Therapeutic Interventions for Traumatic Brain Injury

Introduction

The traumatic brain injury (TBI) sequelae are various in nature. They include: physical; cognitive; behavioural; psychological; and emotional (as well as their intensity and complexity). The individual brain structure and functional organisation, as well as neuroplastic change potential, determine the functional recovery following brain damage.  The limited knowledge about the neurophysiology and neuroplasticity of the nervous system imposes limitations on understanding of functional recovery from traumatic brain injury, motor relearning and effectiveness of therapeutic methods.

The goal of the interventions in traumatic brain injury is to achieve the highest possible level of independent function for participation in daily activities. It may address the individual’s: structures and functions; activities and participation; environment and barriers modifications.  At this point in time there are no standardised recommendations regarding physiotherapeutic protocols for treatment of individuals with traumatic brain injury and the neurological physiotherapy community utilises variable and multiple methods and intensity[1]. Moreover, the limitations with the research in this patient group forces physiotherapists to utilise evidence related to neuroscience and other pathologies, like stroke.

The complex nature of traumatic brain injury outcomes and possible accompanying injuries might require the neurological physiotherapist to use core skills like facilitation, therapeutic exercises or physical activity prescription, but also to clinically reason and apply the knowledge of therapeutic interventions and strategies from other specialities, eg. respiratory care, orthopaedic and trauma protocols, behaviour de-escalation techniques, communication strategies, equipment provision, etc.

Gait Training and Supporting Practice

  • Strength training of lower limbs, trunk and pelvis surrounding muscles
  • Sit-to-stand sequence practice (of various height surfaces, with different level of upper limbs use or/and facilitation) in closed and opened biomechanical chain
  • Standing balance training (dynamic training over ground or/and on uneven base of support, reduced base of support like step stance or tandem stance) 
  • Gait training: (partial body weight support use by treadmill suspension or manually assisted trunk and limb movements, stepping variety and strategies practice in parallel bars practice, with aids, over ground practice, ,acceleration-deceleration, stop-start, stepping over-stepping on, stairs practice, dual tasking, on/off floor transfer, community mobility training including environment screening, zebra crossing timed walking, getting on/off transport, extending distance).

Arm Mobility Training

Constraint-Induced Movement Therapy (CIMT)

CIMT concentrates on repetitive tasks of affected upper limb, designed with principles of task specific training to address the specific motor deficit and utilise the upper limb for as long as possible. A mitten worn on the non-affected side for at least 90% of the time of waking hours or in some studies averaging 6 hours a day for 2-3 weeks or up to 10 weeks with modified CIMT protocol.

Behavioural techniques used to engage in practice, i.e. intensity and parameters contract, modelling, goal setting, reward for correct movement execution and feedback. Some voluntary wrist or/and fingers extension required to engage in CIMT training. Reported improved function in the affected arm and patient-reported ADLs use. Protocol adherence is the most important factor determining the outcome. 

There is increasing volume of research on CIMT, however a recent Cochrane review in stroke was unable to establish the superiority of CIMT to other forms of upper limb rehabilitation[4].

Queen Square Upper Limb Neurorehabilitation Programme

The Queen Square Upper Limb Neurorehabilitation Programme is primarily designed to address upper limbs problems following stroke, however the protocol principles could be successfully applied to rehabilitation following other acquired brain injuries forms including TBI. The programme involves high-quality, high-dose, high-intensity upper limb neurorehabilitation delivered over 3 weeks based on 90 hours schedule. Each day contains at least 4 hours of goal-orientated and task-specific training with structured rest. The treatment involved:

  1. adaptation of the task, for example, decomposing tasks into individual components to be practiced;
  2. adaptation of the environment, for example, fabrication of functional splints and adaptation of tools such as cutlery or screwdrivers, to enable integration of the affected hand in meaningful activities;
  3. assistance, for example, de-weighting the arm to allow strengthening and training of movement quality and control through increased range and
  4. independent task practice. Coaching was considered a key component of the programme and used throughout to embed new skills and knowledge into individual daily routines[7].

The programme participants demonstrate better impairment-based measures and functional outcomes, pointing towards superiority of high dose and high intensity intervention based on individual patient’s goals[8].

Range of Movement

Range of Movement must be sufficient for optimal recruitment, normal alignment and effective functional movement. Inactivity and immobility reduce the joints mobility, tissues flexibility and physical ability. Tissue malnutrition and local pain increase might be also related to the loss of ROM flexibility. Techniques improving mobility include:

  • Range of movement exercises (passive, active, facilitated i.e. using PNF techniques) 
  • Passive stretching through positioning, splinting, serial bracing [cross-reference to splinting guideline page]
  • Joint mobilisation
  • Use of heat
  • Warm-up prior to other forms of training

Strength and Conditioning[9]

Training principles include:

  • Overload
  • Specificity 
  • Cross training (include elements of concentric, eccentric, isometric and endurance training)

For efficient training the following needs to be considered:

  • Goals and optimal outcome measures (preferably based on functional tasks requiring strength)
  • Type of muscle contraction (concentric, eccentric, isometric)
  • Model of training (opened versus closed chain, circuit training, aquatic training, synergistic patters, i.e.: PNF dynamic reversal, repeated contraction)
  • Resistance type, i.e.: free weight, elastic bands, water resistance, manual resistance, body weight
  • Frequency, intensity, duration, number of repetitions
  • Warm up / cool down protocol

Endurance Training

When addressing poor muscular endurance, fatigue (inability to contract muscle repetitively over time[9]), both physical and cognitive, needs to be taken into consideration. Fatigue might affect three levels of movement component:

  • the CNS (central fatigue)
  • the peripheral nerves or neuromuscular junction
  • the muscle itself.

The management of patients with low endurance and fatigue focuses on energy conservation techniques, activity pacing and lifestyle changes, regular active and rest periods within a day, and sleep hygiene. An activity log might be helpful to identify habits responsible for period of exhaustion.

Aerobic Training enhances:

  • cardiovascular and peripheral (muscular) endurance
  • physical function
  • mood - emotional wellbeing by decreasing anxiety and depression

Recommended routine for people with traumatic brain injury:

  • Intensity 40-70%
  • Frequency 3-5 times a week
  • Duration 20-30 minutes with possibility of 10 minutes increments used for people with excessive fatigue.

Balance and Postural Control Training

Balance training components reflect the required components of effective balance reactions and include:

  • Postural alignment, body mechanics, and static postural control including midline orientation 
  • Dynamic postural control, including musculoskeletal responses necessary for control of movement and posture including strength, flexibility and ability to make effective anticipatory postural adjustment prior to voluntary movements.
  • Balance skills and balance reactions repertoire for various task and environmental conditions
  • Mobility training
  • Use of sensory monitoring for postural control (visual, vestibular, proprioceptive)
  • Safety awareness and compensatory strategies for effective fall prevention[9], including advice with regards to physical activity, polypharmacy, environment, personal choices and behaviours like footwear, coping strategies coaching to inhibit fear of falling.

For training to be efficient it needs to meet the individual person’s needs and be designed at an optimal level of challenge without compromising safety. Use of various postural sets and techniques to ensure versatile challenge and transferable skills:

  • Manual techniques re-educating postural stability like rhythmic stabilisation or stabilising reversal
  • Even versus uneven base of support like balance pads and inclines
  • Reduced base of support like feet together, tandem standing / walking, 1 legged standing
  • Use of head and upper limbs movements 
  • Adjusting complexity of tasks like dual tasking with cognitive or additional physical element can be used to tailor the programme to individual’s goal. 

Co-ordination and Agility Training

Coordination is the ability to execute smooth, accurate, and controlled movements. Agility is the ability to perform coordinated movements combined with upright standing balance[9]. Co-ordination and agility training goals should include:

  • Improve postural stability and balance element under dynamic conditions
  • Limbs movements accuracy
  • Functional application of co-ordination and agility skills
  • Safety awareness and compensatory strategies for effective movement control and fall prevention including mobility aid advice.

Use of Equipment and Supportive Devices

Functional Electrical Stimulation

Adding electrical stimulation to functional task practice enhances motor function and strength. There is no optimal protocol for patients with traumatic brain injury.

Robotics and Virtual Reality

Interactive simulation with use of the computer interface and carefully designed software. Can be delivered via widely available consoles like Wii, PCs, tablets but also via complex systems like CAREN. The practice can concentrate on specific area for example hand by means of devices like Amadeoor full body movement sequences like gait by means of Locomat. There is an increasing evidence looking into the effectiveness of gaming and use of robotics in neurological rehabilitation.

    

Falls Prevention

There is widely evidenced multifactorial nature of falls risks in individuals with TBI. Falls prevention and falls training points to behaviour shaping interventions with intensive long term physical training along with education being the most effective. Multiple and complex TBI sequelae are often overlapping with impairment contributing to falls risk like weakness, reduced joints mobility, stiffness, slow processing speed, inability to complete complex tasks. Therefore, falls prevention exercise-based interventions should contain elements of:

  • Physical and cognitive components with flexibility, strength, dual tasking skills activities
  • Steady stance, pro-active and reactive balance components to address various tasks’ attributes (required stability, mobility or skills)
  • Interaction with environment (regulatory o non-regulatory)

Intensive programmes with 2-3 times/week sessions, possible tasks and exercises progression and minimum 26 weeks duration are deemed most effective. Addressing fear of falling and exposure to situations challenging balance systems are currently researched and emerging evidence is pointing to importance of addressing the negative attitude to falls, teaching on/off transfer to improve confidence and recognising the “fall feeling” to address with appropriate strategy.

For patients who are unable to practice movement voluntarily or have an insufficient recovery there might ebea need to physically assist the movements. The facilitated movement will be agreed as part of the task to be learned, i.e.: pelvic tilt to facilitate sit to stand, reach to grasp, etc. The manual assistance can provide stability, demonstrate tactile and kinesthetics feel of movement, reduce errors, provide target, provide confidence. The hands-on treatment should aim to be timely discontinued when the active movement components are enhanced to prevent dependency. Ultimately, the facilitated movement should be practised independently to allow consolidation of acquired skills.

Neurodevelopmental Treatment (Bobath Concept)

Problem-solving approach developed by Karel and Berta Bobath advocating that every person with neurological dysfunction have a potential to improve and have a need to improve the functional skills not only to develop compensation as a result of neurological damage. 

The concept does so via thorough functional movement analysis and identifying deficits in motor control and task performance and through highly skill handling techniques allowing inhibition of abnormal postural reflex mechanism (righting, equilibrium, protective extension reactions) and facilitating the postural alignment, stability and normal movement. Facilitation of key points of control and sensory stimulation is the most commonly used techniques. 

Although in the recent years the focus on motor control theories allowed to systemise the Bobath Concept’s the underpinning principles there has been an intensive discussion about effectiveness and cost effectiveness of the Bobath approach. [12][13] However, so far there its no sufficient evidence in favour in any currently used concept or methods of rehabilitation of people with traumatic brain injury or stroke sequels and further research is required to establish superiority of any approach. 

Proprioceptive Neuromuscular Facilitation PNF

Approach developed by Herman Kabat and Margaret Knott based on the basic principles of:

  • Being integrated approach: PNF focuses on 
  • Reinforce motivation, physical practice and results
  • The highest possible level of functioning is the main goal of treatment.

The concept clearly systemises facilitation tool into:

  • Basic procedures like resistance, irradiation and reinforcement, body mechanic, use of tactile-kinaesthetic, auditory, visual stimuli, traction & approximation, timing
  • Techniques like rhythmic stabilisation, combination of isotonics, dynamic reversal, use of stretch, contract-relax or hold-relax, etc.
  • 3D patterns, which are the most recognisable element of the approach focusing on scapula, pelvis, upper limbs, lower limbs, neck and trunk patterns. 

Sensory Stimulation

Tactile, proprioceptive, visual, or vestibular sensory deficit impacts systems ability to move and learn new activities. Through sensory stimulation we aim to improve attention and arousal level and enhance sensory perception, selection and discrimination. [9]

Techniques used to stimulate sensory system include:

  • Maintained pressure, can be manual, Lycra garment, etc
  • Slow, repetitive stroking
  • Light touch
  • Neutral warmth like towel wraps, gloves and tights
  • Prolonged cooling like cold water bath, ice massage
  • Slow vestibular stimulation like rocking, swinging on the gym ball or in hammock
  • Rapid vestibular stimulation like spinning on the chair.

The intensity of the stimuli needs to be carefully picked to prevent overstimulation and consideration given to the area where the stimuli is applied, as some areas like face, especially around mouth, sole of feet or palm have high receptors concentration and big cortical representation. 

Classes

  • Circuit set up - when the group of patients completes exercises at designed workstations independently with some degree of supervision, 
  • Common groups activity include: locomotion, upper limbs skills, strength and conditioning, falls prevention, hydrotherapy.
  • Recommended duration 6-26 weeks depends on the theme of the group and the goal; on average 3/week; duration approx. 30-60 minutes.

Hydrotherapy / Aquatic Therapy

There is sufficient evidence suggesting benefits of water-based therapy in traumatic brain injury patient outcomes. Water environment improves neuromuscular re-education and enhances strengthening. The buoyancy allows freedom of movement in the case of weakness or paralysis whilst water resistance provides strengthening medium. Warm water allows increased tone normalisation whilst water viscosity and buoyancy alllows postural control and balance training in sitting and standing.

There are safety principles to be followed with the water access, level of supervision and evacuation plan, which should be risk assessed prior to accessing water environment. However, all complexity patient benefit from water-based exercises. 

Postural Sets

Various functional postures will have different aims and benefits when used through therapy process. Depending on the posture they might:

  • Improve control of various body parts: upper trunk, lower trunk, LE hips, UE (shoulders, elbows), and neck/head control
  • Allow the weight-bearing through specific body parts: hips, shoulders, feet, hands, etc.
  • Improve strength and stability of joints: hip, knee, ankle, shoulder, and elbow, wrist
  • Normalise tone through decreasing and increasing in antagonistic muscle groups
  • Offer different base of support to influence tone (the greater base of support the lower the tone) or COM placement (the higher COM the greater the tone).
  • Limit degrees of freedom: control of upper or lower extremity
  • Load lower or upper and lower limbs. [9]

Different postures that you might use include:

  • Crook position
  • Bridging
  • Side lying to side sitting 
  • Prone and prone on elbows
  • Prone standing
  • 4-point kneeling to 2-point kneeling variations to high kneeling
  • Sitting variations also on uneven base of support 
  • standing variations including various base of support, de-weighting systems, active versus passive 

This useful resource describes various different postures and the impact they may have on rehabilitation.

Enabling

To enable patient to internalise the movement being learned various motor learning components might be considered:

  1. Determining need of training: enhance the understanding of “the responsibility for your own rehabilitation” need 
  2. Goal setting using SMART goal principles with salience and achievability to enhance motivation. Be realistic about timescales of recovery!
  3. Optimal activities for supervised and unsupervised practice to allow the patient to success and practice safely the agreed movement within established parameters
  4. Parameters of training: intensity, minimal number of repetitions, duration, progression, fatigue levels, types of practice (mass versus distributed; blocked versus random; order blocked versus serial versus random; part versus whole, mental practice, transfer of skills practice)
  5. Feedback strategies: Feedback can be intrinsic like proprioceptive, vestibular, visual, cutaneous and extrinsic like auditory, tactile, visual; concurrent and terminal; amount, timing, mode to individualised; knowledge of performance versus knowledge of results.
  6. Environment set-up: closed versus open, context specific
  7. Monitoring strategies: sensitive, valid and reliable measures meaningful for patient and therapist as well as IDT communication
  8. Internalisation and responsibility for one’s rehabilitation process including encouragement to problem solve and use of timetable, reminders, guidelines

References

  1. Hellweg S, Johannes S. Physiotherapy after traumatic brain injury: A systematic review of the literature. Brain Injury. 2008;22(5):365–373.
  2. leadingall. Gait training for patient with brain injury. Available from: https://www.youtube.com/watch?v=CTDjEvfe2IY[last accessed 30/08/19]
  3. Physio Fitness | Physio REHAB | Tim Keeley. Gait re-training after T.B.I. | Feat. Juliann Desjardins | No.121 | Physio REHAB. Available from: https://www.youtube.com/watch?v=3ou46UyvAvw[last accessed 30/08/19]
  4. Corbetta D, Sirtori  V, Castellini  G, Moja L, Gatti  R. Constraint‐induced movement therapy for upper extremities in people with stroke. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD004433. DOI: 10.1002/14651858.CD004433.pub3.
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  7. Ward NS, Brander F, Kelly K. Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry. 2019 May 1;90(5):498-506. Available from: https://jnnp.bmj.com/content/90/5/498 (last accessed 20.10.2019)
  8. Ward NS, Brander F, Kelly K Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme Journal of Neurology, Neurosurgery & Psychiatry 2019;90:498-506.
  9. 9.0 9.1 9.2 9.3 9.4 9.5 O’Sullivan SB, Fulk GD, Schmitz TJ. (2014) Physical Rehabilitation 6th edition, F.A. Davis Co, Philadelphia. Available at:  https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=652549&site=eds-live  (Accessed: 29 August 2019).
  10. Cleveland Clinic. CAREN Virtual Reality Treadmill: Take a Video Tour. Available from: http://www.youtube.com/watch?v=TntXjlTUhII[last accessed 30/08/19]
  11. City of Tampa. C A R E N - Computer Assisted Rehabilitation Environment System at the University of South Florida. Available from: http://www.youtube.com/watch?v=a6Quza3WmVA[last accessed 30/08/19]
  12. Díaz-Arribas MJ, Martín-Casas P, Cano-de-la-Cuerda R, Plaza-Manzano G. Effectiveness of the Bobath concept in the treatment of stroke: a systematic review. Disability and Rehabilitation. 2019 Apr 24:1-14. doi: 10.1080/09638288.2019.1590865.
  13. Gray C, Ford C. Bobath Therapy for Patients with Neurological Conditions: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2018 Nov 28. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538920/
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