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HEAD
INJURY
By Dr. Nidhi Vedawala
 Traumatic head injury is a condition in which an insult to the brain
is caused to due any external force, which usually leads to alteration
in the state of consciousness in the person that impairs the cognitive
and physical function along with behavioural or emotional
disturbances.
 These changes may be temporary or permanent and may cause
partial or total disability.
Introduction
Layers
Mechanism Of Injury
 open head injury
 closed head injury
 coup injury
 countercoup injury e.g. When a patient falls on the forehead, the
frontal part of the brain suffers damage due to direct impact of the
brain (coup injury) but along with it there could be damage to the
occipital part of the brain (countercoup injury)
 Primary Damage
 Involved by acceleration force, deceleration force, rotational force
or penetrating objects. These sources of injury can caused
laceration, contusion, shearing, tension, or compression that causes
primary damage to the brain structures. Primary damages are due
to either a blow on the head by the object or head striking against
the object.
 Vascular lesion may also accompany due to either direct
laceration of the blood vessels in the brain or due to lesion of the
face, neck that can compromise the blood vessels supplying the
brain.
Pathophysiology
 Diffuse axonal injury or shearing injuries.
 If penetrating object is of very high velocity like bullets then not
only is the site of impact injured but even the surrounding areas
due to the generation of shock waves as a result of high velocity. If
the penetrating object is of low velocity like the toys then the insult
is limited to only the site of impact.
 Secondary Damage
 Increased Intracranial Tensions
 Cerebral Hypoxia or Ischemia
 Intracranial Hemorrhage
 Electrolyte Imbalance and Acid Base Imbalance
 Infection Secondary to Open Wounds
 Seizures due to Scarring or Pressure
 Three basic category of head injury based upon the severity of brain damage :
 Mild Head Injury :
 Minimal damage to the neuroanatomical structures with slight or no permanent
impairment.
 Repeated minor injuries over a time have been responsible for gradual loss of
neurological or cognitive functions with marked cerebral atrophy.
 The characteristic symptom of this type of injury consists of headache, dizziness,
increased fatigability, decreased concentration power, poor memory and in some
cases irritability.
 loss of consciousness for less than 20 minutes,
 Glasgow Coma Scale of more than 13, no focal neurological findings, no
abnormality on CT scan and discharge from hospital within 48 hours.
Degree Of Severity Of Head Injury
 Moderate Head Injury
 between mild and severe type of injury.
 The Glasgow Coma Scale ranges from anywhere between 8 to 13 and
the post-traumatic amnesia lasting between 1 to 24 hours.
 Severe Head Injury
 severe enough to produce an obvious disabling deficit but who regain the
conscious activity status.
 This condition occurs in acutely brain damaged patient after the stage of
coma during which the patient is unaware of the surrounding
environment, he can neither speak, and neither can communicate through
any other means and does not exhibit any voluntary functions.
 However, certain activity like sleep- awake cycle, yawning, lip smacking,
grimacing, withdrawal from painful stimuli, visual fixation and tracking
presumably mediated through lower brain structures are usually
preserved.
 Alteration is the State of Consciousness
 Coma
 Stupor
 Obtundity
 Delirium
 Clouding of Consciousness
Changes In The Bodily Functions After Head
Injury
 Motor abnormalities after head injury is common.
 The patient may have decerebrise rigidity or decorticate rigidity.
 Motor deficit could be in the form of hemiplegia, monoplegia with
either presence of spasticity or flaccidity.
 Cranial nerve involvement is not unusual with certain cranial
nerves like facial, optic, oculomotor, vestibulocochlear and
abducent being commonly involved.
 Patient who have sustained severe head injury may even have a
permanent physical deficit.
Sensorimotor
 The abnormality in the memory and intellectual function of the
patient may be temporary or permanent.
 Memory loss is very common after head injury.
 The patient may have posttraumatic amnesia, retrograde amnesia or
anterograde amnesia.
 Retrograde amnesia is inability of the patient to recollect events that
took place just before the injury.
Cognitive, Emotional and Behavioural
Changes
 Posttraumatic amnesia is the time lapse between the injury till the
time when the patient is supposed to have recovered back his
memory function.
 Anterograde amnesia is inability of the patient to form new
memory in future.
 Behavioural changes may be like depression, impulsiveness or
hyperactivity
 Glasgow Coma Scale
 Rancho Los Amigos Level of Cognitive
Function
 Rappaport Disability Rating Scale
Clinical Rating System
 History collection and physical examination
 Computerised tomography
 Magnetic resonance imaging
 Positron emission tomography
 X-RAY
Diagnostic measures
 Mechanism of injury
 Loss of consciousness or amnesia
 Level of consciousness at scene and on
 transfer
 Evidence of seizures
 History of vomiting
 Pre-existing medical conditions
 Medications (especially anticoagulants)
 Illicit drugs and alcohol
Taking a history in head injury
 Glasgow Coma Score
 Pupil size and response
 Signs of skull fracture
 Bilateral periorbital edema (raccoon eyes)
 Battle’s sign (bruising over mastoid)
 Cerebrospinal fluid rhinorrhoea or otorrhoea
 Haemotympanum or bleeding from ear
 Full neurological examination: tone, power, sensation, reflexes
Physical examination
 CT scan is considered the best diagnostic test to evaluate for
cranio-cerebral trauma because it allows rapid diagnosis and
intervention in the setting
 The National Institute for Health and Clinical Excellence (NICE)
has published some guidelines for when to carry out a CT scan in
a patient with head injury
Computerised tomography
 Glasgow Coma Score (GCS) < 13 at any point
 GCS 13 or 14 at 2 hours
 Focal neurological deficit
 Suspected open, depressed or basal skull fracture
 Seizure
 Vomiting > one episode
 Urgent CT head scan if none of the above but:
 Age > 65
 Coagulopathy (e.g. on warfarin)
 Dangerous mechanism of injury (CT within 8
 hours)
 Antegrade amnesia > 30 min (CT within 8 hours)
NICE guidelines for (CT) in head
injury
 An MRI scan is more sensitive than CT scan in detecting small
lesions
 A cervical spine X-ray indicated to detect any cervical injury
 Transcranial Doppler allow the measurement of CBF
 determined by the state of the patient.
 Patient level of
 consciousness,
 alertness and
 ability to comprehend as well as learn taught skills.
 For practical purposes patient are classified into two category for
treatment purposes as
1. Patient who are totally unconscious and
2. Patient who have regained their consciousness.
PT Management
 The treatment comprises of passive maneuvers that are necessary
to maintain certain functions in the patient to prevent secondary
problems.
1. Respiratory Care
2. Preventing Contractures and Deformity
3. Prevention and Treatment of Pressure Sores
4. Sensory Stimulation
Management of Unconscious
Patients
 The need for chest care is directly proportional to the extent of
unconsciousness.
 Generally chest physiotherapy is given every 4 to 5 hourly. This is
necessary to maintain good bronchial hygiene.
 Proper positioning of the patient associated with regular
suctioning and nebulization enable the patient to have a relative
clear lung.
 Head low position should never be given to the head injury patient
as it may cause a severe increase in the intracranial pressure that
may prove to be hazardous.
Respiratory Care
Preventing Contractures and
Deformity
 Passive movements should be given to the patient for all the joints including all
the movements at that particular joint. Each movement may be repeated at least 8
to 12 times. Passive movements should be given every 3 to 4 hours .
 Gentle rhythmic stretching is very essential especially for bi -articular muscles as
they become very prone to develop tightness.
 Use of appropriate splints and proper positioning is also desirable to prevent the
chances of the patient developing any contracture.
 The patient should be kept clean.
 The cloths should be regularly changed. Moisture increases the changes of skin
infection and at the same time dry skin cause easy breakdown hence the patient's
skin should be maintained in correct manner.
 The chances of sores can be kept to the minimum by taking certain
preventive measures.
 The patient position should be changed from supine to side lying
on either sides every 2 hourly at least. This will cause
vascularization of almost all the areas of the body.
Prevention and Treatment of Pressure
Sores
 The patient should be made to lie on
water bed or air bed which helps in
evenly distributing the weight
throughout the body thus relieving
some pressure from the above
mentioned areas.
 Regular massage of pressure prone areas helps in increasing the circulation of these
areas hence preventing pressure sores.
 Regular sponge bath helps in maintaining proper hygienic condition of the patients
skin which offers resistance to development of unwanted infection.
 In case the patient develops pressure sore then its healing can be accelerated by
giving
 ozone therapy,
 UVR, IR or direct current.
 Ice massage given at the edges of the sores
 Sterile dressing should be applied following these physical therapy modalities.
Prevention and Treatment of Pressure
Sores
 Auditory,
 Tactile and
 Proprioceptive stimulation
Sensory Stimulation
Management of Conscious Patient
 In patients who is conscious, active participation of the patient
should be encouraged which in turn will speed up the rehabilitation
process.
1. Improve Alertness or Arousal through Sensory Stimulation
2. Prevention of Spasticity
3. Maximize the Patient’s Functional Capacity
4. Development of High Level Skilful Functioning
 The main aim is to stimulate the reticular activating system by
making the patient sit or even stand in the tilt table.
 The therapist should provide tactile, visual, auditory and
proprioceptive stimulation to the patient that will send facilitator
signals to the brain and will enable the alert response to be
provoked.
 Auditory stimulation can be given by speaking to the patient
during the course of treatment.
Improve Alertness or Arousal through
Sensory Stimulation
 Visual stimulation is given by showing familiar faces, objects or
movement in the visual field of the patient.
 Tactile stimulation is provided by the therapist’s touch for
carrying out various functional tasks. The touch of the patient also
stimulates the receptors in the muscles and can be used for
facilitating or inhibiting contraction of muscles.
Improve Alertness or Arousal through
Sensory Stimulation
 Proprioceptive stimulation by giving
traction and approximation at joint
structures is very helpful in stimulating
the arousal response in the patient.
Prevention of Spasticity
 Gentle passive movement,
 gradual rhythmic sustained stretch,
 prolonged icing for 20 minutes over the muscles,
 biofeedback,
 proper positioning
Maximize the Patient’s Functional
Capacity
 The main aim of this management is to
 improve the ROM,
 improve the control of voluntary movement,
 strengthening paretic muscles,
 improve the coordination,
 balance and teach various safety measures which will enable the
patient to return back to the community.
 Neuromuscular training
Maximize the Patient’s Functional
Capacity
 activities like
 bridging,
 prone on elbow,
 side lying to sitting,
 sitting,
 kneeling,
 half kneeling,
 standing and
 walking.
 Proper documentation
Maximize the Patient’s Functional
Capacity
 Use of vestibular ball while training the patient for crawling, bridging,
sitting balance helps in building the proprioceptive stimulation and
teaches proper control to the patient.
 Each task has various sub tasks which needs to be mastered by the
patient so that he learns the actual activity using normal movement
combination and performs it with precision.
 Repetition of activities
 Ambulation training should always be done in upright position by
training the patient in each and every phase of the gait cycle. If the
patient’s balance is poor then assistance may be used.
Maximize the Patient’s Functional
Capacity
 Functional electrical stimulation
 Reversing tasks : For instance lowering a glass of water on the table
may help the patient in getting the glass close to the mouth by
improving motor control of biceps during eccentric contraction.
Development of High Level Skilful
Functioning
 These achievements may not be applicable to all head injury .Patient belonging
to the last two grades of cognitive grading may be considered as appropriate
client for this training.
 The safety awareness of the patient need to be improved because he is already
in ambulatory stage.
 Balance and postural control training is very essential. Some patients may have
good balance and postural control during normal walking but will have
problems while trying to perform speedy actions. Dancing, basket ball, karate,
tennis and certain other sports often promote additional progress in balance,
sequencing, and speed of movement.
Development of High Level Skilful
Functioning
 The therapist should encourage those components of the activities that best
address the deficits in the patient and plan out enjoyable activities that provide
specific training for the deficits in balance, gait, upper extremity functions.
Head injury...Physiotherapy by Dr.Nidhi Vedawala

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Head injury...Physiotherapy by Dr.Nidhi Vedawala

  • 2.  Traumatic head injury is a condition in which an insult to the brain is caused to due any external force, which usually leads to alteration in the state of consciousness in the person that impairs the cognitive and physical function along with behavioural or emotional disturbances.  These changes may be temporary or permanent and may cause partial or total disability. Introduction
  • 4. Mechanism Of Injury  open head injury  closed head injury  coup injury  countercoup injury e.g. When a patient falls on the forehead, the frontal part of the brain suffers damage due to direct impact of the brain (coup injury) but along with it there could be damage to the occipital part of the brain (countercoup injury)
  • 5.  Primary Damage  Involved by acceleration force, deceleration force, rotational force or penetrating objects. These sources of injury can caused laceration, contusion, shearing, tension, or compression that causes primary damage to the brain structures. Primary damages are due to either a blow on the head by the object or head striking against the object.  Vascular lesion may also accompany due to either direct laceration of the blood vessels in the brain or due to lesion of the face, neck that can compromise the blood vessels supplying the brain. Pathophysiology
  • 6.  Diffuse axonal injury or shearing injuries.  If penetrating object is of very high velocity like bullets then not only is the site of impact injured but even the surrounding areas due to the generation of shock waves as a result of high velocity. If the penetrating object is of low velocity like the toys then the insult is limited to only the site of impact.
  • 7.  Secondary Damage  Increased Intracranial Tensions  Cerebral Hypoxia or Ischemia  Intracranial Hemorrhage  Electrolyte Imbalance and Acid Base Imbalance  Infection Secondary to Open Wounds  Seizures due to Scarring or Pressure
  • 8.  Three basic category of head injury based upon the severity of brain damage :  Mild Head Injury :  Minimal damage to the neuroanatomical structures with slight or no permanent impairment.  Repeated minor injuries over a time have been responsible for gradual loss of neurological or cognitive functions with marked cerebral atrophy.  The characteristic symptom of this type of injury consists of headache, dizziness, increased fatigability, decreased concentration power, poor memory and in some cases irritability.  loss of consciousness for less than 20 minutes,  Glasgow Coma Scale of more than 13, no focal neurological findings, no abnormality on CT scan and discharge from hospital within 48 hours. Degree Of Severity Of Head Injury
  • 9.  Moderate Head Injury  between mild and severe type of injury.  The Glasgow Coma Scale ranges from anywhere between 8 to 13 and the post-traumatic amnesia lasting between 1 to 24 hours.
  • 10.  Severe Head Injury  severe enough to produce an obvious disabling deficit but who regain the conscious activity status.  This condition occurs in acutely brain damaged patient after the stage of coma during which the patient is unaware of the surrounding environment, he can neither speak, and neither can communicate through any other means and does not exhibit any voluntary functions.  However, certain activity like sleep- awake cycle, yawning, lip smacking, grimacing, withdrawal from painful stimuli, visual fixation and tracking presumably mediated through lower brain structures are usually preserved.
  • 11.  Alteration is the State of Consciousness  Coma  Stupor  Obtundity  Delirium  Clouding of Consciousness Changes In The Bodily Functions After Head Injury
  • 12.  Motor abnormalities after head injury is common.  The patient may have decerebrise rigidity or decorticate rigidity.  Motor deficit could be in the form of hemiplegia, monoplegia with either presence of spasticity or flaccidity.  Cranial nerve involvement is not unusual with certain cranial nerves like facial, optic, oculomotor, vestibulocochlear and abducent being commonly involved.  Patient who have sustained severe head injury may even have a permanent physical deficit. Sensorimotor
  • 13.  The abnormality in the memory and intellectual function of the patient may be temporary or permanent.  Memory loss is very common after head injury.  The patient may have posttraumatic amnesia, retrograde amnesia or anterograde amnesia.  Retrograde amnesia is inability of the patient to recollect events that took place just before the injury. Cognitive, Emotional and Behavioural Changes
  • 14.  Posttraumatic amnesia is the time lapse between the injury till the time when the patient is supposed to have recovered back his memory function.  Anterograde amnesia is inability of the patient to form new memory in future.  Behavioural changes may be like depression, impulsiveness or hyperactivity
  • 15.  Glasgow Coma Scale  Rancho Los Amigos Level of Cognitive Function  Rappaport Disability Rating Scale Clinical Rating System
  • 16.  History collection and physical examination  Computerised tomography  Magnetic resonance imaging  Positron emission tomography  X-RAY Diagnostic measures
  • 17.  Mechanism of injury  Loss of consciousness or amnesia  Level of consciousness at scene and on  transfer  Evidence of seizures  History of vomiting  Pre-existing medical conditions  Medications (especially anticoagulants)  Illicit drugs and alcohol Taking a history in head injury
  • 18.  Glasgow Coma Score  Pupil size and response  Signs of skull fracture  Bilateral periorbital edema (raccoon eyes)  Battle’s sign (bruising over mastoid)  Cerebrospinal fluid rhinorrhoea or otorrhoea  Haemotympanum or bleeding from ear  Full neurological examination: tone, power, sensation, reflexes Physical examination
  • 19.  CT scan is considered the best diagnostic test to evaluate for cranio-cerebral trauma because it allows rapid diagnosis and intervention in the setting  The National Institute for Health and Clinical Excellence (NICE) has published some guidelines for when to carry out a CT scan in a patient with head injury Computerised tomography
  • 20.  Glasgow Coma Score (GCS) < 13 at any point  GCS 13 or 14 at 2 hours  Focal neurological deficit  Suspected open, depressed or basal skull fracture  Seizure  Vomiting > one episode  Urgent CT head scan if none of the above but:  Age > 65  Coagulopathy (e.g. on warfarin)  Dangerous mechanism of injury (CT within 8  hours)  Antegrade amnesia > 30 min (CT within 8 hours) NICE guidelines for (CT) in head injury
  • 21.  An MRI scan is more sensitive than CT scan in detecting small lesions  A cervical spine X-ray indicated to detect any cervical injury  Transcranial Doppler allow the measurement of CBF
  • 22.  determined by the state of the patient.  Patient level of  consciousness,  alertness and  ability to comprehend as well as learn taught skills.  For practical purposes patient are classified into two category for treatment purposes as 1. Patient who are totally unconscious and 2. Patient who have regained their consciousness. PT Management
  • 23.  The treatment comprises of passive maneuvers that are necessary to maintain certain functions in the patient to prevent secondary problems. 1. Respiratory Care 2. Preventing Contractures and Deformity 3. Prevention and Treatment of Pressure Sores 4. Sensory Stimulation Management of Unconscious Patients
  • 24.  The need for chest care is directly proportional to the extent of unconsciousness.  Generally chest physiotherapy is given every 4 to 5 hourly. This is necessary to maintain good bronchial hygiene.  Proper positioning of the patient associated with regular suctioning and nebulization enable the patient to have a relative clear lung.  Head low position should never be given to the head injury patient as it may cause a severe increase in the intracranial pressure that may prove to be hazardous. Respiratory Care
  • 25. Preventing Contractures and Deformity  Passive movements should be given to the patient for all the joints including all the movements at that particular joint. Each movement may be repeated at least 8 to 12 times. Passive movements should be given every 3 to 4 hours .  Gentle rhythmic stretching is very essential especially for bi -articular muscles as they become very prone to develop tightness.  Use of appropriate splints and proper positioning is also desirable to prevent the chances of the patient developing any contracture.  The patient should be kept clean.  The cloths should be regularly changed. Moisture increases the changes of skin infection and at the same time dry skin cause easy breakdown hence the patient's skin should be maintained in correct manner.
  • 26.  The chances of sores can be kept to the minimum by taking certain preventive measures.  The patient position should be changed from supine to side lying on either sides every 2 hourly at least. This will cause vascularization of almost all the areas of the body. Prevention and Treatment of Pressure Sores  The patient should be made to lie on water bed or air bed which helps in evenly distributing the weight throughout the body thus relieving some pressure from the above mentioned areas.
  • 27.  Regular massage of pressure prone areas helps in increasing the circulation of these areas hence preventing pressure sores.  Regular sponge bath helps in maintaining proper hygienic condition of the patients skin which offers resistance to development of unwanted infection.  In case the patient develops pressure sore then its healing can be accelerated by giving  ozone therapy,  UVR, IR or direct current.  Ice massage given at the edges of the sores  Sterile dressing should be applied following these physical therapy modalities. Prevention and Treatment of Pressure Sores
  • 28.  Auditory,  Tactile and  Proprioceptive stimulation Sensory Stimulation
  • 29. Management of Conscious Patient  In patients who is conscious, active participation of the patient should be encouraged which in turn will speed up the rehabilitation process. 1. Improve Alertness or Arousal through Sensory Stimulation 2. Prevention of Spasticity 3. Maximize the Patient’s Functional Capacity 4. Development of High Level Skilful Functioning
  • 30.  The main aim is to stimulate the reticular activating system by making the patient sit or even stand in the tilt table.  The therapist should provide tactile, visual, auditory and proprioceptive stimulation to the patient that will send facilitator signals to the brain and will enable the alert response to be provoked.  Auditory stimulation can be given by speaking to the patient during the course of treatment. Improve Alertness or Arousal through Sensory Stimulation
  • 31.  Visual stimulation is given by showing familiar faces, objects or movement in the visual field of the patient.  Tactile stimulation is provided by the therapist’s touch for carrying out various functional tasks. The touch of the patient also stimulates the receptors in the muscles and can be used for facilitating or inhibiting contraction of muscles. Improve Alertness or Arousal through Sensory Stimulation  Proprioceptive stimulation by giving traction and approximation at joint structures is very helpful in stimulating the arousal response in the patient.
  • 32. Prevention of Spasticity  Gentle passive movement,  gradual rhythmic sustained stretch,  prolonged icing for 20 minutes over the muscles,  biofeedback,  proper positioning
  • 33. Maximize the Patient’s Functional Capacity  The main aim of this management is to  improve the ROM,  improve the control of voluntary movement,  strengthening paretic muscles,  improve the coordination,  balance and teach various safety measures which will enable the patient to return back to the community.  Neuromuscular training
  • 34. Maximize the Patient’s Functional Capacity  activities like  bridging,  prone on elbow,  side lying to sitting,  sitting,  kneeling,  half kneeling,  standing and  walking.  Proper documentation
  • 35. Maximize the Patient’s Functional Capacity  Use of vestibular ball while training the patient for crawling, bridging, sitting balance helps in building the proprioceptive stimulation and teaches proper control to the patient.  Each task has various sub tasks which needs to be mastered by the patient so that he learns the actual activity using normal movement combination and performs it with precision.  Repetition of activities  Ambulation training should always be done in upright position by training the patient in each and every phase of the gait cycle. If the patient’s balance is poor then assistance may be used.
  • 36. Maximize the Patient’s Functional Capacity  Functional electrical stimulation  Reversing tasks : For instance lowering a glass of water on the table may help the patient in getting the glass close to the mouth by improving motor control of biceps during eccentric contraction.
  • 37. Development of High Level Skilful Functioning  These achievements may not be applicable to all head injury .Patient belonging to the last two grades of cognitive grading may be considered as appropriate client for this training.  The safety awareness of the patient need to be improved because he is already in ambulatory stage.  Balance and postural control training is very essential. Some patients may have good balance and postural control during normal walking but will have problems while trying to perform speedy actions. Dancing, basket ball, karate, tennis and certain other sports often promote additional progress in balance, sequencing, and speed of movement.
  • 38. Development of High Level Skilful Functioning  The therapist should encourage those components of the activities that best address the deficits in the patient and plan out enjoyable activities that provide specific training for the deficits in balance, gait, upper extremity functions.

Editor's Notes

  1. The more number of days patient remains uncons- cious more intense and regular is the need for chest physiotherapy.
  2. As the tone of the muscles increases the need for passive movement and stretching is even more to maintain range of motion at all joints.
  3. Due to prolonged immobilization certain part of the body especially the ones with bony prominence are very prone to get subject to pressure sore due to lack of proper circulation to that area. Thus the lateral malleolus, lateral aspect of the knee, ischial tuberosity, sacrum, occiput are very likely to develop sore.
  4. Although the patient is unconscious effort should be made to stimulate the reticular activating system by using various sensory stimulation
  5. The patient who is drowsy or confused need to be stimulated by make them more alert and awake. The therapist should encourage the patient’s cooperation during the treatment.
  6. by inhibiting abnormal movement pattern and by facilitating normal movement pattern.
  7. Like for training the patient to get up from bed, he may be taught to do asymmetrical push up with the trunk in partial rotation, then lower leg patterns are incorporated and finally the whole task of get up from side lying is practiced.