Is There Anyone In There? - ASHA PDF
Preview Is There Anyone In There? - ASHA
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
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