Interventions for Moderate to Severe TBI

• Patients with moderate to severe TBI


  • Present with a wide variety of physical, cognitive, and behavioral impairments that may greatly impact the patient's ability to fully participate in his or her desired social roles
• Immediately following TBI


  1. Focus of care is on saving the individual's life

  2. Physical therapists focus on determining the severity of the injury, preserving life, and prevention of further damage
• As recovery progresses and the patient becomes more stable


  Therapy can be progressed to include interventions that address body structure function impairments, activity limitations, and participation restrictions
• Rancho levels I to III


  Patients have disorders of consciousness which consist of decreased arousal, alertness, and awareness of self and environment
• Physical therapy plan of care for Rancho levels I-III

  1. Interventions to limit common secondary complications

  2. Increasing level of arousal to promote normal sleep-wake cycles

  3. Upright positioning and sensory stimulation to increase arousal level
• Patients post TBI who are in a vegetative or minimally conscious state are most responsive in standing, but also more responsive sitting in a wheelchair compared to lying supine
• Tilt table


  Used to gradually increase upright posture and position for medically unstable patients, provides benefits such as early weight-bearing, redistribution of pressure points, improve respiration, preserve bone density, etc.
• Sensory stimulation to promote arousal

  Auditory, tactile, visual, olfactory, gustatory, and kinesthetic graded inputs
• For persons in and emerging from the minimally conscious state

  1. Physical therapy goals should focus on increasing the level of awareness of self and the environment

  2. Encourage purposeful responses, eye and/or head tracking, reaching, grasping, and placing objects

  3. Use familiar activities to increase automaticity and motivation

  4. Allow adequate time for delayed processing
• Behavioral treatment strategy


  Used for patients in Rancho levels IV-V, focus is on impairments and is more compensatory in nature
• Patients in Rancho levels IV-V


  • Cannot learn alternate ways to behave or understand the consequences of their actions
• Behavior modification strategies used for patients in Rancho levels IV-V


  Manage agitation, confusion, impulsivity, disinhibition, perseveration, confabulation, inability to self-reflect, apathy, depression, and lack of initiation
• Working with patients in Rancho levels IV-V

  • Be calm and controlled, flexible, and consistent
  • Therapy should be short, highly structured, and in a quiet environment with minimal distractions
  • Family members should be involved to facilitate cooperation and keep the patient calm
• When agitation occurs


  The activity is stopped, and the patient is allowed to rest
• Strategies for patients with confusion and agitation

  • Consistency is critical due to impaired learning and cognition
  • Use simple cues and strategies, positive reinforcement plans, allow personal choices
  • Model calm behavior, be flexible, have appropriate expectations, control the environment, ensure safety
• Provide safe choices for the patient


  • Patient can feel some control over the situation
• Redirect the patient


  1. Physically

  2. Verbally
• End the session on success
• Expect egocentricity


  • Patient is not able to see another's perspective
• Expect no carryover


  • Teaching new skills is unrealistic
• Patient may begin to perform automatic functional skills
• Charts or graphs may help the patient progress each day because the patient is likely to not be able to recall the previous day's performance
• Initially interventions should be performed in a closed environment


  • Limited distractions
• Open environments such as a busy rehab gym

  • Too many distractions
  • Can lead to increased agitation
  • Limited ability to participate in the intervention
• Progress to more open environment

  To challenge the patient as he/she improves
• Keep the patient and those interacting with the patient safe
• Patients in this level of recovery may be kept on a locked unit of the hospital
• Patients may require one-to-one staff supervision and assistance throughout the day
• The focus of rehabilitation immediately following injury is on motor recovery and improving safety and independence with functional mobility for patients who are emerging from disorders of consciousness and those who are at the IV to VI levels of cognitive functioning
• Motor learning principles, as well as the neurophysiological principle of neuroplasticity, should be applied throughout interventions for persons recovering from a TBI
• Motor learning


  • Not dependent on cognitive learning
  • Can occur starting in Ranchos Stage IV, or when the patient is able to actively move
• The ability to motor learn is also dependent on which areas of the brain have been damaged and the severity of that damage
• Persons with TBI have impairments in declarative memory tasks and preservation of procedural tasks
• For patients in levels of cognitive functioning IV to VI, any motor learning would be

  • Implicit or procedural
  • From repetitive practice of the movement
• Procedural tasks, such as riding a bike

  1. More automatic

  2. Automaticity may be augmented by use of familiar and desirable items and objects
• Procedural task example


  • Handing a basketball to a person who played on their high school team before the injury, then placing a hoop in front of them to encourage them to place or throw the ball
• This task provides an internal perturbation for sitting or standing balance, promotes trunk stabilization and motor coordination, is a functional strengthening task for the upper extremities, and may even improve activity tolerance if repeated multiple times
• The therapist can simultaneously address several body structure function impairments commonly present in persons with TBI through this procedural task
• Patients in the VI through X levels are able to learn cognitively with various levels of assistance
• Patients at level VI

  • Still going to be confused
  • Have attention and memory impairments
  • Able to retain learning for familiar tasks that they performed pre-injury
  • Challenged with retaining learning for new tasks