I.

Definition
An alteration in brain function, or other evidence of brain pathology, caused by an external force.
Most TBIs are classified as closed head injuries, wherein the skull is not actually penetrated.
Traumatic brain injury is a heterogenous injury, with a wide variety of pathophysiological
mechanisms
This can be differentiated from head injury which is caused by a blow to the head or laceration
without causing injury to the brain
Definition of Terms
Skull The structure of bones that form the head and face of a person
Heterogeneous Made of parts that are different
Laceration A deep cut or tear of the flesh
Brain The organ of the body in the heat that controls functions, movements, sensations and
thoughts
Injury Harm or Damage to the physical body
II.

III.

Epidemiology
Traumatic brain injury is the leading cause of injury related death and disability in the United
States. Approximately 1.7 million people in the United States are admitted to emergency
departments with TBI each year. Of these, 50,000 people die as a result of the injury and
300,000 require hospitalization. In all likelihood these numbers underrepresent the true
incidence of TBI.
Falls are the leading cause of TBI (32%) followed by motor vehicle/traffic accidents
(19%), struck by/against events (18%), and assaults (10%). Children, older adolescents/
young adults (less than 25 years old), and older adults are most at risk for experiencing
TBI. Traumatic brain injuries are most common in young children (0 to 4 years old).
However, hospitalization and death as a result of TBI is most common in older adults (65
years old and over).
The long-term consequences of TBI on the health care system, society, and the individual are
high. There are approximately 5.3 million people living in the United States who are disabled
as a result of TBI. Four out of ten are not working 1 year after injury and one-third have
difficulty with social integration. One quarter of people with severe to moderate TBI require
assistance with activities of daily living (ADL), and approximately 40% report poor mental
and physical health.
Male to female ratio 2.5:1
Mortality in males is 34 times higher than in females
Anatomy

is the largest and most complex portion of the nervous system

it occupies the cranial cavity and is composed of one hundred billion multipolar neurons
A. Functions of the Brain
interprets sensations
determines perception
stores memory
reasoning
makes decisions
coordinates muscular movements

 regulates visceral activities

determines personality
B. Brain divisions
1. Prosencephalon/Endbrain/Cerebral hemisphere
a) Telencephalon (cerebrum)
1. Cerebral cortex
2. Subcortical white mater
3. Basal ganglia
b) Diencephalon
a. Thalamus
b. Hypothalamus
c. Epithalamus
d. Subthalamus
2. Mesencephalon (midbrain)
3. Rhombencephalon
a) Metencephalon (pons)
b) Myelencephalon (medulla oblongata)
c) Cerebellum
C. Major Parts
Cerebrum
Diencephalon
Brainstem
Cerebellum
1. CEREBRUM
the largest, most conspicuous portion of the brain
has 2 hemispheres connected by corpus callosum
composed of an inner portion (bulk of cerebrum) that is composed of white matter

and an outer portion, the cerebral cortex which is composed of gray matter
the surface is marked by ridges called gyri separated by grooves called sulci

MAJOR CEREBRAL LOBES

a. Cerebral Cortex
responsible for all conscious behavior by containing 3 kinds of functional
areas, which includes motor, sensory, and association areas:
Motor areas are located in the frontal cortex
Sensory areas are concerned with conscious awareness of
sensations and are located in the parietal, occipital, and temporal

cortex
Association areas include areas that are involved in many traits
like analyzing, interpreting sensory experiences, memory,
reasoning, verbalizing, judgment and emotions

b. Hemisphere Dominance (Brain Lateralization)

Most basic functions (sensory & motor) are equally controlled by both

left & right hemisphere

communicating exits through corpus callosum

Left Hemisphere

Right Hemisphere

Sequential analysis:

Holistic functioning:

Systematic, logical interpretation of

information

Processing multi-sensory input

simultaneously to provide holistic
picture of ones environment

Interpretation and production of symbolic

Holistic functions such as:

information:

dancing
gymnastics
singing
arts
Visual spatial skills

language
mathematics
abstraction
reasoning

Memory stored in language format

Memory is stored in auditory, visual and

spatial modalities

2. DIENCEPHALON
forms the central core of the forebrain
includes two important areas of gray matter:
a. Thalamus
central relay station for incoming sensory impulses (except smell) that directs
the impulse to the appropriate are of the cerebral cortex for interpretation
b. Hypothalamus
main visceral control center the body (i.e. regulates homeostasis)
i.
heart rate & blood pressure
ii.
body temperature
iii.
water & electrolyte balance
iv.
control of hunger & body weight
v.
control of digestive movements & secretions
vi.
regulation of sleep-wake cycles
vii.
control of endocrine system functioning

 involved in emotional response: Limbic System

controls emotional experience and expression
can modify the way a person acts
produces a feeling of fear, anger, pleasure, and sorrow, etc.
THE LIMBIC SYSTEM

3. BRAIN STEM
located between the cerebrum and the spinal cord which provides pathway for

tracts running between higher and lower neural centers

consists of the midbrain, pons, and medulla oblongata
produce automatic behaviors necessary for survival

3 Major Parts:
a. Midbrain
located between diencephalon and pons
2 bulging cerebral peduncles on the ventral side
acts in reflex actions (visual and auditory)
also contains areas associated with reticular formation
b. Pons
literally means bridge or pathway of conduction tracts

location of pneumotaxic area (regulation of breathing rate) of respiratory

center
relays nerve impulses to and from the medulla and cerebellum
c. Medulla oblongata
enlarged continuation of the spinal cord
contains an autonomic reflex center involved in maintaining homeostasis of
important visceral organs, and contains:
o cardiac center
o vasomotor center
o respiratory center
o reticular formation
THE BRAINSTEM PARTS

4. CEREBELLUM
large, cauliflower-like structure located dorsally to the pons and medulla and

inferiorly to the occipital lobe of the cerebrum (separated by transverse fissure)

pattern of white matter (within gray matter) - arbor vitae
coordinates all voluntary muscle movements (subconsciously); skilled movements,
posture, balance and equilibrium

BRAIN MENINGES

Meninges

 The brain, as well as the spinal cord, is surrounded by three layers of membranes (the
meninges) a tough, outer layer (the dura mater), a delicate, middle layer (the arachnoid
mater), and an inner layer firmly attached to the surface of the brain (pia mater).
1. Dura mater
2. Arachnoid mater
a. Subarachnoid space
3. Pia mater
THE KORBINIAN BRODMANN
The cerebral cortex has been divided by KORBINIAN BRODMANN into 47 distinct regions,
each having a Brodmanns number
Functional Areas:

The Brodmanns areas

divided into 47 cytoarchitectural areas

BRODMANNS

NAME

FUNCTION

AFFECTATION

AREA
FRONTAL LOBE (Motor Function)
Area 4
Primary motor area

Voluntary movement of

Immediate paresis if

Area 6

Premotor cortex/

skeletal muscles
Appropriate response of

damaged
Complex defects of

Motor association

movement

movements in the

Movement of the eyeball

absence of weakness
Defective scanning of

Area 8

area
Frontal eye field
movement area

opposite side, no

Area 9,10,11,12

Prefrontal

Insight, emotion

conjugate eye movement

Disturbance in behavior,

Area 44

cortex/area
Brocas area

Speech production

poor judgment, no insight

Brocas/non-fluent/nonexpressive, anterior
aphasia

PARIETAL LOBE (Somatosensory Function)

Area 3, 1, 2
Primary sensory
Receives tactile stimulus

Impaired 2 point-

area/ Somatosensory

discrimination, touch,

area

position sense, and

Area 5, 7

Sensory association

Interprets tactile

stereognosis
--

Area 43

area
Primary gustatory

sensations
Taste sensation

Loss of taste

Area 39, 40

area
Gnostic/Common

Memory, behavior, sexual

Area 39: Angular gyrus

integration areas

desires

syndrome (aka

Area 39:

Gerstmanns syndrome);

Angular gyrus

combined acalculia,
agraphia, finger agnosis

Area 40:

R-L disorientation

Temporal gyrus

Area 40: Ideomotor

apraxia

TEMPORAL LOBE (Hearing)

Area 41, 42
Primary auditory

Hearing

Complete cortical

Heschls gyrus
Area 21, 22

Speech integration/

deafness
Wernickes/fluent/expres

cortex
Wernickes area

language interpretation

sive/posterior aphasia

Sight

Complete sight blindness

area
Visual association

Interpretation of visual

--

areas

stimulus

OCCIPITAL LOBE (Sight)

Area 17
Primary visual
cortex/Calcarine
Area 18, 19

Blood Supply of the Brain

The brain receives it arterial supply from two pairs of vessels, the vertebral and internal carotid

arteries, which are interconnected in the cranial cavity to produce an arterial circle (of Willis).
The two vertebral arteries enter the cranial cavity through the foramen magnum and just inferior

to the pons fuse to form the basilar artery.

The two internal carotid arteries enter the cranial cavity through the carotid canals on either side.

Arteries of the Brain

The brain is supplied by the two internal carotid and the two vertebral arteries. The four arteries
anastomose on the inferior surface of the brain and form the circle of Willis (circulus arteriosus).
Veins of the Brain
The veins of the brain have no muscular tissue in their thin walls, and they possess no valves.
They emerge from the brain and drain into the cranial venous sinuses. Cerebral and cerebellar
veins and veins of the brainstem are present. The great cerebral vein is formed by the union of
the two internal cerebral veins and drains into the straight sinus

Vertebral Arteries
Each vertebral artery arises from the first part of each subclavian artery in the lower part of the neck,
and passes superiorly through the transverse foramina of the upper six cervical vertebrae. On entering the
cranial cavity through the foramen magnum each vertebral artery gives off a small meningeal branch.
Continuing forward, the vertebral artery gives rise to three additional branches before joining with its
companion vessel to form the basilar artery:

one branch joins with its companion from the other side to form the single anterior spinal
artery, which then descends in the anterior median fissure of the spinal cord;

a second branch is the posterior spinal artery, which passes posteriorly around the medulla then
descends on the posterior surface of the spinal cord in the area of the attachment of the posterior

roots-there are two posterior spinal arteries, one on each side;

just before the two vertebral arteries join, each gives off a posterior inferior cerebellar artery.

The basilar artery travels in a rostral direction along the anterior aspect of the pons. Its branches in a
caudal to rostral direction include the anterior inferior cerebellar arteries, several small pontine arteries,
and the superior cerebellar arteries. The basilar artery ends as a bifurcation, giving rise to two posterior
cerebral arteries.
Internal Carotid Arteries
The two internal carotid arteries arise as one of the two terminal branches of the common carotid arteries.
They proceed superiorly to the base of the skull where they enter the carotid canal.
Entering the cranial cavity each internal carotid artery gives off the ophthalmic artery, the posterior
communicating artery, the middle cerebral artery, and the anterior cerebral artery.
Arterial Circle
The cerebral arterial circle (of Willis) is formed at the base of the brain by the interconnecting
vertebrobasilar and internal carotid systems of vessels. This anastomotic interconnection is accomplished
by:

an anterior communicating artery connecting the left and right anterior cerebral arteries to each

other;
two posterior communicating arteries, one on each side, connecting the internal carotid artery
with the posterior cerebral artery.

ANATOMY OF BLOOD VESSELS

1. ARTERIES AND ARTERIOLES
Arteries are strong, elastic vessels that are designed to carry blood away from the heart
under fairly high pressure. These vessels branch into progressively thinner tubes and

eventually give rise to fine branches called arterioles.

The wall of an artery consists of three distinct layers:
o The innermost layer, tunica intima, is composed of simple squamous epithelium, called
endothelium, resting on a connective tissue membrane, which is rich in elastic and
collagen fibers.

The middle layer, tunica media, makes up the bulk of the arterial wall. It includes
smooth muscle fibers, which encircle the vessel, and a thick layer of elastic connective

tissue.
The outer layer, tunica adventitia, is relatively thin and consists chiefly of connective
tissue with irregularly arranged elastic and collagen fibers. This layer attaches the artery

to the surrounding tissues, be it muscle, adipose, or other tissue types.

The smooth muscles in the walls of arteries and arterioles are innervated by the sympathetic
branches of the autonomic nervous system (ANS). Impulses on these vasomotor fibers cause the
smooth muscles to contract, reducing the diameter of the vessels. This action is called
vasoconstriction. If such vasomotor impulses are inhibited, the muscle fibers relax and the

diameter of the vessels increases. In this case, the vessels are said to undergo vasodilatation.
Changes in the diameters of arteries and arterioles greatly influence the flow and pressure of

blood.
IV.
Etiology
Physical force
Vehicular Accident
V.

Pathophysiology

External
Force

Hypoxia

Brain Tissue
Damage

Primary
Injury or
Secondary
Injury

Edema

Elevated
Intracranial
pressure

The pathophysiologic processes associated with TBI are complex and consists of:
Primary Injury
Blast Injury
Secondary Injury
Primary Injury

Primary TBI results from either brain tissue coming into contact with an object (e.g., bony skull
or external object such as a bullet or sharp instrument creating a penetrating injury) or rapid
acceleration/deceleration of the brain. Contact injuries often result in contusions, lacerations, and
intracerebral hematomas.
This damage is generally focal in nature as the brain comes into contact with bony protuberances
on the inside surface of the skull or damage from the penetrating object. Common areas of focal
injury are the anterior temporal poles, frontal poles, lateral and inferior temporal cortices, and
orbital frontal cortices.
Acceleration and deceleration cause shear, tensile, and compression forces within the brain,
which causes diffuse axonal injury (DAI), tissue tearing, and intracerebral hemorrhages. Diffuse
axonal injury is the predominant mechanism of injury in most individuals with severe to
moderate TBI. It is common in high-speed motor vehicle accidents (MVAs) and can be seen in
some sports related TBIs.
The mechanism of DAI is microscopic, so often there are minimal initial findings on computed
tomography (CT) and magnetic resonance imaging (MRI). The acceleration/deceleration forces
cause disruption of neurofilaments within the axon leading to Wallerian-type axonal
degeneration.

Blast Injury
Blast injury is considered a signature injury of the U.S. military conflicts in the Middle East.
When an explosive device detonates a transient shock wave is produced, which can cause brain
damage. Primary blast injury results from the direct effect of blast overpressure on organs (in this
case the brain), secondary injury results from shrapnel and other objects being hurled at the
individual, and tertiary injury occurs when the victim is flung backward and strikes an object.
The exact mechanisms are not fully understood, there appear to be three mechanisms by which
primary blast brain injury may occur:
o Direct transcranial blast wave propagation
o The transfer of kinetic energy from the blast wave through the vasculature, which
triggers pressure oscillations in the blood vessels leading to the brain;
o Elevations in cerebrospinal fluid (CSF) or venous pressure caused by
compression of the thorax and abdomen and by propagation of a shock wave
through the blood vessels or CSF.
Blast-related brain injury can result in edema, contusion, DAI, hematomas, and hemorrhage. A
wide spectrum of injury severities ranging from mild (blast concussion) to severe and fatal can
result from blast TBI.
Secondary Injury
Secondary cell death occurs as a result of a chain of cellular events that follow tissue damage in
addition to the secondary effects of hypoxemia, hypotension, ischemia, edema, and elevated ICP.
Secondary processes develop over hours and days, and include glutamate neurotoxicity, influx of
calcium and other ions, free radical release, cytokines, and inflammatory responses that can lead
to cell death.
Normal ICP is 5 to 20 cm H2O. Severely increased ICP typically results in herniation of the
brain, requiring prompt emergency treatment.
Common types of herniations are uncal, central, and tonsillar.
It is important to keep in mind that both primary and secondary mechanisms of injury are not
mutually exclusive and often do not occur in isolation.
The release of glutamate and other excitatory neurotransmitters exacerbates ion-channel leakage
and contributes to brain swelling and raised ICP.

VI.
Impairments
Neuromuscular Impairments
Individuals with TBI commonly exhibit
impaired motor function. Upper extremity
(UE) and lower extremity (LE) paresis,
impaired coordination, impaired postural
control, abnormal tone, and abnormal gait
may be present as life-long impairments.
Abnormal, involuntary movements such as
tremor and chorea form and dystonic
movements are less common. Patients may
also present with impaired somatosensory
function, depending on the location of the
lesion.
Cognitive Impairments
Cognition is the mental process of knowing
and applying information.
Cognition includes many complex neural
processes, including arousal, attention,
concentration, memory, learning, and
executive functions. Executive functions can
be categorized into the following main areas:
planning, cognitive flexibility, initiation and
self-generation, response inhibition, and serial
ordering and sequencing.
Neurobehavioral Impairments
Patients can exhibit profound behavioral
changes as they progress through recovery.
These impairments can be closely linked to cognitive impairments and are often more debilitating
in the long run than physical disability.
Common behavioral sequelae include low frustration tolerance, agitation, disinhibition, apathy,
emotional lability, mental inflexibility, aggression, impulsivity, and irritability.
Communication
Language and communication deficits after brain injury are generally nonaphasic in nature and
are related to cognitive impairment.
Common language and communication deficits include disorganized and tangential oral or
written communication, imprecise language, word retrieval difficulties, and disinhibited and
socially inappropriate language.
Patients may also exhibit difficulties communicating in distracting environments, reading social
cues, and adjusting communication to meet the demands of the situation.
Secondary Impairments and Medical Complications
Due to the high potential of prolonged immobility and concomitant injury, patients with TBI are
at risk of developing a number of secondary impairments and other medical issues.

Up to 50% of patients with severe brain injury

develop gastrointestinal difficulties, 45% develop
genitourinary problems, 34% develop respiratory
problems, 32% develop cardiovascular problems,
and 21% develop dermatological complications.

VII.

Differential Diagnosis
Brain tumor
Encephalitis
Bacterial meningitis
Stroke
Cerebral aneurysm
Arteriovenous malformations

VIII.

Diagnostic Tools
1. CT Scan
In the acute postinjury period, CT scanning can detect intracranial hemorrhage,
brain swelling, hydrocephalus, and infarction. The raw data can be adjusted to
better evaluate structures of different radiodensities.
However, CT is not sensitive in identifying small contusions, white matter injury,
or in the evaluation of the posterior fossa.
In the postacute phase, CT scanning can be useful, especially when a patients
neurological status is deteriorating or failing to progress as anticipated. In such
situations, CT may identify progression of hydrocephalus or hygromas, evidence
of increased ICP, or new bleeds.
2. Brain MRI
MRI has some advantages over CT, including lack of x-ray exposure, greater
resolution in the brainstem, better identification of isodense collections of blood,
and detection of small white matter lesions.
However, MRI takes longer to perform, and requires that the patient not have any
MRI incompatible implants or equipment. In the broadest sense, CT is of greatest
use in the acute setting, while MRI may be more appropriate in the sub-acute and
chronic setting.
3. PET, SPECT, fMRI
Single photon emission CT (SPECT), positron emission tomography (PET), and
functional MRI (fMRI) can all measure regional cerebral perfusion, although
only PET and perfusion fMRI can quantify blood flow in absolute terms.
Since perfusion may be compromised in structurally intact brain tissue, either as
a result of reduced vascular delivery, or reduced perfusion demand by inactive
neural tissue, reductions in flow may identify areas of functional compromise.

Pharmacological Treatment
Benzodiazepines
Are GABAnergic agents often used in controlling agitation and anxiety. They have minimal
hemodynamic effects, and lorazepam does not diminish the respiratory drive.
They have no direct effect in decreasing ICP, but long-term use can delay neurologic recovery.
Barbiturates

Can be used to induce a coma and decrease the metabolic requirements of the brain. Pentobarbital
can also control ICP.
Profopol infusion
Can provide the same CNS depression as the barbiturates, and its short half-life can allow for
frequent neurologic examinations.
It can produce dose-dependent hemodynamic and respiratory depression, and should be used only
in hemodynamically stable patients.
Believed to manifest its effect through the GABAA system; can be used for sedation in patients
who are intubated in the ICU. It has a relatively favorable side-effect profile, with a rapid return
to consciousness after the infusion is discontinued
Clinical Rating Scale
Glasgow Coma Scale
The GCS is a simple scale for assessing
the depth of coma.
Lower GCS scores are associated with
worse outcomes based on the best GCS
within the first 24 hours.
Using the highest GCS score within the
first few hours after the injury is
preferred, as this reduces the likelihood
of using excessively low, very early
scores (often before CPR) and
confounding factors such as decreased
arousal due to use of sedatives or
paralytic agents.
Severity of TBI:
GCS score 3 to 8 = severe
TBI (coma)
GCS score 9 to 12 =
moderate TBI
GCS score 13 to 15 = mild
TBI
Galveston Orientation and Amnesia Test (GOAT)

Measure of PTA
Series of standardized questions related to
orientation and the ability to recall events
prior to and after the injury high interrater
reliability.
o Scores between 100 and 76 are
considered normal
o Score >700 indicates emergence from
coma

Rancho Los Amigos Level of Cognitive Functioning (RLALOCF)

Descriptive scale used to examine cognitive ad behavioural recovery in individuals with TBI as
they emerge from coma and progress after a brain injury together with the GCS, is among the
most widely used in clinical facilities.
RLA LOCF
Level
I

II

III

Description
No response: Total Assistance

Complete absence of observable change in

behaviour when presented visual, auditory, tactile,
proprioceptive, vestibular or painful stimuli.
Generalized response-Total Assistance

Demonstrate generalized reflex response to painful

stimulus.

Responds to repeated auditory stimuli with

increased or decreased activity.

Responds to external stimuli with physiological

changes generalized, gross body movement and/or
not purposeful vocalization.

Responses noted above may be same regardless of

type & location of stimulation.

Responses may be significantly delayed.

Localized response: Total Assistance

Demonstrates withdrawal or vocalization to painful

stimulus.

Turns toward or away from auditory stimuli.

Blinks when strong light crosses visual field.

Follows moving object passed within visual field.

Responds to discomfort by pulling tubes or

restraints.

Responds inconsistently to simple commands.

Responses directly related to type of stimulus.

May respond to some persons (especially family &

friends) but not to others.

IV

Confused/Agitated: Maximal Assistance

Alert and in heightened state of activity.

Purposeful attempts to remove restraints or tubes or

crawl out of bed.

May perform motor activities such as sitting,

reaching & walking but without any apparent
purpose or upon anothers request.

Very brief & usually non-purposeful moments of

sustained alternatives and divided attention.

Absent short-term memory.

May cry out or scream out of proportion to stimulus

even after its removal.

May exhibit aggressive or flight behaviour.

Mood may swing from euphoric to hostile with no

apparent relationship
To environmental events.

Unable to cooperate with treatment efforts.

Verbalizations are frequently incoherent and/or

inappropriate to activity or environment.
Confused, Inappropriate Non-agitated: Maximal Assistance

Alert, not agitated but may wander randomly or with

a vague intention of going home.

May become agitated in response to external

stimulation, and/or lack of environmental structure.

Not oriented to person, place or time.

Frequent brief periods, non-purposeful sustained

attention.

Severely impaired recent memory, with confusion of

past and present in reaction to on-going activity.

Absent goal-directed, problem solving, selfmonitoring behaviour.

Often demonstrates inappropriate use of objects

without external direction.

Maybe able to perform previously learned tasks

when structures and cues provided.

Unable to learn new information.

Able to respond appropriately to simple commands

fairly consistently with external
structures and
cues.

Responses to simple commands without external

structure are random & non-purposeful in relation to
command.

Able to converse on a social, automatic level for

brief periods of time when provided external

VI

VII

structure and cues.

Verbalizations about present events become
inappropriate & confabulatory when external
structure and cues are not provided.

Confused, Appropriate: Moderate Assistance

Inconsistently oriented to person, time and place.

Able to attend to highly familiar tasks in nondistracting environment for 30 minutes with
moderate redirection.

Remote memory has more depth and detain than

recent memory.

Vague recognition of some staff.

Able to use assistive memory aide with maximum

assistance.

Emerging awareness of appropriate response to self,

family and basic needs.

Moderate assist to problem solve barriers to task

completion.

Supervised for old learning (e.g. self-care).

Shows carry over for relearned familiar tasks (e.g.

self-care).

Maximum assistance for new learning with or no

carry over.

Unaware of impairments, disabilities and safety

risks.

Consistently follows simple directions.

Verbal expressions are appropriate in highly familiar

and structured situations.
Automatic, Appropriate: Minimal Assistance for Daily
Living Skills

Consistently oriented to person and place, within

highly familiar environments.
Moderate assistance for orientation to time.

Able to attend to highly familiar tasks in a nondistraction environment for at least 30 minutes with
minimal assist to complete tasks.

Minimal supervision for new learning.

VIII

Demonstrates carryover of new learning.

Initiates and carries out steps to complete familiar
personal and household routine but has shallow
recall of what he/she has been doing.

Able to monitor accuracy and completeness of each

step in routine personal and household ADLs and
modify plan with minimal assistance.

Superficial awareness of his/her condition but

unaware of specific impairments and disabilities and
the limits they place on his/her ability to safely,
accurately and completely carry out his/her
household, community, work and leisure ADLs.

Minimal supervision for safety in routine home and

community activities.

Unrealistic planning for the future.

Unable to think about consequences of a decision or

action.

Overestimates abilities

Unaware of others needs and feeling;

Oppositional/uncooperative

Unable to recognize inappropriate social interaction

behaviour
Purposeful, Appropriate: Standby-By Assistance

Consistently oriented to person, place and time.

Independently attends to and completes familiar

tasks for 1 hour in distracting environments.

Able to recall and integrate past and recent events.

Uses assistive memory devices to recall daily

schedule, to do list and record critical
information for later use with stand-by assistance.

Initiates and carries out steps to complete familiar

personal, household, community, work and leisure
routines with stand-by assistance and can modify the
plan when needed with minimal assistance.

Requires no assistance once new tasks/activities are

learned.

Aware of and acknowledges impairments and

disabilities when they interfere with task completion
but requires stand-by assistance to take appropriate
action.

Thinks about consequences of a decision or action

with minimal assistance.

Overestimates or underestimates abilities

Acknowledges others needs/feelings and responds

IX

appropriately with minimal assistance

Depressed; irritable

Low frustration tolerance/easily angered

Argumentative; self-cantered; Uncharacteristically

dependent/independent

Able to recognize and acknowledge inappropriate

social interaction behaviour while it is occurring and
takes corrective action with minimal assistance.
Purposeful, Appropriate: Standby-By Assistance on Request

Independently shifts back and forth between tasks

and completes them accurately for at least two
consecutive hours.

Uses assistive memory devices to recall daily

schedule, to do list and record critical
information for later use with stand-by assistance.

Initiates and carries out steps to complete familiar

personal, household, community, work and leisure
tasks independently and unfamiliar personal,
household, work and leisure tasks with assistance
when requested.

Aware of and acknowledges impairments and

disabilities when they interfere with task completion
and takes appropriate corrective action but requires
stand-by assistance to anticipate a problem before it
occurs and take action to avoid it.

Able to think about consequences of decisions or

actions with assistance when requested.

Accurately estimates abilities but requires stand-by

assistance to adjust to task demands.

Acknowledges others needs and feelings and

responds appropriately with stand-by assistance.

Depression may continue

May be easily irritable

May have low frustration tolerance

Able to self-monitor appropriateness of social

interaction with stand-by assistance.
Purposeful, Appropriate: Modified Independent

Able to handle multiple tasks simultaneously in all

environments but may require periodic breaks.

Able to independently procure, create and maintain

own assistive memory devices.

Independently initiates and carries out steps to

complete familiar and unfamiliar personal,
household, community, work and leisure tasks but

may require more than usual amount of time and/or

compensatory strategies to complete them.
Anticipates impact of impairments and disabilities
on ability to complete daily living tasks and takes
action to avoid problems before they occur but may
require more than usual amount of time and/or
compensatory strategies.
Able to independently think about consequences of
decisions or actions but may require more than usual
amount of time and/or compensatory strategies to
select the appropriate decision or action.
Accurately estimates abilities and adjust to task
demands.
Able to recognize the needs and feelings of others
and automatically respond in appropriate manner.
Periodic periods of depression may occur.
Irritability and low frustration tolerance when sick,
fatigued and/or under emotional stress
Social interaction behaviour is consistently
appropriate.

Glasgow Outcome Scale (GOS)

General outcomes measure after a TBI

Often used in prognostic studies at discharge and 6 months to a year after injury
Has good reliability

Glasgow Outcome Scale

Patients
Definition
Abilities
Death
Persistent
No cerebral cortical function as judged
vegetative
behaviorally
state
Unable to interact with environment
Unresponsive
Severe
Conscious
disability
Able to follow commands but dependent on
24h care
Unable to live independently
Moderate
Disabled but capable of independent care
disability
Unable to return to work or school
Good
Mild impairment with persistent sequelae
recovery
Able to participate in normal social life,
including able to return to work
Posttraumatic Amnesia (PTA)

Score
1
2

4
`5

PTA is one of the most commonly used predictors of outcome.

Longer PTA duration is associated with worse outcomes.
Resolution of PTA clinically corresponds to the period when incorporation of ongoing daily
events occurs in the working memory.
Threshold Values:
Severe disability is unlikely when PTA lasts less than 2 months.
Good recovery is unlikely when PTA lasts longer than 3 months.
PTA correlates strongly with length of coma (and with GOSsee below) in patients with DAI
but poorly in patients with primarily focal brain injuries (contusions).

PT Management
Physical Therapy Mx of Moderate to Severe Traumatic Brain Injury in the Acute Stage
Preventing Secondary Impairments
Because of the patients inability to move at these levels, he or she is susceptible to indirect
impairments such as contractures, decubiti, pneumonia, and DVT.
Early Mobility
Upright sitting is extremely important because it addresses elements of treatment goals for the
early levels of recovery. As soon as medically stable, the patient should be transferred to a sitting
position and out of bed to a wheelchair.

Sensory Stimulation
Sensory stimulation is an intervention used to increase the level of arousal and elicit movement in
individuals in a coma or persistent vegetative state.

Physical Therapy Mx of Moderate to Severe Traumatic Brain Injury Active Rehabilitation

Motor (Re) Learning Strategies
Treatment sessions should be thoughtfully planned to maximize the patients motor learning
capabilities.
Practice should be distributed, with frequent rest periods.
The impact of manipulating motor learning variables on motor skill acquisition and
generalizability has not been thoroughly studied in patients with TBI.
Restorative versus Compensatory-Based Interventions
Two basic treatment strategies are a compensatory and a restorative (recovery) approach.
The compensatory approach seeks to improve functional skills by compensating for the lost
ability.
A simple example of this would be teaching one-handed dressing techniques to a patient with UE
hemiparesis resulting from a TBI.
A restorative approach seeks to restore the normal use of the affected UE.
Both approaches seek to reinstitute functional independence, and the exact definition of each
approach is a subject of ongoing debate.
Task-Oriented Approach
Also in line with these principles, current theories of motor control and motor learning advocate
for a task oriented approach to interventions for individuals with neurological deficits.
Locomotor Training with Body Weight Support
Locomotor training with BWS and a treadmill involves suspending the client in a parachute-like
overhead harness that allows for a percentage of body weight to be relieved.
Therapists assist the patient by providing trunk/pelvic stabilization, assistance with weight
shifting, and advancing the LEs.
Locomotor training with BWS is commonly combined with treadmill ambulation, but can be
done over ground as well.
Constraint-Induced Therapy
Constraint-induced movement therapy involves promoting the use of the more affected UE for up
to 90% of waking hours and reducing the use of the least affected UE.
Intensive, task-oriented training is provided for the affected UE for up to 6 hours per day over a
2- to 3-week period.
Aerobic and Endurance Conditioning

Fatigue and cardiopulmonary pathology are common after TBI. The severity of deconditioning
found in persons with TBI is significantly greater than that found in sedentary persons without
disabilities.
Aerobic training is effective for persons with TBI.
Appropriately dosed aerobic exercise has the potential to not only reduce long-term
cardiovascular risks, but also may improve sleep hygiene and reduce both depression and reports
of fatigue.

Resistance Training
Interventions aimed at improving force-production capacity may be beneficial supplements to the
physical therapists POC.
There is currently a dearth of literature investigating the role of strength training in TBI
rehabilitation.
There is, however, evidence of a positive effect in other progressive and nonprogressive
neurological disorders.
Electrical Stimulation
The application of functional electrical stimulation (FES) to motor rehabilitation has increased
significantly in the last decade.
Patient/Family/Caregiver Education
Patient/family/caregiver education and training are important goals across each level of
rehabilitation.
The goals of this education and training will vary based on the cognitive and behavioral abilities
of the patient.
Behavioral Factors
Therapists may encounter a variety of behavioral barriers to examining and treating patients with
moderate to severe TBI.
As the patient begins to emerge from coma, he or she often experiences a period of acute posttraumatic agitation.
Reference:
DeLisa, Joel. DeLisas Physical Medicine & Rehabilitation: Principles and Practice. 5th ed.
OSullivan, Susan & Schmitz, Thomas. Physical Rehabilitation. 5th ed.
Snell's Clinical Anatomy by Regions 9th Edition
Physical Medicine and Rehabilitation, Braddom