Assessment of Traumatic Brain Injury

Preparation for Physiotherapy Assessment

Photograph of goniometer, EMG graph & EMG unit
Physiotherapy assessment commences once the patient is medically stable. In view of the complexity of many patients with traumatic brain injury, 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 Patient with Acute Traumatic Brain Injury

Before starting physiotherapy assessment on an acute traumatic brain injury 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.

For more information on the subject of impairments of Loss of Consciousness, see Disorders of Consciousness page.

Handling during Assessment

In the initial stages following traumatic brain injury, 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.

Communication in the Assessment

Once the cognitive level of the patient with traumatic brain injury has been established, it is important for the therapist to adapt their communication style to the individual if required. If the person has a significant speech impairment, then simplifying questions to require a Yes or No answer is helpful. If the person understands spoken language but is unable to speak, establishing a clear physical gesture for Yes and No will be essential. This will usually be done in conjunction with the Speech and Language Therapist, and often family members can be very helpful in providing information on communication.

Remember to allow more time for the patient to respond.

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 traumatic brain injury 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

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 traumatic brain injury hypertonicity and spasticity can develop very quickly, sometimes as early as one week post traumatic brain injury.[2][3] The symptoms may start to occur as sedation is reduced, or as the patient emerges from a 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 traumatic brain injury patients suffer from spasticity that requires treatment.[4] Studies show that in the region of 85% of people with severe traumatic brain injury demonstrate significant spasticity at a level that induces contracture. [5][6]

Muscle Paresis

Muscle paresis is very common following traumatic brain injury. [7]

It often occurs as part of an Upper Motor Neuron Syndrome [UMNS], accompanied by impairments of motor control, and coordination as well as alteration in muscle tone.[7]

The pattern of muscle paresis can vary - quadriparesis or hemiparesis can occur.[8] Other injuries sustained during the trauma incident may contribute to muscle paresis, such as bony fractures, as may the period of extended bed rest in the initial post-injury period.

Movement Disorders

Ataxia, dyspraxia, dyskinesia, or reduced motor control can all occur in traumatic brain injury.

Ataxia is generally a result of trauma to the back of the head, which causes damage to the cerebellum.

Balance and Vestibular Dysfunction

This is very common in traumatic brain injury, and varies enormously in degree.[9] A full vestibular assessment is indicated in individuals with traumatic brain injurywith vestibular deficit.

Pain

Over 50% of people who have traumatic brain injury experience persistent pain.[10] Many studies conclude that, for understandable reasons, the head is the most common site of pain.[11]

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. Unfortunately, in many cases, physiotherapy treatment in the acute period is limited by musculoskeletal injuries, which can prevent passive stretches and strategies to maintain range of movement.
  • Secondary pain generally in the limbs may occur as a result of spasticity and hypertonicity.

Goal Setting

Particularly in the early stages of traumatic brain injury rehabilitation, goal setting should be done collaboratively by the whole team,[12] which commonly comprises:

  • the patient, level of consciousness permitting
  • medical team - physicians and/or surgeons, psychologist, physiotherapist, occupational therapist, speech and language therapist
  • the patient's family and carers

Later in the rehabilitation process, physiotherapy goals may be established between the patient (and still often the main care-givers too) and the therapist.

In the early stages of rehabilitation in traumatic brain injury, setting goals is often straightforward and can often be focused on increasing physical autonomy, working towards functional goals such as more independent transfers, functional mobility whether walking or in a wheelchair, etc.

Later on in the rehabilitation, in order to establish pertinent long term rehabilitation goals it is essential to encompass more information specific to the individual patient.[13] This will include, but is not limited to:

  • details of the person's life, interests and activities prior to their traumatic brain injury
  • knowledge of the patient's new priorities in life following their traumatic brain injury
  • the individuals home circumstances, including level of personal care required, physical constraints of their home environment (available space, hygiene facilities, etc.)
  • other family members' expectations and wishes

For more detailed information please see the goal setting in rehabilitation page.

It is important to recognise that the patient's priorities for goal setting are of greater importance than the therapist's; but of course the therapist may need on occasion to challenge the patient's expectations, [13] with the aim of reaching a goal which is not only meaningful to the person themselves but is also achievable.

References

  1. Bohman LE, Schuster JM. Decompressive craniectomy for management of traumatic brain injury: an update. Curr Neurol Neurosci Rep. 2013;13(11):392. doi: 10.1007/s11910-013-0392-x.
  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. pii: S1877-0657(18)30059-9. doi: 10.1016/j.rehab.2018.04.004.
  3. Bose P, Hou J, Thompson FJ. Traumatic Brain Injury (TBI)-Induced Spasticity: Neurobiology, Treatment, and Rehabilitation. In: Kobeissy, FH editor. Boca Raton (FL): CRC Press/Taylor & Francis, 2015.
  4. Verplancke D, Snape S, Salisbury CF, Jones PW, Ward AB. A randomised controlled trial of botulinum toxin on lower limb spasticity following acute acquired severe brain injury. Clinical Rehabilitation. 2005; 19(2): 117-125
  5. Corrigan JD, Selassie AW, Orman JA. The epidemiology of traumatic brain injury. J Head Trauma Rehabil. 2010; 25(2):72–80
  6. McGuire L. The epidemiology of traumatic brain injury, National Centers for Disease Control and Prevention. 2011.
  7. 7.0 7.1 Ivanhoe CB, Reistetter TA. Spasticity: the misunderstood part of the upper motor neuron syndrome. Am. J. Phy. Med. Rehabil.2004; 83:S3-S9
  8. Williams G, Lai D, Schache A, Morris ME. Classification of gait disorders following traumatic brain injury. J Head Trauma Rehabil. 2015;30(2):E13-23. 
  9. Kleffelgaard I, Soberg H, Bruusgaard K, Tamber A, Langhammer B. Vestibular Rehabilitation After Traumatic Brain Injury: Case Series. Physical Therapy. 2016;96(6):839-49.
  10. Widerström-Noga E, Govind V, Adcock JP, Levin BE, Maudsley AA. Subacute Pain after Traumatic Brain Injury Is Associated with Lower Insular N-Acetylaspartate Concentrations. J Neurotrauma. 2016;33(14): 1380–1389
  11. Smith-Seemiller L, Fow NR, Kant R, Franzen MD.Presence of post-concussion syndrome symptoms in patients with chronic pain vs mild traumatic brain injury. Brain Inj. 2003; 173:199-206
  12. Wade P. Goal setting in rehabilitation: an overview of what, why and how. Clin Rehabil. 2009;23(4):291-5 
  13. 13.0 13.1 Levack WMM. Goal Setting in Rehabilitation. In: Lennon S, Ramdherry G, Verheyden, G editors: Physical Management for Neurological Conditions. Elsevier, 2018. p91-109