Post-Traumatic Brain Injury (TBI) Rehabilitation
By
William A. Garlisi Sr, PT, DPT
19 Jun 2019
Post-Traumatic Brain Injury (TBI) Rehabilitation
OBJECTIVES
TBI in U.S. Armed Forces
Provider Clinical Recommendations
Physical Therapy Evidence Based Practice
Assessment Tools for Return To Duty (RTD)
Challenges in Rehabilitation with TBI Patients
TBI in U.S. Armed Forces
More than 287,000 service members have sustained a traumatic
brain injury (TBI) over the last decade in support of operations in
Iraq and Afghanistan. The majority of these (83.3%) were
classified as mild TBI (mTBI), also known as concussion.
TBI’s in U.S. Armed ForcesCommon Sign and Symptoms
PHYSICAL
• Headaches
• Sleep Disturbance
• Dizziness
• Balance Problems
• Fatigue
• Visual Disturbances
• Sensitivity to light
• Ringing in ears
COGNITIVE
• Concentration Problems
• Temporary gaps in memory
• Attention Problems
• Slowed Thinking
• Difficulty finding words
EMOTIONAL
• Irritability
• Anxiety
• Depression
• Mood Swings
TBI’s in U.S. Armed ForcesImpact of Concussion
Soldiers May Experience:
Difficulty sleeping at night
Decreased energy and alertness
Reduced work performance
Trouble multi-tasking
Easily distracted
Difficulty processing multiple sources of information
Interpersonal problems
TBI’s in U.S. Armed ForcesGradation and Causes
TYPES OF TBI’s
MILD
MODERATE
SEVERE
Glassgow Coma Scale, duration loss of
consciousness (LOC), duration of
alteration of consciousness (AOC), post
traumatic amnesia duration, and
neuroimaging
CAUSES
BLASTS
BULLETS
FRAGMENTS
FALLS
MV CRASH/ROLLOVER
Provider Clinical RecommendationsCriteria for Diagnosing
Severity Index Mild Moderate Severe_
Neuroimaging findings Normal structural Normal or abnormal Normal or abnormal
imaging structural imaging structural imaging
GCS score 13-15 9-12 < 9
Duration of LOC 0-30 min > 30 min & < 24 hr > 24 hr
Duration of AOC A moment up to AOC > 24 hr (use
24 hr other criteria)
Duration of posttraumatic 0-1 day >1 and < 7 > 7
Amnesia, days
Provider Clinical RecommendationsProgressive Return to Activity
Patient education is the single most effective intervention following acute mTBI
showing the greatest decrease in the number and duration of symptoms.
Provide and Review with patient the “Acute Concussion Educational Brochure”
as well as “Return to Activity Educational Brochure”.
**NOTE** Return to Activity Brochure only provided once patient has achieved a 24 hour
mandatory recovery and presents asymptomatic
Utilize a 6 stage Progressive Return to Activity Process
Stage advancement based on post exertion Neurobehavioral Symptom
Inventory (NSI) completion
Provider Clinical RecommendationsProgressive Return to Activity
Provider Clinical RecommendationsProgressive Return to Activity
Provider Clinical RecommendationsProgressive Return to Activity
Provider Clinical RecommendationsProgressive Return to Activity
Physical Therapy Evidence Based Practice
Military physical therapists (PT) work as physician extenders via operation of
Direct Access clinics
Perform a complete & thorough patient history, review of systems, and
evaluation
Initiate referrals to other clinics as warranted, order appropriate imaging, or
defer to PCM if beyond scope
Leads, coordinates, and provides continuum of care over course of patient
recovery
Physical Therapy Evidence Based Practice
Methods of Treatment
Functional Training
Fitness or aerobic training
Serial casting, splinting
Treatment intensity
Sensory stimulation
Proprioception
Strength training
Modalities?
Physical Therapy Evidence Based Practice
Currently there are no standardized PT treatment recommendations for patients
with TBI’s
Lack of randomized controlled studies for patients with TBI
Possibly due to heterogeneity of the symptoms
Physical Therapy Evidence Based Practice
A systematic literature review was conducted by Hellwig & Johannes (2008)
regarding physiotherapy following TBI
Strong evidence exists for positive rehabilitation effects when early & intensive
functional and/or aerobic training was utilized
Better patient outcomes when:
Patient compliant
Family actively engaged
Good support system
Physical Therapy Evidence Based Practice
HVLA-T to TS as a possible adjunct treatment?
Patients with h/a’s, dizziness, anxiety, neck pain (TBI w/ PTSD)
Case series provides preliminary evidence suggesting supraspinal
mechanisms may be associated with thoracic thrust manipulation and
hypoalgesia (Sparks 2017)
Assessment Tools for Return to Duty (RTD)
Currently criteria for RTD in operational environment based primarily on sports
concussion literature
Transition readiness determination from impairment-based approach to
functionally oriented based approach
Something that will challenge sensorimotor, cognitive, and physical impairments
simultaneously and target higher-level functioning
Assessment Tools for Return to Duty (RTD)
Computer Assisted Rehabilitation Environment (CAREN)
RTD Testing Modules
Assessment of Military Multitasking Performance (AMMP)
Assessment Tools for Return to Duty (RTD)
• CAREN
• Pros: Assesses multiple performance domains
simultaneously
• Cons: Cost; Required tech support for
programming, running, and maintaining
system; immaturity of evidence for
generalization of readiness; availability to
facilities
• RTD Testing Modules
• Pros: Good face validity and favorable RTD
generalization
• Cons: Lacks precise measurement and
repeatability; requires significant resources;
costly technology; substantial logistics
support; a large clinical staff; increased staff
hours to coordinate and execute testing
Assessment Tools for Return to Duty (RTD)
AMMP
Novel battery of militarized dual tasks and multitasks designed to challenge known mTBI
vulnerabilities
Pros: Incorporates complex testing methods into RTD assessment & potential application
of standards-based assessment in clinical environment which can be performed in remote
clinics or in a deployed setting; less cost compared to VR
Cons: Ability to discriminate duty readiness in service members with mTBI has not been
validated with reliability of individual test tasks yet to be reported; training required to
solidify standardized testing procedure
Assessment Tools for Return to Duty (RTD)
AMMP DUAL TASK EXAMPLE
TASK: Illinois Agility Test
TASK DEMANDS: Memory, attention, dynamic stability, and agility
TASK DESCRIPTION: Single task (motor) running distance of 30 feet with rapid direction changes and navigation of serpentine obstacles; single task (cognitive) 7-word list memory task; Dual-task condition: agility task and the memory task are done at the same time
ASSESSMENT METRIC: Accuracy of memory recall and time to complete the agility task are measured in single and dual-task conditions. Dual-task costs for cognitive and motor components
TASK RATIONALE: Tests of walking with dual-task performance are unlikely to identify discernible dual-task costs. Service member demand for speed and agility during quick maneuvers while attending to other information supports this high-level balance, running, and working memory task.
Assessment Tools for Return to Duty (RTD)
AMMP MULTITASK EXAMPLE
TASK: SALUTE
TASK DEMANDS: Executive function, attention, memory, visual scanning, gaze stability, and exertion
TASK DESCRIPTION: Service member is challenged to gather information from video surveillance
recordings and radio communication recordings (SALUTE) while performing a continuous modified step
test at >65% of age-predicted max HR
ASSESSMENT METHOD: Accuracy/errors of SALUTE report; ability to maintain appropriate exertional
load
TASK RATIONALE: The ability to integrate and retain in ones working memory visual and auditory
stimuli that are operationally significant under exertion represents a high level of functional readiness in a
clinical environment in a task that is clearly relevant to a service member
Challenges in Rehabilitation with TBI Patients
Acute and Chronic Pain are common after TBI
Acute pain, usually associated with defined tissue damage, last up to several weeks
and is expected to resolve
Chronic pain tended not to be associated with tissue damage.
Reported as high as in 71% of patients 12 months after injury, typically in form
of headache followed by declining incidents in neck, shoulders, back, and upper
& lower limbs
NOTE: Female gender, prior h/a disorder, and family hx of h/a disorder were found to be
associated with increased risk for developing posttraumatic h/a
Challenges in Rehabilitation with TBI Patients
“Polytrauma Triad”
TBI, PTSD, and Chronic Pain
Stojonavic et al found perceived pain intensity was higher in patients diagnosed with
PTSD as opposed to mTBI, but subjects with both disorders had highest perceived pain
levels
Overlapping symptoms which characterize these conditions make accurate diagnosis
problematic
Cognitive impairments associated with TBI can adversely affect a person’s ability to engage in
therapies
Post-Traumatic Brain Injury (TBI) Rehabilitation
SUMMARY
TBI in U.S. Armed Forces
Provider Clinical Recommendations
Physical Therapy Evidence Based Practice
Assessment Tools for Return To Duty (RTD)
Challenges in Rehabilitation with TBI Patients
Post-Traumatic Brain Injury (TBI) Rehabilitation
References
TBI Basics. Retrieved from: https://dvbic.dcoe.mil/articles/tbi-basics
Defense and Veterans Brain Injury Center. (2013). DoD Worldwide Numbers for TBI Worldwide totals. Retrieved
from: http://dvbic.dcoe.mil
Chapman, J.C., Diaz-Arrastia, R. (2014). Military traumatic brain injury: A review. Alzheimers & Dementia (10),
94-104.
Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury: Guidance for the
Primary Care Manager in Deployed and Non-deployed Settings (2014). Retrieved from:
https://dvbic.dcoe.mil/system/files/resources/2014
Hellwig, S., Johannes, S. (2008). Physiotherapy after traumatic brain injury: A systematic review of the literature.
Brain Injury, 22(5), 365-373.
Scherer, M.R., et al., (2013). Returning Service Members to Duty Following Mild Traumatic Brain Injury:
Exploring the Use of Dual-Task and Multitask Assessment Methods. Physical Therapy, 93(9), 1254-1267.
Irvine, K., and Clark, D., (2018). Chronic Pain After Traumatic Brain Injury: Pathophysiology and Pain
Mechanisms. Retrieved from: https://academic.oup.com/painmedicine/article
References
Gironda, R.J., et.al. (2006). Pain among vetereans of Operations Enduring Freedom and Iraqi Freedom. Pain
Medicine, 7(4), 339-343.
Stojanovic, M.P., et. al. (2016). Influence of Mild Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder
(PTSD) on Pain Intensity Levels in OER/OIF/OND Veterans. Pain Med, 17(11): 2017-2025.
Sparks, C., Cleland, J., Elliott, J., Zagardo, M., & Liu, W. (2013). Using Functional MRI to Determine if Cerebral
Hemodynamic Response to Pain Change Following Thoracic Spine Thrust Manipulation in Healthy Individuals.
Journal of Orthopaedic & Sports Physical Therapy 43(5): 340-348