Physiotherapy Management of Traumatic Brain Injury

Introduction

Just as no two people are exactly alike, no two brain injuries are exactly alike. Therefore, neurorehabilitation and physical therapy approaches for posttraumatic brain injury should follow the principles of neuroplastic motor learning and motor control and a patient-centered approach Individual goal setting and treatment program selection.

Specific, measurable, achievable, relevant timed goals and patient-involved goal setting allow for clarity in the direction of the rehabilitation process and enhance individual professional goals and plans to contribute to overall rehabilitation outcomes. patient goals Recovery varies according to the stage of recovery and their condition.

Physical therapy is an integral part of the MDT/IDT neurorehabilitation team, and neurophysical therapy is an integral part of neurorehabilitation. Physiotherapy programs may require input from a range of clinicians, including physiotherapists, occupational therapists and orthopedist. It should be directed by professionals experienced in the management of neurologic disorders.

[1]

Neurophysiotherapy is an interrelated process of assessment, treatment and management through which traumatic brain injury patients and their relatives/carers are supported to achieve optimal outcomes in terms of participation in bodily cognitive, social and psychological functioning social and quality of life. Discharge planning starts in the early stages of rehabilitation and overlaps with the UK Rehabilitation Prescribing scheme, starting in the subacute stage, with a process of identifying future rehabilitation needs The recovery journey is determined by the needs of the individual patient and proceeds through a tiered pathway of services. Goals and expected outcomes are closely monitored and, when achieved, will enhance the process of discharge to another service or home/care facility.

Return of function after brain injury may occur in two processes:

1. Spontaneous recovery: a process associated with early central nervous system repair and resolution of schizophrenia after brain injury.
2. Function-induced recovery: Based on the process of promoting neuroplasticity in response to active practice and environmental stimuli, resulting in behavioral changes, such as restraint-induced exercise therapy training programs.

Principles of Experience-Dependent Neuroplasticity [2]

1. Use it or lose it: unused functionality deteriorates
2. Use it and improve it: used features are improved
3. Specificity: Neuroplastic changes are determined by the task used
4. Timing matters: Different training times are linked to different neuroplastic changes
5. Repetition Matters: Enough Repetition is Needed to Enhance Neuroplasticity
6. Strength Matters: Sufficient Strength Needed to Enhance Neuroplasticity
7. Saliency matters: sufficiently meaningful tasks trigger plasticity
8. Age matters: Younger brains show more plastic changes with training
9. Empathy: changes in neuroplasticity following training on one task may enhance acquisition of similar tasks
10. Interference: Plasticity to one experience interferes with the acquisition of other behaviors. [2]

Physiotherapeutic Interventions

Physical therapy interventions can be broken down into three broad categories:

• Restorative interventions focus on reactivating the penumbra and schizophrenia and restoring premorbid movements
• Compensatory interventions focusing on optimal functional enhancement using remaining skills to compensate for loss, ie: personal care using the non-hemiplegic side
• Focuses on preventive interventions that reduce injury and promote overall health, namely: respiratory physiotherapy that enhances chest health.

These categories include therapeutic techniques and activities such as; [3]

1. Therapeutic exercises
2. Manual therapeutic techniques such as mobilization or manipulation
3. Prescription and application of devices such as orthotic or prosthetic devices, mobility aids, wheelchairs
4. Airway clearance techniques
5. Functional training for self-care (ADL) and home care
6. Functional training during work school play and leisure activities, including community reintegration
7. Using physical agents and other modalities such as hydrotherapy, electrotherapy, cryotherapy
8. Integumentary protection technology that enhances tissue vitality
9. Discharge Planning

In the intervention, the following parameters are available:

• Method, Mode or Device 
• Intensity, Load or Tempo 
• Duration and Frequency
• Progression

Physiotherapy management of moderate to severe traumatic brain injury

Acute

Good practice recommends a complete medical record examination to identify precautions and contraindications, as patients may be unstable due to increased intracranial pressure (ICP) respiratory demands such as mechanical ventilation, orthopedic injuries in situ limiting load or extent sports. A recent literature review suggests the need for a comprehensive cardiorespiratory assessment because maximal aerobic capacity and resting vital capacity parameters are reduced in patients with moderate-to-severe TBI following injury. Failure to address these issues may result in poor functionality Results [4].

Goal setting should be informed by examinations, which may include arousal, attention and cognition, skin integrity, sensory integrity, range of motor function, motor reflex integrity, ventilation and respiration/gas exchange, tolerance to handled transfers and sitting positions.

Treatment in the acute phase should address:

• Stimulate alertness levels through a multifactorial approach
• Physical function stimulation to improve movement and postural control, maintain mobility, and normalize muscle tone
• Reduction of secondary complications through spasticity management and contracture prevention Heterotrophic ossification prevention Breast management Skin integrity management Infection prevention DVT prevention
• Respiratory care optimized by an IDT team of consultant nurse physiotherapists and speech and language therapists, including positioning mobilization oxygen therapy manual techniques tracheostomy management and weaning strategies
• Maintain or restore tolerance to physical challenges and sitting or standing positions
• Manage pain, such as arm paralysis or hypersensitivity reactions, with skilled handling support and analgesia
• Family and caregiver education about patient diagnosis and management of traumatic brain injury complications, including device use.
• Rising Safety Awareness
• Discharge Planning 

Treatment techniques and procedures may include:

• Paramedics and physiotherapists recommend early mobilization through passive or active assisted management.
• Facilitating movement using neurodevelopmental or neuromuscular concepts
• Position in bed in various positions, including side and prone [5], at appropriate times, changing positions every 2 hours.
• Ambulation positioning [6], ie: sitting in a wheelchair or specialized support chair to facilitate early recovery and increase alertness levels, led by a physiotherapist and supported by an appropriate seating system.

For more information and guidance, check out this optional resource: A Beginner’s Guide to Posture Management

• Verticalize, ie: use a tilting table or increase the number of therapists (3-4) to ensure loading and stimulate alertness.
• The cleats include Lycra apparel and collection casting that takes into account communicating cognitive and behavioral deficits and their impact on safety and compliance.
• Sensory stimulation and environmental enrichment for the auditory, olfactory, gustatory, visual, tactile-motor and vestibular systems.
• Balance and postural control exercises, such as transfers and center-of-mass shifts and midline-oriented activities while lying on your side or sitting.

Randomized controlled trials in patients with severe traumatic brain injury (TBI) have shown positive effects of neuromuscular electrical stimulation (NMES). Research shows no significant reduction in muscle thickness of tibialis anterior and rectus femoris when NMES is used Fourteen days of continuous application compared with a control group who received only conventional physical therapy [7].

To facilitate the MDT/IDT approach, 24-hour written and photo guidelines should be provided to ensure consistency among team members. This guideline may contain elements of postural recommendations [8] Chest clearance techniques using dynamic orthoses/Lycra garments or splints. [9] A clear goal Interpretations and expected outcomes will be defined and included to increase awareness and rationale for choosing treatment.

Active Rehabilitation Stage

Patients with moderate-to-severe traumatic brain injury require structured rehabilitation and appropriate services, ranging from acute to long-term community-based services providing home and outpatient care. Patients according to BSRM guidelines for “Rehabilitation after brain injury” Traumatic brain injuries should be transferred as quickly as possible to a rehabilitation program of appropriate intensity to meet their needs and receive as much treatment as they need and deem acceptable [10]. (G11)

Rehabilitation Settings:

• Inpatient rehabilitation is an intensive specialist rehabilitation for people who are not clinically and functionally ready to be discharged from the acute setting. The Neurorehabilitation Center offers a structured program of intensive interdisciplinary intervention care on a daily basis Nursing and medical services of consultants in rehabilitation medicine. Interventions are goal-based and carefully planned from the beginning of the process.
• Outpatient rehabilitation is for people who are well enough to go home but need further rehabilitation. It may be provided by holistic or individual rehabilitation centers.
• Community-based rehabilitation is for people who have completed inpatient rehabilitation but still need to learn independent living skills often in a transitional living unit. Some may continue the recovery process while living at home and receiving community support A rehabilitation team or an outreach team helps them make further progress. Treatment may take place in the patient’s home at a local community facility such as a supermarket, sports school, etc.

Pathways to recovery after illness or injury [11]

Likewise, goal setting in the acute phase should include an examination of physical and cognitive impairment to determine the ability to relearn motor skills. Prior to the physical examination, the physical therapist should determine the patient’s directed attention span memory insight Security awareness and alertness. According to Fulk and Nirider [12], key initial questions to ensure an optimal baseline for assessment and goal setting in patients with traumatic brain injury include:

• Is the patient able to follow commands: one-step two-step or multi-step commands?
• Is the patient oriented to the place and/or time of the person?
• Does the patient recognize family members?
• Does the patient demonstrate any insight into what is going on?

It is recommended to consult with other members of the MDT/IDT before assessing body structure and function activity and participation, including sports or community reintegration assessed in a variety of settings, as traumatic brain injury patients may have difficulty performing skills in different settings.

Treatment during the active rehabilitation phase should address the following:

• Secondary Impairments Risks
• Educate patient caregivers and families about injury prognosis and care planning
• Joints Integrity and Mobility
• Motor functions (motor control and motor learning)
• Muscle Performance (Strength Endurance)
• Postural Control and Balance
• Gait and Locomotion
• Aerobic Capacity and General Fitness
• Sensory Awareness Skin Integrity Perception and Cognitive Enhancement
• Vestibular assessment[13]
• Manage pain, such as arm paralysis or hypersensitivity reactions, with skilled handling support and analgesia
• Strengthen activities of daily living, including self-care skills, household management, and social roles
• Restore ability to play/school/work and social and recreational activities
• Safety 
• Discharge Planning

Interventions to support the recovery and rehabilitation process after moderate to severe traumatic brain injury should adhere to motor learning principles such as the use of augmented feedback doses and practice distribution taking into account fatigue and cognitive impairment Extended use Restorative and compensatory interventions.

Therapeutic techniques and procedures used in physical therapy for moderate to severe traumatic brain injury patients may include:

• For task-oriented practice, the most promising approaches are CIMT and motor gait training.
• Exercise training with bodyweight support and ground exercises.
• Locomotion supports sit-stand exercises for strength training and stand-up balance retraining.
• Do cardiovascular training with a bicycle ergometer or equipment such as a treadmill or circuit training.
• Range of motion and stretching.
• Mobilization and manipulation and use of other MSK techniques.
• Resistance training using general principles but with postural control impairments and associated adjustments in mind for safe and effective training.
• Hands-on training for patients who are unable to move voluntarily or who have not recovered adequately, including movement-facilitated-inhibition techniques and active-assisted exercises.
• Use a variety of modalities for sensory stimulation, including auditory, olfactory, gustatory, visual, tactile-kinesthetic, and vestibular systems [13], as well as environmental enrichment.
• Functional electrical stimulation (FES) has limited evidence of long-term efficacy, but can aid in repetitions and support movement quality.
• Midline oriented exercises enhance body pattern and weight transfer.
• Use a variety of pose groups, including bends, bridges, side lying, prone, four point kneeling, high kneeling, sitting, perching, standing, step, standing, prone, etc.
• Dual-task training supports motor and balance recovery or re-education using motor and cognitive additional tasks.
• Structured Community Reintegration Program/Community Reintegration Program to develop higher levels of motor skills, social and cognitive skills, safety awareness, interaction with others, money management, etc. to prepare a person with a brain injury to return to independent living and Possibly go to work/school/play.
• Educate patients/carers/families to enhance understanding of the cognitive deficits that determine motor-acquired behaviors that challenge the principles of mobility and balance practice management safety, use workshop format talks guidelines resources membership of non-profit organizations Examples include Headway or the American Brain Injury Association.
• By raising awareness of the required practice and need to take responsibility for one’s recovery goal setting, selection of activities to practice, feedback on environmental settings, reminder strategies, scheduling guide usage and monitoring.
• Use equipment and provide instructions to patient relatives and caregivers for safe use and proper installation.
• A multifactorial approach addressing all balance components takes into account individual tasks and fall prevention for environmental change interventions.

Individuals who have suffered a traumatic brain injury should be offered as many opportunities as possible to practice their skills outside of formal physical therapy sessions.

Chronic Stage

The rehabilitation process is a continuum from inpatient to community based, and adults with persistent impairment from traumatic brain injury should have ongoing access to clinicians and other health and social care workers who are trained and experienced in care and support support Human traumatic brain injury. According to the “Rehabilitation After Brain Injury” BSRM guidelines, every brain-injured patient should receive specialist neurorehabilitation as needed, possibly for life. [10] Powell et al. [14] proposed Multidisciplinary community-based rehabilitation after severe traumatic brain injury can yield benefits even years after the traumatic brain injury exceeds the active treatment period.

Input for this phase will be similar to the previous phases and the focus should be on:

• Receive the support and treatment needed to meet the changing clinical social and psychological environment of patients and their caregivers
• Interlocking assessment and treatment
• Need for goal setting and patient-centered care
• Choose safe and effective treatments and procedures
• Initiate the process and self-manage activities with the guidance and support provided by the clinician
• Emphasize education on when to seek advice and which health professional to seek it from
• Facilitate access to charitable help from community initiative support groups.

During this phase, different subpopulations of patients will have different needs depending on the degree of functional recovery.

• Patients with a “severe disability” may require ongoing assistance with all aspects of their primary care specialist intervention, such as postural support programs and specialized equipment for spasticity management supervised by a therapist or consultant and provided by a trained support team.
• Patients residing in community facilities, after some recovery, can participate in outpatient treatment to address problem areas caused by brain injuries.
• Patients who recover significantly may be able to engage in mainstream activities focused on physical and mental health, with minor adjustments such as yoga mindfulness classes, strength and conditioning exercises, group cycling or running activities, as advised by a therapist.
• Patients with potential and goals to return to work/school will benefit from a combination of cognitive and occupational therapy to prepare them for the transition back to a potentially more stimulating environment with multitasking demands. [15]

Resources

• Safer Patient Care Clinical Procedures
• A Beginner’s Guide to Posture Management
• Lycra apparel for neurological and musculoskeletal disorders
• Posture Care – A 24-Hour Posture Management Guide for Home Caregivers