Physiotherapy management in Traumatic Brain Injury

(TBI) in an unconscious patient

Prepared by Moderated by
Rachana Timalsina Govinda Mani Nepal
Roll no: 28 Lecturer, MPT
BPT 3rd year Dhulikhel hospital,
KUSMS
 Introduction

 Traumatic Brain Injury ( TBI) , an injury to the brain rather than an injury to
●

the head , is identified by confusion or disorientation,loss of consciousness ,

post traumatic amnesia and other neurological abnormalities.

New Zealand guidelines group ,2007

●
Most susceptible site is Fronto-temporal.

Teresa et al
●
TBI is predicted to surpass many disease as major cause of death & disability
in year 2020.
Mandeep et al ,2012

2
Epidemiology of TBI

●
One and three-quarter million people sustain a TBI every year.
●
52 thousand people die yearly of TBI, 80,000 injuries result in disabilities
and 5.3 million people are living with permanent disabilities from TBI.

 Motor vehicle crashes- 20%,Fall- 28%,Violence- 11%,Sports and

●

recreation -10% of TBI

 Falls are the leading cause of TBI in people aged 65 years and older with
●

  11% proving fatal.

 Incidence of TBI is 506.4 per 100,000 population,with 43% of hospitalization

●

   having long activity limitation.

3
Changes after brain injury/1

Autonomic nervous system

●
Changes in pulse and respiratory rate or regularity
●
Temperature elevation
●
Blood pressure changes
●
Excessive sweating, salivation, tearing and sebum secretions
●
Dilated pupils
●
Vomiting

4
Changes in brain injury/2
Motor
●
Paralysis or paresis such as monoplegia or hemiplegia.
●
Cranial nerve injury resulting in paralysis of eye muscle, facial paralysis,
vestibular and vestibula ocular reflex abnormalities, slurred speech,  
   dysphagia and paralysis of tongue muscle.
●
Abnormal reflex
●
Abnormal muscle tone
●
Poor balance
●
Loss of bowel or bladder control

5
Changes after brain injury/3
Sensory and perception
●
Hypersensitivity to light and noise
●
Loss of hearing and sight
●
Visual field changes
●
Numbness and tingling (peripheral nerves are often injured)
●
Loss of somatosensory functions
●
Dizziness or vertigo
●
Visuospatial abnormalities
●
Agnosia and apraxia
6
Changes after brain injury /4

Cognitive and behavioural change

●
Temporary or permanent disorder of intellectual function.
●
Memory loss
●
Shortened attention span
●
Confusion
●
Irritability
●
Euphoria
●
Uncontrolled anger

7
Classification of TBI

Classification by severity of injury

(Head Injury Severity Classification System )

Severity LOC GCS PTA Imaging

Mild <60 min >13 <60 min Negative
Moderate 1-24 hrs 9-12 hrs 1-24 hrs Negative or
positive

Severe >24 hrs <9 >24 hrs Negative or

positive
Sawchyn JM et al , Satman KE et al 2008

8
Coma, Vegetative state (VS) and minimally conscious state are disastrous
●

outcomes following severe traumatic brain injury. Teresa et al , 2013

VS is state of wakefulness without the detectable awareness. Patient are in

the altered state of consciousness.

9
 MCS is defined as the condition of severely altered consciousness in which
minimal but definite behavioural evidence of self or environmental awareness
is demonstrated.
Giacino et al, 2002

10
Assessment
●
Immediate assessment : Glasgow coma scale
●
Assessment of an unconscious patient : characteristics of headache and vomiting.
●
Cognitive functions: MMSE , Mini cog
●
Sensory : FMA, NIH sensory domain
●
Motor : MMT
●
Spasticity : MAS / mMAS

GCS ; 3-8 ( Severe TBI) Highest mortality and morbidity

9-12( Moderate TBI)

13-15 ( Mild TBI)

11
PT management

Source :- https://multipleapplicationstable.com
12
Tilt-Table
Therapeutic benefit of Tilt table :-
●
Reintroduce the patient to vertical position.
●
Facilitate early weight bearing .
●
Promote and maintain the bone density in LE.
●
Prevent the muscle contracture.
●
Cardiovascular conditioning.
●
Postural improvement
●
Decrease the prolonged bed rest complications.

13
Tilt-Table (Cont..)
●
Before transferring to Tilt table , measure the baseline resting BP and pulse
   rate.
●
After transfer ,Therapist secures the safety straps over the knees , pelvic and
   chest.
●
 Check BP and HR at 20 degree , 45 degree , 85 degree , within every 3-5 mins.
●
Avoid prolonged upright because it may lead to venous stasis.
●
Be alert for s/s of insufficient cerebral circulation like dizziness , nausea ,
  diaphoresis , sensation of faint.

14
PT management /2

●
Chest strap should be secured properly and make sure that it is not too  
   tight so that patient could breathe properly.

Duration of tilt table : once/twice a day regime for up to 10-30 mins

each session.
: up to 4 weeks then try higher level
( one level below if fainting , headache occurs)

15
Coma Arousal Therapy

 An approach based sensory stimulation to one or more of patients five senses

●

   in order to help to recovery. Teresa et al , 2013

●
Aim to provide multiple sensory stimulation to patient in coma or vegetative
state needed to activate reticular system( responsible for arousal ).

 Prevent environmental ( sensory) deprivation which has been shown to

●

retard recovery.
●
Exposure to sensory stimulation facilitate dendritic growth and improve
    synaptic connections.
●
Improve both cognitive function and environmental interaction .

16
Principles of coma arousal therapy
●
Do not harm
●
Organize the stimuli
●
Explain patient before & while stimuli are presented.
●
Allow extra time for patient to response
●
Conduct session frequently
●
Select meaningful stimuli
●
Verbally reinforce response
●
Include participation by family and significant others

17
Techniques of Coma arousal therapy/1
1) Approaching the patient
●
Identify yourself and talk slowly with normal tone of voice.
●
Give time to think about what you have said.
●
Explain what you are going to do.

18
Techniques of Coma arousal therapy/1 (Cont..)

2) Visual Stimulation
●
Visually stimulating familiar object or pictures( 10 -15 min at a time)
●
Provide normal visual orientation by positioning patient upright in bed or
   wheelchair.
●
Eliminate distractions to allow patient to focus on stimulation.
●
Attempt visual tracking after focusing is established.

19
Techniques of coma arousal therapy/2
3) Auditory stimulation
●
Provide the regular auditory stimulus.
●
Permit only one person to speak at a    time.
●
Use recording of familiar voice , music
  (10-15 mins).

 Work to localizing and focusing sound

●

   (call name , ring bells ) for (5-10 sec)     and

look for response.
●
Avoid stimulation that evokes startled
Mandeep et al, 2013
   response.
20
 Techniques of coma arousal therapy/3
4) Movement stimulus
●
ROM exercise , change in body position .
●
Slow movement tends to be inhibitory while fast movement tends to be
facilitatory.
●
Watch for early physical protective reactions.

21
 Techniques of coma arousal therapy/4
5) Tactile stimulation
●
 Can be facilitatory (maintained touch ,pressure to oral ar
ea ,slow stroking of the spine) or Inhibitory (pain and light 
touch).
●
 Use different texture ( cloths, cotton) and variety of temp -
r (cloths or metal spoon dipped in hot or cold water for 30 s
ecs).
●
Use different degree of pressure( grasping muscle and
maintain pressure for 3-5 seconds or rubbing the sternum).
●
 Avoid ice to face or body as it may trigger sympathetic system.
22
 Techniques of coma arousal therapy/5
6) Olfactory stimulation
●
Use the familiar smell ( can be coffee , shampoo, chocolates).
●
Provide stimuli no more than 10 seconds.

7) Gustatory stimulation
●
Provide taste stimulation unless patient is prone of aspiration.
●
Use cotton swab dipped in sweet , salty or sour solution.
●
Provide stimulation to lips and area around mouth (soft toothbrush , cotton
     swab, lemon , mint).
●
Do not attempt feeding if patient is in coma.

23
Parameters

●
All the senses
●
Lasting approximately 15 -20 minutes.
●
5-times in a day.
●
Resting period 2-3 hours in between.
●
6-days in a week.
●
For two weeks.
Anna Domina et al , 2016

24
Evidences

●
Coma arousal therapy is having
significant effect on GCS and CRS
in TBI when compared to the
patients who did not receive coma
arousal therapy.

25
 Evidences
 Intervention should be tailored to client toleran
●

   ce and premorbid preference. Bimodal or multi    
  modal stimulation should begin early, and be sus  
 tained until more complex activity is possible. 

 Unimodal includes stimulation through any one
●

  of the five senses.

●
Bimodal or multimodal;
Tactile + auditory
Visual + Proprioceptive
Auditory + Visual
Auditory + Olfactory

26
27
28