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Introduction
1. Cardiovascular system
2. Pulmonary system
3. Neuromuscular system
3.1 Central nervous system
3.2 Anatomy and function of spinal cord
3.3 Peripheral nervous system
3.4 Stroke deficits and recovery
3.5 Traumatic brain injury
3.6 Spinal cord injury
3.7 Neurodegenerative disorders and epilepsy
3.8 Peripheral nervous system conditions
3.9 Other neurological conditions
3.10 Interventions for neurological conditions
3.11 Vestibular system
4. Pediatrics
5. Musculoskeletal system
6. Other systems
7. Non-systems
Wrapping up
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3.5 Traumatic brain injury
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3. Neuromuscular system
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Traumatic brain injury

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Definitions
Traumatic brain injury (TBI)
An injury to the brain caused by a force to the skull that produces rotational acceleration, with severity that varies by case.

Types of injury:

  • Open head injury: skull fracture that results in brain exposure
    • Increased risk of infection
  • Closed head injury: no skull fracture or exposed brain
    • Increased risk for intracranial pressure

Pathophysiology:

  • Local brain injury
    • Damage to a specific region of the brain due to bruising, bleeding, laceration, or swelling
  • Coup-countercoup injury
    • Injury in which the brain is damaged due to the point of impact and the opposite side due to rebound forces
  • Diffuse axonal injury
    • Tearing of axons and small vessels due to the acceleration of the brain in the skull, leading to neuronal death
  • Edema
    • Swelling of brain tissue after injury (vasogenic or cytotoxic edema), which raises intracranial pressure
  • Hypoxic-ischemic injury
    • Loss of cerebral circulation, typically due to compromise of the cardiovascular and respiratory systems

Stratification of brain injury:

Brain injuries can be stratified into three categories: mild, moderate, and severe based on symptomatology present. Stratification can be done with the use of the Glasgow Coma Scale (GCS):

  • Mild TBI (i.e., concussion)
    • GCS score: 13-15
    • Loss of consciousness: 0-30 minutes
    • Alteration of consciousness: brief; up to 24 hours
    • Post-traumatic amnesia: <1 day
    • Imaging: normal
    • Recovery: full recovery of physical and cognitive function, with the patient seen in an outpatient setting
  • Moderate TBI
    • GCS score: 9-12
    • Loss of consciousness: >30 minutes; <24 hours
    • Alteration of consciousness: >24 hours
    • Post-traumatic amnesia: 1-7 days
    • Imaging: normal or abnormal
    • Recovery: potential to have full recovery of physical and cognitive function with intense rehabilitation in an inpatient rehabilitation or skilled nursing facility
  • Severe TBI
    • GCS score: 8 or less
    • Loss of consciousness: >24 hours
    • Alteration of consciousness: >24 hours
    • Post-traumatic amnesia: >7 days
    • Imaging: normal or abnormal
    • Recovery: permanent physical and cognitive impairment; typically in a nursing home setting or home setting with total care
Definitions
Alteration of consciousness
Change in baseline perception, awareness, and mental functioning.
Post-traumatic amnesia
Inability to recall events occurring after injury.
Retrograde amnesia
Inability to recall events preceding the injury.
Imaging
Magnetic resonance imaging (MRI) is utilized to assess the level of injury.

Behavioral stratification of traumatic brain injury:

Rancho Los Amigos Cognitive Scale is utilized to classify behaviors through a predictable sequence. Individuals progress through levels in sequence but can plateau at any point. Level of behavior:

  • Level I: No response
    • Cognitive assistance needed: total assistance with all cognitive functions
    • Response to stimuli: no response to sounds, sights, touch, or pain
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: individuals are typically in a comatose state
  • Level II: Generalized response
    • Cognitive assistance needed: total assistance with all cognitive functions
    • Response to stimuli: inconsistent, non-purposeful, generalized response to stimuli
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: individuals in a vegetative state
  • Level III: Localized response
    • Cognitive assistance needed: total assistance with all cognitive functions
    • Response to stimuli: localized response to stimuli
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: individuals within a minimally conscious state; able to inconsistently track objects and respond to their name
  • Level IV: Confused, agitated
    • Cognitive assistance needed: maximal assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: confused, combative, easily agitated, hypersexual behavior
  • Level V: Confused, inappropriate
    • Cognitive assistance needed: maximal assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow simple commands consistently; difficulty with complex commands
    • Characteristics of level: confused, inappropriate behaviors (combative and hypersexual behaviors have subsided), severely impaired memory
  • Level VI: Confused, appropriate
    • Cognitive assistance needed: moderate assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow single-step commands
    • Characteristics of level: confused but behaviors are appropriate (goal-directed); no combative characteristics
  • Level VII: Automatic, appropriate
    • Cognitive assistance needed: minimal assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow single-step commands
    • Characteristics of level: improved carryover with activity, minimal assistance for learning new tasks, increased awareness of deficits
  • Level VIII: Purposeful and appropriate
    • Cognitive assistance needed: stand-by assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow single-step commands
    • Characteristics of level: able to integrate new and old memory into making decisions, able to make adjustments to behavior in social interaction with minimal assistance

Traumatic Brain Injury (TBI) Overview

  • Brain injury from force to skull causing rotational acceleration
  • Severity varies case by case

Types of Injury

  • Open head injury: skull fracture with brain exposure
    • Increased infection risk
  • Closed head injury: no fracture/exposed brain
    • Increased risk for intracranial pressure

Pathophysiology

  • Local brain injury: bruising, bleeding, laceration, or swelling in specific region
  • Coup-countercoup injury: damage at impact site and opposite side (rebound)
  • Diffuse axonal injury: axon/vessel tearing from brain acceleration, causes neuronal death
  • Edema: brain swelling (vasogenic or cytotoxic), raises intracranial pressure
  • Hypoxic-ischemic injury: loss of cerebral circulation from cardiovascular/respiratory compromise

Stratification of Brain Injury (Glasgow Coma Scale)

  • Mild TBI (concussion): GCS 13-15, LOC 0-30 min, amnesia <1 day, normal imaging, full recovery (outpatient)
  • Moderate TBI: GCS 9-12, LOC 30 min-24 hrs, amnesia 1-7 days, normal/abnormal imaging, possible full recovery with intense rehab (inpatient/SNF)
  • Severe TBI: GCS ≤8, LOC >24 hrs, amnesia >7 days, normal/abnormal imaging, permanent impairment (nursing home/home with total care)

Key Definitions

  • Alteration of consciousness: change in baseline awareness/mental functioning
  • Post-traumatic amnesia: can’t recall events after injury
  • Retrograde amnesia: can’t recall events before injury
  • Imaging: MRI used to assess injury level

Behavioral Stratification (Rancho Los Amigos Cognitive Scale)

  • Predictable sequence of levels; individuals may plateau at any point
  • Level I-III: Total cognitive assistance needed; progression from no response → generalized → localized response; comatose to minimally conscious states
  • Level IV-V: Maximal assistance; confused/agitated → confused/inappropriate; combative/hypersexual behaviors present in IV, subsiding by V
  • Level VI-VII: Moderate to minimal assistance; confused but appropriate → automatic appropriate; goal-directed behavior, increasing awareness of deficits
  • Level VIII: Stand-by assistance; purposeful and appropriate; integrates memory for decision-making, adjusts behavior socially with minimal help

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Traumatic brain injury

Definitions
Traumatic brain injury (TBI)
An injury to the brain caused by a force to the skull that produces rotational acceleration, with severity that varies by case.

Types of injury:

  • Open head injury: skull fracture that results in brain exposure
    • Increased risk of infection
  • Closed head injury: no skull fracture or exposed brain
    • Increased risk for intracranial pressure

Pathophysiology:

  • Local brain injury
    • Damage to a specific region of the brain due to bruising, bleeding, laceration, or swelling
  • Coup-countercoup injury
    • Injury in which the brain is damaged due to the point of impact and the opposite side due to rebound forces
  • Diffuse axonal injury
    • Tearing of axons and small vessels due to the acceleration of the brain in the skull, leading to neuronal death
  • Edema
    • Swelling of brain tissue after injury (vasogenic or cytotoxic edema), which raises intracranial pressure
  • Hypoxic-ischemic injury
    • Loss of cerebral circulation, typically due to compromise of the cardiovascular and respiratory systems

Stratification of brain injury:

Brain injuries can be stratified into three categories: mild, moderate, and severe based on symptomatology present. Stratification can be done with the use of the Glasgow Coma Scale (GCS):

  • Mild TBI (i.e., concussion)
    • GCS score: 13-15
    • Loss of consciousness: 0-30 minutes
    • Alteration of consciousness: brief; up to 24 hours
    • Post-traumatic amnesia: <1 day
    • Imaging: normal
    • Recovery: full recovery of physical and cognitive function, with the patient seen in an outpatient setting
  • Moderate TBI
    • GCS score: 9-12
    • Loss of consciousness: >30 minutes; <24 hours
    • Alteration of consciousness: >24 hours
    • Post-traumatic amnesia: 1-7 days
    • Imaging: normal or abnormal
    • Recovery: potential to have full recovery of physical and cognitive function with intense rehabilitation in an inpatient rehabilitation or skilled nursing facility
  • Severe TBI
    • GCS score: 8 or less
    • Loss of consciousness: >24 hours
    • Alteration of consciousness: >24 hours
    • Post-traumatic amnesia: >7 days
    • Imaging: normal or abnormal
    • Recovery: permanent physical and cognitive impairment; typically in a nursing home setting or home setting with total care
Definitions
Alteration of consciousness
Change in baseline perception, awareness, and mental functioning.
Post-traumatic amnesia
Inability to recall events occurring after injury.
Retrograde amnesia
Inability to recall events preceding the injury.
Imaging
Magnetic resonance imaging (MRI) is utilized to assess the level of injury.

Behavioral stratification of traumatic brain injury:

Rancho Los Amigos Cognitive Scale is utilized to classify behaviors through a predictable sequence. Individuals progress through levels in sequence but can plateau at any point. Level of behavior:

  • Level I: No response
    • Cognitive assistance needed: total assistance with all cognitive functions
    • Response to stimuli: no response to sounds, sights, touch, or pain
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: individuals are typically in a comatose state
  • Level II: Generalized response
    • Cognitive assistance needed: total assistance with all cognitive functions
    • Response to stimuli: inconsistent, non-purposeful, generalized response to stimuli
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: individuals in a vegetative state
  • Level III: Localized response
    • Cognitive assistance needed: total assistance with all cognitive functions
    • Response to stimuli: localized response to stimuli
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: individuals within a minimally conscious state; able to inconsistently track objects and respond to their name
  • Level IV: Confused, agitated
    • Cognitive assistance needed: maximal assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: unable to follow single-step commands
    • Characteristics of level: confused, combative, easily agitated, hypersexual behavior
  • Level V: Confused, inappropriate
    • Cognitive assistance needed: maximal assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow simple commands consistently; difficulty with complex commands
    • Characteristics of level: confused, inappropriate behaviors (combative and hypersexual behaviors have subsided), severely impaired memory
  • Level VI: Confused, appropriate
    • Cognitive assistance needed: moderate assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow single-step commands
    • Characteristics of level: confused but behaviors are appropriate (goal-directed); no combative characteristics
  • Level VII: Automatic, appropriate
    • Cognitive assistance needed: minimal assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow single-step commands
    • Characteristics of level: improved carryover with activity, minimal assistance for learning new tasks, increased awareness of deficits
  • Level VIII: Purposeful and appropriate
    • Cognitive assistance needed: stand-by assistance for cognitive function
    • Response to stimuli: localized response
    • Single-step commands: able to follow single-step commands
    • Characteristics of level: able to integrate new and old memory into making decisions, able to make adjustments to behavior in social interaction with minimal assistance
Key points

Traumatic Brain Injury (TBI) Overview

  • Brain injury from force to skull causing rotational acceleration
  • Severity varies case by case

Types of Injury

  • Open head injury: skull fracture with brain exposure
    • Increased infection risk
  • Closed head injury: no fracture/exposed brain
    • Increased risk for intracranial pressure

Pathophysiology

  • Local brain injury: bruising, bleeding, laceration, or swelling in specific region
  • Coup-countercoup injury: damage at impact site and opposite side (rebound)
  • Diffuse axonal injury: axon/vessel tearing from brain acceleration, causes neuronal death
  • Edema: brain swelling (vasogenic or cytotoxic), raises intracranial pressure
  • Hypoxic-ischemic injury: loss of cerebral circulation from cardiovascular/respiratory compromise

Stratification of Brain Injury (Glasgow Coma Scale)

  • Mild TBI (concussion): GCS 13-15, LOC 0-30 min, amnesia <1 day, normal imaging, full recovery (outpatient)
  • Moderate TBI: GCS 9-12, LOC 30 min-24 hrs, amnesia 1-7 days, normal/abnormal imaging, possible full recovery with intense rehab (inpatient/SNF)
  • Severe TBI: GCS ≤8, LOC >24 hrs, amnesia >7 days, normal/abnormal imaging, permanent impairment (nursing home/home with total care)

Key Definitions

  • Alteration of consciousness: change in baseline awareness/mental functioning
  • Post-traumatic amnesia: can’t recall events after injury
  • Retrograde amnesia: can’t recall events before injury
  • Imaging: MRI used to assess injury level

Behavioral Stratification (Rancho Los Amigos Cognitive Scale)

  • Predictable sequence of levels; individuals may plateau at any point
  • Level I-III: Total cognitive assistance needed; progression from no response → generalized → localized response; comatose to minimally conscious states
  • Level IV-V: Maximal assistance; confused/agitated → confused/inappropriate; combative/hypersexual behaviors present in IV, subsiding by V
  • Level VI-VII: Moderate to minimal assistance; confused but appropriate → automatic appropriate; goal-directed behavior, increasing awareness of deficits
  • Level VIII: Stand-by assistance; purposeful and appropriate; integrates memory for decision-making, adjusts behavior socially with minimal help

More from Neuromuscular system

  • Central nervous system
  • Anatomy and function of spinal cord
  • Stroke deficits and recovery
  • Spinal cord injury
  • Neurodegenerative disorders and epilepsy