AIOT

Amity Institute of Occupational Therapy

Programme: M.O.T
Semester number: II
Course: Neurological Conditions-II
Faculty name: Baijnath Roy

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 Head Injury AIOT

An insult to the skull and brain due

to external physical force is known
as Head Injury
 AIOT

The incidence of head injury is higher in male

than in female.

Male Female Ratio 2:1.

50% head injury b/w 15yrs-25 yrs.

Head injury also causes childhood disability.

 Causes AIOT

 Accidents
 Fall from a height
 Trauma
 Gun Shot injuries
 Sports injuries
 Occupational injuries
 Indirect Violence
 Epilepsy
 Electric Burns
 Alcoholism
 Mechanisms of Head Injuries AIOT

• Acceleration – movement of the brain inside

the skull when the stationary head is struck.
Ex-Fall of heavy weight on the head

• Deceleration- sudden rapid slowing of the

brain when head strikes a solid surface.
Ex-Banging of head on a wall.
 Forces that injure the brain AIOT

• Compression - pushing of the brain

tissues together.
• Tension - tearing of the tissue apart.
• Shearing - sliding of portions of the
tissues over the other portions.
• All these injuries can be encountered as
coup injuries and counter coup injuries.
 AIOT

Coup Injuries- damage occurs to the skull

where blow was sustained.

Counter coup injuries- damage occurs to the

skull where opposite to blow was applied
 Classification of head injury AIOT

Head injury
Injury to skull Injury to brain

Closed open A/c to pathology A/c to onset A/c to damage

mild Depressed fracture Concussion Primary Focal damage

moderate Compound Fracture contusion Secondary Diffuse damage

Serve laceration
 Classification of head injury AIOT

• Injury to the skull

• Injury to the brain

 Injury to the skull AIOT

• Closed Injuries
 Mild - loss of consciousness for short period, no oedema
and concussion
 Moderate - longer period of unconsciousness, cerebral
oedema and concussion.
 Severe – prolonged period of unconsciousness,
contusion and laceration.

• Open Injuries
 Depressed fracture
 Compound fracture
 Injuries to the brain AIOT

• A/c to pathology
 Concussion – no macroscopic pathological
changes.
 Contusion – stretch on the brain substance.
 Laceration – tearing of the brain substance

• A/c to onset
 Primary brain damage - takes place at the time
of injury
 Secondary brain damage - takes place because
of some complications in later stage.
 AIOT

Focal Brain Damage - Visualized by naked

eye
Ex- Cortical contusion, Epidural haematoma,
Subdural haematoma

Diffused Brain Damage – Scattered and

associated with more wide spread global
disruption of neurological function
 AIOT

Signs & Symptoms of Head Injury

In Cerebral Concussion
 Motor and sensory paralysis
 Unconsciousness for short duration
 No retrograde amnesia

In Cerebral Contusion and Laceration

 Headache,Nausea,Vomiting
 Confussion,Defective memory
 Cerebral Irritation
 Also damage to the brain tissue may lead to Sclerosis & epilepsy
Signs and Symptoms A/c Lobes AIOT

Frontal Lobes
 Anosmia
 Optic atrophy
 Confusion
 Disorientation
 Mental disturbances
 Recent memory disturbances
 Broca’s aphasia
 Intellectual and cognitive impairment
 AIOT

Parietal lobe
Sensory disturbances in speech
Dyslexia
Disgraphia
Finger Agnosia
Dyscalculia
Hemiparesis
Hemiplegia
Homonymous hemianopia
 AIOT
Temporal lobe
Wernicke’s Aphasia
Impairment of taste & smell
Visual field defects
Cochlear Deafness
Bleeding from ear
Hemiplegia on opposite side
Homonymous hemianopia
Recent memory disturbances
 AIOT

Occipital lobes

Visual Fields defects

Crossed Homonymous hemianopia

Visual object agnosia

Agnosia of colours

Blindness
 Signs & Symptoms A/c various AIOT

levels
Cortical level

 Monoplegia

 Hemiplegia

 Decorticate posture-flexion pattern of UEs &

extension of LEs.
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Brainstem level

Decerebrate rigidity –hyperextension of trunk &

upper & lower limbs

Increase salivation, respiration & temperature

Phonation

Horizontal eye movements Impairment

Impairment of movements of all 4 limbs & face

 Investigative Procedure AIOT

• X-ray Skull
• X-ray cervical spine
• X-ray chest
• CT Scan
• MRI Brain
• Echo encephalogram indicated in cerebral
hemorrhage and cerebral compression
• ICP monitoring
 Investigative Procedure AIOT

• X-ray Skull
• X-ray cervical spine
• X-ray chest
• CT Scan
• MRI Brain
• Echo encephalogram indicated in cerebral
hemorrhage and cerebral compression
• ICP monitoring
 ICP Monitoring AIOT

• There are three ways to monitor ICP.

1.INTRAVENTRICULAR CATHETER
2.SUBDURAL SCREW (BOLT)
3.EPIDURAL SENSOR
 INTRAVENTRICULAR CATHETER AIOT

The intraventricular catheter is the most accurate monitoring

method.
• To insert an intraventricular catheter, a hole is drilled through
the skull. The catheter is inserted through the brain into the
lateral ventricle. This area of the brain contains cerebrospinal
fluid (CSF). CSF is a liquid that protects the brain and spinal
cord.
• The intraventricular catheter can also be used to drain fluid out
through the catheter.
• The catheter may be hard to get into place when the intracranial
pressure is high.
 SUBDURAL SCREW (BOLT) AIOT

• This method is used if monitoring needs to be

done right away. A hollow screw is inserted
through a hole drilled in the skull. It is placed
through the membrane that protects the brain
and spinal cord (dura mater). This allows the
sensor to record from inside the subdural
space.
 EPIDURAL SENSOR AIOT

• An epidural sensor is inserted between the

skull and dural tissue. The epidural sensor
is placed through a hole drilled in the skull.
This procedure is less invasive than other
methods, but it cannot remove excess
CSF.
 Assessment Scales AIOT

Glasgow Coma Scale

Eye Opening Motor Resp. Verbal Resp.

• Sponts – 4 Obeys Command- 6 Oriented- 5

• Speech – 3 Localize - 5 Confuse conv – 4
• Pain - 2 Withdraws - 4 Inapr. Word – 3
• Nil - 1 Abn. Flexion - 3 Incom. Sound- 2
• -------- Extensor Resp.- 2 Nil - 1
• -------- Nil – 1 ------------
Coma score range from 3 to 15
General Comma assessment
scale AIOT

 Coma – no response to painful

stimulus
Semi coma – withdrawal of body part
to painful stimulus.
Stupor – Spontaneous mvts and
groaning to stimulus.
Obtundity – arouses by stimulus and
responds to a question.
Full consciousness – full recovery of
orientation and memory.
Rancho Los Amigo scale AIOT

I. No Response – unresponsive to any stimuli

II. General Response – non purposeful response to stimulus
III. Localized Response – specific but inconsistent response,
may follow simple command.
IV. Confused agitated - incoherent verbalization, easily agitated
and dependent in ADL.
V. Confused inappropriate - responds to simple commands
and becomes agitated with unfamiliar situation, assisted ADL
VI. Confused appropriate - independent in ADL, follow simple
directions, better remote memory.
VII. Automatic appropriate – oriented with familiar
environment, independent in ADL, impaired judgment.
VIII. Purposeful appropriate – able to recall recent and past
events, Tolerate stress, judgment intact
 AIOT

Rappaport’s Disability Rating Scale

Category Item
• Arousability, • Eye opening,
awareness and Verbalization, Motor
responsivity. response.
• Cognitive ability for • Feeding, Grooming.
self care. • Level of functioning.
• Dependence on • Employability.
others.
• Psychosocial
adaptability.
 Disability rating scale AIOT

Level of functioning Employability

• Complete independent-0 • Not restricted – 0
• Independent in spl • Selected jobs- 1
environment – 1
• Sheltered workshop-2
• Mildly dependent – 2
• Moderate dependent-3 • Not employable- 3
• Severe dependent- 4
• Total dependent - 5
 AIOT
Self Care
• Complex – 0

•Partial – 1

•Minimal – 2

•None - 3
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GLASGOW OUTCOME SCALE

VEGETATIVE STATE
A persistent state characterized by reduced responsiveness associated with
wakefulness. The patient may exhibit eye opening, sucking, yawning, and localized
motor responses.
SEVERE DISABILITY
An outcome characterized by consciousness, but the patient has 24-hour
dependence because of cognitive, behavioral, or physical disabilities, including
dysarthria and dysphasia.
MODERATE DISABILITY
An outcome characterized by independence in activities of daily living and in home
and community activities but with disability. Patients in this category may have
memory or personality changes, hemiparesis, dysphagia, ataxia, acquired
epilepsy, or major cranial nerve deficits.
GOOD RECOVERY
Patient able to reintegrate into normal social life and able to return to work. There
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may be mild persisting sequelae.
 AIOT

MEASUREME MILD MODERATE SEVERE

NT
Glasgow Coma 13-15 9-12 3-8
Scale
Loss of <30 min 30 min-24 hr >24 hr
consciousness
Posttraumatic 0-1 day >1 to ≤ 7 days >7 days
amnesia

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 Prognostic Indicators
AIOT

1. Time Since Lesion

2. Lesion Size and Area
3. Age
4. Posttraumatic Amnesia
5. Sitting and Standing Balance: Measures of severity of TBI, including
admission Glasgow Coma GCS score, length of PTA, length of coma, and
acute care length of stay, were also each significantly related to impaired
sitting and standing balance.
6. Other Factors

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Common Problems in Head injury AIOT

Direct Impairments Indirect Impairments

 Cognitive  Contractures
 Perceptual  Mobility deficits
 Motor  Decubitus ulcer
 Sensory  Heterotrophic ossification
 Swallowing  Decreased endurance
 Behavioral  Infection
 Communication  Pneumonia
 Tracheotomy
 DVT
 Management of Head Injury AIOT

Medical management
 Protection of airways
 Posture
 Bladder and Bowel care
 Nutrition
 Hyperbaric oxygen chamber
 Maintenance of systemic blood pressure
 Drugs
 Drugs AIOT

 Osmotic agent – 20% solution of Mannitol IV

 Diuretics – Frusemide 40-80 mg IM
 Steroids – Dexamethsone/Betamethsone
60mg/ day
 Antibiotic – to combat infection
 Sedative – Paraldehyde 8- 10 mg IM for
restless pts.
 Aspirin – for headache
 Barbiturates – Phenytoin 15 mg/kg Iv
 Surgical Management AIOT

• Surgery is generally not necessary treatment of

HI .However in case of haematoma an
emergency surgery is the only means of saving
life.
• Pt. with open injury who has sustained
depressed fracture of skull will require surgery to
remove dead tissue & foreign bodies.
• Craniotomy & exploratory Burr Hole is generally
performed.
 Rehabilitative Management AIOT

Sensory stimulation
1. Tactile stimulation
2. Auditory stimulation
3. Olfactory stimulation
4. Gustatory stimulation
5. Visual stimulation
6. Vestibular stimulation
 Maintenance of muscle tone AIOT

1. SI Approach
2. NDT Approach
3. PNF Approach
 Positioning

 Maintenance of range of motion

 Splinting

 Tilt table

 Resistive exercises
Mat exercises AIOT

Coordination training exercise

Cognitive & Perceptual training
Exercise of larynx ,pharynx & Facial muscles
Language & Communication training
Balanced training
Gait training
Adaptive & Assistive devices
ADL training
Prevocational & Vocational counseling
 Assessment & Evaluation AIOT
• Higher function

Vision

Speech

Memory

Cognition & Intelligence

•Cranial Nerve examination

Motor examination cont. AIOT

 Associated mvts.
Associated reaction
Bladder/ Bowel
Skull & Spine
Balance
Gait
Hand function
ADL
• Sensory examination AIOT

 Light touch
Pain
Pressure
Temp.
2PD
Stereognosis
 Kinesthesia
Propriception
AIOT