Impairments Associated with Traumatic Brain Injury

 Neuromuscular
 Abnormal tone
 Sensory impairments
 Motor function (motor control and motor learning) impairments
 Impaired balance
 Paresis/paralysis

 Cognitive
 Altered level of consciousness/alertness
 Memory loss
 Altered orientation
 Attention deficits
 Impaired insight and safety awareness
 Problem solving/ reasoning impairments
 Perseveration
 Impaired executive functioning

 Visual
 Perceptual

 Behavioural
 Disinhibition
 Impulsiveness
 Physical and verbal aggressiveness
 Apathy
 Lack of concern
 Sexual inappropriateness
 Irritability
 Egocentricity

 Communication
 Receptive aphasia
 Expressive aphasia
 Dysarthria
 Auditory deficits
 Impaired reading comprehension
 Impaired written expression
 Impaired pragmatics (use of language)

 Dysphagia
Rancho Los Amigos Levels of Cognitive Functioning

I. No Response
o Patient appears to be in a deep sleep and is completely unresponsive to any stimuli
II. Generalized Response
o Patient reacts inconsistently and nonpurposefully to stimuli in a nonspecific manner.
o Responses are limited and often the same regardless of stimulus presented.
o Responses may be physiological changes, gross body movements, and/or
vocalization.
III. Localized Response
o Patient reacts specifically but inconsistently to stimuli.
o Responses are directly related to the type of stimulus presented.
o May follow simple commands such as closing or squeezing hand in an inconsistent,
delayed manner.
IV. Confused-Agitated
o A patient is in a heightened state of activity.
o Behaviour is bizarre and nonpurposeful relative to immediate environment.
o Does not discriminate among persons or objects.
o Is unable to cooperate directly with treatment efforts.
o Verbalizations frequently are incoherent and/or inappropriate to the environment.
o Confabulations may be present.
o Gross attention to environment is very brief.
o Selective attention is often nonexistent.
o Patient lacks short- and long- term recall.
V. Confused-Inappropriate
o Patient is able to respond to simple commands fairly consistently.
o However, with increased complexity of commands or lack of any external structure,
responses are nonpurposeful, random or fragmented.
o Demonstrates gross attention to the environment but is highly distractible and lacks
ability to focus attention on specific task.
o With structure, may be able to converse on a social automatic level for short period
of time.
o Verbalization is often inappropriate and confabulatory.
o Memory is severely impaired.
o Often shows inappropriate use of objects.
o May perform previously learned tasks with structure but is unable to learn new
information.
VI. Confused-Appropriate
o Patient shows goal-oriented behaviour but is dependent on external input or
direction.
 o Follows simple directions consistently and shows carryover for relearned tasks such
as self care.
o Responses may be incorrect due to memory problems, but they are appropriate to
the situation.
o Past memories show more depth and detail than recent memory.
VII. Automatic-Appropriate
o Patient appears appropriate and oriented within the hospital and home settings.
o Goes through daily routine automatically, but frequently robot like.
o Patient shows minimal to no confusion and has shallow recall of activities.
o Shows carryover for new learning but at a decrease rate.
o With structure is able to initiate social or recreational activities; judgement remains
impaired.
VIII. Purposeful-Appropriate
o Patient is able to recall and integrate past and recent events and is aware of and
responsive to environment.
o Shows carryover for new learning and needs no supervision once activities are
learned.
o May continue to show a decreased ability relative to premorbid abilities, abstract
reasoning, tolerance for stress, and judgment in emergencies or unusual
circumstances.

References:

Richard S. Snell. Clinical Neuroanatomy for Medical Students. 5 th ed. 2001. Lippincott Williams & Wilkins.

Lewis Flint, et.al. Trauma: Contemporary Principles & Therapy. 2008. Lippincott Williams & Wilkins.

K. Lindsay, et. Al. Neurology & Neurosurgery Illustrated. 3 rd ed. 1998. Harcourt Brace & Company, Ltd.

J. Gilroy, MD. Basic Neurology. 2nd ed. 1990. Pergamon Press, Inc.

S. O’Sullivan. Physical Rehabilitation : Assessment & Treatment. 4 th ed.& 5th ed. 2001. FA Davis Company.

R. Braddom. Physical Medicine & Rehabilitation.3 rd ed. 2008. Elsevier (Singapore) Inc.

De Lisa. Physical Medicine & Rehabilitation.