Dr Kurian Zachariah

Professor & Head,

Dept of Physical Medicine & Rehabilitation

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 1. Its not about an individual

 2. Place / Phase in the lives of the FU

 3. Best possible equilibrium ∞

a) ac Nx Sx Mx

b) Rehab Process

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 Demographics

 Evaluation

 Disorders of Consciousness

 Problem List

 Rehabilitation Goals & an over-arching maxim

 Rehabilitation Interventions CONSENT

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 Mild Moderate Severe
 GCS 13-15 9-12 3-8
 Freq: 70% 14% 16%

---------------
More in elderly

Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario,

Neurological Research 2002; 24: 24-28
Number of PMR in-patients in 2018 with:

Acquired Brain Injury (includes TBI) : 61

Traumatic Brain Injury alone: 34

V+
 Functional Scales in Acute phase
 Rancho Los Amigos scale of Cognitive Functioning – R

 Functional Scales in Sub-acute & Chronic phases

 Rancho Los Amigos scale of Cognitive Functioning – R
 Disability Rating Scale
 Montreal Cognitive Assessment (MOCA)
 Addenbrooke Cognitive Examination – Revised (ACE-R)
 Glasgow Outcome Scale – Extended
 Agitation Behavior Scale

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 Hagen C, Malkmus 0, Durham P. Levels of cognitive functioning. . .
. Downey: Rancho Los Amigos Hospital; 1972.
7
Wright, J. (2000). The Disability Rating Scale. The Center for Outcome
Measurement in Brain Injury. http://www.tbims.org/combi/drs 8
 MINIMALLY ACUTE
VEG
CONSCIOUS CONFUSIONAL
COMA STATE
STATE STATE

- + +
V
AROUSAL
(Preparedness) Dis-oriented

Agitated
AWARENESS - +/- ++/-

v
(Ability to respond)

Object Functional use of

Manipulation objects

Eapen Blessen, Georgekutty Jason, Subbarao Bruno, Disorders of Consciousness,

PMR Clinics of North America, TBI Rehabilitation, May 2017, Vol 28, 2 9
 MINIMALLY ACUTE
VEG
CONSCIOUS CONFUSIONAL
COMA STATE
STATE STATE

AROUSAL - + +
(Preparedness) Dis-oriented

Agitated
AWARENESS - +/- ++/-
(Ability to respond)

Object Functional use of

Manipulation objects

Eapen Blessen, Georgekutty Jason, Subbarao Bruno, Disorders of Consciousness,

PMR Clinics of North America, TBI Rehabilitation, May 2017, Vol 28, 2 10
 Disorders of  Agitation
consciousness  Deterioration in
 Sepsis neurological status

 Autonomic  DVT
dysfunction  Seizures and movement
 Spasticity disorders

 Heterotopic Ossification  Incontinence

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1. To improve neurological recovery
2. To prevent complications
3. Transfer care to the caregiver / family member
4. Reduce caregiver burden

The planned…

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1. To improve neurological recovery

2. To prevent complications

3. Transfer care to the caregiver

4. Reduce caregiver burden

The planned…

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1. To improve neurological recovery

2. To prevent complications

3. Transfer care to the caregiver

4. Reduce caregiver burden

The planned…

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1. To improve neurological recovery

2. To prevent complications

3. Transfer care to the caregiver

4. Reduce caregiver burden

The planned
withdrawal
The planned…
of support

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 Autonomic dysfunction
 Improve neurological function
 Agitation
 Heterotopic Ossification
 DVT
 Seizures, movement disorders
 Spasticity
 Chest Physiotherapy & Mobilization
 Neurogenic Bladder
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18
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  Criteria
1. Fever
2. Hypertension
3. Hyperhydrosis
4. Tachypnoea
5. Tachycardia
6. Posturing
7. Dystonia
Blackman James, Patrick Peter, Buck Marcia; Paroxysmal Autonomic Instability
With Dystonia After Brain Injury. Neurological Review, March 2004

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  Criteria
1. Fever  Diagnosis
2. Hypertension
3. Hyperhydrosis  5 out of 7 to be
4. Tachypnoea present
5. Tachycardia
6. Posturing
7. Dystonia
Blackman James, Patrick Peter, Buck Marcia; Paroxysmal Autonomic Instability
With Dystonia After Brain Injury. Neurological Review, March 2004

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1. Beta-blockers
2. Clonidine
3. Benzo-diazepines
4. Bromocryptine
5. Opioid pain medications

Baguley, I.J.M., Cooper, J.P., Felmingham, K.P., 2006. Aggressive behavior

following traumatic brain injury: How common is common? J. Head
Trauma Rehabil. Focus Clin. Res. Pract. 21 (1), 45–56.
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  Formation of mature
lamellar bone in soft
tissue.

 Incidence of clinically
significant cases is
10%–20%

Edwards Dafydd, Kevin Kuhn, Potter Benjamin, “Heterotopic Ossification: A Review of

Current Understanding, Treatment, and Future”, J Orthop Trauma, Vol 30:10s, Oct 2016
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  Etiology:
 Frontal & Temporal involvement
 Interconnections of Frontal lobe

 Contributing Factors

 Monitoring

 Rancho Los Amigos – Revised Level 4

Sandel ME, Mysiw WJ. The agitated brain injured patient. Part 1: definitions,
differential diagnosis, and assessment. Arch Phys Med Rehabil 1996; 77 (6):
617-23 24
 Hagen C, Malkmus 0, Durham P. Levels of cognitive functioning.
. Downey: Rancho Los Amigos Hospital; 1972.
25
1. Nil
2. Beta-blockers
3. Trazodone
4. Quetiapine
5. Carbamazepine
6. TCAs,
7. SSRIs
8. Valproic acid
 Avoid Haloperidol

Williamson et al. Pharmacological interventions for agitation in patients with

traumatic brain injury: protocol for a systematic review and meta-analysis;
Systematic Reviews (2016) 5:193
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 Cochrane review
 Mx of agitation in severe TBI
 Non-selective beta-blockers

 Valproate Carbamazepine

 Adverse effect of Propranolol

Bhatnagar S, Iaccarino MA, Zafonte R, Review: Pharmacotherapy in

rehabilitation of post-acute traumatic brain injury; Brain Research, 2016: 164-179
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 84%

 Positioning, ROM exercises , stretching,

splinting

 Baclofen, diazepam & tizanidine

 Focal chemo-denervation

De Lisa JA (Ed): Rehabilitation Medicine: Principles & Practice, 5th ed.

Philadelphia, JB Lippincott, 2010

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Dopamine agonist Improves consciousness

Prospective trial To improve L/C

8 pts
Vegetative state 2 wks: Consciousness ++ in all

Av. 104 days

Wakoto Matsuda1 , Yoji Komatsu , Kiyoyuki Yanaka , and Akira

Matsumura, Levodopa treatment for patients in persistent vegetative or
minimally conscious states, Neuropsychological Rehabilitation, July 2005
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Dopamine agonist Improves consciousness

Prospective trial ↑’ doses of L/C

till response plateaued
8 pts
Vegetative state 2 wks: Consciousness ++ in all

Av. 104 days

Wakoto Matsuda1 , Yoji Komatsu , Kiyoyuki Yanaka , and Akira

Matsumura, Levodopa treatment for patients in persistent vegetative or
minimally conscious states, Neuropsychological Rehabilitation, July 2005
30
 Dopamine agonist & NMDA antagonist Improves consciousness

• MC, db, pc- trial

• Fnc’l recovery
• Severe TBI
• Veg’t or MC state
• 4 – 16 wk post TBI
• 184 pts

Giacino JT, Whyte J, Bagiella E,et al.Placebo controlled trial of Amantadine for
severe traumatic brain injury. N Engl J Med 2012; 366(9): 819-26

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 Dopamine agonist & NMDA antagonist Improves consciousness

MC, db, pc- trial Amantadine 100mg bd  400mg /d

Functional recovery in Assessed on DRS
severe TBI
184 pts

Weekly improvement 0.24

(p=.007)184 – wk post TBI

184 pts
Scott D. Spritzer, DO,* Carolyn L. Kinney, MD, John Condie, MD Amantadine
for Patients With Severe Traumatic Brain Injury, The Neurologist ,Volume 19,
Number 2, January 2015
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 Dopamine agonist & NMDA antagonist Improves consciousness

MC, db, pc- trial Amantadine 100mg bd  400mg /d

Functional recovery in Assessed on DRS
severe TBI
184 pts

W Regardless of interval
Weekly improvement 0.24
(p=.007)184 eekly improvement 0.24
Amantadine √√
(p=.007)184 – wk post TBI

184 pts
Scott D. Spritzer, DO,* Carolyn L. Kinney, MD, John Condie, MD Amantadine
for Patients With Severe Traumatic Brain Injury, The Neurologist ,Volume 19,
Number 2, January 2015
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