TRAUMATIC BRAIN

INJURY (TBI)

Andre Newcome, PT, DPT, NCS

Trustpoint Rehabilitation Hospital (Lubbock, TX)

1
OBJECTIVES
• By the end of the presentation the participants will be able to:
• Describe the differences between ABI and TBI
• Recognize the common mechanisms of injury for TBI
• Define and describe the 8 levels of brain injury using the Ranchos Los Amigos Brain
Injury Scale
• Recognize the physical, cognitive and social manifestations that are a part of the
sequelae of TBI
• Implement physical therapy techniques to treat this patient population
• Understand case studies of real patients with TBI
TRAUMATIC BRAIN INJURY

• Definition:

• TBI is an insult to the brain, not of a degenerative or congenital nature but caused
by external physical force, that may produce a diminished or altered state of
consciousness, which results in an impairment of cognitive abilities or physical
functioning. It can also result in the disturbance of behavioral or emotional
functioning. These impairments may be either temporary or permanent and cause
partial or total functional disability or psychological maladjustment

• National Head Injury Foundation (1996)

TBI VS. ABI (ACQUIRED BRAIN IN JURY)

• Acquired Brain Injury

• An ABI is an injury to the brain that has occurred after birth and is not
hereditary, congenital or degenerative. The injury commonly results in a change
in neuronal activity, which affects the physical integrity, the metabolic activity,
or the functional ability of the cell. The term does not refer to brain injuries
induced by birth trauma. This includes TBI and injuries caused by an internal
insult to the brain

• A TBI is an ABI; an ABI is not necessarily a TBI

• Brain Injury Association of America (1997)

PATIENT POPULATION - DIAGNOSES
• Traumatic Brain Injuries

• Subdural hematoma ( often pairs with SAH)

• Subarachnoid hemorrhage (often pairs with SDH)

• Epidural hemorrhage

• Acquired Brain Injuries

• Brain tumors

• Anoxic brain injuries

• Seizure disorders ie. status epilepticus vs. myotonic vs. myoclonic vs. absent
seizure
Subarachnoid hemorrhage
Subdural hematoma
CLASSIFICATION OF BRAIN INJURY
• Rancho Los Amigos Brain Injury Scale
• I - No Response

• II - Localized Response

• III - Generalized Response

• IV - Confused Agitated

• V - Confused Inappropriate

• VI - Confused Appropriate (forms new memories)

• VII - Automatic Appropriate (terminal point in hospital)

• VIII - Purposeful Appropriate

CASE STUDY - 1

“The Lone Ranger”

CASE STUDY 1 HP
• Patient is a 19 year old female admitted to OU Medical Center on 3/30 following MVC.
Patient was reportedly a restrained driver who rear-ended an 18 wheeler that had juste merged
onto the highway front he side of the road. Patient had immediate loss of consciousness, GCS
3. Prolonged extraction from vehicle and was intubated at the scene. Injuries included closed
TBI with right frontal lobe contusions, diffuse axonal injury, crushed sternum, multiple rib
fractures with lung contusions, pneumothorax, facial fractures/lacerations and right ear
avulsion. She required prolonged intubation and sedation and ultimately underwent PEG and
trach placement on 4/17.

• She was transferred to LTAC on 4/24 for continued care. She had marked agitation, requiring
Haldol, ativan and scheduled seroquel. Fit for braces due to left knee and ankle contracture.
During stretching of lower extremities family reports that patient screams and cries. She has
been on baclofen and scheduled fentanyl patch.

• She is total to maximal assistance for transfers, limited by increased tone in right and left leg.
Negative doppler in bilateral lower extremities. Per parents, she has not been out of bed since
injury

• LOS: 10 weeks
DETAILS - 1

• Presentation

• Treatment progression

• Equipment

• Discharge
EPIDEMIOLOGY
• 1.7 million people with brain injuries are treated in emergency departments

• 275,000 with injuries severe enough to require hospitalizations

• 50,000 people die of TBI per year

• 80,000 injuries result in disability

• 5.3 million people are living with permanent disability

INCIDENCE
• Higher for males than females

• 2:1

• Ages between 15 and 24 years old

• Child abuse

• Accounts for 64% of infant TBI

• 50,000 children sustain bike related TBI

• Helmets reduce the risk by 85%

COSTS ASSOCIATED WITH TBI
• Annual cost: 56.3 million per year

• Per individual cost:

• Moderate TBI: $14,000 - $60,000 per year

• Severe TBI: $85,000 – $145,000 per year

• Vegetative state: $145,000 - $185,000 per year

CAUSES OF TRAUMATIC BRAIN INJURY
• Motor vehicle crashes (44-50%)

• Falls (20-26%)

• Gunshot wounds (primary cause of fatality from BI)

• Sports injuries

• Workplace injuries

• Domestic violence

• Military actions
CAUSES OF ACQUIRED BRAIN INJURY
• TBI

• Tumor

• Blood clot

• Stroke (Intracerebral hemorrhage)

• Seizure

• Partial - simple, complex

• Generalized - Myotonic, myoclonic, absence seizure, status epilepticus

• Toxic Exposure (substance abuse)

• Lack of oxygen to the brain (hypoxia vs. anoxia)

CASE STUDY - 2

“Long Live the King”

CASE STUDY 2 HP
• Patient is an 18 year old right handed male involved in MVC on 5/19 resulting in severe injuries. He was a front
seat passenger, ejected from car, presumed unrestrained, +LOC with fatality of passenger in back of car. He was
brought to BUMC for care requiring intubation in ER for GCS of 3. Injuries included severe closed TBI, right
proximal femur fracture, right 1st and 2nd rib fracture, pulmonary contusions with aspiration, bilateral
pneumothoraces, right adrenal hemorrhage, right kidney laceration, avulsion injury to the right cheek, right orbital
floor fracture, dorsal maxillary sinus wall fracture, right zygomatic arch fracture, lateral nasal bone fracture, right
frontal process of maxillary fracture and left clavicle fracture. MRI of the brain on 5/25 showed bilateral
temporal lobe contusions, innumerable foci of hemorrhagic sheer injury to bilateral cerebral hemispheres
including frontal lobes, corpus callosum, left caudate nucleus, right lentiform nucleus, right posterior limb of the
internal capsule, right SDH and IVH without shift. EEG showed moderate to severe encephalopathy with
bilateral focal slowing, bilateral epileptiform sharp waves bilaterally.

• On 5/19 right frontal twist drill burr hole for insertion of ventriculostomy shunt. He required IVC filter on 5/20.
Underwent right IM nail placement to right hip. Percutaneous trach and PEG tube placed on 5/29.

• Managed with blood transfusion, given metoprolol in ICU for tachycardia and developed hypernatremia which
was managed with free water. He was decannulated on 6/14; started following commands on 6/11. He uses
gestures to communicate including head nods and pointing. He has not been verbalizing as of yet.

• He presents with left sided weakness; arm more than leg and spasticity in left UE managed with splinting.

• LOS: 8 weeks
DETAILS - 2

• Presentation

• Treatment progression

• Equipment

• Discharge
ANATOMY REVIEW - FRONT LOBE
• Frontal Lobes

• Have extensive connections with many brain regions, especially with the parietal lobe and
the limbic system (emotions)

• Includes the motor strip

• Prefrontal lobes - located at front part of frontal lobes

• Holds information in memory for several minutes=working memory

• Regulates judgment/behaviors, motivation, executive functions, and working memory

• Responsible for teaching a person to learn from mistakes

• Ex. carryover
ANATOMY REVIEW - FRONTAL LOBE
• Application - difficulty with the following:

• Apply signals from environment

• Assign priorities

• Make decisions

• Initiation

• Attend to tasks

• Control emotions

• Behave in social situations

ANATOMY REVIEW - PARIETAL LOBES

• Parietal Lobes

• Behind frontal lobes

• Includes the primary sensory cortex which is posterior to motor strip

• First part of brain to consciously register physical sensations

• Regulates responses to touch, heat, cold, pain, and body awareness

• With injury to one side there is limited recognition that anything is wrong with
movement on the contralateral side
ANATOMY REVIEW - OCCIPITAL LOBE

• Occipital lobe

• Posterior aspect of brain

• Involves the visual cortex

• Connected to the eyes by optic nerves

• Optic nerves carrying signals which meet at optic chiasm

ANATOMY REVIEW - TEMPORAL LOBES

• Temporal lobes

• Lateral sides of brain

• Centers for language, hearing, and their connections to the hippocampus

• Helps in long-term storage of permanent memories

PATHOPHYSIOLOGY OF BRAIN INJURY

• Contusions and lacerations

• Can present with or without skull fracture

• Injury can be associated cranial nerves

• II, III, IV, VII, VIII

• Lacerations of dura and/or arachnoid

• Can cause CSF to discharge from nose

PATHOPHYSIOLOGY OF INJURY

• Penetrating injury (open TBI)

• Fracture of skull

• Linear

• Depressed

• Jagged border

• Basilar fracture

• Due to blunt trauma

DAMAGE TO BRAIN TISSUE

• Caused by:

• Compression

• Tension/tearing/distraction of tissue

• Shearing

• Ischemia

• Combination of the above

DAMAGE TO BRAIN TISSUE

• Diffuse Axonal Injury (DAI):

• Shearing injury

• One of most common type of injury

• Unequal acceleration/deceleration of force to brain tissue

• Severing of axons

• Results in coma and decreased conscious state

DAMAGE TO BRAIN TISSUE (Pathophysiological)
• Secondary damage

• Increased intracranial pressure

• Due to swelling or intracranial hematoma

• Can lead to herniation of parts of brain

• Cingulate herniation under falx cerebri

• Uncus herniation

• Herniation of brainstem through foramen magnum

• Midline shift
DAMAGE TO BRAIN TISSUE (Pathophysiological)
• Secondary damage

• Acute hydrocephalus

• Blood in ventricular system

• Increased pressure changes the PaCO2

• Symptoms include:

• Headache, nausea, vomiting, incontinence

• CT shows increased size of ventricles

• Treatment includes insertion of drain

NEUROCHEMICAL CHANGES

• Post-traumatic neurochemical changes due to alterations in synthesis or release of both

exogenous neuroprotective agents and autodestructive agents

• Complex and specific neurochemical changes occur

• Excitotoxicity related to excessive release of glutamate, acetylcholine and other NT

• Derangement of cellular metabolic processes and membrane potentials

• Apoptosis – happens more in pediatric TBI

• Cellular activation after diffuse TBI strongly differs from type found in local injury
CASE STUDY - 3

“Brown eyes”
CASE STUDY 3 HP
• Patient is a 23 year old right handed female with reported past medical history of seizures
and atrioventricular nodal re-entrant tachycardia; struggled with ETOH abuse. While family
was at her apartment patient felt and looked visibly weak developing generalized seizures;
prompted 911 call. She received treatment in the ER for seizures and was discharged home
with family. Upon waiting to leave hospital patient fell back onto hospital bed and became
unresponsive. She had ventricular tachycardia and ventricular fibrillation with cardiac arrest
requiring prolonged CPR. Diagnosed with anoxic brain injury. Received cardiac
echocardiogram showing ejection fraction less than 20%.

• Transferred to long term acute care for ongoing medical issues. While at LTAC unit patient
had repeat echo and showed normalized ejection fraction.

• Clinically she has severe deficits with tone, contractures and weakness. She has severe
communication deficits limiting her functional communication efforts.

• LOS: 4+2 weeks

DETAILS - 3

• Presentation

• Treatment progression

• Equipment

• Discharge
SECONDARY SEQUELAE – PHYSICAL PRESENTATION
• Tone (spasticity)/myoclonus

• contractures - heel cords, adductors, hamstrings, biceps

• Hemiparesis

• Vision changes - diplopia, hemianopsia

• Vestibular conditions

• Peripheral (Benign paroxysmal positional vertigo) - quick results if true BPPV

• Central - habituation exercises to increase threshold

• Apraxia/Ataxia - motor planning and coordination of limbs

• Balance

• Sensation and proprioception impairments

SECONDARY SEQUELAE - BEHAVIORAL/COGNITIVE

• Agitation

• Decreased safety awareness

• Initiation - apraxia

• Decreased insight into deficits

• Confusion (Corpus Christi, 1943)

• Confabulations (Reece)
SECONDARY SEQUELAE
• Insight and participation in rehabilitation

• Demonstrate decreased insight into physical and cognitive deficits

• Increases fall risk and decreases safety

• Leads to issues with participating in rehabilitation and returning to work

• Most patients are young, male

SECONDARY SEQUELAE
• Insight
• Title: Insight vs. Readiness: Factors affecting engagement in therapy from the
perspectives of adults with TBI and their significant others
• Purpose: Explore self-awareness and insight while considering the concept of readiness
as it relates to the experiences of engaging with care for adults with moderate-severe TBI
and their significant others
• Methods: Minimal prompting interview with TBI survivors and their loved ones
describing their stories of care during rehabilitation

O’Callaghan, A., McAllister, L., Wilson, L. (2012). Insight vs. readiness: factors affecting engagement in therapy from the
perspective of adults with TBI and their significant others. Brain Injury. 26 (13-14); 1599-1610
SECONDARY SEQUELAE
• Results
• Data from responses suggests that having insight and being ready for rehabilitation
was essential in assuring engagement in physical therapy
• When patients were engaged and willing to participate there was quicker uptake of
strategies learned with improved physical results
• Timing of rehabilitation was also an important factor
• Dilemma
• Is it ethical and in our best practice act to delay rehabilitation in this population
considering their best window for recovery is 0-3 months?
SECONDARY SEQUELAE
• Vestibular treatment
• Title: Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology
• Purpose: Provide assessment and intervention strategies to treat those with mild TBI and
associated complaints of dizziness.

Gottshall, K. (2011). Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology.
NeuroRehabilitation. 29; 167-171.
SECONDARY SEQUELAE
• Vestibular treatment
• Treatment:
• Integration of visual, somatosensory, and vestibular system
• Habituation exercises to increase tolerance level to feelings of imbalance
• Sensory organizational testing (SOT)
• Dynamic gait exercises
• Focus on VOR
• Aerobic training with associated head movements/body movements to facilitate
somatosensory system
BRAIN INJURY TERMS
• Anosognosia - lack of awareness of abilities (no insight)

• Flaccidity - decreased muscle tone

• Paresis - weakness in one or more limbs

• Ataxia - decreased coordination

• Apraxia - difficulty planning muscle movements (ideomotor/ideational)

• Spasticity - increased muscle tone

• Nystagmus - involuntary eye movements

• Dysphagia - difficulty swallowing

CASE STUDY - 4

“NNNNOOOOOOOOOOOOOOOOOOOOO”
CASE STUDY 4 HP
• Patient is a 56 year old right handed female who sustained a severe closed TBI with major
multiple trauma in a MVC on 12/31. Injuries included large hemorrhagic contusions,
subarachnoid hemorrhage, diffuse cerebral edema with ischemic infarcts, right pneumothorax
with multiple rib fractures, shattered left wrist, left ankle and fibular fracture, left
pelvic/acetabular fracture, C4 fracture, mandibular fracture, right 5th phalanx and 5th
metacarpal fracture, right clavicle and scapular fracture. She underwent ORIF left ankel and
left wrist, ORIF right mandible, IVC filter, PEG tube placement and trach. Cervical fracture
managed with Miami J collar.

• Transferred from acute care to LTAC unit; then transferred to BIR for TBI specific
rehabilitation. She has had extensive residual deficits from her injuries including aphasia,
apraxia, dysphagia, respiratory failure, right more than left sided weakness and debility.

• During stay at BIR patient was making progress towards functional mobility requiring
intermittent minimal assistance for gait and transfers.

• 4/19

• LOS: 6+7 weeks

DETAILS - 4

• Presentation

• Treatment progression

• Equipment

• Discharge
PHYSICAL PRESENTATION

• Tracheotomy tube

• Percutaneous endoscopic gastronomy tube (PEG tube)

• Continuous feedings

• Medication

• Helmet

• Bone Flap

• Evacuation of swelling/bleeding

• PRAFO boots
Tracheotomy tube
Percutaneous endoscopic gastronomy tube (PEG tube)
Helmet
Bone flap
PRECAUTIONS
• Seizure potential/history

• Fall history/potential

• Fall precautions

• Swallowing precautions

• Dysphagia

• Specialized diet

• Pureed, ground, chopped, regular

• Honey consistency, nector consistency

• Agitation/violent behavior
TREATMENT PLANNING
• Functional mobility

• Tone management

• Weight bearing/strength training for extremities and core

• Single limb stance/forced use of affected side

• Gait training

• Balance training

• Static and dynamic

• Safety education

• Vestibular maneuvers
No Response (I) No response to pain, touch, sound or movement. PT Focus: STIMULATION
Generalized Begins to respond to external stimuli; responses include breathing, PT Focus: STIMULATION
Response (II) sweating, chewing, moaning, moving, increased BP

Localized Response Reacts more specifically to stimuli; may turn towards sound or withdraw PT Focus: STIMULATION
(III) from pain, visually track, inconsistent YES/NO responses

Confused Agitated Overreacts to stimuli, restless, impulsive, responds by PT Focus: STRUCTURE

(IV) hitting/screaming/cursing, highly focused on basic needs, attention is a
few seconds, unable to comprehend help from staff

Confused Attention for a few minutes, requires continual redirection, can be PT Focus:
Inappropriate (V) agitated, confabulation, wanders, perseveration, no new learning, STRUCTURE/REPETITIO
inappropriate in social situations N
Confused Consistently follows commands, goal directed behavior with help, poor PT Focus:
Appropriate (VI) STM, confused by changes in schedule, able to attend to simple task for STRUCTURE/REPETITIO
up to 30 minutes, impulsive, susceptible to over stimulation N

Automatic Self centered, robot like manner, distractible, overestimates abilities, PT Focus: COMMUNITY
Appropriate (VII) unable to grasp consequences to actions, poor safety and judgement,
demonstrates carryover of new learning

Purposeful Consistently oriented, initiates and completes familiar routines with PT Focus: COMMUNITY
Appropriate (VIII) intermittent assistance, able to attend for 1 hour, low frustration
tolerance, irritability/depression, recognizes impairments, poor
judgement in new situations
No Response (I) PT Focus: STIMULATION Continue to orient to time, place and situation, introduce yourself
every time, inform patient of plan, simple commands, increased time
for response, use familiar faces/voices
Generalized Response PT Focus: STIMULATION Continue to orient to time, place and situation, introduce yourself
(II) every time, inform patient of plan, simple commands, increased time
for response, use familiar faces/voices
Localized Response PT Focus: STIMULATION Continue to orient to time, place and situation, introduce yourself
(III) every time, inform patient of plan, simple commands, increased time
for response, use familiar faces/voices
Confused Agitated (IV) PT Focus: STRUCTURE Behavior is not their fault, reorientation, limit stimulation, remain
calm, quiet room, use energy to release agitation, frequent changes in
activity, rest breaks, nothing forced
Confused Inappropriate PT Focus: Quiet room, give timed or task oriented goals, have several activities
(V) STRUCTURE/REPETITION ready, make balance tasks functional, allow time for patient time to
assess their own responses

Confused Appropriate PT Focus: Quiet room, give timed or task oriented goals, have several activities
(VI) STRUCTURE/REPETITION ready, make balance tasks functional, allow time for patient time to
assess their own responses
Automatic Appropriate PT Focus: COMMUNITY Treat and talk to patient as an adult, caution with jokes or making fun,
(VII) continue to educate on impairments and that they are part of the brain
injury
Purposeful Appropriate PT Focus: Community Treat and talk to patient as an adult, caution with jokes or making fun,
(VIII) continue to educate on impairments and that they are part of the brain
injury
TREATMENT PLANNING - EVIDENCE
• Evidence for motor recovery - course of motor recovery
• Title: Review of motor recovery in patients with traumatic brain injury
• Purpose: Review motor recovery progression in those with TBI

• Jang, S.H. (2009). Review of motor recovery in patients with traumatic brain injury. NeuroRehabilitation.
24(4):349-353
TREATMENT PLANNING - EVIDENCE
• Evidence for motor recovery
• Patients with diffuse axonal injury (DAI) had slower recovery rate compared to those
with focal lesions
• DAI recovery took 6 months (upper extremity function)
• Focal damage took 3 months (upper extremity function)
• Predictors for motor recovery
• initial severity of motor weakness
• duration of loss of consciousness
TREATMENT PLANNING - EVIDENCE
• Evidence for motor recovery - motor recovery mechanisms
• Overall the recovery of DAI seems to be attributed to the recovery of the
ipsilateral and contralateral corticospinal tract
 TREATMENT PLANNING
• Evidence suggests repetition is key for motor learning and neuroplasticity
• High number of repetitions leads to cortical reorganization
• Motor learning theory states neuromuscular re-education requires thousands of repetitions
for motor learning to occur
• Remember: task specific skills with multiple repetitions
• Ex. Gait training - 1000s of steps to relearn
 TREATMENT PLANNING - EVIDENCE
• Repetition
• Title: Comparison of amounts and types of practice during rehabilitation for traumatic
brain injury and stroke
• Purpose:
• Quantify the number and type of activities performed by patients with TBI and stroke
in PT and OT sessions to determine whether the number of repetitions approaches the
number in neuroplasticity research
• Determine if there were differences based on patient diagnosis
• Determine if patient or therapist characteristics affected the type or amount of activities
performed

• Kimberley, T.J., Samargia, S., Moore, L.G., Shakya, J.K., Lang, C.E. (2010). Comparison of amounts and types of
practice during rehabilitation for traumatic brain injury and stroke. Journal of Rehabilitation Research and
Development. 47; 851-862.
 TREATMENT PLANNING - EVIDENCE
• Repetition
• Results
• Comparison between TBI and CVA groups
• No differences in reps per session were found between groups for any of the UE
and LE categories
• TBI group had more total UE reps per minute than the stroke group
• No differences were found between groups for mobility related repetitions for reps
per session
• For reps per minute TBI group had higher as compared to stroke group
• Quantified for transfers and gait training
 TREATMENT PLANNING - EVIDENCE
• Repetitions: TBI
• Average gait steps per session: 318
• Average transfers per session: 9
• Average gait steps per minute: 13
• Average transfers per minute: 0.39

• Research states repetitions need to be in the 1000s

 TREATMENT PLANNING - EVIDENCE
• Evidence for types of treatment
• Title: Effectiveness of physical therapy for improving gait and balance in individuals with
traumatic brain injury: A systematic review
• Purpose:
• Attempt to investigate the efficacy or effectiveness of non-aerobic exercise
interventions to improve balance and gait in patients with TBI
• Provide evidence based guidelines for clinical practice
• Methods:
• Literature search to evaluate outcomes of all studies on PT interventions aimed at
improving gait and balance in ambulatory or potentially ambulatory adults with TBI

• Daniel, C.B., Zampieri, C., Damiano, D.L. (2011). Effectiveness of physical therapy for improving gait and balance
in individuals with traumatic brain injury: a systematic review. Brain Injury. July 2011, 25 (644-679).
 TREATMENT PLANNING - EVIDENCE

• Evidence for types of treatment

• Results
• Exercise type
• Strong evidence that BWSTT is no better at improving gait and balance outcomes as
compared to over ground gait or gait/balance training together
• Gait and balance training together yield better outcome scores then gait and balance
exercises separately
• Exercise prescription
• Results on intensity, duration and frequency were variable
• Generally:
• PT sessions lasted 30 minutes - 1 hour
• Frequency was 1-3 times per week
• Duration was 2 weeks to 6 months
 TREATMENT PLANNING - EVIDENCE
• Evidence for motor recovery
• Title: Long-term recovery of motor function in a quadriplegic patient with diffuse axonal
injury and traumatic hemorrhage: A case report
• Purpose: To report on the motor recovery of a 17 year old male who suffered a severe
traumatic brain injury
• Case presentation:
• lost consciousness for 20 days after accident and had post-traumatic amneisa (PTA) for 6
months following
• complete paralysis in all extremities
• After 7 months transferred to inpatient facility; dependent for all ADLs; could not sit on
edge of bed without total assist
• By 28 months post patient was able to walk independently and perform fine motor skills

• Kim, D.G., Kim, S.H., Kim, O.L., Cho, Y.W., Son, S.M., Jang, S.H. (2009). Long-term recovery of motor function in a
quadriplegic patient with diffuse axonal injury and traumatic hemorrhage: a case report. NeuroRehabilitation. 25(2):
117-122.
 TREATMENT PLANNING - EVIDENCE
• Evidence for motor recovery
• After 28 months this patient had recovery of corticospinal tract (CST) as evident by
diffuse tensor imaging studies and functional MRI (fMRI) studies

• Message:
• Neuroplasticity and motor recovery takes time
CASE STUDY - 5

“I know you’re name isn’t Reece; but you are

Reece to me.”
CASE STUDY 5 HP
• Patient is a 57 year old female who was involved in a MVC on 6/16. Her husband did not
survive the collision. Patient sustained traumatic brain injury, including subdural hematoma
and subarachoid hemorrhage, fractured ribs, fractured sternum, left ileum fracture, sacral
fracture, right C6 facet fracture, pneumothorax, pneumomediastinum, and
pneumoperitoneum. All fractures treated conservatively with use of Miami J collar. Patient
had traumatic intubation which tore her esophagus and required criocoidotomy. In the
helicopter on the way to the hospital, patient had cardiac arrest requiring 7 minutes of CPR.
Patient had PEG placement on 6/26; found to have leakage of tube feeds into peritoneum and
became septic, requiring two abdominal washouts.

• LOS: 6 weeks
DETAILS – 5

• Presentation

• Treatment progression

• Equipment

• Discharge
MEDICATION MANAGEMENT
• Medication use to control:

• Agitation/Mood

• Swelling in brain

• Attention/focus

• Sleep patterns

• Incontinence

• Tone

• Deep vein thrombosis (DVTs)

MEDICATION MANAGEMENT
• Lovenox

• Low molecular weight heparin

• Assists with thinning blood for immobile patients; deters DVTs

• Nystatin

• Assists with maintaining oral hygiene

• Provigil

• Wakefulness promoting medication

• Assists with alertness

MEDICATION MANAGEMENT
• Klonopin

• Benzodiazepine

• Assists with calming (ex. Casting)

• Valproic Acid (VPA)

• Anti-epileptic/anti-seizure

• Assists with mood control – can result in elevated ammonia levels

• Keppra

• Anti-seizure
MEDICATION MANAGEMENT
• Trazodone

• Antidepressant

• Amantadine

• Antiviral

• Antiparkinsonian - tremors and involuntary movements

• Seroquel

• Antipsychotic

• Controlling mood and behaviors

• Baclofen

• Controls spasticity/tone
EQUIPMENT USED TO FACILITATE GAINS
• Tilt in space wheelchair

• Body weight supported treadmill system

• Columbia gait trainer and shopping cart – automatic gait training

• Double adjustable ankle foot orthotic

• Traditional gait devices

• Balance master

• Staircase - single limb stance/forced use of affected side

• Swiss ball/peanut/wedges
Double adjustable ankle foot orthotic
Columbia Gait Trainer
EQUIPMENT - WHEELCHAIRS
• Progression:

• Tilt-in-space wheelchair

• Tone management, agitation, fatigue

• Headrest

• Manual wheelchair with solid back

• Jay J3, Comfort Company

• Manual wheelchair with sling back

Tilt-in-Space Wheelchair
EQUIPMENT - RESTRAINTS
• Enclosure bed

• “Caged” bed around hospital bed with zipper

• Encourages safety for patient and staff

• Used for patients who tend to have high fall risk

• Roll belts

• Velcro belt on top of mattress

• Allows for rolling and sitting up

Enclosure Bed
EQUIPMENT - RESTRAINTS
• Mittens

• Padded glove around hand

• Used for patients who punch, pull, pinch

• Wrist restraints

• Velcro around wrist

• Attaches to wheelchair/bed

• Used for pulling, punching, pinching

EQUIPMENT - RESTRAINTS

• Bed alarm

• Set when patient is in bed

• Seat belt alarm

• Attaches around waist in wheelchair

• Used for impulsivity, decreased insight, unsafe patients

TEST AND MEASURES

• BERG balance test - passing score=45/56

• Functional Independence Measure (FIM)

• 6 Minute Walk Test

• Dynamic Gait Index

• Balance Master

• Modified Ashworth Scale

• Agitated Behavioral Scale

• Alertness and Orientation (x4)

PHYSICAL FUNCTIONAL RATINGS – INPATIENT
REHABILITATION
• Functional Independent Measures (FIM)

• 1 - total assist

• 2 - maximal assist

• 3 - moderate assist

• 4 - minimal assist

• 5 - supervision assist

• 6 - modified independent

• 7 - independent
DISCHARGE PLANNING
• Plan according to multiple factors:

• Patient physical status/function

• Availability for caregivers to provide assistance/supervision

• Discharge FIM (<6 will require supervision)

• Insurance
DISCHARGE LOCATIONS
• Transitional Facilities:

• PATE, CNS, TLC

• Provides residential living with nursing staff

• Provides 6 hours of comprehensive, multidisciplinary therapy

• Heavy on cognitive therapy

• Not covered by Medicare

DISCHARGE LOCATIONS
• Day Neuro Program

• Baylor Day Neuro, PATE, CNS, TLC

• Patients live at home and commute in everyday

• 6 hours of therapy

• Emphasis on cognitive therapy

• Group treatments

• Return to work

• Driving

• Not covered by Medicare

DISCHARGE LOCATIONS
• Skilled Nursing Facility (SNF)

• Continues to provide multidisciplinary therapy

• PT, OT, ST

• Reserved for patients who do not qualify for transitional/DN (insurance)

• Reserved for patients who make slow progress

• Accept Medicare
DISCHARGE LOCATIONS

• Traditional outpatient

• Home Health

• Real Life Rehab

FAMILY IMPLICATIONS

• TBI creates complex and long-term demands on the family system and community

• Devastation associated with the physical injury

• Emotional instability of the family

• Financial burdens associated with care

• 5% of families are financially prepared to care for TBI survivor

• A common denominator for all families is the awareness that they have been changed forever
FAMILY IMPLICATIONS
• Blaming and Grieving - normal part of brain injury recovery for family

• Staff should:

• Facilitate coping strategies

• Allow families to express their feelings

• Remind family members not to blame TBI survivor

FAMILY IMPLICATIONS

• Return to work

• Demographics of TBI survivors

• Young, male

• Return to work is a common issue with progression and discharge from hospital setting
 FAMILY IMPLICATIONS
• Evidence for Return to Work

• Title: Prognostic factors to return to work after acquired brain injury: a systematic review

• Purpose

• Provide insight into the prognostic factors of RTW in people with ABI/TBI

• Methods

• Systematic literature search performed using PubMed, EMBASE, CINAHL, PsychINFO

databases

• Van Velzen, J.M., Van Bennekom, C.A.M., Edelaar, M.J.A., Sluiter, J.K., Frings-Dresen, M.H.W. (2009). Prognostic
factors of return to work after acquired brain injury: a systematic review. Brain Injury. 23(5); 385-395.
FAMILY IMPLICATIONS

• Evidence for Return to Work

• Results

• Predicting factor with the most significance for RTW  Length of stay in rehabilitation
unit

• Longer length of stay=decreased chance of returning to work

• Predicting factors with the least significance for RTW 

• Anatomic lesion, injury severity (GCS), presence of anxiety/depression

FAMILY IMPLICATIONS
• Evidence for Return to Work

• Clinical Application

• Awareness of prognostic and non-prognostic factors for RTW can assist in developing a
treatment plan

• Training can focus on the ICF model while including the levels of function/structures and
activities/participation
FAMILY IMPLICATIONS
• Participation in the home

• Title: Gaining insight into patients’ perspectives on participation in home management activities after
traumatic brain injury

• Purpose: examine amount of participation in the home by TBI survivors

• Results:

• Activities performed pre-injury: 4

• Activities performed post-injury: 3

• Implications?

• Powell, J.M., Temkin, N.R., Machamer, J.E., Dikmen, S.S. (2007). Gaining insight int patients’ perspectives on participation
in home management activities after traumatic brain injury. American Journal of Occupational Therapy. 61, 269-279
LAB

• Low level postural control/sitting balance

• Initiating stand with Swiss ball

• Single limb stance/forced use

• Non-traditional gait training

• Dual task (discuss)

CASE STUDY - 6

“My friend, my friend….”

CASE STUDY 6 HP

• Patient is an 18 year old right handed male with history of gastritis who presented to ER on
4/4 with epigastric pain. Prescribed IV Zantac but instead patient received 50 mg of IV
vecuronium. The patient was later to be found unresponsive and a code was called. He was
intubated and placed on hypothermia protocol and managed in the ICU. His course was
complicated with prolonged respiratory failure requiring trach placement and PEG tube. He
was managed for seizures vs. anoxic myoclonus with Phenobarbital, keppra, VPA and
klonopin. EEG early did show diffuse cerebral insult, hypoxic ischemic encephalopathy, and
discharge emanating from the left parieto-occipital region. Developed marked pain and
swelling in left elbow, hip and knee; CT showed myositis ossificans. Pain in these areas is
improving but range of motion and tolerance to movement is still limited. He has required
ongoing need for all functional mobility including transfers and self-care. Patient has not
been able to ambulate since incident.

• LOS: 7 weeks
DETAILS - 6

• Presentation

• Treatment progression

• Equipment

• Discharge
QUESTIONS?
References
• Daniel, C.B., Zampieri, C., Damiano, D.L. (2011). Effectiveness of physical therapy for improving gait and balance in
individuals with traumatic brain injury: a systematic review. Brain Injury. July 2011, 25 (644-679).

• Gottshall, K. (2011). Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology.
NeuroRehabilitation. 29; 167-171.

• Kimberley, T.J., Samargia, S., Moore, L.G., Shakya, J.K., Lang, C.E. (2010). Comparison of amounts and types of practice
during rehabilitation for traumatic brain injury and stroke. Journal of Rehabilitation Research and Development. 47; 851-862.

• Van Velzen, J.M., Van Bennekom, C.A.M., Edelaar, M.J.A., Sluiter, J.K., Frings-Dresen, M.H.W. (2009). Prognostic factors
of return to work after acquired brain injury: a systematic review. Brain Injury. 23(5); 385-395.

• O’Callaghan, A., McAllister, L., Wilson, L. (2012). Insight vs. readiness: factors affecting engagement in therapy from the
perspective of adults with TBI and their significant others. Brain Injury. 26 (13-14); 1599-1610.

• Powell, J.M., Temkin, N.R., Machamer, J.E., Dikmen, S.S. (2007). Gaining insight int patients’ perspectives on participation
in home management activities after traumatic brain injury. American Journal of Occupational Therapy. 61, 269-279.

• Jang, S.H. (2009). Review of motor recovery in patients with traumatic brain injury. NeuroRehabilitation. 24(4):349-353.

• Kim, D.G., Kim, S.H., Kim, O.L., Cho, Y.W., Son, S.M., Jang, S.H. (2009). Long-term recovery of motor function in a
quadriplegic patient with diffuse axonal injury and traumatic hemorrhage: a case report. NeuroRehabilitation. 25(2): 117-122.