Traumatic brain injury

By:Dr Sunjyoth.H.S(PT)
Assistant Professor ,
COPT,DSU
 Introduction
• Head injuries are injuries to the scalp, skull or brain
caused by trauma.
• Brain injury is damage to the brain that results in
impairments in physical, cognitive, speech / language
and behavioral functioning.
• The universal term used to describe brain injury as a
result of head injury is Traumatic Brain Injury.
 Traumatic Brain Injury
• An alteration in brain function or other evidence of brain
pathology caused by an external force

• Etiology: Contact forces to skull and rotational acceleration

forces causing varying degrees of injury to the brain
Epidemiology

• World’s leading cause of injury related death and disability

• Number 1 cause for death in children and young adults
• Male: female 2:1
• More than 50% are between 15-24 years.
 Two varieties of TBI
Open Head Injury Closed Head injury
• Penetration of the head • No open head wound; brain
damaged internally
• Causes localized brain damage

• Causes diffuse tissue damage

• Result in discrete and relatively
predictable disabilities
• Result in generalized and highly
• Common causes: severe fall, variable disabilities
gunshot, assault.
• Common causes: Falls, vehicle
• Easier to detect using medical accidents, sports accidents
imaging technology
 Pathophysiology of TBI
Primary brain damage Secondary brain damage

• Induced by mechanical • Superimposed injury on a brain

force and occurs at the already affected by a mechanical
moment of injury. injury.

• Injuries often result in • Results from a cascade of

contusions, intracerebral biomechanical, cellular, and
hematomas, diffuse axonal molecular events that evolve
injuries etc. over time due to the initial injury
and injury related hypoxia,
edema, and elevated ICP.
 Primary Brain Damage
1. Diffuse Axonal Injury
• Caused by shaking or strong rotation
of the head

• Major cause of unconsciousness &

persistent vegetative state TBI

• There is extensive tearing of nerve

tissue throughout the brain

• Patient presents with a variety of

functional impairments depending on
where the tears occurred in the brain
 2. Concussion
• Results from direct blow to head, gunshot wounds, violent
shaking of the head or force from a whiplash type injury

• Both closed and open head injury can produce a concussion

• When the brain receives trauma from an impact or a sudden

momentum or movement change, the blood vessels in the brain
stretch and cranial nerves may be damaged

• Patient may or may not experience a

brief loss of consciousness
 3. Contusion
• A bruise (bleeding) on the brain

• Results from a direct impact to

the head
• This causes increased pressure
inside the skull which may
result in brain herniation, a life-
threatening condition in which
parts of the brain are squeezed
past parts of the skull.
 4. Coup- Contra coup injury
• Contusions that are both at the site of the impact and on the
complete opposite side of the brain

• Force impacting the head is very strong and causes the brain
to move and slam to the opposite side of the skull
 5. Intra cranial Hemorrhage
Epidural hematoma Subdural Hematoma
Location Space b/w Dura matter & skull Space b/w Dura &
Arachnoid matter
Common cause Rupture middle meningeal artery due to Rupture of bridging veins
temporal bone fracture.
Clinical feature No symptoms (lucid interval)-> increased ICP Vague headache,
-> Herniation -> Death (if no immediate cognitive dysfunction,
intervention) unsteady gait
 6. Subarachnoid Hemorrhage
• Location Space b/w Arachnoid and Pia matter (CSF space)
• Presented with the worst headache ever (head about to explode)
• 70-80% due to arterial aneurysm (Saccular/Berry)
• Aneurysm rupture ischemia + increased ICP
Unrupture  Mass effect e.g. PCA compression painful CN3
palsy
• Traumatic  Cerebral contusion
 7. Locked-in Syndrome
• A rare neurological condition in which a person can not physically
move any part of the body except the eyes.

• The patient is conscious and able to think

• Vertical eye movements and eye blinking can be used to

communicate with others.

• It is caused by damage to specific portions of the lower brain

and brainstem, with no damage to the upper brain.
8. Shaken baby syndrome
 Secondary Brain damage
 Swelling/ edema
 Electrolyte imbalance and mass release of damaging
neurotransmitters
 Increased intracranial pressure
 Cranial nerve damage
 Intracranial infection
 Post traumatic epilepsy
 Neuroendocrine and autonomic disorders
 Severity Classification Scales
• Glasgow Coma Scale
• Rancho Los amigos Level of Cognitive function
• Rappaport’s Disability Rating Scale
• Glasgow Outcome Scale
• Functional Classification Scales (FIM+FAM)
Impairments Commonly Associated with
TBI
• Neuromuscular
 Paresis
 Abnormal tone
 Motor function
 Postural control
 Somatosensory function

• Cognitive
 Arousal level
 Attention
 Concentration
 Memory

• Neurobehavioral
 Agitation/Aggression
 Disinhibition
 Apathy
 Emotional liability
 Mental inflexibility
 Impulsivity
 Irritability

• Sensation
 Paresthesia, Dysesthesia, Allodynia, Hyperpathia, Hypesthesia

• Communication
 Medical Complications of TBI

 DVT
 Heterotopic ossification
 Pressure ulcer
 Pneumonia
 Malnutrition and Dehydration
 Hydrocephalus
 Chronic pain
 Contractures
 Muscle atrophy
 Fracture
 Peripheral nerve damage
 Physiotherapy Management

• Overall objective is maximal functional recovery and

assisting the patient with residual disability.
- Make a problem and an asset list
- Set priorities, sequencing and team work
-Treatment program must be individualized.
 Acute Phase
• Life preservation
- Functioning respiratory system

- Good circulation (check BP, ICP)

- Prevent secondary brain damage (pharmacological

intervention)

- Prevent complications: Pressure sores, contractures, DVT,

respiratory problems, postural hypotension
 Chronic Phase
• Acquiring motor skills or relearning → PT program is built around the
cognitive level

• Owing to cognitive impairments, pts. may experience mental as well as

physical fatigue during treatment sessions.

• Signs of mental fatigue may include: increased irritability, decreased

attention and concentration, deterioration in performance of physical
skills and delayed initiation.

• Treatment sessions should include sufficient rest periods to minimize

 Acute phase management
(1) Positioning
(2) Sensory stimulation
(3) Prevention of secondary complications:
(a) respiratory therapy,
(b) contracture prophylaxis,
(4) Serial casting
(5) Mobilisation/verticalisation,
(6) ADL training,
(7) Therapy intensity
 (1) Positioning
• THE risk of pressure areas, contracture, and
respiratory complications should be
considered when a patient is positioned. To
prevent pressure areas developing, the
patientʼs position should be frequently
changed.
• This can be as simple as ensuring the patient is
moved from supine to side lying, but should
ideally also include the patient sitting out of
bed and standing on a tilt table for a period of
time.

• CLINICAL RESEARCH
Cerebral perfusion pressure, intracranial pressure, and head elevation
..Michael J. Rosner, M.D., and
Irene B. Coley, P.A.-C in 1986

• It is concluded that 0° head elevation

maximizes CPP and reduces the severity and
frequency of pressure-wave occurrence.
Effect of backrest position on intracranial and cerebral perfusion pressures in traumatically brain-injured adults .
Winkelman C in 2000

• compared with use of a flat/horizontal position, use of a

backrest elevation of 30 degrees resulted in significant
and clinically important improvements in both
intracranial and cerebral perfusion pressures.
• None of the subjects experienced adverse clinical
changes in either intracranial pressure or cerebral
perfusion pressure with either backrest position.
• The results strengthen the research foundation for
raising the backrest position for adults, 18 to 45 years
old, who have nonvascular, non penetrating, severe
brain injuries.
 (2) Sensory Stimulation.
• Sensory/basal stimulation refers to the application of
specific structured stimuli such as tactile,
proprioceptive, vestibular, auditory, visual, or
olfactory stimuli.
• Sensory/basal stimulation programmes differ
significantly from each other with respect to duration
and in their mode of stimulation (unimodal versus
multimodal).
• Sensory/basal stimulation programmes exist
for comatose patients or patients in states
ranging from vegetative to minimally
conscious.
• The goal of sensory/basal stimulation is the
activation of the brain, an improved stimulus
transmission, and overall a quicker and better
recovery of the level of consciousness
 Sensory stimulation (Stimulate all sensory modalities)
Auditory: talk to the patient, intermittent use of radio or
T.V
Visual: people, pictures, stimulate all areas of visual
fields.
Olfactory: use patient’s favorite smells.
Gustatory: apply cotton swab with flavored solution to
the lips & gums. Avoid aspiration.
Tactile: use different texture.
Vestibular: head movement (angular or rotational).
 Sensory stimulation (contd.)

 Administer for short period & in an orderly manner.

 After every stimulus wait for a response

 For every response look for its:

• Latency: time between stimulus and response

• Consistency: number of times patient respond/number of

time stimulus is presented

• Response Intensity

• Autonomic nervous system may be impaired

• Watch for changes in vital signs.

• A randomised controlled trial study by Abbasi et al.
from Iran is available for the acute phase,
respectively, the treatment period in the ICU.
• It deals with the question whether contact between
the patient and his/her family is capable of positively
influencing the degree of consciousness.
• In conclusion, sensory/basal stimulation has not
been proven to be effective for the treatment of TBI
survivors.
 (3) Prevention of Secondary Complications

• Respiratory Therapy.
Respiratory therapy is an important component of
physiotherapy in ICUs.
The therapeutic interventions are versatile and focus on
various goals such as the promotion of alveolar
ventilation, secretolysis, improved oxygen saturation,
maintenance, and/or improvement of thorax mobility
and the improvement of resilience.
• In a randomised controlled trial of individuals with
acquired brain injury, Patman et al. researched
whether respiratory therapy had a positive effect on
ventilator associated pneumonia and whether it
leads to a reduction in the length of mechanical
respiration, a shorter length of stay in the ICU, or
prevention of ventilator-associated pneumonia.
• Though this is a widespread intervention, its
efficacy could not be confirmed.
Ntoumenopoulos et al. and Templeton and
Palazzo come to a similar conclusion for
critically ill patients.
• Respiratory therapy should be critically
evaluated for patients who are subject to
mechanical respiration.
 Contracture Prophylaxis

• A common complication following a TBI are

contractures.
• Contractures can be defined as a loss of joint mobility
due to structural changes of muscles, tendons, and
ligaments and other non bony structures.
• The performance of daily routine tasks can be
significantly impaired due to the prevalence of
contractures.
• Although the passive movement of joints and
stretching are standard treatments performed by
physiotherapists for patients with TBI in the ICU, no
randomised controlled trial could be found for this
method.

• This is most likely due to the patients’ rather brief

length of stay in the ICU

• There is currently no evidence to support the use of

passive ranging exercises, and it is believed that this
type of exercise applies a duration of stretch that is
insufficient to prevent the development of contracture
(Ada and Canning 1990).
• Katalinic et al. published a Cochrane Review in which
they studied the impact of stretching (including
prolonged stretching by means of casting)as a treatment
and prevention intervention for contractures for both
neurological patients and musculoskeletal patients. The
authors came to the conclusion that stretching has no
clinically significant effect on joint mobility and the
quality of life. In addition, stretching has little or no
effect with regard to secondary endpoints such as pain,
spasticity, activity limitations, and participation
• Ada et al. (2005) found that 30-minutes of
positioning the shoulder in 45° of abduction and
maximum external rotation prevented a 17% external
rotation contracture in acute stroke patients.

• Tardieu et al (1988) reported that 6 hours was the

minimum time required for the soleus muscle to be
stretched to prevent contracture in a small group of
children with cerebral palsy.
• Harvey and Herbert (2002) argue that while there is
currently no strong evidence to suggest the timing
for stretching to prevent contracture in a spinal cord
injured population, that a minimum of 20 minutes,
and perhaps as long as 12 hours, a day of stretching
should be applied to at risk muscles due to the sound
scientific rationale for prolonged stretching.
 Stretch for the treatment and prevention of contracture: an
abridged republication of a Cochrane Systematic Review☆
• Lisa AHarveyaOwen MKatalinicaRobert DHerbertbAnne
MMoseleycNatasha ALannindKarlSchurre (2017)

Question
• Is stretch effective for the treatment and prevention
of contractures in people with neurological and non-
neurological conditions?
Conclusion
• Stretch does not have clinically important effects on
joint mobility.
 Serial Casting.
• Serial casting is widely used to reduce spastic
hypertonia and to improve the range of motion in
neurological post acute rehabilitation.
• Usually serial casts are applied that need to be
changed in an interval of 4 to 7 days with the primary
goal of improving the mobility of a joint.

• The lack of existing studies that investigate the

efficacy of this intervention in the ICU is likely due to
the brief length of stay in the ICU
• Results of studies in the post acute stage [6,
12–16] come to the conclusion that this
therapy does not result in a verifiable
functional gain.
• However, passive joint mobility can be
improved by serial casting.
 A paper by Moseley et.al
• Serial casting result s showed an average
improvement of elbow mobility by 22 degrees
• However, this range of motion already decreased by
11 degrees on the subsequent day and completely
disappeared after 4 weeks.
• Follow-up treatment with splints was not performed
in this study.
• A reduction of hypertonia through serial casting
cannot be proven on the basis of current scientific
data.
 Mobilisation/Verticalisation
• Bed rest and deep sedation are common in ICUs.
• A number of studies [18– 20] indicate that
immobilisation leads to various negative effects on a
musculoskeletal, pulmonary, cardiovascular, and
endocrine/metabolic level such as neuromuscular
weakness, muscle atrophies, pressure sores,
atelectases and pneumonia, orthostatic
dysregulation, and disturbed microvascularisation.
• There is no existing data on the point in time when
mobilisation is sensible for individuals with traumatic
brain injuries.
• Multiple studies confirm that early mobilisation
improves the patient’s ability to walk
• Three studies were found, whose results highlight
the safety and feasibility of early mobilisation
within the context of ICUs.
• An Australian survey by Chang et al. investigated
whether the tilt table is used by physiotherapists
in the ICU.
• The result of the survey indicated that the tilt
table is frequently used as a method of
mobilisation, especially for patients with severe
disabilities, in order to improve musculoskeletal
functions and to promote consciousness
• Schweickert et al. conducted a noteworthy study in which
he researched the effect of early physiotherapy and
occupational therapy while interrupting the sedation in a
randomised controlled trial with 104 patients who required
mechanical respiration.
• The control group received therapy according to the orders
of the primary care team.
• The experimental group benefitted from a better functional
outcome when released from the ICU, shorter amount of
time spent in delirium, and shorter periods of mechanical
respiration.
• Lutheretal. Compared the tolerance of conventional
standing exercise with the standing exercise on the
therapy device “Erigo” which integrates stepping
movements of the legs during verticalisation.

• The study group was small (n = 9) and consisted of

unconscious patients in Bad Aibling, Germany within
the first three months following brain injury.

• The tolerance was primarily measured by the

frequency of syncope/presyncope during standing. The
results indicate that the patients on the Erigo exhibit
significantly less syncopes during verticalisation
 ADL Training/Self-Care.
• Training of self-care activities and activities of daily
living (ADL) is frequently administered to patients
with sensory, motor, or cognitive dysfunction. Some
ICUs already start with this intervention at a very
early point in time.

• Bowen et al. evaluated such non pharmacological

interventions for sensory dysfunction due to a stroke
or an acquired brain injury in their 2011 Cochrane
Review .
• ADL improvements were measured as
outcome parameter. The authors come to the
conclusion that it is not possible to make a
statement on the effectiveness of this
measure on the basis of the currently
available data.
• In summary, the evidence of the efficacy for
ADL training in the ICU is still to be
determined.
 Therapy Intensity
• Hellweg come to the conclusion that early
intensive rehabilitation significantly improves
the functional outcome of the first months
following the accident but that no difference
can be observed at the end of the
rehabilitation.

• No additional studies could be found for the

very early phase within the context of ICUs.
RECENT ADVANCES
• Using Virtual Reality and Videogames for Traumatic
Brain Injury Rehabilitation: A Structured Literature
Review (2014)
• CONCLUSION :The evidence that the use of virtual
reality in rehabilitation of traumatic brain injury
improves motor and cognitive functionality is
currently very limited. However, this approach has
the potential to provide alternative, possibly more
affordable and available rehabilitation therapy for
traumatic brain injury in settings where access to
therapy is limited by geographical or financial
constraints.
• Virtual reality-based therapy for the treatment of
balance deficits in patients receiving inpatient
rehabilitation for traumatic brain injury (2014)
• To evaluate the feasibility and safety of utilizing a
commercially available virtual reality gaming system
as a treatment intervention for balance training.
• This study provides a modest level of evidence to
support using commercially available VR gaming
systems for the treatment of balance deficits in
patients with a primary diagnosis of TBI receiving
inpatient rehabilitation.
• Motion-based gaming to improve balance and physical
activity in patients with mild traumatic brain injury
(mTBI) (2017)
• Motion based gaming was used in combination with
standard therapy in 17 mild traumatic brain injury
participants when compared to 20 controls to study
the effectiveness of motion based gaming on physical
activity level and postural stability measured by using
body worn sensors. Significant improvements in
number of steps, stability, and perceived motivation
suggest promising use of motion based gaming in
combination with physical therapy for improved
rehabilitation outcomes in this population.
• Changes in gait patterns induced by rhythmic
auditory stimulation for adolescents with acquired
brain injury (2016)
• This study evidenced that RAS training with the
consideration of patients’ preferred music was
effectively utilized to improve gait patterns in
adolescents with ABI. In this study, the sagittal
magnitude of hip and knee joint angles increased
from terminal stance to mid-swing phase,
accompanied by cadence, walking velocity, and step
time after RAS training. This indicates that gait
training with RAS can enhance locomotive function.
• This study also corroborated the rationale for
applying musically adapted RAS to gait training in
that increased spatiotemporal limb control with
increased tempo of cueing led to the adjusted ROM,
accordingly facilitating kinematic changes during gait.
Additional studies are needed to clearly validate the
mechanisms of RAS with the use of patients’
preferred music in terms of music perception as well
as temporal and motor control from a neurological
perspective.
• E2Rebot: A robotic platform for upper limb
rehabilitation in patients with neuromotor disability
• The use of robotic platforms for neuro-
rehabilitation may boost the neural plasticity process
and improve motor recovery in patients with upper
limb mobility impairment as a consequence of an
acquired brain injury.
• A robotic platform for this aim must provide
ergonomic and friendly design, human safety,
intensive task-oriented therapy, and assistive forces.
Its implementation is a complex process that involves
new developments in the mechanical, electronics,
and control fields.
• This article presents the end-effector rehabilitation
robot, a 2-degree-of-freedom planar robotic platform
for upper limb rehabilitation in patients with
neuromotor disability after a stroke.

• We describe the ergonomic mechanical design, the

system control architecture, and the rehabilitation
therapies that can be performed.
• The impedance-based haptic controller implemented
in end-effector rehabilitation robot uses the
information provided by a JR3 force sensor to
achieve an efficient and friendly patient–robot
interaction.
• Two task-oriented therapy modes have been
implemented based on the “assist as needed”
paradigm.
• As a result, the amount of support provided by the
robot adapts to the patient’s requirements,
maintaining the therapy as intensive as possible
without compromising the patient’s health and
safety and promoting engagement.
• Postural responses after utilization of a computerized
biofeedback based intervention aimed at improving
static and dynamic balance in traumatic brain injury:
A case study (2016)
• Balance dysfunction is one of the most disabling
aspects of Traumatic Brain Injury (TBI). Without rapid
transmission and accurate perception of
somatosensory inputs, the automatic postural
responses required during standing may be delayed
or absent after TBI which can lead to instability.
• Further, the sensitivity level to which environmental
perturbations can be detected is also vital, as the
central nervous system will only employ balance
control strategies when it perceives a change in
equilibrium
• Such undetectable perturbations, however small
they may be, can result in fatal falls, especially after
TBI. In this investigation we used a novel
computerized biofeedback based (CBB) intervention
aimed at improving perception of external
perturbations, and static and dynamic balance in a
single male participant with severe TBI
• A Comparison of Locomotor Therapy Interventions: Partial-
Body Weight−Supported Treadmill, Lokomat, and G-EO
Training in People With Traumatic Brain Injury (2016)

Objective

• To examine the impact of 3 different modes of locomotor

therapy on gait velocity and spatiotemporal symmetry using
an end effector robot (G-EO); a robotic exoskeleton
(Lokomat), and manual assisted partial-body weight–
supported treadmill training (PBWSTT) in participants with
traumatic brain injury.
Conclusions
• Locomotor therapy using G-EO, Lokomat, or PBWSTT
in individuals with chronic TBI increased SSV and MV
without significant changes in gait symmetry.