Brunnstrom Approach
Brunnstrom's Approach (SIGNE BRUNNSTROM)
Objectives: ➢ Discuss the concepts and principles underlying Brunnstrom’s approach ➢ Brunnstrom recovery stages ➢ Treatment principles & techniques
★ Brunnstrom’s approach was developed by the physical therapist from Sweden in the early 1950’s
★ Brunnstrom used motor control theory and observations of the patients'
★ Procedure: In a “trial & error” fashion ★ Later modified: in light of neurophysiological knowledge
Introduction: Reflex Theory Movement is controlled by stimulus-response. Reflexes are the basis for movement: reflexes are combined into actions that create behavior. Hierarchical Theory Characterized by a top-down structure, in which higher centers are always in charge of lower centers.
● When the CNS is injured, as, in a cerebrovascular accident, an individual goes through an “evolution in reverse”. Movement becomes primitive, reflexive, and automatic.
● Changes in tone and the presence of reflexes are considered a normal process of recovery.
● Movement recovery tends to be stereotypic.
● Patients exhibit only a few stereotypic movement patterns: Basic Limb Synergies.
● Based on observations of recovery following a stroke, this approach makes use of associated reactions, tonic reflexes, and the development of basic limb synergies to facilitate movements.
● The use of such a procedure is temporary.
Basic Limb Synergies:
● Normal synergistic movements are purposeful movements with maximum precision and minimum waste of energy.
● Basic limb synergy (BLS) does not permit the different combinations of muscles.
● BLS is considered primitive, automatic, and reflexive due to loss of inhibitory control from higher centers.
● Mass movement patterns in response to a stimulus or voluntary effort both Gross flexor movement (Flexor Synergy) Gross extensor movement (Extensor Synergy) Combination of the strongest component of the synergies (Mixed Synergy)
● Appear during the early spastic period of recovery
Upper Limb Flexor Synergy: Scapula: Retraction / Elevation Shoulder: Abduction and External rotation Elbow: Flexion Forearm: Supination Wrist and Finger: Flexion Lower Limb Extensor Synergy: Pelvis: posterior tilt Hip: Extension, Adduction & Internal rotation Knee: Extension Ankle: Plantarflexion Toes: Flexion Upper Limb Extensor Synergy: Scapula: Protraction / Depression Shoulder: Adduction and Internal rotation Elbow: Extension Forearm: Pronation Wrist: Extension Finger: Flexion Lower Limb Flexor Synergy: Pelvis: anterior tilt Hip: Flexion, Abduction & External rotation Knee: Flexion Ankle: Dorsiflexion Toes: Extension
Upper Limb Mixed Synergy: Scapula retraction Shoulder add.+IR Elbow flexion Forearm pronation Wrist & fingers flexion Lower Limb Mixed Synergy: Pelvis post tilt hip add.+IR Knee extension Ankle & toes plantarflexion
Rubrospinal tract Vestibulospinal tract
Associated Reactions
Primitive Reflexes
Brunnstrom Approach
Brunnstrom's Approach (SIGNE BRUNNSTROM)
Objectives: ➢ Discuss the concepts and principles underlying Brunnstrom’s approach ➢ Brunnstrom recovery stages ➢ Treatment principles & techniques
★ Brunnstrom’s approach was developed by the physical therapist from Sweden in the early 1950’s
★ Brunnstrom used motor control theory and observations of the patients'
★ Procedure: In a “trial & error” fashion ★ Later modified: in light of neurophysiological knowledge
Introduction: Reflex Theory Movement is controlled by stimulus-response. Reflexes are the basis for movement: reflexes are combined into actions that create behavior. Hierarchical Theory Characterized by a top-down structure, in which higher centers are always in charge of lower centers.
● When the CNS is injured, as, in a cerebrovascular accident, an individual goes through an “evolution in reverse”. Movement becomes primitive, reflexive, and automatic.
● Changes in tone and the presence of reflexes are considered a normal process of recovery.
● Movement recovery tends to be stereotypic.
● Patients exhibit only a few stereotypic movement patterns: Basic Limb Synergies.
● Based on observations of recovery following a stroke, this approach makes use of associated reactions, tonic reflexes, and the development of basic limb synergies to facilitate movements.
● The use of such a procedure is temporary.
Basic Limb Synergies:
● Normal synergistic movements are purposeful movements with maximum precision and minimum waste of energy.
● Basic limb synergy (BLS) does not permit the different combinations of muscles.
● BLS is considered primitive, automatic, and reflexive due to loss of inhibitory control from higher centers.
● Mass movement patterns in response to a stimulus or voluntary effort both Gross flexor movement (Flexor Synergy) Gross extensor movement (Extensor Synergy) Combination of the strongest component of the synergies (Mixed Synergy)
● Appear during the early spastic period of recovery
Upper Limb Flexor Synergy: Scapula: Retraction / Elevation Shoulder: Abduction and External rotation Elbow: Flexion Forearm: Supination Wrist and Finger: Flexion Lower Limb Extensor Synergy: Pelvis: posterior tilt Hip: Extension, Adduction & Internal rotation Knee: Extension Ankle: Plantarflexion Toes: Flexion Upper Limb Extensor Synergy: Scapula: Protraction / Depression Shoulder: Adduction and Internal rotation Elbow: Extension Forearm: Pronation Wrist: Extension Finger: Flexion Lower Limb Flexor Synergy: Pelvis: anterior tilt Hip: Flexion, Abduction & External rotation Knee: Flexion Ankle: Dorsiflexion Toes: Extension
Upper Limb Mixed Synergy: Scapula retraction Shoulder add.+IR Elbow flexion Forearm pronation Wrist & fingers flexion Lower Limb Mixed Synergy: Pelvis post tilt hip add.+IR Knee extension Ankle & toes plantarflexion
Rubrospinal tract Vestibulospinal tract
Associated Reactions
Primitive Reflexes
-Detailed Introduction, Patho-physiology, Evaluation & Physiotherapy Management of Parkinsonism.
-Clinical classification is discussed.
-Various measures of evaluation and physical therapy is discussed in this.
This PPT describes neurological gait deviations.
It describes Hemiplegic/circumductory gait, Spastic Diplegic gait, Parkinson gait, Myopathic & Ataxic gait in detail along with its causes and management in with Physiotherapy treatment. detail
Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt.
In normal individual, these occur a smooth, rhythmic movt. Because there is a presence of control from higher center on lower center.
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
Vojta technique is neuromuscular approach deals with all the conditions of CNS and Musculoskeletal system.
Contents :
Introduction
Definition
What is REFLEX LOCOMOTION
Indication
Stimulating Points
Reflex locomotion
Reflex Rolling phase 1
Reflex Rolling phase 2
Reflex creeping
Effects of Vojta technique
At the end of the lecture, the students should be able to:
Discuss the theoretical basis of the neurodevelopmental approaches
Discuss the concepts and principles underlying the Bobath approach
Discuss the concepts and principles underlying the Brunnstrom approach
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
CIMT involves constraining the unaffected limb, along with intense therapy, in order to force the use of the affected limb with intent to improve motor function.
Physiotherapy in MND
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
Types of MND
Clinical Features of MND
Diagnostic Procedure
Management: 1) Pharmaceutical
2) Physiotherapy
Motor Neuron Disease
Motor Neuron Disease are a group of neurodegenerative disorders that affects the nerves in the spine and brain to progressively lose its function.
Motor neuron diseases (MND) include a heterogeneous spectrum of inherited and sporadic (no family history) clinical disorders of the upper motor neurons (UMNs), lower motor neurons (LMNs), or a combination of both.
Types of MND
Amyotrophic Lateral Sclerosis
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease, characterized by progressive degeneration of motor neurons in the spinal cord, brain stem, and motor cortex, leading to progressive muscle atrophy and weakness.
Clinical Features
UPPER MOTOR NEURON
Loss of Dexterity
Muscle Weakness
Spasticity
Hyperreflexia
Pathological reflexes
LOWER MOTOR NEURON
Muscle Weakness
Muscle Atrophy
Hypotonicity
Hyporeflexia
Fasciculation
Muscle Cramp
Impairment related to LMN
Other clinical features
Diagnostic Criteria
Diagnostic Procedure
EMG-
It include signs of active denervation, such as fibrillation potentials and positive sharp waves;
Signs of chronic denervation, such as large motor unit potentials (increased duration, increased proportion of polyphasic potentials, increased amplitude)
Unstable motor unit potential
Nerve Conduction Velocity Studies,
Muscle And Nerve Biopsies,
Neuroimaging Studies - MRI
Management- Multidisciplinary Approach
Physical Therapy Examination
Cognition
Pain
Psychosocial Function
Joint integrity, ROM and Muscle strength.
Motor Function: Gross motor and Fine motor
Muscle tone and reflexes
Cranial nerve integrity
Sensations
Gait
Respiratory Function
Physiotherapy goals in MND treatment.
Pain reduction
Prevention for contractures
Maintenance of joint mobility
Regular review of posture
Positioning to relieve discomfort
House Modification and ergonomic advice.
Management of Sialorrhea and Pseudobulbar Affect
Management for Dysphagia
PEG procedure.
A PEG may be recommended as the disease progresses.
A PEG is a type of gastrostomy tube inserted via endoscopic surgery that creates a permanent opening into the stomach for the introduction of food.
Studies have found that PEG insertion may prolong survival. Patients with PEG were found to live 1 to 4 months longer than those individuals who refused it.
Management of Dysphagia
A palatal lift prosthesis may be prescribed for individuals with good articulation but who have a breathy voice quality or decreased loudness because of excessive air loss through the nose.
The device, a dental appliance designed to attach to the existing teeth and to elevate the soft palate, is custom-made by a prosthodontist.
-Detailed Introduction, Patho-physiology, Evaluation & Physiotherapy Management of Parkinsonism.
-Clinical classification is discussed.
-Various measures of evaluation and physical therapy is discussed in this.
This PPT describes neurological gait deviations.
It describes Hemiplegic/circumductory gait, Spastic Diplegic gait, Parkinson gait, Myopathic & Ataxic gait in detail along with its causes and management in with Physiotherapy treatment. detail
Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt.
In normal individual, these occur a smooth, rhythmic movt. Because there is a presence of control from higher center on lower center.
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
Vojta technique is neuromuscular approach deals with all the conditions of CNS and Musculoskeletal system.
Contents :
Introduction
Definition
What is REFLEX LOCOMOTION
Indication
Stimulating Points
Reflex locomotion
Reflex Rolling phase 1
Reflex Rolling phase 2
Reflex creeping
Effects of Vojta technique
At the end of the lecture, the students should be able to:
Discuss the theoretical basis of the neurodevelopmental approaches
Discuss the concepts and principles underlying the Bobath approach
Discuss the concepts and principles underlying the Brunnstrom approach
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
CIMT involves constraining the unaffected limb, along with intense therapy, in order to force the use of the affected limb with intent to improve motor function.
Physiotherapy in MND
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
Types of MND
Clinical Features of MND
Diagnostic Procedure
Management: 1) Pharmaceutical
2) Physiotherapy
Motor Neuron Disease
Motor Neuron Disease are a group of neurodegenerative disorders that affects the nerves in the spine and brain to progressively lose its function.
Motor neuron diseases (MND) include a heterogeneous spectrum of inherited and sporadic (no family history) clinical disorders of the upper motor neurons (UMNs), lower motor neurons (LMNs), or a combination of both.
Types of MND
Amyotrophic Lateral Sclerosis
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease, characterized by progressive degeneration of motor neurons in the spinal cord, brain stem, and motor cortex, leading to progressive muscle atrophy and weakness.
Clinical Features
UPPER MOTOR NEURON
Loss of Dexterity
Muscle Weakness
Spasticity
Hyperreflexia
Pathological reflexes
LOWER MOTOR NEURON
Muscle Weakness
Muscle Atrophy
Hypotonicity
Hyporeflexia
Fasciculation
Muscle Cramp
Impairment related to LMN
Other clinical features
Diagnostic Criteria
Diagnostic Procedure
EMG-
It include signs of active denervation, such as fibrillation potentials and positive sharp waves;
Signs of chronic denervation, such as large motor unit potentials (increased duration, increased proportion of polyphasic potentials, increased amplitude)
Unstable motor unit potential
Nerve Conduction Velocity Studies,
Muscle And Nerve Biopsies,
Neuroimaging Studies - MRI
Management- Multidisciplinary Approach
Physical Therapy Examination
Cognition
Pain
Psychosocial Function
Joint integrity, ROM and Muscle strength.
Motor Function: Gross motor and Fine motor
Muscle tone and reflexes
Cranial nerve integrity
Sensations
Gait
Respiratory Function
Physiotherapy goals in MND treatment.
Pain reduction
Prevention for contractures
Maintenance of joint mobility
Regular review of posture
Positioning to relieve discomfort
House Modification and ergonomic advice.
Management of Sialorrhea and Pseudobulbar Affect
Management for Dysphagia
PEG procedure.
A PEG may be recommended as the disease progresses.
A PEG is a type of gastrostomy tube inserted via endoscopic surgery that creates a permanent opening into the stomach for the introduction of food.
Studies have found that PEG insertion may prolong survival. Patients with PEG were found to live 1 to 4 months longer than those individuals who refused it.
Management of Dysphagia
A palatal lift prosthesis may be prescribed for individuals with good articulation but who have a breathy voice quality or decreased loudness because of excessive air loss through the nose.
The device, a dental appliance designed to attach to the existing teeth and to elevate the soft palate, is custom-made by a prosthodontist.
A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. If you have two or more seizures or a tendency to have recurrent seizures, you have epilepsy.
Introduction , Muscle and Postural tone,Aim,Types :General and Local Relaxation,Additional methods of relaxation :Consciousness of breathing,PRE,Contrast method, Reciprocal method,passive movement and pendular swinging.
Postural deviations of spine by Dr. NidhiNidhiVedawala
Types of Postural deviation ,Spinal deviation -Lordosis,Forward head posture,Sway back,Flat back,Kyphosis and Scoliosis....Each deformity's causes and correction...Physiotherapy Treatment.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. Traumatic head injury is a condition in which an insult to the brain
is caused to due any external force, which usually leads to alteration
in the state of consciousness in the person that impairs the cognitive
and physical function along with behavioural or emotional
disturbances.
These changes may be temporary or permanent and may cause
partial or total disability.
Introduction
4. Mechanism Of Injury
open head injury
closed head injury
coup injury
countercoup injury e.g. When a patient falls on the forehead, the
frontal part of the brain suffers damage due to direct impact of the
brain (coup injury) but along with it there could be damage to the
occipital part of the brain (countercoup injury)
5. Primary Damage
Involved by acceleration force, deceleration force, rotational force
or penetrating objects. These sources of injury can caused
laceration, contusion, shearing, tension, or compression that causes
primary damage to the brain structures. Primary damages are due
to either a blow on the head by the object or head striking against
the object.
Vascular lesion may also accompany due to either direct
laceration of the blood vessels in the brain or due to lesion of the
face, neck that can compromise the blood vessels supplying the
brain.
Pathophysiology
6. Diffuse axonal injury or shearing injuries.
If penetrating object is of very high velocity like bullets then not
only is the site of impact injured but even the surrounding areas
due to the generation of shock waves as a result of high velocity. If
the penetrating object is of low velocity like the toys then the insult
is limited to only the site of impact.
7. Secondary Damage
Increased Intracranial Tensions
Cerebral Hypoxia or Ischemia
Intracranial Hemorrhage
Electrolyte Imbalance and Acid Base Imbalance
Infection Secondary to Open Wounds
Seizures due to Scarring or Pressure
8. Three basic category of head injury based upon the severity of brain damage :
Mild Head Injury :
Minimal damage to the neuroanatomical structures with slight or no permanent
impairment.
Repeated minor injuries over a time have been responsible for gradual loss of
neurological or cognitive functions with marked cerebral atrophy.
The characteristic symptom of this type of injury consists of headache, dizziness,
increased fatigability, decreased concentration power, poor memory and in some
cases irritability.
loss of consciousness for less than 20 minutes,
Glasgow Coma Scale of more than 13, no focal neurological findings, no
abnormality on CT scan and discharge from hospital within 48 hours.
Degree Of Severity Of Head Injury
9. Moderate Head Injury
between mild and severe type of injury.
The Glasgow Coma Scale ranges from anywhere between 8 to 13 and
the post-traumatic amnesia lasting between 1 to 24 hours.
10. Severe Head Injury
severe enough to produce an obvious disabling deficit but who regain the
conscious activity status.
This condition occurs in acutely brain damaged patient after the stage of
coma during which the patient is unaware of the surrounding
environment, he can neither speak, and neither can communicate through
any other means and does not exhibit any voluntary functions.
However, certain activity like sleep- awake cycle, yawning, lip smacking,
grimacing, withdrawal from painful stimuli, visual fixation and tracking
presumably mediated through lower brain structures are usually
preserved.
11. Alteration is the State of Consciousness
Coma
Stupor
Obtundity
Delirium
Clouding of Consciousness
Changes In The Bodily Functions After Head
Injury
12. Motor abnormalities after head injury is common.
The patient may have decerebrise rigidity or decorticate rigidity.
Motor deficit could be in the form of hemiplegia, monoplegia with
either presence of spasticity or flaccidity.
Cranial nerve involvement is not unusual with certain cranial
nerves like facial, optic, oculomotor, vestibulocochlear and
abducent being commonly involved.
Patient who have sustained severe head injury may even have a
permanent physical deficit.
Sensorimotor
13. The abnormality in the memory and intellectual function of the
patient may be temporary or permanent.
Memory loss is very common after head injury.
The patient may have posttraumatic amnesia, retrograde amnesia or
anterograde amnesia.
Retrograde amnesia is inability of the patient to recollect events that
took place just before the injury.
Cognitive, Emotional and Behavioural
Changes
14. Posttraumatic amnesia is the time lapse between the injury till the
time when the patient is supposed to have recovered back his
memory function.
Anterograde amnesia is inability of the patient to form new
memory in future.
Behavioural changes may be like depression, impulsiveness or
hyperactivity
15. Glasgow Coma Scale
Rancho Los Amigos Level of Cognitive
Function
Rappaport Disability Rating Scale
Clinical Rating System
16. History collection and physical examination
Computerised tomography
Magnetic resonance imaging
Positron emission tomography
X-RAY
Diagnostic measures
17. Mechanism of injury
Loss of consciousness or amnesia
Level of consciousness at scene and on
transfer
Evidence of seizures
History of vomiting
Pre-existing medical conditions
Medications (especially anticoagulants)
Illicit drugs and alcohol
Taking a history in head injury
18. Glasgow Coma Score
Pupil size and response
Signs of skull fracture
Bilateral periorbital edema (raccoon eyes)
Battle’s sign (bruising over mastoid)
Cerebrospinal fluid rhinorrhoea or otorrhoea
Haemotympanum or bleeding from ear
Full neurological examination: tone, power, sensation, reflexes
Physical examination
19. CT scan is considered the best diagnostic test to evaluate for
cranio-cerebral trauma because it allows rapid diagnosis and
intervention in the setting
The National Institute for Health and Clinical Excellence (NICE)
has published some guidelines for when to carry out a CT scan in
a patient with head injury
Computerised tomography
20. Glasgow Coma Score (GCS) < 13 at any point
GCS 13 or 14 at 2 hours
Focal neurological deficit
Suspected open, depressed or basal skull fracture
Seizure
Vomiting > one episode
Urgent CT head scan if none of the above but:
Age > 65
Coagulopathy (e.g. on warfarin)
Dangerous mechanism of injury (CT within 8
hours)
Antegrade amnesia > 30 min (CT within 8 hours)
NICE guidelines for (CT) in head
injury
21. An MRI scan is more sensitive than CT scan in detecting small
lesions
A cervical spine X-ray indicated to detect any cervical injury
Transcranial Doppler allow the measurement of CBF
22. determined by the state of the patient.
Patient level of
consciousness,
alertness and
ability to comprehend as well as learn taught skills.
For practical purposes patient are classified into two category for
treatment purposes as
1. Patient who are totally unconscious and
2. Patient who have regained their consciousness.
PT Management
23. The treatment comprises of passive maneuvers that are necessary
to maintain certain functions in the patient to prevent secondary
problems.
1. Respiratory Care
2. Preventing Contractures and Deformity
3. Prevention and Treatment of Pressure Sores
4. Sensory Stimulation
Management of Unconscious
Patients
24. The need for chest care is directly proportional to the extent of
unconsciousness.
Generally chest physiotherapy is given every 4 to 5 hourly. This is
necessary to maintain good bronchial hygiene.
Proper positioning of the patient associated with regular
suctioning and nebulization enable the patient to have a relative
clear lung.
Head low position should never be given to the head injury patient
as it may cause a severe increase in the intracranial pressure that
may prove to be hazardous.
Respiratory Care
25. Preventing Contractures and
Deformity
Passive movements should be given to the patient for all the joints including all
the movements at that particular joint. Each movement may be repeated at least 8
to 12 times. Passive movements should be given every 3 to 4 hours .
Gentle rhythmic stretching is very essential especially for bi -articular muscles as
they become very prone to develop tightness.
Use of appropriate splints and proper positioning is also desirable to prevent the
chances of the patient developing any contracture.
The patient should be kept clean.
The cloths should be regularly changed. Moisture increases the changes of skin
infection and at the same time dry skin cause easy breakdown hence the patient's
skin should be maintained in correct manner.
26. The chances of sores can be kept to the minimum by taking certain
preventive measures.
The patient position should be changed from supine to side lying
on either sides every 2 hourly at least. This will cause
vascularization of almost all the areas of the body.
Prevention and Treatment of Pressure
Sores
The patient should be made to lie on
water bed or air bed which helps in
evenly distributing the weight
throughout the body thus relieving
some pressure from the above
mentioned areas.
27. Regular massage of pressure prone areas helps in increasing the circulation of these
areas hence preventing pressure sores.
Regular sponge bath helps in maintaining proper hygienic condition of the patients
skin which offers resistance to development of unwanted infection.
In case the patient develops pressure sore then its healing can be accelerated by
giving
ozone therapy,
UVR, IR or direct current.
Ice massage given at the edges of the sores
Sterile dressing should be applied following these physical therapy modalities.
Prevention and Treatment of Pressure
Sores
29. Management of Conscious Patient
In patients who is conscious, active participation of the patient
should be encouraged which in turn will speed up the rehabilitation
process.
1. Improve Alertness or Arousal through Sensory Stimulation
2. Prevention of Spasticity
3. Maximize the Patient’s Functional Capacity
4. Development of High Level Skilful Functioning
30. The main aim is to stimulate the reticular activating system by
making the patient sit or even stand in the tilt table.
The therapist should provide tactile, visual, auditory and
proprioceptive stimulation to the patient that will send facilitator
signals to the brain and will enable the alert response to be
provoked.
Auditory stimulation can be given by speaking to the patient
during the course of treatment.
Improve Alertness or Arousal through
Sensory Stimulation
31. Visual stimulation is given by showing familiar faces, objects or
movement in the visual field of the patient.
Tactile stimulation is provided by the therapist’s touch for
carrying out various functional tasks. The touch of the patient also
stimulates the receptors in the muscles and can be used for
facilitating or inhibiting contraction of muscles.
Improve Alertness or Arousal through
Sensory Stimulation
Proprioceptive stimulation by giving
traction and approximation at joint
structures is very helpful in stimulating
the arousal response in the patient.
32. Prevention of Spasticity
Gentle passive movement,
gradual rhythmic sustained stretch,
prolonged icing for 20 minutes over the muscles,
biofeedback,
proper positioning
33. Maximize the Patient’s Functional
Capacity
The main aim of this management is to
improve the ROM,
improve the control of voluntary movement,
strengthening paretic muscles,
improve the coordination,
balance and teach various safety measures which will enable the
patient to return back to the community.
Neuromuscular training
34. Maximize the Patient’s Functional
Capacity
activities like
bridging,
prone on elbow,
side lying to sitting,
sitting,
kneeling,
half kneeling,
standing and
walking.
Proper documentation
35. Maximize the Patient’s Functional
Capacity
Use of vestibular ball while training the patient for crawling, bridging,
sitting balance helps in building the proprioceptive stimulation and
teaches proper control to the patient.
Each task has various sub tasks which needs to be mastered by the
patient so that he learns the actual activity using normal movement
combination and performs it with precision.
Repetition of activities
Ambulation training should always be done in upright position by
training the patient in each and every phase of the gait cycle. If the
patient’s balance is poor then assistance may be used.
36. Maximize the Patient’s Functional
Capacity
Functional electrical stimulation
Reversing tasks : For instance lowering a glass of water on the table
may help the patient in getting the glass close to the mouth by
improving motor control of biceps during eccentric contraction.
37. Development of High Level Skilful
Functioning
These achievements may not be applicable to all head injury .Patient belonging
to the last two grades of cognitive grading may be considered as appropriate
client for this training.
The safety awareness of the patient need to be improved because he is already
in ambulatory stage.
Balance and postural control training is very essential. Some patients may have
good balance and postural control during normal walking but will have
problems while trying to perform speedy actions. Dancing, basket ball, karate,
tennis and certain other sports often promote additional progress in balance,
sequencing, and speed of movement.
38. Development of High Level Skilful
Functioning
The therapist should encourage those components of the activities that best
address the deficits in the patient and plan out enjoyable activities that provide
specific training for the deficits in balance, gait, upper extremity functions.
Editor's Notes
The more number of days patient remains uncons- cious more intense and regular is the need for chest physiotherapy.
As the tone of the muscles increases the need for passive movement and stretching is even more to maintain range of motion at all joints.
Due to prolonged immobilization certain part of the body especially the ones with bony prominence are very prone to get subject to pressure sore due to lack of proper circulation to that area. Thus the lateral malleolus, lateral aspect of the knee, ischial tuberosity, sacrum, occiput are very likely to develop sore.
Although the patient is unconscious effort should be made to stimulate the reticular activating system by using various sensory stimulation
The patient who is drowsy or confused need to be stimulated by make them more alert and awake. The therapist should encourage the patient’s cooperation during the treatment.
by inhibiting abnormal movement pattern and by facilitating normal movement pattern.
Like for training the patient to get up from bed, he may be taught to do asymmetrical push up with the trunk in partial rotation, then lower leg patterns are incorporated and finally the whole task of get up from side lying is practiced.