Physiotherapy Management of Traumatic Brain Injury: Difference between revisions

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== Introduction  ==
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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 a patient-centred approach with individual’s goals setting and choice of treatment procedures.
 


'''S'''pecific '''M'''easurable '''A'''chievable '''R'''elevant '''T'''imed goals and patient’s involvement in goal setting allows clear orientation of rehabilitation process and enhances individual speciality targets and plans contto contributeoverall rehabilitation outcome. Patient’s goals for rehabilitation vary according to stagthe e of recovery and their condition.


Physiotherapy is an integral part of 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.
== Introduction  ==
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 Control and Learning|motor learning, and motor control principle]]<nowiki/>s as well as the patient-centred approach with an individual’s [[Goal Setting in Rehabilitation|goals setting]] and choice of treatment procedures.


{{#ev:youtube|cLJyESfqyI4|250}} <div class="row"><div class="col-md-6 col-md-offset-3"><div class="text-right"><ref>MUSHPWeb1. Physical Therapy Following Traumatic Brain Injury (TBI). Available from: https://youtu.be/cLJyESfqyI4[last accessed 30/08/19]</ref></div></div></div>
'''S'''pecific '''M'''easurable '''A'''chievable '''R'''elevant '''T'''imed 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.


Neurological Physiotherapy is a process of interlocked assessment, treatment and management by which the individual with TBI 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. 
Physiotherapy is an integral part of the [[Interdisciplinary Management of Traumatic Brain Injury|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.


[[Discharge Management for Traumatic Brain Injury|Discharge planning]] starts at early stage of rehabilitation and overlaps with UK Rehabilitation Prescription initiative where frm subthe 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 agren aed pathway of services.
{{#ev:youtube|cLJyESfqyI4|400}} <div class="row"><div class="col-md-6 col-md-offset-3"><div class="text-right"><ref>MUSHPWeb1. Physical Therapy Following Traumatic Brain Injury (TBI). Available from: https://youtu.be/cLJyESfqyI4[last accessed 30/08/19]</ref></div></div></div>


Goals and expected outcomes are closely monitored and when being achieved the process of discharge to another service or home/care institution intensifies.
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 Management for Traumatic Brain Injury|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:
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.
# 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.
# 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 (Kleim and Jones 2008): ==
== Principles of Experience Dependent Neuroplasticity <ref name=":0" />  ==
# Use it or Lose it: Function unused deteriorates
# Use it or Lose it: Function unused deteriorates
# Use it and Improve it: Function used improves
# Use it and Improve it: Function used improves
# Specificity: Neuroplastic change is determined by task used
# Specificity: Neuroplastic change is determined by task used
# Time Matters: Different time of training is related to different neuroplastic changes 
# Time Matters: Different time of training is related to different neuroplastic changes 
# Repetition Matters: [null Sufficient repetitions required to intensify neuroplasticity]
# Repetition Matters: Sufficient repetitions required to intensify neuroplasticity
# Intensity Matters: Sufficient intensity required to intensify neuroplasticity
# Intensity Matters: Sufficient intensity required to intensify neuroplasticity
# Salience Matters: Sufficiently meaningful task triggers plasticity
# Salience Matters: Sufficiently meaningful task triggers plasticity
# Age Matters: Younger brains demonstrate more plastic changes with training
# Age Matters: Younger brains demonstrate more plastic changes with training
# Transference: Neuroplastic change following training of one task might enhance similar task acquisition
# 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.
# Interference: Plasticity in response to one experience can interfere with the acquisition of other behaviour. <ref name=":0">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).
</ref>


== Physiotherapeutic Interventions ==
== Physiotherapeutic Interventions ==
Physiotherapeutic interventions can be grouped in three main categories:
Physiotherapeutic interventions can be grouped into three main categories:
* Restorative interventions focusing on reactivation of penumbra and diaschisis and restoring premorbid movements
* 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 hem-plegic side for personal care
* 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.
* 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:
<br>
 
The categories include treatment techniques and activities like; <ref>Holmberg TS, Lindmark B.
1.    Therapeutic Exercises
How do physiotherapists treat patients with traumatic brain injury?
 
Advances in Physiotherapy. 2008;10:138-145.
2.    Manual Therapy techniques like mobilisations or manipulations
</ref>
 
# Therapeutic exercises
3.    Prescription and application of equipment like orthotic or prosthetic devices, mobility aid, wheelchair
# Manual therapy techniques like mobilisations or manipulations
 
# Prescription and application of equipment like orthotic or prosthetic devices, mobility aid, wheelchair
4.    Airway Clearance Techniques
# Airway clearance techniques
 
# Functional training in self-care (ADLs) and home care
5.    Functional Training in Selfcare (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
6.    Functional training at work, school, play and leisure activities including community reintegration
# Integumentary protective techniques enhancing tissue viability
 
# Discharge Planning
7.    Use of physical agents and other modalities use like hydrotherapy, electrotherapy, cryotherapy
 
8.    Integumentary protective techniques enhancing tissue viability
 
9.    Discharge Planning
 
In prescription of interventions following parameters could be used: 
In prescription of interventions following parameters could be used: 
* Method, Mode or Device 
* Method, Mode or Device 
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* Progression
* Progression


== '''Physiotherapy Management of Moderate to Severe Traumatic Brain Injury''' ==
== Physiotherapy Management of Moderate to Severe Traumatic Brain Injury ==
=== Acute/Early Stage ===
=== Acute ===
Good practice recommends complete medical record examination to establish precautions and contraindications as patient might not be medical stable due to increased ICP, respiratory needs like mechanical ventilation in situ, orthopaedic injuries restricting loading or range of motion. 
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<ref>Hamel RN, Smoliga JM. [https://www.ncbi.nlm.nih.gov/pubmed/31098990 Physical Activity Intolerance and Cardiorespiratory Dysfunction in Patients with Moderate-to-Severe Traumatic Brain Injury.] Sports Medicine. 2019 May 16:1-6.</ref>


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. 
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: 
Treatment at acute stage should address: 
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* Physical function stimulation to improve motor and postural control, maintain mobility, normalise muscle tone
* 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
* 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 
* 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
* 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
* 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 TBI complications including equipment use.
* Family and caregivers’ education on patient’s diagnosis and management of traumatic brain injury complications including equipment use.
* Rising Safety Awareness
* Rising Safety Awareness
* Discharge Planning 
* [[Discharge Planning]] 
 


Treatment techniques and procedures might include:
Treatment techniques and procedures might include:
* Early mobilising via passive or active-assisted handling advised by nursing and physiotherapy staff.
* Early mobilising via passive or active-assisted handling advised by nursing and physiotherapy staff.
* Movement facilitation using neurodevelopmental or neuromuscular concepts
* Movement facilitation using neuro-developmental or neuromuscular concepts
* Positioning on bed in various postural sets including side lyi-g and prone when appropriate and position changes every 2 hours.
* Positioning on the bed in various postural sets including [https://opentextbc.ca/clinicalskills/chapter/3-4-positioning-a-patient-in-bed/ side-lying and prone]<ref>Rees Doyle G, McCutcheon JA. Clinical Procedures for Safer Patient Care. British Columbia: BC Open Textbook Project, Minneapolis, 2015.</ref> 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 lead by Physiotherapist and supported by provision of suitable seating system.
* [https://hub.permobil.com/wheelchair-seating-and-positioning-guide Positioning out of Bed]<ref>Permobil. Wheelchair Seating & Positioning Guide. Available from: https://hub.permobil.com/wheelchair-seating-and-positioning-guide (accessed 09/09/2019)</ref> 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.
 
 
For more information and guidance, please view this optional resource:{{pdf|Beginners_Guide_to_Postural_Management1.pdf|Beginner's Guide to Postural Management}}
* Verticalization, i.e.: using a tilt table or with an increased number of therapists (3-4) to ensure weight bearing and stimulate alertness.
* 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.
* 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.
* 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.
* Balance and postural control training like weight shift and midline orientation activities when transferring and in side-lying or sitting.
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 chosesntreatments
 
 
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<ref>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. [https://pubmed.ncbi.nlm.nih.gov/31890221-neuromuscular-electrical-stimulation-in-critically-ill-traumatic-brain-injury-patients-attenuates-muscle-atrophy-neurophysiological-disorders-and-weakness-a-randomized-controlled-trial/ 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.</ref>. 
 
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 [http://pamis.org.uk/site/uploads/postural-care.pdf postural advice],<ref>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)</ref> chest clearance techniques, use of [https://www.spioworks.com/files/Lycra-garments-for-the-treatment-of-Cerebral-Palsy-NTAG-appraisal-report.pdf Dynamic Orthosis / Lycra Garmentsor Splinting].<ref>Elizabeth Uhegwu. Lycra Garments for Neurological and Musculoskeletal Conditions. Regional Drug & Therapeutics Centre (Newcastle): Northern Treatment Advisory Group, 2018. </ref> Clear goals explanation and expected outcomes to be defined and included to promote awareness and rationale from choses treatments


=== Active Rehabilitation Stage ===
=== Active Rehabilitation Stage ===
Patients with moderate to severe TBI 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 TBI 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)
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<ref name=":1">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)
</ref>. (G11)


Rehabilitation Settings:
Rehabilitation Settings:
* 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. 
* 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 hospital or separate rehabilitation centre.
* 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 patient’s home, within local community facilities like supermarket, gym, school, etc. 
* 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. 
Similarly, to acute stage goal setting should be informed by examination of physical and cognitive impairment to establish ability to relearn motor skills. Before processing with physical examination Physiotherapist should determine patithe ent’s orientation, attention span, memory, insight, safety awareness, and alertness. According to Fulk and Nirider (2014 p.870) key, initial questions that ensure optimal baseline for assessment and goal setting of persa on with TBI include the following:
[[File:Bmjopen-2016-September-6-9--F1.large.jpg|''Pathways for Rehabilitation Following Illness or Injury'' <ref>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.</ref>|center|thumb|700x700px]]
 
 
Similarly, acute stage goal setting should be informed by an examination of physical and cognitive impairment to establish the ability to relearn motor skills. Before processing with physical examination, Physiotherapist should determine the patient’s orientation, attention span, memory, insight, safety awareness, and alertness. According to Fulk and Nirider, <ref>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</ref> key initial questions that ensure optimal baseline for assessment and goal setting of the person on with traumatic brain injury include the following:
* Is the patient able to follow commands: one-step, two-step, or multistep commands?
* Is the patient able to follow commands: one-step, two-step, or multistep commands?
* Is the patient oriented to person, place, and/or time?
* Is the patient oriented to person, place, and / or time?
* Does the patient recognize family members?
* Does the patient recognise family members?
* Does the patient demonstrate any insight into what has happened?
* Does the patient demonstrate any insight into what has happened?
Consultation with other members of MDT/IDT is recommended followed by assessment of body structure and function, activity and participation including locomotion or community reintegration evaluated in various environments as patients with TBI might struggle to perform skills in different settings. 
 
 
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 [[Overview of Traumatic Brain Injury|traumatic brain injury]] might struggle to perform skills in different settings. 


Treatment in the active rehabilitation stage should address the following:
Treatment in the active rehabilitation stage should address the following:
* Secondary Impairments Risks
* Secondary Impairments Risks
* Provision of education for patient, care givrs and family about the injury, prognosis and care plan
* Provision of education for patient, care givers and family about the injury, prognosis and care plan
* Joints Integrity and Mobility
* Joints Integrity and Mobility
* Motor Function (motor control and motor learning)
* Motor Function (motor control and motor learning)
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* Aerobic Capacity and General Fitness
* Aerobic Capacity and General Fitness
* Sensory awareness, skin integrity, perception and cognition enhancement 
* 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
* Vestibular assessment<ref name=":2">Zollman FS, editor. [https://www.google.com/books/edition/Manual_of_Traumatic_Brain_Injury_Third_E/shcaEAAAQBAJ?hl=en&gbpv=1&dq=physical+therapy+Management+of+Traumatic+Brain+Injury&pg=PP1&printsec=frontcover Manual of traumatic brain injury: Assessment and management]. Springer Publishing Company; 2021 Jul 22.</ref>
* 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
* 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 
* Capacity to resume Play / School / Work and Social and Recreational Activities 
* Safety 
* Safety 
* Discharge Planning
* Discharge Planning
Interventions supporting recovery and rehabilitation process following moderate to severe TBI 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 TBI physiotherapy might include:
 
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.
* Task orientated practice with most promising approaches being CIMT and Locomotor gait training.
* Locomotion training with body weight support and ove ground practice.
* Locomotion training with bodyweight support and overground practice.
* Locomotion’s supporting training of strength, sit-to-stand practice and standing balance retraining.
* Locomotion’s supporting training of strength, sit-to-stand practice and standing balance retraining.
* Cardio-vascular training with use of equipment like ergocylometer or treadmill or circuit training.
* Cardio-vascular training with the use of equipment like cycle ergometer or treadmill or circuit training.
* Range of motion and stretching exercises.
* Range of motion and stretching exercises.
* Mobilization and manipulation and use of other MSK techniques.  
* 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.
* 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.
* 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.
* Sensory stimulation using various modalities including auditory, olfactory, gustatory, visual, tactile-kinaesthetic and vestibular systems<ref name=":2" /> 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.
* 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.
* 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
* 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.
* 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.
* 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.
* 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,sfeedback, environment setup, reminder strategies, schedule, use of guidelines and monitoring.
* 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.
* 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 multifactorial approach addressing all balance components.
* Falls prevention with consideration of individual, task and environment changing interventions with a multifactorial approach addressing all balance components.
* Person witithustained TBI should be given as mucany opportunitiess possible to practise their skills outside formal Physiotherapy sessions.
 
 
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.


=== Chronic Stage ===
=== Chronic Stage ===
The rehabilitation process is a continuum from inpatient to community-based activities and adults with sustained impairment from TBI should have ongoing access to support from clinicians and other health and social care workers trained and experienced in care and support of people TBI. 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 (G1). Powell and colleagues (2002) suggested that multidisciplinary community rehabilitation after severe TBI yields benefits even years after the TBI which outlive the active treatment period. 
The rehabilitation process is a continuum from inpatient to community-based activities and adults with sustained impairment from a [[Traumatic Brain Injury|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.<ref name=":1" /> Powell et al<ref>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 <nowiki>http://dx.doi.org/10.1136/jnnp.72.2.193</nowiki></ref> 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:
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
* Access to required support and therapy to meet patient’s and their caregivers changing clinical, social and psychological circumstances
* Interlocking assessment and treatment
* Interlocking assessment and treatment
* Need for goal setting and patient-centred care
* Need for [https://physio-pedia.com/Goal_Setting_in_Rehabilitation goal setting] and patient-centred care
* Choice of safe and effective treatment and procedures
* Choice of safe and effective treatment and procedures
* Enabling process and self-administered activities with guidance and support provided from clinician
* Enabling process and self-administered activities with guidance and support provided from clinician
* Education highlighting when to seek advice and from which health professional
* Education highlighting when to seek advice and from which health professional
* Facilitating access to community initiatives, support groups, charity help.
* 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.
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 ‘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 some degree of recovery living in community facilities may attend outpatient therapies to address problem areas resulting from their brain injury.
* Patients with significant degree of recovery might be able to access mainstream activities focusing on physical and psychological wellbeing with therapist advice and minor adjustments like yoga, mindfulness courses, strength and conditioning exercise groups, cycling or running initiatives, games etc.
* 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.
* Patients with the potential and set goal to return to work/school would benefit from a combination of cognitive and vocational therapy to prepare them for the transition back into a potentially more stimulating environment with multi-tasking requirements.<ref>Fure SC, Howe EI, Andelic N, Brunborg C, Sveen U, Røe C, Rike PO, Olsen A, Spjelkavik Ø, Ugelstad H, Lu J. [https://www.sciencedirect.com/science/article/pii/S1877065721000567 Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: a randomised controlled trial]. Annals of physical and rehabilitation medicine. 2021 Sep 1;64(5):101538.</ref>
 
== Resources  ==
* [https://opentextbc.ca/clinicalskills/ Clinical Procedures for Safer Patient Care]
* [https://www.rhn.org.uk/content/uploads/2016/07/LECTURESPMCpreswebcopy.pdf A Beginner’s Guide to Postural Management]
* [https://www.spioworks.com/files/Lycra-garments-for-the-treatment-of-Cerebral-Palsy-NTAG-appraisal-report.pdf Lycra Garments for Neurological and Musculoskeletal Conditions]
* [http://pamis.org.uk/site/uploads/postural-care.pdf Postural Care - A Guide to 24 Hour Postural Management for Family Carers]


== References  ==
== References  ==

Latest revision as of 14:11, 16 December 2022


Introduction[edit | edit source]

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:

  1. Spontaneous Recovery: process related to repair of central nervous system early after brain injury and regression of diaschisis.
  2. 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 [2][edit | edit source]

  1. Use it or Lose it: Function unused deteriorates
  2. Use it and Improve it: Function used improves
  3. Specificity: Neuroplastic change is determined by task used
  4. Time Matters: Different time of training is related to different neuroplastic changes 
  5. Repetition Matters: Sufficient repetitions required to intensify neuroplasticity
  6. Intensity Matters: Sufficient intensity required to intensify neuroplasticity
  7. Salience Matters: Sufficiently meaningful task triggers plasticity
  8. Age Matters: Younger brains demonstrate more plastic changes with training
  9. Transference: Neuroplastic change following training of one task might enhance similar task acquisition
  10. Interference: Plasticity in response to one experience can interfere with the acquisition of other behaviour. [2]

Physiotherapeutic Interventions[edit | edit source]

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; [3]

  1. Therapeutic exercises
  2. Manual therapy techniques like mobilisations or manipulations
  3. Prescription and application of equipment like orthotic or prosthetic devices, mobility aid, wheelchair
  4. Airway clearance techniques
  5. Functional training in self-care (ADLs) and home care
  6. Functional training at work, school, play and leisure activities including community reintegration
  7. Use of physical agents and other modalities use like hydrotherapy, electrotherapy, cryotherapy
  8. Integumentary protective techniques enhancing tissue viability
  9. Discharge Planning

In prescription of interventions following parameters could be used: 

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

Physiotherapy Management of Moderate to Severe Traumatic Brain Injury[edit | edit source]

Acute[edit | edit source]

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[4]

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[5] when appropriate and position changes every 2 hours.
  • Positioning out of Bed[6] 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.


For more information and guidance, please view this optional resource:Beginner's Guide to Postural Management

  • 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[7]

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,[8] chest clearance techniques, use of Dynamic Orthosis / Lycra Garmentsor Splinting.[9] Clear goals explanation and expected outcomes to be defined and included to promote awareness and rationale from choses treatments. 

Active Rehabilitation Stage[edit | edit source]

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[10]. (G11)

Rehabilitation Settings:

  • 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. 
Pathways for Rehabilitation Following Illness or Injury [11]


Similarly, acute stage goal setting should be informed by an examination of physical and cognitive impairment to establish the ability to relearn motor skills. Before processing with physical examination, Physiotherapist should determine the patient’s orientation, attention span, memory, insight, safety awareness, and alertness. According to Fulk and Nirider, [12] key initial questions that ensure optimal baseline for assessment and goal setting of the person on with traumatic brain injury include the following:

  • 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 
  • Vestibular assessment[13]
  • 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 
  • Safety 
  • 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[13] 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.

Chronic Stage[edit | edit source]

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.[10] Powell et al[14] 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.
  • Patients with the potential and set goal to return to work/school would benefit from a combination of cognitive and vocational therapy to prepare them for the transition back into a potentially more stimulating environment with multi-tasking requirements.[15]

Resources[edit | edit source]

References[edit | edit source]

  1. MUSHPWeb1. Physical Therapy Following Traumatic Brain Injury (TBI). Available from: https://youtu.be/cLJyESfqyI4[last accessed 30/08/19]
  2. 2.0 2.1 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).
  3. Holmberg TS, Lindmark B. How do physiotherapists treat patients with traumatic brain injury? Advances in Physiotherapy. 2008;10:138-145.
  4. 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.
  5. Rees Doyle G, McCutcheon JA. Clinical Procedures for Safer Patient Care. British Columbia: BC Open Textbook Project, Minneapolis, 2015.
  6. Permobil. Wheelchair Seating & Positioning Guide. Available from: https://hub.permobil.com/wheelchair-seating-and-positioning-guide (accessed 09/09/2019)
  7. 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.
  8. 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)
  9. Elizabeth Uhegwu. Lycra Garments for Neurological and Musculoskeletal Conditions. Regional Drug & Therapeutics Centre (Newcastle): Northern Treatment Advisory Group, 2018.
  10. 10.0 10.1 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)
  11. 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.
  12. 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
  13. 13.0 13.1 Zollman FS, editor. Manual of traumatic brain injury: Assessment and management. Springer Publishing Company; 2021 Jul 22.
  14. 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
  15. Fure SC, Howe EI, Andelic N, Brunborg C, Sveen U, Røe C, Rike PO, Olsen A, Spjelkavik Ø, Ugelstad H, Lu J. Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: a randomised controlled trial. Annals of physical and rehabilitation medicine. 2021 Sep 1;64(5):101538.