Therapeutic Interventions for Traumatic Brain Injury
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- 1 Introduction
- 2 Gait Training and Supporting Practice
- 3 Arm Mobility Training
- 4 Range of Movement
- 5 Strength and Conditioning
- 6 Endurance Training
- 7 Balance and Postural Control Training
- 8 Co-ordination and Agility Training
- 9 Use of Equipment and Supportive Devices
- 10 Falls Prevention
- 11 Hands on Treatments
- 12 Sensory Stimulation
- 13 Classes
- 14 Hydrotherapy / Aquatic Therapy
- 15 Postural Sets
- 16 Enabling
- 17 References
The Traumatic Brain Injury sequel are various in nature, 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 determines 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 and might address individual’s structures and functions, activities and participation, environment and barriers modifications. At this point in time there is no standardise recommendations regarding physiotherapeutic protocols for treatment of individuals with traumatic brain injury and the neuro physiotherapists community utilises variable and multiple methods and intensity.  Moreover, the difficulties with research organisation in this patient group forces Physiotherapists to reach for the 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 the 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, i.e.: 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)
Concentrates on repetitive tasks of affected upper limb, designed with principles of task specific training to address specific motor deficit and utilise the upper limb for as long as possible. Mitten worn on nonaffected 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 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 recent Cochrane review in stroke was unable to establish superiority of CIMT to other forms of upper limb rehabilitation. 
Queen Square Upper Limb Neurorehabilitation Programme
It is primarily designed to address upper limbs problems following strokes, however the protocol principles could be successfully applied to rehabilitation following other acquired brain injuries forms including TBI. High-quality, high-dose, high-intensity upper limb neurorehabilitation programme 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 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. 
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 loss of rom and flexibility. Techniques improving mobility include:
- Range of Movement Exercises (Passive, Active, Facilitated i.e.: Using PNF Techniques)
- Passive stretching through Positioning, Splinting, Serial Casting [cross-reference to splinting guideline page]
- Joint Mobilization
- Use of Heat
- Warm-up prior to other forms of training
Strength and Conditioning
- Cross Training (include elements of concentric, eccentric, isometric and endurance training)
For efficient training following needs to be agreed:
- 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 
When addressing poor muscular endurance consideration needs to be taken of the fatigue (inability to contract muscle repetitively over time) , physical but also cognitive. The 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 an 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,  including advice with regards to physical activity, polypharmacy, environment, personal choices and behaviours like footwear, copping strategies coaching to inhibit fear of falling.
The training to be efficient needs to meet individual person’s needs and be designed at optimal level of challenge without compromising safety. Use of various postural sets and techniques to be ensured for 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, incline
- 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.  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; no optimal protocol for patients with traumatic brain injury
Robotics and Virtual Reality
Interactive stimulation by use of the computer interface and carefully designed software. Can be delivered via widely available consoles like Wii, PCs, tablets but also via complex system 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 effectiveness of the gaming and use of robotics in neurological rehabilitation.
Nintendo Wii use and examples of robots use in neurorehabilitation. (Krebs & Volpe 2015)
Widely evidenced multifactorial nature of falls risks, falls prevention and falls training points to behaviour shaping interventions with intensive lonterm physical training along with education being the most effective. Multiple and complex TBI sequel 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 element 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 nonregulatory)
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.
Hands on Treatments
For patients who are unable to practice movement voluntarily or have insufficient recovery there might eb a need to physical 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.
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 are 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.  However, so far there is 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.
Pelvic tilt facilitation. (Bohman 2003)
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, combination of scapula and pelvis, upper limbs, lower limbs, neck and trunk patterns.
O’Sullivan S, TJ Schmitz. (2016) Improving Functional Outcomes in Physical Rehabilitation 3nd Edition. F.A. Davis Company Philadelphia.
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. 
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.
- Circuit set up, when 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.
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 buoyance allow 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.
Various functional postures will have different aims and benefits when used through therapy process. Depends 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. 
- Crook position
- 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, deweighing systems, active versus passive
Human Positions and Posture https://slideplayer.com/slide/5687906/
To enable patient to internalise the movement being learned various motor learning components might be considered:
- Determining need of training: enhance the understanding of “the responsibility for your own rehabilitation” need
- Goal setting using SMART goal principles with salience and achievability to enhance motivation. Be realistic about timescales of recovery!
- Optimal activities for supervised and unsupervised practice to allow the patient to success and practice safely the agreed movement within established parameters
- 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)
- 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.
- Environment set-up: closed versus open, context specific
- Monitoring strategies: sensitive, valid and reliable measures meaningful for patient and therapist as well as IDT communication
- Internalisation and responsibility for one’s rehabilitation process including encouragement to problem solve and use of timetable, reminders, guidelines
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