Interventions for Mild TBI

• Physical therapy management of persons with mild TBI depend heavily on reliable patient reports of their symptom responses to provocation tests and interventions
• Paradigm shifts have occurred in the prescription of strict rest until symptom resolution and intense bouts of cognitive or physical activity acutely after injury
• Observational and experimental studies have found these approaches are associated with delayed recovery trajectories
• Prolonged rest may result in patients experiencing symptoms comparable to postconcussion complaints such as deconditioning with exertional intolerance, anxiety or depression secondary to social isolation and/or decreased participation
• Most clinical practice guidelines are currently recommending relative rest defined as gradual reintegration of usual activity advising patients to rest as needed followed by phased activity progressions based on symptom response to increasing activity
• Most clinical recommendations advocate resuming low levels of activity in the presence of mild symptoms as long as symptom exacerbation does not occur
• New models are encouraging active rehabilitation that contain skilled rehabilitation interventions within the scope of physical therapist practice
• Overarching impairment domains that align with the scope of physical therapist practice

  • Cervical musculoskeletal impairments
  • Vestibulo-oculomotor impairments
  • Exertional tolerance impairments
  • Motor function impairments

  
• Irritability


  The body system's ability to handle physical or physiological stress which is likely associated to the physical status and extent of injury and inflammatory activity
• The module will review the evidence based recommendations for physical therapist management of mild TBI outlined in the APTA's clinical practice guidelines
• The importance of education in providing care to persons post mild TBI cannot be overstated
• Education related to the patient's current condition and expectations regarding the patient's potential course of recovery should be emphasized throughout the continuum of care
• The APTA clinical practice guideline stresses the importance of clearly communicating and educating patients and their families regarding an expectation for recovery seen in the majority of cases and avoid inadvertently strengthening patients and their families insecurities and worries or facilitating a path of catastrophizing about the concussion

  
• Education regarding the risks for subsequent injury during high-risk activities, management strategies, and return-to-activity progressions should be provided
• Emphasis should be placed on teaching the patient and family strategies for self-management of symptoms, the differences between relative rest versus strict rest, the advantages of graded return to activities and safe strategies for pacing, the significance of sleep, and signs and symptoms indicating the need for follow-up care
• Patients and their families should be educated on symptoms, impairments, and functional limitations that are associated with concussion

  
• Persons with mild TBI may present with altered motor function abilities which include static and dynamic balance and postural control impairments, alterations in dual or multitasking impairments, delayed motor reaction time, and increased difficulty with motor coordination especially with more complex environments or tasks

  
• These motor function impairments may be somewhat subtle and difficult to detect without laboratory equipment
• Evidence indicates that these underlying impairments may persist for months to years even when symptoms have subsided
• The extent of the interference of these impairments with daily functioning and participation in life roles is not clear
• The prevalence of these associated impairments is unknown
• These types of impairments may lead to increased risks for future concussions and other injuries among athletes and those in high-activity and/or high risk jobs such as active-duty military, firefighters, and police officers
• The APTA clinical practice guidelines recommends an individualized plan of care that aligns with the patient's impairments, activity limitations, participation restrictions, self-management capabilities, and levels of irritability
• Physical therapists must refer patients for further consultation and follow-up care with the appropriate health care professionals as indicated by the examination findings
• Interventions should target the patient's specific movement-related impairments with the goals of reducing symptoms and improving ability to return to preinjury activities

  
• Interventions are initiated after an initial period of relative rest and potentially biological and physiological improvement
• Patients may also experience a range of other persistent postconcussion symptoms and impairments such as cognitive deficits in attention, memory, and executive functions, visual and auditory impairments, sleep problems, migraine, and mood and psychological disorders which may require intervention from other health care professionals
• Cervical musculoskeletal impairments can manifest in commonly reported symptoms by persons with mild TBI including neck pain, headache with or without neck pain, dizziness, and diminished balance and postural control

  
• The incidence of cervical musculoskeletal impairments associated with concussive events has not been studied comprehensively or well-reported

  
• It is hypothesized that given the biomechanical mechanism of injury for mild TBI that cervical musculoskeletal impairments may be present

  
• Cervical musculoskeletal impairments in the absence of a concussive event include decreased ROM, poor strength, insufficient muscle endurance and control, and sensorimotor control deficits due to altered cervical afferent input

  
• Impairments in cervical reflex responses and cervical proprioception can affect visual and vestibular systems leading to dizziness, visual dysfunction, balance problems, and difficulties with head and eye movement control
• Persons who suffered a concussive event even without complaints of neck pain may have underlying cervical musculoskeletal impairments driving the patient's symptoms of dizziness, imbalance, and headache

  
• The APTA clinical practice guidelines recommend interventions to address cervical musculoskeletal impairments in persons with mild TBI

  
• Findings indicate that addressing cervical musculoskeletal impairments results in improvements in symptoms, function, and return to activity after concussion

  
• Persons who received combined cervical and vestibular interventions were 3.91 times more likely to be medically cleared for return to sport by 8 weeks compared to controls
• Neck strength and muscle strength imbalances have been associated with concussion risk
• Even when cervical spine impairments are not present as a result of concussion, it may be beneficial to provide cervical musculoskeletal interventions to decrease a patient's risk for subsequent concussive injuries

  
• There is a multitude of evidence that supports the frequent presence of vestibular and oculomotor deficits in persons with mild TBI
• These impairments contribute to many of the postconcussion symptoms, impairments and functional limitations persons with mild TBI present with