Therapeutic Interventions for Traumatic Brain Injury

Introduction

The nature of the sequelae of traumatic brain injury (TBI) is varied. They include: physical; cognitive; behavioral; psychological; and emotional (and their intensity and complexity). Individual brain structural and functional organization and potential for neuroplastic change determine Functional recovery after brain injury. Limited knowledge about the neurophysiology and neuroplasticity of the nervous system limits the understanding of functional recovery and the effectiveness of therapeutic approaches for motor relearning in traumatic brain injury.

The goal of intervention for traumatic brain injury is to achieve the highest possible level of independent functioning to participate in daily activities. It can address an individual’s: structure and function; activity and participation; modification of environment and impairments. exist There are currently no standardized recommendations for physical therapy protocols for treating patients with traumatic brain injury, and the neurophysical therapy community uses variable and varied approaches and intensities [1]. Additionally, with Research on this patient population compels physiotherapists to draw on evidence relevant to neuroscience and other pathologies such as stroke.

The complexity of traumatic brain injury outcomes and possible accompanying injuries may require the neurophysiotherapist to use core skills such as facilitation of therapeutic exercises or physical activity prescriptions, but also clinical reasoning and knowledge of applied therapy Interventions and strategies from other professions, eg. Respiratory care, orthopedic and trauma protocols, behavioral de-escalation techniques, communication strategies, equipment supplies, and more.

Gait Training and Supporting Practice

• Strength training of the muscles around the trunk and pelvis of the lower limbs
• Perform sequential exercises from sitting to standing in closed and open biomechanical chains (surfaces at different heights, different levels of upper body use or/and facilitation)
• Standing balance exercises (dynamic exercises on the ground and/or on an uneven or reduced base of support, such as striding or standing in pairs)
• Gait: (Partial body weight supported by treadmill suspension or manually assisted trunk and extremity movements, footwork and strategy exercises in parallel bars, assisted ground exercises, acceleration-deceleration stop-start steps, strides, exercises on stairs double duty Up and down stairs transfer community mobility training, including environmental screening zebra crossing timed walk to get on and off the bus traffic to extend the distance).

[2][3]

Arm Mobility Training

Constraint Induced Movement Therapy (CIMT)

CIMT focuses on repetitive tasks of the affected upper extremity designed according to the principles of task-specific training to address specific motor deficits and utilize the upper extremity for as long as possible. A mitten worn on the unaffected side for at least 90% of waking hours or some of the time The study averaged 6 hours per day for 2-3 weeks or up to 10 weeks using a modified CIMT protocol. Behavioral techniques for engaging practice i.e. intensity and parametric contract modeling goal setting rewards for correct movement execution and feedback. Some voluntary wrist or/and fingers Attendance at CIMT training requires an extension. Functional improvements in the affected arm and patient-reported use of ADLs were reported. Protocol adherence is the most important factor in determining the outcome. There is a growing body of research on CIMT, but a recent Cochrane review on stroke is The superiority of CIMT over other forms of upper extremity rehabilitation cannot be established [4]. UPDATE: Lack of research and awareness of difficulties may be limiting factors in the use of CIMT in stroke rehabilitation. A study published in 2022 found that people with chronic mild to moderate Patients with upper limb hemiplegia after stroke are highly satisfied with the treatment effect of CIMT. Both stroke patients and therapists have found CIMT to be only moderately difficult in training to perform correctly [5]. [6] Queen Square Upper Limb Neurorehabilitation Program The Queen Square Upper extremity neurorehabilitation programs are primarily designed to address upper extremity problems after stroke, but the principles of this protocol can be successfully applied to rehabilitation after other forms of acquired brain injury, including TBI. The program involves high-quality High-dose high-intensity upper extremity neurorehabilitation was performed over 3 weeks on a 90-hour schedule. Include at least 4 hours of goal-oriented and task-specific training and structured rest each day. Processing involved: Adaptation of tasks, e.g. decomposing tasks into individual components to practice; adaptation, such as making a functional splint and adjusting tools such as utensils or screwdrivers, to enable the affected hand to participate in meaningful activities; assistance, such as reducing weight on the arm to allow Strengthen and train movement quality and control with increased range and independent task exercises. Coaching is considered a key component of the program and is used throughout to incorporate new skills and knowledge into the individual’s daily work [7]. Program participants demonstrated Better impairment-based measures and functional outcomes point to the superiority of high-dose and high-intensity interventions based on individual patient goals [8]. Range of motion must be sufficient for optimal recruitment, normal alignment and efficient function move. Inactivity and immobility reduce joint range of motion, tissue flexibility, and performance. Tissue dystrophy and increased local pain may also be associated with loss of ROM flexibility. Techniques to improve mobility include: range of motion exercises (passive active facilitation i.e. using PNF techniques) Passive stretching with continuous braces in positioned splints [Cross reference splint guide page] Joint mobilization Warming up before other forms of training Using strength and conditioning [9] Training principles include: Overload-specific cross-training (Includes elements of centripetal isometric and endurance training) To train effectively, the following need to be considered: Goals and optimal outcome measures (preferably based on functional tasks that require strength) Muscle contraction type (centripetal isometric) Model Workouts (Open & Closed Circuit Training Aquatic Synergy Mode ie: PNF Dynamic Reversal Repetitions) Resistance Type ie: Free Weights Elastic Bands Water Resistance Manual Resistance Bodyweight Frequency Intensity Duration Reps Warm Up/Cool Down protocolEndurance Training requires both physical and cognitive considerations when addressing muscular endurance fatigue (the inability to repeatedly contract a muscle over time [9]). Fatigue can affect the motor component at three levels: CNS (central fatigue) peripheral Or the neuromuscular junction muscle itself. Management of patients with low endurance and fatigue focuses on energy-saving techniques, activity rhythms and lifestyle changes, regular activity and rest periods throughout the day, and sleep hygiene. Activity logs may help identify habits lead to a period of fatigue. Aerobic Training Enhances: Cardiovascular and Peripheral (Muscular) Endurance Physical Performance Emotional – Emotional Health by Reducing Anxiety and Depression Recommended Routine for Traumatic Brain Injury Patients: 40-70% Intensity Frequency 3-5 Reps weekDuration 20-30 minutes with 10 minutes increments Possibility for people who are overtired. Balance and Postural Control TrainingBalance training components reflect the required components of effective balance reactions and include: Postural alignment body mechanics and static Postural control, including midline orientation Dynamic postural control, including the musculoskeletal responses necessary to control movement and posture, including strength flexibility and the ability to make effective anticipatory postural adjustments prior to voluntary movement. balance skills and Balance Response Repertoire Mobility Training for Various Tasks and Environmental Conditions Postural Control Using Sensory Monitoring (Visual Vestibular Proprioception) Safety Awareness and Compensation Strategies for Effective Fall Prevention [9], Including Advice on Physical Fitness Activities Polydrug environment Personal choices and behaviors such as footwear Coping strategies Guidance to curb fear of falling. For training to be effective, it needs to meet the needs of the individual and be designed for an optimal level of challenge without compromising safety. use Various postural setups and techniques to ensure varied challenges and transferable skills: Retrain postural stability with manual techniques such as rhythmic stabilization or steady reversal, even with uneven support bases such as balance pads and inclines for reduced support base (like feet) Standing/walking together in tandem 1 leg standing Using head and upper body movements Adjusting task complexity, such as dual tasks with cognitive or additional physical elements, can be used to tailor the program to individual goals. coordination and agility TrainingCoordination is the ability to perform smooth accurate and controlled movements. Agility is the ability to perform coordinated movements combined with upright standing balance [9]. Coordination and agility training goals should include: improving postural stability and balance elements Dynamic conditions Functional application of limb movement accuracy Coordination and dexterity skills Safety awareness and compensatory strategies for effective motor control and fall prevention, including mobility assistance recommendations. Using equipment and supporting equipment for functional electrical stimulation (FES) Adding electrical stimulation to functional task exercises enhances motor function and strength. There is no optimal regimen for people with traumatic brain injury. UPDATE: There are still knowledge gaps regarding the use and mechanism of FES in patients after TBI [10]. However, there are more and more There is substantial evidence that the use of FES improves mobility by increasing muscle control and recruitment [11]. It should be noted that the majority of this study also included stroke and spinal cord injury patients. Robotics and virtual reality use computer interface for interactive simulations and well-designed software. Available via widely available consoles such as the Wii PC tablet, or via complex systems such as CAREN. Exercises can focus on specific areas, such as the hands, through equipment such as Amadeoor or whole-body movement sequences, such as gait locomotive. A growing body of evidence examines the effectiveness of gaming and the use of robotics in neurorehabilitation. [12][13] Fall Prevention The multifactorial nature of fall risk in TBI patients is widely documented. Fall Prevention and Fall Training Essentials Behavioral shaping interventions are most effective through intensive long-term physical activity and education. Multiple complex TBI sequelae often overlap with injuries that contribute to fall risk, such as weakness, reduced joint mobility, stiffness, slow processing Inability to complete complex tasks. Therefore, an exercise-based fall prevention approach should incorporate the following elements: physical and cognitive components with flexibility strength dual task skills mobility stable posture active and reactive balance components to address a variety of tasks Attributes (stability, mobility or skill required) Interaction with the environment (supervised or unsupervised) Intensive program of 2-3 sessions per week Possible progression of tasks and exercises and a duration of at least 26 weeks is considered most effective. Addressing Fears of Falling and Exposure Situations that challenge the balance system are currently being researched, and emerging evidence suggests the importance of addressing falls, negative attitudes, teaching on/off transfers to improve confidence and recognizing the “feeling of falling” for appropriate strategies to address. for Patients who are unable to practice their movements on their own or who have not recovered adequately may require physically assisted movements. Facilitated movements will be agreed upon as part of the task to be learned, ie: pelvic tilt to facilitate sitting to standing, reaching, grasping, etc. manual Helping provides stability Demonstrates tactile and kinesthetic movement Reduces errors Provides purpose Provides confidence. The goal of hands-on therapy is to stop when the active motor component is enhanced to prevent dependence. ultimately led to Movements should be practiced independently to consolidate acquired skills. Neurodevelopmental Therapy (Bobath Concepts) A problem-solving approach developed by Karel and Berta Bobath that argues that every neurologically dysfunctional patient has the potential for improvement and needs Improving functional skills goes beyond developing compensation for neurological damage. The concept achieves this through thorough functional movement analysis and identification of deficiencies in motor control and task performance and through highly skilled processing techniques, thereby inhibiting Abnormal postural reflex mechanisms (righting balance protective stretch response) and promote postural alignment stability and normal movement. Facilitating key point control and sensory stimulation are the most commonly used techniques. Although in recent years the focus The validity and cost-effectiveness of Bobath’s method has been discussed in depth in the theory of motor control that allows the systematization of the underlying principles of Bobath’s concept. [14][15] However, to date, there is insufficient evidence to support any Concepts or approaches to the rehabilitation of patients with traumatic brain injury or post-stroke sequelae require further research to determine the superiority of any approach. Proprioceptive neuromuscular facilitation of PNF based on a method developed by Herman Kabat and Margaret Knott Principles: As an integrative approach: PNF focuses on intensively motivated physical exercises and results in the highest possible level of functioning as the primary goal of treatment. The concept explicitly systematizes facilitation tools into: basic programs such as resistance irradiation and reinforcement Body mechanics using tactile-kinesthetic auditory visual stimuli traction and approximate timing techniques such as rhythmic stabilization combined with isotonic dynamic reversal using stretch-contract-relax or hold-relax 3D patterns are the most recognizable elements of the method Focus on the scapula, pelvis, upper limbs, lower limbs, neck and trunk lines. [16][17] Sensory stimuli tactile proprioception Visual or vestibular sensory deficits can affect the system’s ability to move and learn new activities. Through sensory stimulation, we aim to increase concentration and arousal levels, Enhanced sensory perception selection and discrimination. [9] Techniques used to stimulate the sensory systems include: Hold pressure can be manual Lycra garments such as slow repeated stroking light touch towel wrap gloves and tights such as Massage Slow vestibular stimulation, such as swinging on an exercise ball or hammock Fast vestibular stimulation, such as spinning in a chair. The intensity of stimulation needs to be chosen carefully to prevent overstimulation and to consider the area to be applied Some areas, such as the face and especially the mouth around the soles of the feet or palms, have high receptor concentrations and large cortical representation. ClassesCircuit setup – when groups of patients complete exercises designing workstations independently with some degree of supervision Common group activity Includes: Movement Upper Body Skills Strength and Conditioning Fall Prevention Hydrotherapy. Suggested duration 6-26 weeks depending on group theme and goals; average 3 sessions per week; duration approx. 30-60 minutes. Hydrotherapy / Aquatic Therapy has enough evidence Benefits of water-based therapy on outcomes in patients with traumatic brain injury. The water environment improves neuromuscular re-education and builds strength. Buoyancy allows freedom of movement in the event of weakness or paralysis, while water resistance provides a reinforcing medium. Warm The water allows for increased tone normalization, while the viscosity and buoyancy of the water allow for postural control and balance training in sitting and standing. There are water access levels where safety principles need to be followed for surveillance and evacuation plans, which should be preceded by a risk assessment into the water environment. However, patients of all complexities can benefit from aquatic exercise. [18][19] The posture group uses various functional postures during therapy with different purposes and benefits. According to their possible poses: Improve control of various body parts: Up trunk lower trunk LE hips UE (shoulders elborbits) and normal/head controlAllow the weight-bearing through specific body parts: hips shoulders feet hands etc. Improve the strength and stability of joints: hip knee ankle should and elbor wrist 通過減少和增加正常音調在 Antagonist muscle groups provide different bases of support to affect pitch (higher base lower pitch) or COM position (higher COM higher pitch). Restricted degrees of freedom: Control lowering of upper or lower body loads or upper and lower loading of extremities. [9] Different poses Some that you may use include: Bent Position Bridge Side to Side Sit Prone and Prone Over Elbow Prone Standing 4-Point Kneeling to 2-Point Kneeling Variations to High Kneeling A useful resource, System Active Versus Passive, describes a variety of different postures and their possible impact on rehabilitation. To enable the patient to internalize the movement being learned, various motor learning components can be considered: Identify training needs: Reinforcement Understanding “responsibility for your own recovery” requires setting goals using the SMART goal principles of being salient and achievable to build motivation. Be realistic about recovery timescales! Optimal activity allows for supervised and unsupervised exercises Patiently successfully and safely within established parameters to practice the agreed upon parameters of exercise training: intensity minimum number of repetitions duration progression fatigue level type of exercise (mass vs. distributed; block vs. random; sequential block vs. serial vs. random; Partial vs Whole Mental Practice Skills Transfer Practice) Feedback Strategies: Feedback can be intrinsic such as proprioceptive vestibular visual skin or extrinsic such as auditory-tactile-visual; concurrent and terminal; individualized amount timing patterns; performance knowledge and result knowledge. Setting: Closed vs. Open Situation-specific Monitoring Strategies: Sensitive Effective and reliable measures meaningful to patient and therapist and IDT communication Internalizing and taking responsibility for one’s recovery process, including encouraging Problem Solving and Using Timesheet Reminders Guide