Management of traumatic brain injury

Associate Professor Leanne Hassett, an expert on interventions to increase physical activity in neurological populations, has written an Invited Topical Review on physiotherapy management of moderate- to-severe traumatic brain injury.

Invited Topical Reviews are hugely popular because they summarise the causes, assessment, diagnosis, prognosis and management of a condition.

Your Invited Topical Review focuses on moderate-to-severe traumatic brain injury—how are these levels of severity defined and why is it pertinent to consider them as distinct groups?

Traumatic brain injuries (TBIs) are typically categorised as mild, moderate or severe. Severity is based on the Glasgow Coma Scale, length of loss of consciousness and/or duration of post- traumatic amnesia. 

A moderate injury is defined as post-traumatic amnesia between one and seven days and/or an altered level of consciousness (Glasgow Coma Scale score 9 to 12) or loss of consciousness between 30 minutes and 24 hours post-trauma.

A severe injury is defined as post-traumatic amnesia longer than seven days or a period of coma with a Glasgow Coma Scale score of eight or less or a loss of consciousness greater than 24 hours.

The presentation of an individual with moderate-to-severe TBI varies considerably depending on the site and severity of the brain injury and other injuries sustained at the same time (eg, fractures).

The person with TBI may present with cognitive and language impairments, behavioural disturbances and physical impairments.

The more severe the TBI, the more likely it is that these impairments will affect the person’s life in the long term and that they will require multidisciplinary rehabilitation including physiotherapy.

What sort of burden is associated with this injury?

Although the incidence of TBI varies, an incidence proportion of 295/100,000 has been reported in Australia.

Moderate and severe TBIs make up a small proportion of the total incidence but are estimated to account for most health-related costs. TBI primarily affects people during their most economically productive years and the effects are lifelong. Consequently, the economic and social costs are very high.

What intervention is appropriate during the period of post- traumatic amnesia?

Post-traumatic amnesia is defined as a period of confusion and disorientation, with retrograde and anterograde amnesia, poor attention and, frequently, agitation.

The newly updated INCOG (international cognitive) guidelines for cognitive rehabilitation after TBI recommend physiotherapy during post-traumatic amnesia. Although post-traumatic amnesia includes deficits in short-term memory, procedural memory is retained.

This enables the practice of motor tasks relevant to the individual such as standing up from sitting, reaching in standing and walking. Using demonstration, keeping instructions brief and conducting short, frequent sessions are strategies to use when working with an individual in post-traumatic amnesia.

What about management of increased tone?

Hypertonus is commonly seen in individuals with TBI and is likely due to spasticity and/or contracture.

Providing evidence-based management of contracture and spasticity in individuals with
TBI remains challenging for clinicians.

It is unlikely that 30 to 60 minutes of routine stretching over a short period of time will prevent or reverse contracture. 

Serial casting may be an effective way of reversing contracture, but the effect is likely to be transient if muscle activity does not return, which highlights the importance of strength training in very weak muscles. 

When moderate-to-severe spasticity is present, the risk of contracture developing may be reduced by positioning at-risk muscles in lengthened positions combined with more neutral positions through the day and commencing active training that encourages movement through range.

Pharmacological interventions such as botulinum toxin A could be trialled where moderate-to-severe focal spasticity is present and interferes with function or personal care. In this instance, patient-centred goals should be identified and a multidisciplinary team involved.

What other interventions does the Invited Topical Review consider the evidence for?

The topical review also considers the evidence for mobility training, cardiorespiratory fitness training and the promotion of physical activity.

What are some priorities for future research in this area?

There is a clear need for research across the life span.

Trials summarised in this review are predominantly trials involving working age adults. Studies including children, adolescents and older adults are desperately needed to fill these evidence gaps. 

Older adults are particularly important given the increasing number of TBIs in older adults due to falls. All areas of physiotherapy management require further research considering the low or very low certainty evidence that is currently available. 

Priorities in these areas should be discussed with key stakeholders, including people living with TBI, to ensure that the most important questions are addressed first.

Leanne Hassett APAM is an associate professor in physiotherapy at the University of Sydney and co-leads the Implementation Science Academy at Sydney Health Partners. Leanne worked for 15 years as a clinical physiotherapist in brain injury rehabilitation at Liverpool Hospital in Sydney.