLOW THE MOTION
• VISUAL STIMULATION
• FAMILIAR OBJECTS LIKE PHOTOS OF FRIENDS AND
FAMILY MEBERS
• VISUAL ATTENTION
• VISUAL TRACKING ASSESSED

• OLFACTORY STIMULATION

• PROVIDE UNDER NOSE FOR 10-15 SEC

• PATIENT FAVORITE
• FRESHLY BREWED COFFEE
• MATE FAVORITE SCENT
GUSTATORY STIMULATION

• THE APPLICATION OF A COTTON SWAB DIPPED IN A

FLAVORED SOLUTION TO THE LIPS AND GUMS
• FLAVOURED ICE CHIPS
• FOOD STUFF
• THIS TREATMENT MAY PRODUCE A COMPLICATIONS
ASPIRATION
• TACTILE STIMULATION
• USED MOST FUNTIONAL ACTIVITES
• TURNING
• BATHING
• DRESSING
• COMBING
• MOST OFTEN OUR DIFFERENTS PARTS OF THE
BODY CONTACT WITH ONE ANOTHER
• GUIDING THE PATIENT HAND TO WASHING FACE
• WEARING CLOTHES
• COMBING
• VESTIBULAR STIMULATION
• NECK RANGE OF MOTION
• ROLLING ON A MAT
• ROCKING
• PUSHING THE PATIENTS IN WHEEL CHAIR

• ITS MAINLY USED TO DEVELOPING THE PATIENT

POTENTIALS TO PERFORM A CONSISTENT,RELIABLE
RESPONSE WITH MINIMAL LATENCY
• Eg EYE BLINKING
PREVENTION OF SECONDARY IMPAIRMENTS

INABILITY TO MOVE THE AT THESE STAGES POSSIBLE TO

PRODUCE TO MANY SECONDARY COMPLICATIONS
LIKE CONTRACUTRES,PREESURE ULCERS ,HETROTROPIC
OSSIFICATION AND CHEST COMPLICATIONS.

POSTIONING
POSTURAL DRAINAGE
PASSIVE MOVEMENTS
ARE THE MAJOR INVTERVETNION TO PREVENT IT
 POSITIONING
• GOOD POSITION WILL PREVENT SKIN BREAK
DOWN,CONTRACTURES,CONTROL ABNORMAL
NECK REFLEXES AND ASSIST PULOMNARY
HIGENE
AREA POSITIONING HANDLING

HEAD NEUTRAL POSITION GENTLE ROM

ROLL BEHIND NECK ICP IS STABLE
TO SUPPORT HEAD HANDS OS BASE OF
AND NECK THE SKULL OR SIDES
CURVATURE OF THE HEAD
ROLL PARALLEL TO
SIDES
TRUNK NORMAL ALIGNMENT HAND ON SCAPULA ,
OF THE TRUNK ARM
ROLLS BEHIND SUPPORTED,RYTHAMI
SHOULDERS AND HIP CAL PROTRACTION
TO PREVENTS AND
ROTATIONS RETRACTION,ELEVATI
ON AND DEPRESSION
SEGMENTAL ROLLING-
STABLE
AREA POSITIONING HANDLING

UPPER EXTREMITY ROLLS BEHIND RELAXATION OF

SHOULDER SCAPULA,HAND
CONE IN HAND FOR PLACEMENT ON LEFT
EXTENSION SIDE DECREASE
WEDGES BETWEEN FLEXOR TONES IN
FINGERS FINGERS,WRIST AND
Pt STABLE TURN SIDES HAND
RANGE OF MOTION OF
THE FIFTH FINGER AND
THUMB ALSO REDUCE
THE TONE

LOWER EXTREMITY HIPS AND KNEES HAND ON LATERAL

SUPPORTED IN A SIDE OF THE FOOT FOR
SLIGHT FLEXION PASSIVE MOVEMENTS
NO PRESSURE ON BALL
OF FOOT MEDIALLY
ROLL BETWEEN LEGS
IF STRONG ADDUCTION
AND INTERNAL
ROTATION
POSTURAL DRAINAGE
• PERCUSSION,VIBRATION USED FOR RESPIRATORY
CARE
• PERCUSSION DEFFERED IN THE PRESENCE OF
INCREASED ICP
PASSIVE MOVEMENTS
ITS PREVENTS CONTRACTURES AND DEEP VEIN
THROMBOSIS AND MAY REDUCED SPASTICITY
FORCEFUL OR AGGRESSIVE MOTION PRODUCE
HETROTROPHIC OSSIFICATION.
IT MUST BE AVOIDED
HETROTROPHIC OSSIFICATION IS THE FORMATION OF
BONE IN MUSCLE AND OTHER SOFR TISSUES
COMMON IN SHOULDER HIP AND KNEE
 DOCUMNETATION
• PATIENT PROGRESSION AT SLOW RATE
• THE FOLLOWING WAY FIND THE PROGRESS AND
DOCUMENTED
• PATIENT WITH DRAWS TO PAINFUL STIMULI
• NO REACTION TO PAINFUL STIMULI
 PATIENT & FAMILY
EDUCATION
• THIS GOAL IS TO TEACH THE FAMILY ABOUT THE
STAGES OF RECOVERY AND EXPECTED
PROGRESS IN FUTURE
• FAMILY MEMBERS PARTICIPATION FOR
TREATMENT IS SOME EXTEND IMPROVE THE
PATIENT STATUS
 RLA IV
CONFUSED -AGITATED
• NOT POSSIBLE TO MAKE POSSIBLE MEASURMENTS
LIKE ROM,MUSCLE STRENGTH etc.
• PT COULD ABLE TO MEASURE THE COGNITIVE
ABILITIES –ORIENTATION,MEMORY,ALERTNESS
AND SAFETY
• FUNCTIONAL MOBILITY – SITTING STANDING
 RLA IV
CONFUSED –AGITATED-INTERVENTION
• JOINT MOBILITY AND INTEGRITY IS MAINTAINED
• PATIENT ENDURANCE IS IMPROVED
• RISK OF SECONDARY IMPAIRMNETS ARE REDUCED
• TOLERANCE OF ACTIVITES ARE INCREASED
• IMPLEMENTED THE FAMILY CARE
• PREVENT AGITATION OUTBURSTS
• TO HELP DECREASE THE CONFUSION
• THE PATIENT SHOULD BE SEEN BY THE SAME
PERSON ,AT THE SAME TIME AND IN THE SAME
PLACE EVERY DAY.
• ESTABLISHING A DAILY ROUTINE IS VERY
IMPORTANT
 RLA-V& VI CONFUSED&
INAPPROPRIATE,CONFUSED&APPROPRIATE
• ASSESSMENT INCLUDES
• ROM-PASSIVE AND ACTIVE
• SENSATION
• REFLEXES
• BED MOBILITY AND TRANSFER SKILLS
• IT ASESED IN OPEN AND CLOSED
• MOSTLY PATIENT WILL RESPOND FOR CLOSED
 RLA-V& VI CONFUSED&
INAPPROPRIATE,CONFUSED&APPROPRIATE - INTERVENTION

• IMPROVE THE FUNCTIONAL MOBILITY AND ADL

• MOBILITY,BALANCE AND GAIT IS IMPROVED
• STRENGTH AND ENDURANCE IS INCREASED
• SAFETY WITH FUNCTIONAL MOBILITY AND ADL
• TOLERNACE OF ACTIVITY IS INCREASED
• RISK OF SECONDARY IMPAIRMENT IS REDUCED
• IMPLEMENTED DEVEELOPMENTAL SEQUENCES
•
 RLA VII & VIII
• IT’S THE APPROPRIATE RESPONSE LEVEL
• ABILITY TO PERFORM PHYSICAL TASK RELATED
TO ADL,COMMUNITY,WORK RE INEGRATION AND
LESIURE ACTIVITES ARE INCREASED
• MOTOR CONTROL,BALANCE AND POSTURAL
CONTROL IS IMPROVED
 ACUTE CARE (HOSPITAL)
• FULL RANGE OF MOTORIC, COGNITIVE,
BEHAVIORAL, AND COMMUNICATION DEFICITS.
 SUB ACUTE SKILLED NURSING
FACILITY /SPECILAITY UNIT
• SIGNIFICANT GENERALIZED MOTORIC,
COGNITIVE AND COMMUNICATION DEFICITS.
• NON-WEIGHT BEARING LIMITATIONS.
• SIGNIFICANT SPASTICITY WITH HIGH
CONTRACTURE
• SKIN BREAKDOWN RISK.
• USUALLY RANCHO LOS AMIGOS SCALE (RLAS) OF
1-3, BUT OCCASIONAL AGITATION.
• HYPOAROUSAL COMMON.
INPATIENT REHABILITATION
• MODERATE FOCAL TO GENERALIZED MOTORIC,
COGNITIVE, BEHAVIORAL, AND
COMMUNICATION DEFICITS.
• RLAS 4-6.
• DECREASED ATTENTION AND AGITATION
COMMON.
 DAY CARE
• MODERATE FOCAL TO MILD GENERALIZED
MOTORIC (USUALLY IMBALANCE), COGNITIVE,
AND COMMUNICATION DEFICITS.
• OCCASIONAL BEHAVIORAL DYSFUNCTION.
• RLAS 5-7.
 OUTPATIENT
• MILD TO MODERATE FOCAL MOTORIC,
COGNITIVE, AND COMMUNICATION DEFICITS.
• INTERMITTENT BEHAVIORAL DYSFUNCTION MAY
BE AMENABLE.
• RLAS 5-8.
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• SIGNIFICANT GENERALIZED MOTORIC DEFICITS
OR WEIGHT-BEARING LIMITATIONS.
• MAY BE USED TO TRAIN FAMILY OR SLOWLY
IMPROVE ENDURANCE.