TBI

• TBI Rehabilitation Team


  • Medical team: physician, resident, physicians assistant, nurse practitioner, nurse, nursing assistant
  • Neuropsychologist
  • Therapy Team: OT, COTA, PT, PTA, SLP
  • Social Worker/Case Manager
  • Others: Recreation Therapist, Respiratory Therapist
• TBI Rehabilitation


  • Record and track recovery
  • Optimize recovery
  • Provide the optimal environment to maximize rehabilitation outcomes
  • Provide support and education to the patient and family
  • Design therapy activities that maximize neuroplastic changes and guide recovery
  • Guide discharge planning to the next phase of rehab
• Typical course of TBI rehab


  • ICU -> acute care
  • Inpatient Rehab (Physical Medicine rehab Unit)
  • long term care facility prn
  • outpatient rehabilitation
  • Comprehensive Outpt Rehab Facility
  • community based programs
  • vocational re-entry
  • exercise programs
• When do we start therapy?


  • No set standard- patient/provider dependent
  • Team Decision
  • 2 primary reasons: Normalization of ICP (<20mmHg, Patient dependent!)
  • Hemodynamic stability
• Impairments addressed in TBI rehab


  • Neuromuscular impairments
  • Communication Impairments
  • Cognitive Impairments
  • Behavioral Challenges
• Neuromuscular Impairments


  • Impaired motor control
  • Impaired coordination
  • Hemiparesis
  • Hypertonicity
  • Abnormal postural reflexes (decorticate or decerebrate posturing)
  • Somatosensory impairment
  • Impaired postural control
• Behavioral Impairments


  • Easily frustrated
  • Agitation
  • Mental inflexibility
  • Impulsivity
  • Disinhibition
  • Emotional lability
  • Irritability
• Cognitive Impairments


  • Arousal/ Disorder of Consciousness (Coma, UWS, MCS)
  • Attention
  • Concentration
  • Memory
  • Learning
  • Executive functions (Planning, Cognitive flexibility, Initiation and self generation, Response inhibition, Serial ordering and sequencing)
• Post Traumatic Amnesia (PTA)


  • Patient is unable to form new memories
  • Neuropsychologist typically determines the patient's length of PTA by reassessing cognitive status and ability to form new memories daily
• Other impairments


  • Communication/language (NOT typically Aphasia)
  • Cranial nerve involvement
  • Visual Deficits
  • Perceptual Deficits
  • Dysphagia
  • secondary impairments due to immobility or comorbid injuries
• Pharmacology: post-acute phase to address impairments


  • Baclofen, diazepam, dantrolene (Tone)
  • Anti-epileptics: Depakote, keppra (Levitiracetam) , Dilantin (phenytoin), Cerebyx (fosphenytoin) (Seizure Control)
  • Neurostimulants, Dopamine (Attention)
  • Amantadine (4-16wks after dx) (Dopamine agonists) Other neurostimulants; methylphenidate, bromocriptine (Arousal)
  • NSAIDs, Bisphosphonates (Heterotopic Ossification)
  • nontricyclic meds are most effective (Depression)
• Clinical Manifestations


  • Activity Limitations (Ambulation, Basic mobility, ADLs, and more)
  • Participation Restrictions (Return to employment, Family Role, Community/Social Role, and more)
• Rancho Los Amigos Levels of Cognitive Functioning


  • Level I: Coma
  • Level II: Unresponsive Wakefulness
  • Level III: Minimally Conscious State
  • Level IV: Confused, Agitated
  • Level V-VI: Confused, Inappropriate
  • Level VII-VIII: Automatic, Appropriate
• Level of Cognitive Functioning impacts your PT Plan of Care

  • Low Level Patient: Rancho I-III
  • Management of Confused/Agitated Patient: Level IV
  • The Confused patient: Levels V-VI
  • High Level Patient: Levels VII-VIII
• Acute Care Concerns for Low Level Patients (Rancho I-III)


  • Ventilator?
  • ICP monitoring?
  • Weightbearing restrictions?
  • ROM restrictions?
  • Cardiac Precautions?
  • Open wounds?
  • Surgical Sites?
  • External fixators?
  • Dysautonomia (monitor vitals)
  • Presence of other tubing: IV, feeding tubes, oxygen, catheters etc.
• PT Goals Levels I-III


  • Consistently assess Level of Consciousness and track progress
  • Increase arousal and functional mobility
  • Improve tolerance to upright
  • Reduce risk of secondary impairments
  • Improve or retain joint integrity and ROM
  • Educate family and caregivers
  • Maintain coordinated care among all team members
• Levels of Consciousness


  • Coma (Rancho Level I)
  • Unresponsive Wakefulness (Rancho Level II)
  • Minimally Conscious State (Rancho Level III)
• Assessing patient's consciousness is crucial for prognosis, informing treatment, education, etc.
• Factors that impact a patient's ability to respond to stimuli and commands


  • Limited motor function
  • Communication impairments
  • Sedating medications
  • Impaired sensation
  • Impaired cognition
• Outcome Measures for Assessing Levels of Consciousness


  • Coma Recovery Scale Revised (CRS-R)
  • Disorders of Consciousness Scale (DOCS)
  • Rancho Los Amigos Levels of Cognitive Functioning
  • Sensory Modality and Rehabilitation Techniques (SMART)
  • Western Neurosensory Stimulation Profile (WNSSP)
• The CRS-R is the gold standard for assessing levels of consciousness
• Multi-Modal Sensory Stimulation Programs


  • Goal: increase arousal and attention
  • Stimulate Reticular Activating System
  • Cortical processing is multisensory, better engage cortical function by including lots of stimulation
  • Neuroplasticity occurs through environmental factors
• Providing sensory stimulation


  • Controlled and structured manner
  • Formal: systematic approach, all team members involved, multiple x/day, graded stim, document, track progress
  • Multisensory (auditory, olfactory, gustatory, visual, tactile, kinesthetic, and vestibular)
  • Balance of stimulation and rest
  • Monitor pt response
  • Use Outcome measure to assess change
• Other Sensory Stimulation Interventions


  • FAST (Familiar Auditory stimulation training)
  • Music Therapy in MCS
  • Movement (supported sitting on trampoline with vertical motions and listening to music)
  • Multimodal Stimulation
• Multi-Modal Sensory Stimulation Programs


  • Tailor to client tolerance and preference
  • Bi-modal (auditory and tactile) and multi-modal (all 5 senses) has greatest effect
  • Auditory response: (name called by someone with pre-existing emotional bond)
  • Begin early and perform frequently (3-5x/d, 7-20min, for atleast 2 weeks)
  • Avoid Overstimulating
  • Non-Distracting environment
  • Give pt time to respond
  • Use until more complex activity is possible
• Evidence for sensory stimulation programs remains under debate
• Early Mobilization


  • Shorter length of stay
  • Increase chance of d/c to home
  • Decreased secondary complications
  • Improved outcomes (neuroplastic changes)
• Early Mobilization Precautions/Contraindications


  • WB restrictions
  • Unstable Spine
  • Skin/joint integrity
  • Increased(ing) ICP
  • Autonomic instability
  • CV status
• Early mobility to varied positions relative to tolerance and safety
• Multimodal Stimulation


  • More effective in Minimally Conscious State (MCS) than Vegetative State (VS)/Unresponsive Wakefulness Syndrome (UWS)
  • Improved Coma Recovery Scale (CRS) scores
• Multi-Modal Sensory Stimulation Programs


  1. Tailor to client tolerance and preference

  2. Bi-modal (auditory and tactile) and multi-modal (all 5 senses) has greatest effect

  3. Auditory response: (name called by someone with pre-existing emotional bond)

  4. Begin early and perform frequently (3-5x/d, 7-20min, for at least 2 weeks)

  5. Avoid Overstimulating

  6. Non-Distracting environment

  7. Give patient time to respond

  8. Use until more complex activity is possible
• Early Mobilization


  • Shorter length of stay
  • Increase chance of discharge to home
  • Decreased secondary complications
  • Improved outcomes (neuroplastic changes)
• Early Mobilization Precautions and Contraindications


  • Weight-bearing restrictions
  • Unstable Spine
  • Skin/joint integrity
  • Increased(ing) Intracranial Pressure (ICP)
  • Autonomic instability
  • Cardiovascular status
• Early Mobility


  1. Mobility to varied positions relative to gravity (sitting on the side of the bed, sitting in wheelchair, tilt table, standing frame)

  2. Monitor vitals closely

  3. Goal: Increase alertness with stimulation in different positions/environment

  4. Improve level of consciousness

  5. Improve Gastrointestinal (GI) motility, Range of Motion (ROM), Cardiovascular (CV) response
• Preventing Secondary Impairments


  • Contractures
  • Pressure Sores
  • Pneumonia
  • Deep Vein Thrombosis (DVT)
• Proper Positioning


  1. Wheelchair (Tilt in Space, Cushion, Weight shifting parameters - every 30min for 2min)

  2. Bed (Turn every 2 hours, Hips/knees slightly flexed, Specialty Beds)

  3. Provide education to family
• Proper Positioning


  1. Assess and Monitor ROM and tone

  2. Family Education

  3. Prioritize management of muscle tightness and joint stiffness (Stretching, Weightbearing, Splinting, Serial Casting)

  4. Neurogenic Heterotopic Ossification is a risk factor
• Splinting Options


  • Serial Casting
• Serial Casting


  • Help to improve Passive Range of Motion (PROM)
  • Used in various neurologic conditions including pediatrics
• Family Education and Support


  1. Maintain open communication

  2. Involve the family in Plan of Care (POC) and decisions (stim programs, ROM)

  3. Educate on current evidence when appropriate

  4. Provide realistic and consistent messages