Physiotherapy Management of Traumatic Brain Injury
Original Editor - Anna ZiemerDisha Rupareliya as part of the One Page Project
Just as two people are not exactly alike, no two brain injuries are exactly alike. Therefore, approach to neurological rehabilitation and physiotherapy post-traumatic brain injury should observe neuroplasticity, motor learning, and motor control principles as well as the patient-centred approach with an individual’s goals setting and choice of treatment procedures.
Specific Measurable Achievable Relevant Timed goals and patient’s involvement in goal setting allows the clear orientation of the rehabilitation process and enhances individual speciality targets and plans to contribute to the overall rehabilitation outcome. Patient’s goals for rehabilitation vary according to the stage of recovery and their condition.
Physiotherapy is an integral part of the MDT/IDT neurological rehabilitation team and neurological physiotherapy is an integral part of neurological rehabilitation. The physiotherapy programme may require input from a range of clinicians, including Physiotherapists, Occupational Therapists and Orthotists. It should be directed by professionals with experience in the management of neurological conditions.
Neurological physiotherapy is a process of interlocked assessment, treatment and management by which the individual with traumatic brain injury and their relatives/caregivers are supported to achieve the best possible outcome in physical, cognitive, social and psychological function, participation in society and quality of life. Discharge planning starts at an early stage of rehabilitation and overlaps with the UK Rehabilitation Prescription initiative wherefrom the sub-acute stage there is a process of identification of future rehabilitation needs being established and patients’ rehabilitation journey is informed by individual patient’s needs and takes place through a graded pathway of services. Goals and expected outcomes are closely monitored and when being achieved the process of discharge to another service or home/care institution intensifies.
Recovery of function following brain damage can occur in two processes:
- Spontaneous Recovery: process related to repair of central nervous system early after brain injury and regression of diaschisis.
- Function-induced Recovery: process based on promoting neuroplasticity in response to activity practice and environmental stimulation leading to behavioural change like in Constraint-Induced Movement Therapy training protocol.
Principles of Experience Dependent Neuroplasticity 
- Use it or Lose it: Function unused deteriorates
- Use it and Improve it: Function used improves
- Specificity: Neuroplastic change is determined by task used
- Time Matters: Different time of training is related to different neuroplastic changes
- Repetition Matters: Sufficient repetitions required to intensify neuroplasticity
- Intensity Matters: Sufficient intensity required to intensify neuroplasticity
- Salience Matters: Sufficiently meaningful task triggers plasticity
- Age Matters: Younger brains demonstrate more plastic changes with training
- Transference: Neuroplastic change following training of one task might enhance similar task acquisition
- Interference: Plasticity in response to one experience can interfere with the acquisition of other behaviour. 
Physiotherapeutic interventions can be grouped into three main categories:
- Restorative interventions focusing on reactivation of penumbra and diaschisis and restoring premorbid movements
- Compensatory interventions focusing on optimal function enhancement using remaining skills to compensate the loss, i.e.: using non hempleigic side for personal care
- Preventative interventions focusing on reducing impairment and promoting general health, i.e.: respiratory physiotherapy enhancing chest health.
The categories include treatment techniques and activities like; 
- Therapeutic exercises
- Manual therapy techniques like mobilisations or manipulations
- Prescription and application of equipment like orthotic or prosthetic devices, mobility aid, wheelchair
- Airway clearance techniques
- Functional training in self-care (ADLs) and home care
- Functional training at work, school, play and leisure activities including community reintegration
- Use of physical agents and other modalities use like hydrotherapy, electrotherapy, cryotherapy
- Integumentary protective techniques enhancing tissue viability
- Discharge Planning
In prescription of interventions following parameters could be used:
- Method, Mode or Device
- Intensity, Load or Tempo
- Duration and Frequency
Physiotherapy Management of Moderate to Severe Traumatic Brain Injury
Good practice recommends complete medical record examination to establish precautions and contraindications as patient might not be medical stable due to increased Intracranial Pressure (ICP), respiratory needs like mechanical ventilation in situ, orthopaedic injuries restricting loading or range of motion. A recent literature review suggests a need for comprehensive cardiopulmonary evaluation as the patients with moderate-to-severe TBI suffer from reduced maximal aerobic capacity and resting pulmonary capacity parameters post-injury. Lack of addressing these issues may lead to poor functional outcomes.
Goal setting should be informed by examination which might include arousal, attention, and cognition, skin integrity, sensory integrity, motor function, range of motion, reflex integrity, ventilation and respiration/gas exchange, tolerance to being handled, transferred as well as seated.
Treatment at acute stage should address:
- Stimulation of level of alertness via multifactorial modalities
- Physical function stimulation to improve motor and postural control, maintain mobility, normalise muscle tone
- Reduction of secondary complications via spasticity management and contracture prevention, heterotrophic ossification prevention, chest management, skin integrity management, prevention of infection, DVT prevention
- Optimising respiratory care containing positioning, mobilisation, oxygen therapy, manual techniques, tracheostomy management and weaning strategy by IDT Team of Consultant, Nurses, Physiotherapist and Speech and Language Therapist
- Maintenance or regaining of tolerance to being physically challenged and positioned in sitting or standing
- Pain management via skilled handling, support and pain relief, i.e. of paretic arm or in case of hypersensitivity
- Family and caregivers’ education on patient’s diagnosis and management of traumatic brain injury complications including equipment use.
- Rising Safety Awareness
- Discharge Planning
Treatment techniques and procedures might include:
- Early mobilising via passive or active-assisted handling advised by nursing and physiotherapy staff.
- Movement facilitation using neuro-developmental or neuromuscular concepts
- Positioning on the bed in various postural sets including side-lying and prone when appropriate and position changes every 2 hours.
- Positioning out of Bed i.e.: in the wheelchair or specialist supportive chairs to enhance early recovery and increased level of alertness led by Physiotherapist and supported by provision of the suitable seating system.
- Verticalization, i.e.: using a tilt table or with an increased number of therapists (3-4) to ensure weight bearing and stimulate alertness.
- Splinting including Lycra garment and serial casting with consideration of communication, cognition and behaviour deficits and its impact on safety and compliance.
- Sensory stimulation of auditory, olfactory, gustatory, visual, tactile-kinesthetic and vestibular systems and environmental enrichment.
- Balance and postural control training like weight shift and midline orientation activities when transferring and in side-lying or sitting.
A randomised control trial carried out on critically ill traumatic brain injury (TBI) patients suggests positive outcomes with neuromuscular electrical stimulation (NMES). The study showed no significant reduction in muscle thickness of the Tibialis Anterior and Rectus Femoris muscle when NMES was applied for fourteen consecutive days as compared to the control group who received only conventional physiotherapy.
To facilitate MDT/IDT approach 24-hour written and photographic guideline should be provided to ensure consistency amongst team members. The guidelines might contain elements of postural advice, chest clearance techniques, use of Dynamic Orthosis / Lycra Garmentsor Splinting. Clear goals explanation and expected outcomes to be defined and included to promote awareness and rationale from choses treatments.
Active Rehabilitation Stage
Patients with moderate to severe traumatic brain injury require structured rehabilitation with appropriate services from acute to long term community-based provision with domiciliary and outpatient options. According to “Rehabilitation following Brain Injury” BSRM guideline patient with traumatic brain injury should be transferred as soon as possible to a rehabilitation programme of appropriate intensity to meet their needs and receive as much therapy as they need, can be given and find tolerable. (G11)
- Inpatient rehabilitation is an intensive specialist rehabilitation for people who are not clinically and functionally ready for home discharge from acute settings. Neurological rehabilitation centres offer structured programmes with intensive daily schedule of interdisciplinary interventions, nursing care and medical care from Rehabilitation Medicine Consultant. The interventions are goals based and discharge carefully planned from the beginning of the process.
- Outpatient rehabilitation is intended for people who are well enough to return home but require further rehabilitation. It might be provided by a otal or separate rehabilitation centre.
- Community rehabilitation is intended for people who completed an inpatient rehabilitation but still need to work on independent living skills often within transitional living unit. Some people might continue the rehabilitation process whilst living in their homes and receiving support from community rehabilitation team or outreach team helping them to make further progress. The therapy might take place at a patient’s home, within local community facilities like supermarket, gym, school, etc.
- Is the patient able to follow commands: one-step, two-step, or multistep commands?
- Is the patient oriented to person, place, and / or time?
- Does the patient recognise family members?
- Does the patient demonstrate any insight into what has happened?
Consultation with other members of MDT/IDT is recommended followed by the assessment of body structure and function, activity and participation including locomotion or community reintegration evaluated in various environments as patients with a traumatic brain injury might struggle to perform skills in different settings.
Treatment in the active rehabilitation stage should address the following:
- Secondary Impairments Risks
- Provision of education for patient, care givers and family about the injury, prognosis and care plan
- Joints Integrity and Mobility
- Motor Function (motor control and motor learning)
- Muscle Performance (strength, power, endurance)
- Postural Control and Balance
- Gait and Locomotion
- Aerobic Capacity and General Fitness
- Sensory awareness, skin integrity, perception and cognition enhancement
- Pain management via skilled handling, support and pain relief, i.e. of paretic arm or in case of hypersensitivity
- Enhancement of activities of daily living including self-care skills, home management and social roles
- Capacity to resume Play / School / Work and Social and Recreational Activities
- Discharge Planning
Interventions supporting recovery and rehabilitation process following moderate to severe traumatic brain injury should abide by the motor learning principles like use of augmented feedback, dose and distribution of practice with consideration of fatigue and cognitive impairment extend, use of restorative versus compensatory interventions.
Treatment techniques and procedures used in motor rehabilitation of people with moderate to severe traumatic brain injury physiotherapy might include:
- Task orientated practice with most promising approaches being CIMT and Locomotor gait training.
- Locomotion training with bodyweight support and overground practice.
- Locomotion’s supporting training of strength, sit-to-stand practice and standing balance retraining.
- Cardio-vascular training with the use of equipment like cycle ergometer or treadmill or circuit training.
- Range of motion and stretching exercises.
- Mobilisation and manipulation and use of other MSK techniques.
- Resistance training with generic principles but with consideration of postural control impairment and relevant adjustments allowing safe and efficient training.
- Hands-on training for patients who are unable to move voluntarily or demonstrating insufficient recovery including movement facilitation, inhibition techniques, and active assisted exercises.
- Sensory stimulation using various modalities including auditory, olfactory, gustatory, visual, tactile-kinaesthetic and vestibular systems and environmental enrichment.
- Functional electrical stimulation (FES) with limited evidence for long term efficacy but good being adjunct generating repetitions and supporting the quality of movement.
- Midline orientation exercises enhancing body schema and weight transference.
- Use of various postural sets including crook position, bridging, side lying, prone, 4-point kneeling, high kneeling, sitting, perching, standing, step stance, prone standing and others
- Dual tasking training supporting locomotion and balance recovery or re-education using motor and cognitive additional task.
- Structured community reintegration programme / Community re-entry programme developing higher level motor skills, social and cognitive skills, safety awareness, interacting with others, money management, etc. in order to prepare the person with a brain injury to return to independent living and potentially to work/school/play.
- Education for patient / caregivers / family to enhance understanding about cognitive deficits determining movement acquisition, behaviour that challenge management, safety principles of mobility and balance practice using seminar format, talks, guidelines, resources, membership of non-profit organisations like Headway or Brain Injury Association of America.
- Enabling through rising awareness of required practice and need to take responsibility for one’s rehabilitation, goal setting, choice of activities to be practiced, feedback, environment setup, reminder strategies, schedule, use of guidelines and monitoring.
- Use of equipment and provision of guidance for patient, relatives and caregivers to ensure safe use and appropriate fitting.
- Falls prevention with consideration of individual, task and environment changing interventions with a multifactorial approach addressing all balance components.
An individual who has sustained a traumatic brain injury should be given as many opportunities as possible to practise their skills outside formal Physiotherapy sessions.
The rehabilitation process is a continuum from inpatient to community-based activities and adults with sustained impairment from a traumatic brain injury should have ongoing access to support from clinicians and other health and social care workers trained and experienced in care and support of people traumatic brain injury. According to “Rehabilitation following Brain Injury” BSRM guideline every patient with acquired brain injury should have access to specialist neurological rehabilitation for as long as required which may be lifelong. Powell et al suggested that multidisciplinary community rehabilitation after severe traumatic brain injury yields benefits even years after the traumatic brain injury which outlives tse active treatment period.
The input at this stage will be similar to the previous stages and emphasis should be put on:
- Access to required support and therapy to meet patient’s and their caregivers changing clinical, social and psychological circumstances
- Interlocking assessment and treatment
- Need for goal setting and patient-centred care
- Choice of safe and effective treatment and procedures
- Enabling process and self-administered activities with guidance and support provided from clinician
- Education highlighting when to seek advice and from which health professional
- Facilitating access to community initiatives, support groups, charity help.
At this stage various subgroups of patients will have different needs depending on the degree of recovery of function.
- Patients with ‘profound disability’ might require ongoing help for all aspects of their basic care, specialist interventions e.g. spasticity management, postural support programmes and specialist equipment overseen by therapists or consultant and delivered by a highly trained support team.
- Patients with some degree of recovery living in community facilities may attend outpatient therapies to address problem areas resulting from their brain injury.
- Patients with a significant degree of recovery might be able to access mainstream activities focusing on physical and psychological well-being with therapist advice and minor adjustments like yoga, mindfulness courses, strength and conditioning exercise groups, cycling or running initiatives, games,tc.
- Clinical Procedures for Safer Patient Care
- A Beginner’s Guide to Postural Management
- Lycra Garments for Neurological and Musculoskeletal Conditions
- Postural Care - A Guide to 24 Hour Postural Management for Family Carers
- MUSHPWeb1. Physical Therapy Following Traumatic Brain Injury (TBI). Available from: https://youtu.be/cLJyESfqyI4[last accessed 30/08/19]
- Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech and Language and Hearing Research. 2008; 51(1):S225–239 doi: 10.1044/1092-4388(2008/018).
- Holmberg TS, Lindmark B. How do physiotherapists treat patients with traumatic brain injury? Advances in Physiotherapy. 2008;10:138-145.
- Hamel RN, Smoliga JM. Physical Activity Intolerance and Cardiorespiratory Dysfunction in Patients with Moderate-to-Severe Traumatic Brain Injury. Sports Medicine. 2019 May 16:1-6.
- Rees Doyle G, McCutcheon JA. Clinical Procedures for Safer Patient Care. British Columbia: BC Open Textbook Project, Minneapolis, 2015.
- Permobil. Wheelchair Seating & Positioning Guide. Available from: https://hub.permobil.com/wheelchair-seating-and-positioning-guide (accessed 09/09/2019)
- Royal Hospital for Neuro-Disability, Hall, S and Marshall, K, A Beginner’s Guide to Postural Management. Available from: https://www.rhn.org.uk/content/uploads/2016/07/LECTURESPMCpreswebcopy.pdf (Last Accessed: 09/09/2019)
- Silva PE, de Cássia Marqueti R, Livino-de-Carvalho K, de Araujo AE, Castro J, da Silva VM, Vieira L, Souza VC, Dantas LO, Cipriano Jr G, Nóbrega OT. Neuromuscular electrical stimulation in critically ill traumatic brain injury patients attenuates muscle atrophy, neurophysiological disorders, and weakness: a randomized controlled trial. Journal of Intensive Care. 2019 Dec 1;7(1):59.
- NHS Lanarkshire Adult Learning Disability Team Physiotherapy Department, NHS Lanarkshire Community Paediatric Physiotherapists and PAMIS South Lanarkshire. A Guide to 24 hour Postural Management for Family Carers. Available from: http://pamis.org.uk/site/uploads/postural-care.pdf (accessed 09/09/2019)
- Elizabeth Uhegwu. Lycra Garments for Neurological and Musculoskeletal Conditions. Regional Drug & Therapeutics Centre (Newcastle): Northern Treatment Advisory Group, 2018.
- Specialist neuro-rehabilitation services: providing for patients with complex rehabilitation needs. British Society of Rehabilitation Medicine. 2016. Available from: https://www.bsrm.org.uk/downloads/specialised-neurorehabilitation-service-standards--7-30-4-2015-pcatv2-forweb-11-5-16-annexe2updatedmay2019.pdf (accessed 17 September 2019)
- Turner-Stokes L, Bavikatte G, Williams H, Bill A, Sephton K. Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis. BMJ open. 2016 Sep 1;6(9):e012112.
- Fulk GD, Nirider CD. Traumatic brain injury. In: O'Sullivan SB, Schmitz TJ, Fulk GD, editors: Physical rehabilitation. 6th edition, Philadelphia:FA Davis Co., 2014. p870
- Powell J, Heslin J, Greenwood R. Community based rehabilitation after severe traumatic brain injury: a randomised controlled trial. Journal of Neurology, Neurosurgery and Psychiatry. 2002;72:193–202 http://dx.doi.org/10.1136/jnnp.72.2.193