Is There Anyone In There? - ASHA

102 Pages·2010·1.23 MB·English

Is There Anyone In
There?
Treatment of the Minimally Conscious
Patient
Objectives
– Why: Increased volume of patients with more acute
needs requiring efficient and effective rehabilitation at
an earlier stage
– What: Intervention approach for Speech-Language
Pathologist to facilitate not just communication but full
sensory function including swallowing.
– Where: Rehabilitation hospital; participation at
LTAC/SNF; home health; family care (family training);
beginning stages while still in acute care
– When: Ideally within 1 year of injury onset but
evidence of progress post-1 yr onset
• Physical gain w/in 1st year vs. plateau
• Cognitive-Linguistic progress w/in 1st year vs. long term
progress
MEASURING PATIENT
FUNCTION
Rancho Los Amigos
1
• Rancho Los Amigos (RLA) Levels of Cognitive Function
• An evaluation tool used by the rehabilitation team
• Eight levels to describe the patterns or stages of recovery
typically seen after brain injury ranging from Level I (No
Response) to Level VIII (Purposeful and Appropriate)
• Level I: No Response
• Level II: Generalized Response
• Level III: Localized Response
• Level IV: Confused & Agitated
• Level V: Confused & Inappropriate
• Level VI: Confused & Appropriate
• Level VII: Automatic & Appropriate
• Level VIII: Purposeful & Appropriate
Functional Independence
Measures (FIM)
• The Functional Independence Measures is a measurement of
disability severity, not impairment
• FIM was designed to be administered comparatively and quickly to
generate data
• FIM is a seven-level scale which ranks individual performance of an
activity, taking into account their need for assistance from another
person or device.
• The amount of help needed is quantified into a numeric score.
• This level of assistance translates into the time and energy that one
person would have to expend to serve the needs of the other.
• FIM 1 = Dependent
• FIM 2 = Maximal Assistance (25-49%)
• FIM 3 = Moderate Assistance (50-74%)
• FIM 4 = Minimal Assistance (75-90%)
• FIM 5 = Supervision (>90% with hands-off assistant)
• FIM 6 = Modified Independent (>90% without assistance with modifications)
• FIM 7 = Independent
Glasgow Coma Scale
• Eye Opening • GLASGOW OUTCOME
SCALE
– Spontaneous = 4
– To Speech= 3 – 5=Good Recovery (Normal or
Near Normal Recovery)
– To Stimulus= 2
– 4=Moderate Disability
– None= 1
(Disabled but Independent)
• Verbal Response
– 3=Severe Disability
– Oriented=5
(Dependent with physical or
– Confused=4 psychological disabilites or
both)
– Inappropriate words=3
– 2=Persistent Vegetative State
– Incomprehensible sounds=2
– 1=Dead
– None=1
• Motor Response (best)
– Obeys commands=6
– Localizes Stimulus=5
– Flexion Withdrawal=4
– Flexion Abnormal=3
– Extension=2
– None=1
Anatomy and Physiology
Key Anatomy
2
• Consciousness consists of 2 major components:
– Arousal
– Awareness
• Arousal: level of alertness
– Supported by function of the subcortical arousal systems in the
brainstem, midbrain and thalamus
– Clinically indicated by opening of eyes
• Awareness: content of consciousness; awareness of environment
and self
– Supported by functional integrity of the cerebral cortex and its
subcortical connections
– Assessed by evaluating command following and observing non-reflex
motor behavior (eye tracking, localized responses to pain, etc.)
– Awareness of self assessed by patient’s response to autoreferential
stimuli (mirror image of his/her own face)
Anatomy
Terminology –
Differentiating between
Levels of Consciousness
9
Condition Consciousne Sleep/Wake Motor Auditory Visual Communicati Emotion
ss Function Function Function on
Coma None Absent Reflex and None None None None
postural
responses only
Vegetative None Present Postures or Startle Startle None None
State withdraws to
noxious stimuli
Occasional non- Brief orienting to Brief visual Reflexive
purposeful sound fixation crying or
movement smiling
Minimally Partial Present Localizes to Localizes sound Sustained visual Contingent Contingent
Conscious noxious stimuli location fixation vocalization crying or
State smiling
Reaches for Inconsistent Sustained Inconsistent
objects command visual pursuit but intelligible
following verbalization
or gestures
Holds or
touches objects
in a manner that
accommodates
size and shape
Automatic
movements
(e.g. scratching)
Locked In Full Present Quadriplegic Preserved Preserved Aphonic/ Preserved
Syndrome
Anarthric
Vertical eye
movement and
blinking
usually intact