Role of Physiotherapy in Traumatic Brain Injury: A case report

Vibinkumar*

Senior Physiotherapist, Kauvery Hospital, Tirunelveli

Abstract

The following fictional case study discusses possible interventions for restoring physical and cognitive function during an in-patient rehabilitation program of a 41-year old man who presented with a traumatic brain injury (TBI). He had an RTA resulting in a TBI. He entered the in-patient rehabilitation program for two weeks, with stable vitals. The initial examination findings included impaired memory, balance issues, limited ambulation and weakness in the right upper and lower extremities. Physiotherapy interventions consisted of balance training, task-specific exercises, strength training, flexibility exercises, gait training and postural education. Outcome measures were then used to reassess the patient’s progress at week 4 of in-patient rehabilitation, including: Rancho Los Amigos scale, Modified Ash-worth Scale, gait speed and distance measurements.

Introduction

Traumatic brain injury is a non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical and psycho social functions, with an associated diminished or altered state of consciousness.

Types

Traumatic brain injury can be classified mainly into two types

  • Closed Brain InjuryWithout the skull being broken or penetrated and the brain has not been exposed
  • Open Brain InjuryOpen or penetrating head injury

Case Presentation

A 41-year-old male came to hospital in an unconscious state on 14/01/2023, with H/O RTA on 13/01/2023, initially treated in Kovilpatti GH and TVMCH. Diagnostic imaging confirmed haemorrhagic contusion in left lung, lower lobe, and minimal subarachnoid and intraventricular haemorrhage. His Glasgow Coma Score (GCS) score upon arrival was 6 (E1; M3; V2) and he presented as a grade I on the Ranchos Los Amigos Scale. The severity of his TBI was classified as ‘severe’.

Course in the hospital

  1. Patient was admitted in IMCU. CT brain was done and showed minimal subarachnoid and intraventricular haemorrhage.
  2. He was initially treated with IV fluids, iv antibiotics, iv anti epileptics and iv osmotic diuretics, Tetanus Toxoid and other supportive drugs along with physiotherapy and supportive care.
  3. On the sixth day of admission patient was still drowsy, responding to painful stimuli, and maintained nasal O2 support. Adequate physiotherapy was given.
  4. He was given adequate chest physiotherapy and weaned off from ventilator.
  5. He symptomatically improved, his GCS also improved and was shifted to room for further physiotherapy protocol.

Condition on discharge

Patient was conscious and obeying commands

Muscle power

Lower limb:

  • Right side -3/5, Left side – 5/5
  • Upper limb: Right side – 2/5, Left side – 5/5

Physiotherapy management during the hospital stay:

Assessment

  1. After the patient was admitted to in-patient rehabilitation, the patient’s screening results showed stable vital signs with a heart rate of 76bmp, blood pressure of 130/80, SpO2 of 97%.
  2. The Ranchos Los Amigos scale is a useful tool to rate the patient’s cognitive level after the patient regains consciousness from a TBI. During initial assessment, he presented with level 1 (No response, total assistance) on the Ranchos Los Amigos scale.
  3. Motor function: Muscle tone graded on the Modified Ash worth Scale (MAS).

Muscle tone: 0 (mas scale)

Left Lower Extremity:

  • No increase in muscle tone was detected

Grade 0 on MAS

Right lower Extremity:

  • No increase in muscle tone was detected

Grade 0 on MAS

Left Upper Extremity:

  • No increase in muscle tone was detected

Grade 0 on MAS

Right upper extremity

  • No increase in muscle tone was detected

Grade 0 on MAS

Muscle strength (MMT)

  • Left side: Grade 5 across both lower and upper extremities
  • Right side: Grade 3 across whole lower extremity, Grade 2 across whole upper extremity.

Reflex integrity

  • Intact UMN and LMN reflexes

Balance:

  • Able to sit in the side of the bed with assistance

Management:

Inside the ICU:

  1. Patient was given adequate chest physiotherapy for maintaining a patent airway.
  2. Passive ROM exercise given to all four limbs to maintain muscle and joint integrity and to prevent DVT (DVT stocking was also donned).
  3. Lower limb positioning was done with a foot drop splint and sandbag.
  4. The position was changed regularly to prevent bedsore.

Inside the ward:

Balance and mobility exercises:

  1. Treatment started with basic static sitting and standing postures.
  2. Patient was first encouraged to high sitting position to improve neck control and sitting balance on the side of the bed and in the chair.
  3. He was then progressed to dynamic sitting such as sitting in the bed and do knee extension, shoulder flexion and abduction and trunk rotation.
  4. Static standing was progressed with standing with eyes` closed and dynamic standing initiated with taking forward, backward and side steps, marching on spot.

Gait Training:

Gait training was encouraged with walker support and progressed with minimal assistance.

On referral patient was on nasal O2 support and GCS was E1 V2 M3, muscle power reduced in right upper (2/5) and lower limb (3/5), and grade 5 in left side. Chest physiotherapy was given for airway clearance and passive ROM exercises to prevent contractures. Patient was then shifted to room where strengthening, balance and mobility training, and gait training encouraged. Discharge advice was given to the patient’s family members and advice to review at the physiotherapy department during every hospital visits.

References

  1. Brazinova A, et al. Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review. J. Neurotrauma. 2018;33:1-30.
  2. Rancho Los Amigos – Revised [Internet]. Rancho Los Amigos Revised. [cited 2020May19]. Available from: https://www.neuroskills.com/education-and-resources/rancho-los-amigos-revised/
  3. In Depth Review of the Modified Ashworth Scale [Internet]. Stroke Engine. [cited 2020May21]. Available from: https://www.strokengine.ca/en/indepth/mashs_indepth/
  4. Ontario Neurotrauma Foundation. Understanding Traumatic Brain Injury: A Handbook for The Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury. Toronto, ON: Ontario Neurotrauma Foundation. 2020.
  5. Cano Porras D, Slemonsma P, Inzelberg R, Zeilig G, Plotnik M. Advantages of virtual reality in the rehabilitation of balance and gait: Systematic Review. Neurology 2018;90:1017-1025. DOI:10.1212/WNL.0000000000005603
  6. www.physiopedia.com

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