Traumatic brain injury (TBI) can cause temporary or permanent impairments in physical, cognitive, and behavioral functioning. Common causes of TBI include motor vehicle accidents, falls, and violence. Injuries range from mild concussions to severe penetrating wounds. Treatment focuses on managing secondary complications, rehabilitating motor skills, and retraining cognitive and behavioral functions through repetitive practice of meaningful tasks. The goal is to help patients regain independence through addressing impairments, disabilities, and participation restrictions.

1. TRAUMATIC BRAIN
INJURY
Dr. Nawaj Pathan (PT)

2. Introduction
• Traumatic head injury is an insult to
the brain caused by an external
physical force, that may produce a
diminished or altered state of
consciousness, which results in
impairment of cognitive abilities or
physical functioning.
• It can also result in the disturbance
of behavioral or emotional
functioning. These may be either
temporary or permanent and cause
partial or total functional disability
or psychological maladjustment.

3. Epidemiology
Motor vehicle
crashes- 50%
Falls- 21% Violence – 12%
Sports and
recreation- 10%
Higher in males 2:1 Majority are
between 15 and 24
years old

4. Mechanisms
of injury
• Injuries include those with
skull fractures and without
skull fracture
• Coup and counter coup
injuries
• Penetrating objects- direct
cellular and vascular
damage
• Injuries to the face and
neck- can damage blood
supply to the brain

5. Classification
Skull contusion
• No evidence of brain injury
• No loss of consciousness or
amnesia
• Normal neurological
examination, and normal
intracranial findings on CT or
MRI
• Some will have scalp
lacerations or even skull
fractures
• Head ache may be present

6. Concussion (mild traumatic brain
injury)
• Brief, transient loss of
consciousness, usually lasting no
more than a few minutes or
followed by a period of
confusion
• Brief retro or anterograde
amnesia
• Headache, nausea, dizziness and
sometimes vomitting

7. Brain
contusion
and
penetrating
injury
• Damage to the brain
parenchyma
• Longer periods of
unconsciousness and
retro and anterograde
amnesia
• Reveals neurological
deficits
• Foci of contusion in CT or
MRI or intra cranial
hemorrhage

9. Pathophysiology
of injury
• Primary damage
• Contusions and lacerations can
occur without skull fractures
• Object hits head or head hits
the object
• Occipital blows are more likely
to produce contusions
• Lacerations of blood vessels
within the brain itself or in the
neck can be injured

10. • It can injure cranial nerves
• Most common ones are
vestibulocochlear, oculomotor,
abducens and facial nerves
• CSF rhinorrhea- CSF discharge
from the nose due to
lacerations of dura and/or
arachnoid
• Discharge increases with neck
flexion, coughing or straining

11. • Diffuse axonal injury- unequal acceleration, deceleration or rotation of contingent
tissues, which differ in structure
• Severe enough to result in coma
• Memory loss concentration difficulties, decreased attention span, headaches,
sleep disturbances and seizures
• Damage involves corpus callosum, basal ganglia, brain stem and cerebellum

12. Penetrating objects with
high velocities such as
bullets can cause
additional damage remote
from the areas of impact
Sticks and sharp toys cause
low velocity injuries,
directly damaging the
tissues they impact

13. Secondary damage
Increased
intracranial
pressure
Cerebral hypoxia
or ischemia
Intracranial
hemorrhage
Electrolytic
imbalance and
acid-base
imbalance
Infection
secondary to open
wounds
Seizures due to
pressure or
scarring

14. Physiological, cognitive, and behavioral changes
after brain injury
AUTONOMIC NERVOUS
SYSTEM CHANGES
CHANGES IN PULSE AND
RESPIRATORY RATE
REGULARITY TEMPERATURE
ELEVATIONS
BLOOD PRESSURE
CHANGES
EXCESSIVE SWEATING,
SALIVATION, TEARING,
AND SEBUM SECRETION

15. Motor,
functional,
sensory
and
perceptual
changes
• Decorticate rigidity and
decerebrate rigidity
• Monoplegia, hemiplegia and
abnormal reflexes
• Initial flaccidity can gradually
become spasticity or rigidity
• Combinations of
asymmetrical cerebellar and
pyramidal signs and bilateral
pyramidal and extrapyramidal
signs

16. Aphasia, dysarthria,
dysphagia, and
visuospatial and
perceptual motor
difficulties
Cranial nerve
involvement

17. Changes in consciousness
Coma –complete paralysis of
cerebral functions, a state of
responsiveness
Stupor- general
unresponsiveness, but the
patient is usually mute, can
be temporarily aroused by a
vigorous and repeated
stimuli
Delirium- disorientation, fear,
and misinterpretation of
sensory stimuli, loud,
agitated, and offensive
Clouding of consciousness-
state of quiet confusion,
distractibility, faulty memory
and slowed responses to the
stimuli

18. • Persistent vegetative state
– Characterized by a wakeful, reduced
responsiveness with no evident
cerebral cortical function.
– Result from diffuse cerebral hypoxia
or from severe diffuse white matter
damage

19. Cognitive, personality and
behavioral changes
TEMPORARY OR
PERMANENT DISORDERS OF
INTELLECTUAL FUNCTION
AND MEMORY
UNCONTROLLED ANGER,
IRRITABILITY, MEMORY LOSS
SHORTENED ATTENTION
SPAN, CONCENTRATION
PROBLEMS, PERSEVERATION
REDUCED PROBLEM
SOLVING SKILL, LACK OF
INITIATIVE
LOSS OF REASONING, POOR
ABSTRACT THINKING,
INAPPROPRIATE SOCIAL
BEHAVIOR

20. Other complications
Infections,
contractures, skin
break down
Thrombo phlebitis,
pulmonary problems
Heterotrophic
ossification, and
surgical complications
Posttraumatic epilepsy

21. EXAMINATION

22. • CT
• MRI
• Cerebral angiography
• PET
• EEG
• ICP monitoring
• Evoked potentials
• Reflex motor responses

24. • Testing of cognitive and behavioral
functions
neuro psychological tests are used
IQ tests
Achievement tests

25. Early
hospitalisation
• Management of respiratory
dysfunction
• Electrolytic balance
• Postural drainage
• Skin
• Contractures

26. Pharmacological intervention
Decreasing ICP –
mannitol
Controlling BP
Physiological injury
Motor, behavioral
and cognitive
function
Anti depressive
drugs

27. Examination and evaluation
• History –injury, job, home environment,
educational level, previous injuries
• Family data- patient and family goals,
personal factors, socio economic factors
relating to handicaps
• Other health care team member
assessments

28. • Tests and measurements
– System review- circulatory/respiratory,
integumentory, musculoskeletel, nervous
system
• Sensory – primary , integrated

29. Motor
Motor impairments – tone, muscle strength,
muscle flexibility, response speed, movement
speed, endurance and fatigue
• Complex impairements – Basic synergies,
modification of synergies, Anticipatory
reactions, use of feed back, variability of
performance
• Disabilities -
Vision, Vestibular

30. • Autonomic nervous system
• Cognitive
• Language
• Emotional

31. Intervention
• Motivation
– Working on patient goals
• Attention span
• Relearning of motor skills

32. Component level treatment of
impairment
• Disability level of intervention
– Mobility and prehension are the two most frequent disability losses after brain injury
– Strength – speed specific
• Production and practice of eccentric contraction
• Functional activities
– Flexibility
• Joint mobilization
• Stretching and dynamic splinting
• Serial casting
• Electrical stimulation

33. Complex level treatment of
impairement
• Synergies
– Whole task-sub task training
– Sub task training in ambulation
– Whole task practice of gait
– Functional electrical stimulation
– Goal oriented tasks for upper extremity
– Specific synergies for hand use
– Restraining
– Motor skills improve better with functional use
– Reversing the tasks

34. – Speed of movement
• Isokinetic equipment
• Manually during resisitve exercises
• Force platforms
– Reaction time
• Can be done on force platforms
• Exercises while standing on foam pads

35. – Endurance
• Repetition
• Increasing duration
• Increasing intensity
• Upper extremity for cardio vascular conditioning
– Sensory
• Manipulation of objects
• Picking up objects
• Gloves while gripping

36. – Tone
• EMG bio feedback
• Functional electrical stimulation
• Strengthening exercises
– Vestibular system
• Patients with sensory mismatches may require
treatment that enhances inputs from two normally
functioning systems to adapt or retrain the faulty
vestibular system
• Progress in treatment by decreasing the additional
input

37. – Visual system
• Occulo motor exercises
• Enhancing visual input-
• Increasing contrast between objects
• Using colours
• Moving visual targets

38. • Anticipatory responses
– Moving the extremities
– Adding weights to extremities during forward
movement
– Changing motion speeds
– Pulling and pushing
– Ball activities
– Treadmills

39. • Variability
– Force production and ROM are critical
components in variability
– Work in water or with weight
– Build environmental consraints

40. • Learning, practice and
feedback
– Trial and error
– External help for patients
with minimal motor function
– Practice needs to be task
specific
– Flexibility of responses can
be built in by changing
environmental and task
constraints