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TRAUMATIC BRAIN INJURY

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A traumatic brain injury (TBI) is defined as “an alteration in brain function, or other evidence of brain pathology, caused by an external force.” Because of the multiple body systems affected by a brain injury and the strong likelihood of secondary impairments, a physical therapist must be proficient in a wide variety of examination procedures and intervention techniques. It is a leading cause of injury related to death and disability. Generally, brain tissue damage can be categorized as either primary injury i.e. either direct trauma to the parenchyma or secondary injury that results from cascade of biochemical , cellular, and molecular events that evolve over time due to the initial injury and injury related hypoxia, edema, and elevated intracranial pressure(ICP).[1]

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IMPAIRMENTS

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DIRECT:

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  • Neuromuscular-

    • Abnormal tone (spastic hypertonia) & Abnormal posturing (decorticate or decerebrate)

    • Sensory affection (impairments in light touch, pain, deep pressure &  temperature, Proprioception &kinesthesia)

    • Loss of motor control (monoparesis, hemiparesis, quadriparesis&  abnormal reflexes)

    • Impaired balance & coordination

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  • Cognitive Impairments-

    • Altered level of consciousness

    • Confusion - bewildered but attentive

    • Lock in syndrome

    • Delirium - irritable, out of contact but alert

    • Obtundation - reduced alertness, slowed responses

    • Stupor - responsive with vigorous & repeated stimuli

    • Coma

    • Orientation & memory deficits

    • Impaired attention

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  • Neurobehavioral Impairments

    • Emotional disturbances

    • Apathy

    • Irritability 

    • Sexual inappropriateness

    • Physical & verbal aggressiveness & impulsiveness

    • Low frustration tolerance

    • Depression & anxiety

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  • Communication

    • Expressive or receptive aphasia,

    • Dysarthria

    • Impaired Reading comprehension & written expression 

    • Language skill deficits

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  • Visual perceptual problem

    • hemianopia & cortical blindness

    • hemi neglect, apraxia, spatial relations syndrome, somatagnosia& right-left discrimination deficit

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  • Sensory changes

    • Hypersensitivity to light or noise

    • Loss of hearing

    • Numbness or tingling (may be involvement of PNS)

    • Dizziness or vertigo

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  • Post-traumatic seizures

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INDIRECT:

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  • Deep vein thrombosis

  • Heterotrophic ossification

  • Pressure ulcer

  • Pneumonia

  • Chronic pain

  • Contracture

  • Decreased endurance

  • Muscle atrophy

  • Fracture

  • Peripheral nerve damage[1]

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GOALS

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ACUTE STAGE-

  1.  Patient, family and care givers education

  2. Improve physical function and level of alertness

  3. Reduce risk of secondary impairments

  4. Improve motor control

  5. Manage the effects of tone

  6. Improve postural control

  7. Increase tolerance of activities and positions

  8. Maintain and improve joint integrity and mobility

  9. Coordination of care among all individuals

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ACTIVE REHABILITATION STAGE

  1. Reduce the risk of secondary impairments

  2. Improve performance of functional mobility and ADL skills

  3. Improve ability to assume or resume self-care and home management roles.[1]

 

MANAGEMENT/PHYSICAL THERAPY INTERVENTIONS

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Patient/Family/Caregiver Education

  • In early phase of recovery, the patients may significantly go through a period where they are significantly confused or agitated. So it is difficult to educate the patient. But family education is extremely important. These patients do not have control his/her behaviour. The family should be educated that these behaviours are a symptom of his/her brain injury just the patient’s inability to walk or eat.

  • Family members should learn how to safely assist the patient with functional mobility.

  • They should also be educated to assist patient with strengthening exercise, passive ROM and other elements of exercise program as family members typically become primary care givers after the discharge.

 

ACUTE PHASE

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Preventing secondary impairments

  • Proper positioning in wheelchair and bed

  • Head should be kept in neutral when in bed, Hips and knees should be slightly flexed.

  • Splints to assist positioning

  • Special boots to position the foot to prevent foot drop and skin breakdown on the heel.

  • Turning

  • Repositioning after every 2 hours

  • Specialized air mattresses

  • Serial casting

  • Reclining wheelchair or a tilt-in-space wheelchair

  • Postural drainage, percussion, vibration and positioning to prevent pulmonary complications

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Early mobilization

  • Upright sitting

  • Transferring to a sitting position and out of bed to wheelchair (After being medically stable)

  • Tilt table use is advantageous as it allows early weight bearing on Les

 

Sensory stimulation

  • The following sensory systems are systematically stimulated- auditory, olfactory, gustatory, visual, tactile, kinaesthetic, and vestibular

 

ACTIVE REHABILITATION

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Motor (Re)learning strategies

  • Video self-modeling - The patient watches himself or herself engaging in skillful behavior on edited video tapes.

  • Concept of self-generation – it is a concept where by items that are self-generated are better learned and remembered compared to information that is provided.

  • Randomized practice schedule more beneficial (employed only after patient has demonstrated some initial learning)

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Restorative approach - Seeks to restore “normal” functional independence.

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Task oriented approach

  • Locomotortraining, utilizing body weight support(BWS) and a tredmill

  • CIMT

 

Aerobic and endurance conditioning

  • Type-Walking, jogging, treadmill, elliptical machines, ergometers

  • Intensity- 60-90% of age predicted maxHR

  • Duration- 20 to 40 mins

  • Frequency- 3 to 4 times a week

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Resistance training

  • Frequency- 2 to 3 days a week

  • Intensity- 3 sets of 8 to 12 repitations at 10 repetation max.

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Dual task performance

  • Progressive dual task performance regimen should be designed

  • The tasks and environment use in training should match those that the patient is anticipated to return to.

  • Walking on a treadmill while reading is an example dual task interventions.

 

MILD TRAUMATIC BRAIN INJURY

 

Patient education

  • Provide with educational material about the symptoms of mTBI.

  • Taught how to perform isometric strengthening exercises, appropriate sleep posture, vestibular positional techniques etc.

  • Advised to begin aerobic and strengthening program.

 

Improve vestibular function, balance and dual tasking

  • Canalith repositioning treatment

  • Gaze stabilization exercises (for patients with unilateral vestibular hypofunction)

  • High level, task oriented balance and gait training

  • Sport specific skill training

  • Balance training that incorporates the use of different sensory modalities

  • Dual task training

 

Other

  • Sretching

  • Strenghtening

  • Manual therapy

  • Modalities           

 

can be used when appropriate for patients with post traumatic headache or temperomandibular disorder.

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REFERENCES​

  1. Susan B. O’Sullivan, Thomas J. Schmitz, et al, Physical Rehabilitation, 6th edition, Page no- 859 to 881

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