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
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the head , is identified by confusion or disorientation,loss of consciousness ,
post traumatic amnesia and other neurological abnormalities.
New Zealand guidelines group ,2007
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Most susceptible site is Fronto-temporal.
Teresa et al
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TBI is predicted to surpass many disease as major cause of death & disability
in year 2020.
Mandeep et al ,2012
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Epidemiology of TBI
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One and three-quarter million people sustain a TBI every year.
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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
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recreation -10% of TBI
Falls are the leading cause of TBI in people aged 65 years and older with
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11% proving fatal.
Incidence of TBI is 506.4 per 100,000 population,with 43% of hospitalization
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having long activity limitation.
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Changes after brain injury/1
Autonomic nervous system
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Changes in pulse and respiratory rate or regularity
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Temperature elevation
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Blood pressure changes
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Excessive sweating, salivation, tearing and sebum secretions
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Dilated pupils
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Vomiting
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Changes in brain injury/2
Motor
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Paralysis or paresis such as monoplegia or hemiplegia.
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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.
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Abnormal reflex
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Abnormal muscle tone
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Poor balance
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Loss of bowel or bladder control
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Changes after brain injury/3
Sensory and perception
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Hypersensitivity to light and noise
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Loss of hearing and sight
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Visual field changes
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Numbness and tingling (peripheral nerves are often injured)
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Loss of somatosensory functions
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Dizziness or vertigo
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Visuospatial abnormalities
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Agnosia and apraxia
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Changes after brain injury /4
Cognitive and behavioural change
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Temporary or permanent disorder of intellectual function.
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Memory loss
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Shortened attention span
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Confusion
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Irritability
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Euphoria
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Uncontrolled anger
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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
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Coma, Vegetative state (VS) and minimally conscious state are disastrous
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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.
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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
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Assessment
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Immediate assessment : Glasgow coma scale
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Assessment of an unconscious patient : characteristics of headache and vomiting.
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Cognitive functions: MMSE , Mini cog
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Sensory : FMA, NIH sensory domain
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Motor : MMT
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Spasticity : MAS / mMAS
GCS ; 3-8 ( Severe TBI) Highest mortality and morbidity
9-12( Moderate TBI)
13-15 ( Mild TBI)
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PT management
Source :- https://multipleapplicationstable.com
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Tilt-Table
Therapeutic benefit of Tilt table :-
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Reintroduce the patient to vertical position.
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Facilitate early weight bearing .
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Promote and maintain the bone density in LE.
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Prevent the muscle contracture.
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Cardiovascular conditioning.
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Postural improvement
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Decrease the prolonged bed rest complications.
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Tilt-Table (Cont..)
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Before transferring to Tilt table , measure the baseline resting BP and pulse
rate.
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After transfer ,Therapist secures the safety straps over the knees , pelvic and
chest.
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Check BP and HR at 20 degree , 45 degree , 85 degree , within every 3-5 mins.
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Avoid prolonged upright because it may lead to venous stasis.
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Be alert for s/s of insufficient cerebral circulation like dizziness , nausea ,
diaphoresis , sensation of faint.
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PT management /2
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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)
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Coma Arousal Therapy
An approach based sensory stimulation to one or more of patients five senses
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in order to help to recovery. Teresa et al , 2013
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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
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retard recovery.
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Exposure to sensory stimulation facilitate dendritic growth and improve
synaptic connections.
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Improve both cognitive function and environmental interaction .
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Principles of coma arousal therapy
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Do not harm
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Organize the stimuli
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Explain patient before & while stimuli are presented.
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Allow extra time for patient to response
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Conduct session frequently
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Select meaningful stimuli
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Verbally reinforce response
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Include participation by family and significant others
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Techniques of Coma arousal therapy/1
1) Approaching the patient
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Identify yourself and talk slowly with normal tone of voice.
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Give time to think about what you have said.
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Explain what you are going to do.
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Techniques of Coma arousal therapy/1 (Cont..)
2) Visual Stimulation
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Visually stimulating familiar object or pictures( 10 -15 min at a time)
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Provide normal visual orientation by positioning patient upright in bed or
wheelchair.
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Eliminate distractions to allow patient to focus on stimulation.
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Attempt visual tracking after focusing is established.
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Techniques of coma arousal therapy/2
3) Auditory stimulation
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Provide the regular auditory stimulus.
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Permit only one person to speak at a time.
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Use recording of familiar voice , music
(10-15 mins).
Work to localizing and focusing sound
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(call name , ring bells ) for (5-10 sec) and
look for response.
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Avoid stimulation that evokes startled
Mandeep et al, 2013
response.
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Techniques of coma arousal therapy/3
4) Movement stimulus
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ROM exercise , change in body position .
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Slow movement tends to be inhibitory while fast movement tends to be
facilitatory.
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Watch for early physical protective reactions.
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Techniques of coma arousal therapy/4
5) Tactile stimulation
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Can be facilitatory (maintained touch ,pressure to oral ar
ea ,slow stroking of the spine) or Inhibitory (pain and light
touch).
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Use different texture ( cloths, cotton) and variety of temp -
r (cloths or metal spoon dipped in hot or cold water for 30 s
ecs).
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Use different degree of pressure( grasping muscle and
maintain pressure for 3-5 seconds or rubbing the sternum).
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Avoid ice to face or body as it may trigger sympathetic system.
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Techniques of coma arousal therapy/5
6) Olfactory stimulation
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Use the familiar smell ( can be coffee , shampoo, chocolates).
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Provide stimuli no more than 10 seconds.
7) Gustatory stimulation
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Provide taste stimulation unless patient is prone of aspiration.
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Use cotton swab dipped in sweet , salty or sour solution.
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Provide stimulation to lips and area around mouth (soft toothbrush , cotton
swab, lemon , mint).
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Do not attempt feeding if patient is in coma.
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Parameters
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All the senses
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Lasting approximately 15 -20 minutes.
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5-times in a day.
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Resting period 2-3 hours in between.
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6-days in a week.
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For two weeks.
Anna Domina et al , 2016
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Evidences
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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.
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Evidences
Intervention should be tailored to client toleran
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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
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of the five senses.
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Bimodal or multimodal;
Tactile + auditory
Visual + Proprioceptive
Auditory + Visual
Auditory + Olfactory
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