Traumatic Brain Injury Physiotherapy

TRAUMATIC BRAIN
INJURY
REHABILITATION
Dr. Darshika Vyas (PT)
BPT, MPT (Neurosciences) MIAP
RLA levels I, II & III – Decreased or low
response levels
Examination key questions should include the following:
1. What posture the patient is in? is there evidence of primitive posture or
reflexes?
2. Are the patient’s eyes open or closed?
3. Is the patient able to track visual or auditory stimulus?
4. Is the patient able to vocalise?
5. Does the patient exhibit any active movement? If yes, is it purposeful or
non purposeful?
6. Does the patient react to tactile/painful stimulus?
7. Do the patient’s vitals change when presented with an external stimulus?
Primitive postures may be:
Decorticate posturing – UE are flexed, LE are extended.

(indicative of lesions at or above the upper brainstem)
Decerebrate posturing – both UE & LE are in extension.

(indicative of lesions in the brainstem between vestibular nucleus &
superior colliculus)
Intervention
GOALS
I. To increase physical function & level of alertness.
II. Reduce the risk of secondary impairments.
III. Improve joint mobility.
IV. Improve motor control.
V. Manage tone.
VI. Improve postural control.
VII. Increase tolerance to activities & positions.
VIII.Educate the family/ caregivers.
Improving arousal through sensory
stimulation
• While performing passive ROM, talk to the patient about what you are
doing & provide orientation.
• Explaining & performing the movements provides tactile, auditory,

proprioceptive and visual stimulus.
• Engage the patient by asking him to attempt movement along with you
performing it passively & track the limb while its moving.
• Treatment sessions of 15-30 mins.
• Stimuli to be presented in orderly fashion – 1 or 2 modalities at a time
• Examples of stimuli – favourite food
favourite music
pictures of family members

• Allow sufficient time for processing, repeat the stimulus if necessary.
• During this time, closely monitor the patient’s vitals, diaphoresis, eye movements, change in
posture, vocalisation etc.
• To monitor & compare responses, note
Latency
Consistency
Intensity
Duration
Categories of stimuli:
• Auditory
• Visual
• Olfactory
• Gustatory
• Tactile
• Vestibular
Preventing secondary impairments
Points to focus on:
• Position in bed
• Appropriate use of splints where required.
• Postural drainage for chest.
• ROM exercises – special care of heterotrophic ossification.

Management of spasticity
• As dicussed in stroke.
Early mobilisation
• As soon as the patient is stable – transfer to sitting position & out of
bed on wheelchair or chair.
• Head should be properly supported.
• Use of a tilt table is advantageous as it allows early weight bearing on
lower limbs & upright position improves overall alertness.

RLA level IV – Confused Agitated
• Patients is confused, has poor memory, decreased attention span & prone to
emotional outburst.
• Difficult to objectively examine as the patient is unable to cooperate, hence

keen observation skills are required to estimate:
• Functional mobility
• Balance (sitting and standing)
• ROM
• Strength
• Motor control
• Tone
• Sensation
• Reflexes
• Cognitive abilities
Intervention
GOALS
• Improve endurance
• Maintain joint mobility
• Reduce risk of secondary impairments
• Increase tolerance to activities
• Family education
• Most important goal in this stage is to prevent the agitated outbursts & to help
the patient control his behaviour.
• Highly structured, stable & closed environment should be given.
• To reduce confusion – same therapist
same time
same place
everyday
• Establishing a daily routine is very important
• Better to provide orientation rather than challenging the patient.
• DO NOT EXPECT CARRYOVER.
• Teaching new skills is unrealistic.
• Use of graphs & charts may be useful to help the patient progress each day.
• Offer options for tasks.

RLA levels V & VI – Confused
Inappropriate & Confused Appropriate
Examination should include concise & objective data for:
• ROM (active & passive)
• Sensations
• Tone & reflexes
• Strength
• Motor control
• Balance & coordination
• Functional status
Intervention
GOALS
• Improve functional mobility & ADL.
• Improve gait, mobility & balance.
• Improve motor control & postural control.
• Increase strength & endurance.
• Safety with functional mobility tasks & ADL.

• Primary goal in these stages is to maximize the patient’s functional
mobility skills.
• Patient may begin to learn new tasks with safety skills necessary to return
to the community.
• A memory book can be a useful tool.
• Swiss ball important tool ton improve balance, modify tone & improve
trunk control.
RLA levels VII & VIII –Appropriate
Response Levels
• Same examination techniques as uses in RLA levels V & VI

Intervention
GOALS
• Patient & family to be educated on the diagnosis & prognosis, PT intervention & goals.
• Safety of patient.
• Patient should be able to perform ADLs related to community & work reintegration &
leisure activities.
• Improve functional mobility.
• Improve self management of symptoms.
• Level of supervision is decreased.

• Major goal of the treatment is to assist the patient in integrating the
cognitive, physical & emotional skills that are necessary to function in the
real world.
• Judgement & problem solving are emphasized.
• Focus of the treatment is to maintain performance while decreasing

structure & supervision.
• Independent work & cooperative work with others is encouraged.

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TRAUMATIC BRAIN

Decorticate posturing – UE are flexed, LE are extended.

Decerebrate posturing – both UE & LE are in extension.

• Explaining & performing the movements provides tactile, auditory,

• Stimuli to be presented in orderly fashion – 1 or 2 modalities at a time

• Examples of stimuli – favourite food

pictures of family members

• To monitor & compare responses, note

• Appropriate use of splints where required.

• Postural drainage for chest.

• ROM exercises – special care of heterotrophic ossification.

bed on wheelchair or chair.

• Head should be properly supported.

• Use of a tilt table is advantageous as it allows early weight bearing on

lower limbs & upright position improves overall alertness.

• Difficult to objectively examine as the patient is unable to cooperate, hence

• Balance (sitting and standing)

• Maintain joint mobility

• Reduce risk of secondary impairments

• Increase tolerance to activities

• Highly structured, stable & closed environment should be given.

• To reduce confusion – same therapist

• Better to provide orientation rather than challenging the patient.

• DO NOT EXPECT CARRYOVER.

• Teaching new skills is unrealistic.

• Offer options for tasks.

• ROM (active & passive)

• Tone & reflexes

• Balance & coordination

• Improve gait, mobility & balance.

• Improve motor control & postural control.

• Increase strength & endurance.

• Safety with functional mobility tasks & ADL.

• A memory book can be a useful tool.

• Same examination techniques as uses in RLA levels V & VI

• Improve functional mobility.

• Improve self management of symptoms.

• Level of supervision is decreased.

• Judgement & problem solving are emphasized.

• Focus of the treatment is to maintain performance while decreasing

• Independent work & cooperative work with others is encouraged.

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