TBI treatment question

[Maggie Knoll]

Hi,

I have two questions regarding TBI in the acute setting:

1. In the study guide, it advises to avoid the supine position. Is this because of risk of bed sores? Or to facilitate increased position changes? Additionally, why would semi-prone be recommended?

2. In treatment for Peds Ranchos Level 3-5, it recommends to avoid use of PROM. Why is this? My thought would be that we should be doing PROM especially during level 5 so as to reduce ulcer risks and contracture risk.

Thank you! Really appreciate all of the help!

[Jessica Lewis]

Hi Maggie!

All great questions!

For the supine position, there can be many reasons. First, the supine position can put a patient at a risk for increase in intracranial pressure due to reduced venous outflow from the brain, especially if the head and neck are not in midline. The can also be an aspiration risk if their is an impaired cough/gag reflex. At times, a supine position can promote abnormal posturing – like an extensor posture. A true supine posture can also be a very overstimulating position for patients, too. So for all of these reasons, supine is typically avoided.

Semi-prone is a modified sidelying position. This position facilitates a more flexed posture and inhibits that extensor tone. It can support a more midline posture of the head and improve secretion management and airway safety for patients. It can also be an overall more calming and pleasant sensory position for patients.

You’re also right to think that all of this can be helpful with bed sores too. But it is also all helpful in terms of neuroprotective positioning.

For the passive range of motion question, I think the main thing here is that there is limited evidence to show that a PT doing passive range of motion exercises is helpful, rather the use of splints and serial casting is what is helpful for maintaining/gaining range of motion. You doing passive range of motion for 5-10 minutes is not doing anything, only long term static stretching devices are doing this (similar thought as to why we don’t stretch kids with CP, we aren’t doing anything, only long term bracing/serial casting is actually making changes). If anything, our stretching may be agitating and causing more harm than good. So, avoid this and focus on more function based activities with these patients if possible.

I hope this helps! Let me know if you have any other questions!

Jessica

[Maggie Knoll]

Ok, it makes sense why we would use sidelying or semi-prone for positioning. If a patient Ranchos peds 5 (no response), we still want to avoid PROM? Shouldn’t we be concerned about heterotopic ossifications or contractures?

This is a silly question, but do we ever see someone not progress through the Ranchos levels (i.e. stay at a level 3 per-say)? What would our focuses be during these levels for these patients?

[Jessica Lewis]

There are no silly questions!

For the first one, I think the key distinction here is that we are avoiding PROM as a treatment goal, but not abandoning joint health all together. We should avoid any type of aggressive, end-range, repetitive passive range of motion because it can trigger sympathetic storms (increased heartrate, increased BP, increased ICP), increased spasticity, increased reflexive tone response, provide non-meaningful sensory input that doesn’t promote recovery. Even in Ranchos Peds V. Instead, use positioning, slow low-load movements, splinting, casting, and early HO monitoring techniques. Forceful and/or repetitive PROM can actually worsen HO risk (microtrauma, inflammation in already damaged tissue, heightened neuroinflammatory response).

Unfortunately kids can stall and stop progressing. Some may plateau for a while and then continue progressing. For those that get stuck and stay stuck, we then move from recovery mode to protection and participation mode. We education the family how to safely care for their child at the level they are at. If this is a higher Ranchos level (lower functional level), we need to teach them how to safely protect their child’s joints, understand how to protect their sensory system, safely position their child for function, and give their child the best quality of life possible. If the child is able to participate, we need to figure out how to maximize participation and safety. It is all about figuring out what the child’s brain can safely tolerate and working within those parameters.

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