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Head injury
- 2. PRESENTED BY NIRUPOM BARDHAN BScin Physiotherapy 18th Batch BHPI, CRP, SAVAR.
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- 4. CONTENTS… Definition Etiology Mechanism of injury Types Pathophysiology Clinical feature Progression Complication Diagnosis Treatment Physiotherapy intervention for head injury Prognosis Conclusion
- 5. DEFINITION Head injurymeans damage to any of the structures of the head as a result of trauma. As defined by National Head Injury Foundation of America, Head Injury is “a traumatic insult to brain capable of producing physical, intellectual, emotional, social and vocational changes. The term “Head Injury” is most often used to refer to an injury to the brain, that may also involve the bones, muscles, blood vessels, skin or other organs of the face or head.
- 6. ETIOLOGY Falls RoadTraffic Accident Violent physical assault Stabbing Sports Shallow water diving Missile injuries Shaken baby syndrome.
- 7. MECHANISM OF INJURY Closed head injuries are due to: 1. Acceleration – deceleration 2. Coup - contra coup Open Head injuries due to: 1. Penetrations 2. Fractures
- 8. MECHANISM OF INJURY… Acceleration: Direct blow to the head Skull moves away from force Brain rapidly accelerates from stationary to in- motion state causing cellular damage
- 9. MECHANISM OF INJURY… Deceleration: Head impacts to a stationary object Moving skull stops motion almost immediately However, brain, floating in cerebral spinal fluid (CSF), briefly continues moving in skull towards direction of impact, resulting in significant forces that damage cells
- 10. MECHANISM OF INJURY… Injuryresulting from rapid, violent movement of brain is called coup and contra coup. Coup: an injury occurring directly beneath the skull at the area of impact. Contra coup: injury occurs on the opposite side of the area that was impacted.
- 11. TYPES A. Depending onthe severity of the injury: 1. Mild Head Injury 2. Moderate Head injury 3. Severe Head injury. We use Glasgow Coma Scale to interpret the severity of the head injury. Glasgow Coma Scale (GCS) is a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment.
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- 13. Glasgow coma scale… ModifiedGCS for vocal responses from children under 5 years: 2-5 years Points <2 years Words of any sort 5 Coos, smiles, cries Monosyllables 4 Cries only Cries or screams 3 Unstimulated screaming Grunts 2 Grunts None 1 None
- 14. TYPES….. B. Depending onthe structures involoved in the injury, there are 5 types. They are: 1. Brain contusion 2. Brain concussion 3. Skull fractures 4. Diffuse axonal injury 5. Intracranial hematoma.
- 15. TYPES… Brain Contusion: Contusion– bruising of brain tissue on the impacted site. Has area of necrosis infarction and hemorrhage Often from coup – contra coup injury.
- 16. TYPES…. Brain concussion: Themost common and least serious type of traumatic brain injury is called a concussion. The word comes from the Latin concutere, which means "to shake violently.“ Here, the brain is pushed towards and against the skull.
- 17. TYPES…. Skull fractures: Linearundisplaced Depressed Compound Basal skull fracture
- 18. TYPES… Basal skull fractureis further divided into: Anterior basal skull fracture Transverse Basal skull fracture Longitudinal basal skull fracture.
- 19. TYPES… Diffuse axonal injury: Diffuse axonal injury occurs when shearing, stretching and/or angular forces pull on axons and small vessels. Impaired axonal transport leads to focal axonal swelling and after several hours may result in axonal disconnection.
- 20. TYPES… Intracranial hematoma: Intracranial hematomahas some sub-types such as: Epidural hematoma Intracerebral hematoma Subdural hematoma Traumatic Subarachnoid hemorrhage
- 21. TYPES… Epidural Hematoma: Comesfrom bleeding between dura and inner surface of the skull. Will be unconscious, then awake, and then deteriorate ( lucid interval )
- 22. TYPES… Intracerebral Hemorrhage: Intracerebral hemorrhage(ICH), also known as cerebral bleed, is a type of intracranial bleed that occurs within the brain tissue or ventricles.
- 23. TYPES… Subdural hematoma: Hematomabetween the dura mater and the pia arachnoid mater. Occurring in approximately 30% of severe head injuries
- 24. TYPES… Traumatic Subarachnoid Hemorrhage: Bloodcollects beneath the arachnoid. Tear of veins in subarachnoid space. Usually associated with types of brain injury –commonly with contusion.
- 25. PATHOPHYSIOLOGY Decrease in venousreturn resulting in reduced ventricular filling Increased sympathetic tone and hypercontractility of ventricles with under filled chamber Ventricular mechanoreceptor activation and feedback to Medulla(CNS) via afferent vagus nerve Sympathetic withdrawal, parasympathetic overdrive leading to bradycardia and hypotension SYNCOPE
- 26. CLINICAL FEATURES Clinical manifestationscome according to the area of damage of the brain. Such as. Damaged Frontal lobe: Problem in intellectual activities. Loss of ability to organize. Problem in personality, behavior and emotional control. Damaged Temporal lobe: Problem in memory, speech and comprehension.
- 27. CLINICAL FEATURES… Damaged Parietallobe: Inability to read and write Difficulty to understand spatial relationship. Damaged Occipital lobe: Problem in vision. Damaged Cerebellum: Posture and trunk instability Loss of body equilibrium and co-ordination of movements. Change in rapid limb movements.
- 28. CLINICAL FEATURES… Some featurescommonly found in head injuries: Anxiety, nervousness. Aphasia Dysphasia Dizziness Headache Seizures Vertigo Sleep difficulties
- 29. PROGRESSION Symptoms typically progressthrough three successive stages- 1. Coma : Severe head injury results in coma, a loss of consciousness. 2. Post – traumatic amnesia : It is a stage of acute confusion and the hallmark of this stage is cognitive impairment. 3. Recovery : recovery is characterized by progressive improvement in cognitive and behavioral functions.
- 30. COMPLICATIONS Deep venousthrombosis Heterotopic ossification Pressure ulcer Pneumonia Hydrocephalus Chronic pain Contractures Muscle atrophy Fracture Peripheral Nerve Damage
- 31. DIAGNOSIS A complete neurologicalevaluation is performed to rule out conditions requiring neurosurgical attention, such as hematomas, depressed skull fractures, and elevated intracranial pressure. Some diagnostic tools are used as: Angiogram: A test to examine blood vessels in the brain. ICP monitor: A device used to monitor intracranial pressure. EEG: A test to measure electrical activity in the brain. X-rays, MRIs, and CT Scans: to detect fractures, hemorrhages, swelling and certain kinds of tissue injury.
- 32. TREATMENT There are threestages of treatment for head injury. Acute – to stabilize the patient immediately after the injury. Sub-acute – to rehabilitate and return the patient to community Chronic – to continue rehabilitation and treat the long – term impairments.
- 33. TREATMENT… ACUTE TREATMENT: Unblockingthe airway Assisting breathing Keeping the blood circulating Cardiopulmonary resuscitation may be necessary. Surgery is indicated if any blood clot causes increased intracranial pressure in case of subdural hematomas and intracerebral hemorrhages.
- 34. TREATMENT… Sub-acute treatment: Sub –acute treatment is provided after stabilization. Which ranges from medical stability to patient’s return to the community or admission to a chronic facility. The main goals of sub-acute treatment are: Early detection of complications, such as: 1. Cranial nerve damage 2. Epilepsy 3. Spasticity 4. Heterotopic ossification 5. Diabetes insipidus. Facilitation of neurological and functional recovery Prevention of additional injury.
- 35. TREATMENT… Chronic Treatment: Disabilities fromhead injury may last a lifetime, and different interventions may be appropriate even many years later. There are two categories of chronic treatment . Community-based rehabilitation and return to work or school, and Treatment of long term consequences of the injury.
- 36. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY Plan of care: The purpose of the plan of care is to maintain an optimal physical condition, thus providing a basis from which learning and relearning may be enhanced. The components of a plan of care are: Respiratory care. Control of posture – in lying, sitting and standing. Maintenance of range of motion in joints. Encouragement of remaining ability.
- 37. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Respiratory care: The patient will have limited lung excursion due to loss of function of respiratory muscle and poor postural control, and this will predispose to chest infection. To prevent respiratory complications, a physiotherapist can prescribe: Breathing exercises : Deep breathing exercise, Breathing control exercise, Active cycle of breathing technique. Postural drainage. Encouraging active coughing.
- 38. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Control of posture: Posture while lying Patients with asymmetrical, decerebrate posture and inability to accept the support of the surface of the bed are vulnerable to joint contractures, pressure sores and respiratory complications. The presenting posture may be modified by providing additional support such as pillows, wedges and foam rolls and thus stability to the body segments.
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- 41. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Posture while sitting There are three typical postural patterns in sitting: 1. C – shaped posture: This is a slumped kyphotic pattern.
- 42. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… 2. Arched posture: The body is arched backwards from the coccyx, with an exaggerated lumbar lordosis. Legs tend to flex, and arms to extend. Inevitably the buttocks will tend to lift and slide forwards,
- 43. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… 3. Asymmetrical posture: In this posture the legs may be windswept, the pelvis tilted and rotate, and the trunk and the side of the head flexed and rotated.
- 44. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… The patient may display a combination of these postures and most will adopt a preferred position in sitting. If a patient is unable to provide own postural support, it must be provided externally to provide stable, balanced, symmetrical and functional position, whilst relieving pressure and shearing forces.
- 45. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Posture while standing: Standing is achieved by the mechanical support of a tilt-able or standing frame, when the joint range of the lower extremities allow this to be a safe and achievable procedure.
- 46. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Maintenance of Joint ROM: Reduced ROM can lead to contractures and contribute to asymmetrical posture and an unstable position. To maintain ROM a physiotherapist can do to a patient: Passive movement Active facilitated and active movements. If contracture is developed then splinting and serial casting can help to stretch the contracted tissues.
- 47. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Encourage remaining ability: Stimulating interest in task, providing an element of competition and frequent repetition, may enhance performance of even the most simple task. Leisure activities are encouraged like swimming, archery and table tennis. These activities will depend on the patients ability to enjoy and/or take part in them.
- 48. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Other Physical therapeutic interventions required for head injury: Inhibit abnormal patterns of reflex activity by : 1. Positioning 2. Reflex inhibiting Establish communication Increase sensory stimulus by: 1. Encouraging awareness of surroundings 2. Afferent cutaneous reactions 3. Encouraging motivation
- 49. PHYSIOTHERAPY INTERVENTION FOR HEADINJURY… Develop normal tone Develop normal reactions Facilitate voluntary movements Reeducate functional activities by: 1. Choice and adaptation of activities which do not conflict with other principles of movements. 2. Choice and use of aids.
- 50. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT Trunk control exercise with the help of Theraband.
- 51. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT High Kneeling exercise.
- 52. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT Knee walking exercise
- 53. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT One limb high kneeling exercise
- 54. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT Balance exercise in high kneeling
- 55. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT Walking in a frame
- 56. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT Balance exercise on balance board
- 57. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT Balance exercise on balance board
- 58. HEAD INJURY PATIENTSIN NUROLOGY UNIT of PT DEPARTMENT Standing in a frame
- 59. PROGNOSIS Prognosis depends onseveral indicators to predict the level of patient’s recovery during first few weeks and months after injury. Duration of coma Severity of coma in the first few hours after the injury. Duration of post-traumatic amnesia Location and size of contusions and hemorrhages in the brain Severity of injuries to other body systems sustained at the time of the injury. Age of the patient.
- 60. CONCLUSION The overall objectiveof a management programme for the brain-injured patient with severe long-term physical disability is to ensure that the patient enjoys the best possible quality of life, in terms of general wellbeing and control of adverse secondary complications, whilst exploring to the full of any independence available.
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