Assessment of Traumatic Brain Injury

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Preparation for Physiotherapy Assessment

Physiotherapy assessment commences once the patient is medically stable.

In view of the complexity of many patients with TBI, the assessment is frequently unable to be completed within a single session so is ongoing for the first few physiotherapy sessions. Close liaison with other members of the multidisciplinary team is extremely beneficial, and on occasion joint assessments by 2 or even 3 therapists from different disciplines can be useful.

The Acute TBI Patient

Before starting physiotherapy assessment on an acute TBI patient, it is essential to check with the medical team, and the patient's medical notes, that the individual is medically stable, and to monitor the vital signs when assessing (or indeed treating).

It is also essential to establish what level of consciousness the individual has before commencing assessment, and bear in mind the following:

Patients with Level Of Conscious impairments:

  • There is no need to delay physiotherapy assessment until the patient demonstrates spontaneous movement or starts to show improved level of consciousness
  • When assessing these patients, it is beneficial to reduce distractions from all senses. Therefore keep noise levels low - if possible switch off any radio or TV in the vicinity, and it may be useful to close the curtains around the bed to reduce visual distractions.
  • Be polite and considerate to the individual: address them by name before you start the assessment, and continue to speak to them at intervals during the assessment. For example you can use phrases such as "I'm going to gently move your right arm now" spoken immediately before doing it. Always work on the assumption that the person might be able to hear you and understand, and simply be unable to respond.

Handling during Ax

In the initial stages following TBI, careful handling is essential when assessing patients, especially if they are in a minimally conscious state. Close liaison with the medical team is required before attempting to change the patient's position, for example, as this may cause blood pressure changes.

Information required before starting the assessment

The following information should be provided by the medical team before beginning the physiotherapy assessment:

  • State of consciousness of the patient - for further information see the Coma Recovery Scale page
  • Areas of the brain injured, including diffuse and secondary injury
  • Site of Decompression Craniotomy, if this has been performed on the patient[1]
  • Any other injuries sustained - patients who have TBI from road traffic accidents frequently also have a range of musculoskeletal, abdominal and chest injuries
  • Any impact on cognition of the patient - neuropsychological assessment is indicated

Subjective Assessment

Objective Assessment

Areas of Assessment

Abnormal Muscle Tone

The major abnormalities in muscle tone encountered in this population are hypertonicity and spasticity.

It is noticeable that, in contrast to Stroke when there is often a period of low tone before high tone develops, in cases of severe TBI hypertonicity and spasticity can develop very quickly, sometimes as early as one week post TBI[2][3]. The symptoms may start to occur as sedation is reduced, or as the patient emerges from coma. A recent study concludes that "Signs of spasticity can often be noted within the first 4 weeks after brain injury and is more common in the upper than lower extremity. Impaired sensorimotor function is a predictor"[2]

Approximately 18% to 30% of all TBI patients suffer from spasticity that requires treatment[4]. Studies show that in the region of 85% of people with severe TBI demonstrate significant spasticity at a level which induces contracture[5][6].

Muscle Paresis

Muscle paresis very common following TBI[7]

Movement Disorders

Ataxia, dyspraxia, dyskinesia, or reduced motor control

Balance and vestibular dysfunction

This is very common in TBI, and varies enormously in degree[8]

Secondary Effects

  • Reduced joint and muscle range of movement occur as a result of a combination of factors, including prolonged bed-rest, hypertonicity and spasticity, and in some cases as a result of musculoskeletal injuries sustained in the accident
  • Pain may occur as a result of spasticity and hypertonicity

Analysis of the Assessment

Goal Setting

References

  1. Bohman LE, Schuster JM. Decompressive craniectomy for management of traumatic brain injury: an update. Curr Neurol Neurosci Rep. Nov 2013;13(11):392
  2. 2.0 2.1 Sunnerhagen KS, Opheim A, Alt Murphy M.Onset, Time course and prediction of spasticity after stroke or traumatic brain injury. Ann Phys Rehabil Med. 2018 May 16. pii: S1877-0657(18)30059-9. doi: 10.1016/j.rehab.2018.04.004. [Epub ahead of print]
  3. Prodip Bose, Jiamei Hou, and Floyd J Thompson Traumatic Brain Injury (TBI)-Induced Spasticity Chapter 14 Neurobiology, Treatment, and Rehabilitation
  4. Verplancke, D, Snape, S, Salisbury, CF et al. 2005. A randomised controlled trial of botulinum toxin on lower limb spasticity following acute acquired severe brain injury. Rehabil. 19, 117-125
  5. Corrigan J.D, Selassie A.W, Orman J.A. The epidemiology of traumatic brain injury. J Head Trauma Rehabil. 2010;25:72–80
  6. McGuire L. The epidemiology of traumatic brain injury, National Centers for Disease Control and Prevention. 2011.
  7. Ivanhoe, CB, Reistetter, TA, 2004. Spasticity: the misunderstood part of the upper motor neuron syndrome. Am. J. Phy. Med. Rehabil. 83, S3-S9
  8. Kleffelgaard I, Soberg H, Bruusgaard K, Tamber A, Langhammer B. Vestibular Rehabilitation After Traumatic Brain Injury: Case Series. Physical Therapy. 2015