Post-Traumatic Brain Injury (TBI) Rehabilitation Traumatic Brain Injury... · 2019-07-03 · as well as “Return to Activity Educational Brochure”. **NOTE** Return to Activity

Post-Traumatic Brain Injury (TBI) Rehabilitation

By

William A. Garlisi Sr, PT, DPT

19 Jun 2019

Post-Traumatic Brain Injury (TBI) Rehabilitation

OBJECTIVES

TBI in U.S. Armed Forces

Provider Clinical Recommendations

Physical Therapy Evidence Based Practice

Assessment Tools for Return To Duty (RTD)

Challenges in Rehabilitation with TBI Patients

TBI in U.S. Armed Forces

More than 287,000 service members have sustained a traumatic

brain injury (TBI) over the last decade in support of operations in

Iraq and Afghanistan. The majority of these (83.3%) were

classified as mild TBI (mTBI), also known as concussion.

TBI’s in U.S. Armed ForcesCommon Sign and Symptoms

PHYSICAL

• Headaches

• Sleep Disturbance

• Dizziness

• Balance Problems

• Fatigue

• Visual Disturbances

• Sensitivity to light

• Ringing in ears

COGNITIVE

• Concentration Problems

• Temporary gaps in memory

• Attention Problems

• Slowed Thinking

• Difficulty finding words

EMOTIONAL

• Irritability

• Anxiety

• Depression

• Mood Swings

TBI’s in U.S. Armed ForcesImpact of Concussion

Soldiers May Experience:

Difficulty sleeping at night

Decreased energy and alertness

Reduced work performance

Trouble multi-tasking

Easily distracted

Difficulty processing multiple sources of information

Interpersonal problems

TBI’s in U.S. Armed ForcesGradation and Causes

TYPES OF TBI’s

MILD

MODERATE

SEVERE

Glassgow Coma Scale, duration loss of

consciousness (LOC), duration of

alteration of consciousness (AOC), post

traumatic amnesia duration, and

neuroimaging

CAUSES

BLASTS

BULLETS

FRAGMENTS

FALLS

MV CRASH/ROLLOVER

Provider Clinical RecommendationsCriteria for Diagnosing

Severity Index Mild Moderate Severe_

Neuroimaging findings Normal structural Normal or abnormal Normal or abnormal

imaging structural imaging structural imaging

GCS score 13-15 9-12 < 9

Duration of LOC 0-30 min > 30 min & < 24 hr > 24 hr

Duration of AOC A moment up to AOC > 24 hr (use

24 hr other criteria)

Duration of posttraumatic 0-1 day >1 and < 7 > 7

Amnesia, days

Provider Clinical RecommendationsProgressive Return to Activity

Patient education is the single most effective intervention following acute mTBI

showing the greatest decrease in the number and duration of symptoms.

Provide and Review with patient the “Acute Concussion Educational Brochure”

as well as “Return to Activity Educational Brochure”.

**NOTE** Return to Activity Brochure only provided once patient has achieved a 24 hour

mandatory recovery and presents asymptomatic

Utilize a 6 stage Progressive Return to Activity Process

Stage advancement based on post exertion Neurobehavioral Symptom

Inventory (NSI) completion

Provider Clinical RecommendationsProgressive Return to Activity

Provider Clinical RecommendationsProgressive Return to Activity

Provider Clinical RecommendationsProgressive Return to Activity

Provider Clinical RecommendationsProgressive Return to Activity

Physical Therapy Evidence Based Practice

Military physical therapists (PT) work as physician extenders via operation of

Direct Access clinics

Perform a complete & thorough patient history, review of systems, and

evaluation

Initiate referrals to other clinics as warranted, order appropriate imaging, or

defer to PCM if beyond scope

Leads, coordinates, and provides continuum of care over course of patient

recovery

Physical Therapy Evidence Based Practice

Methods of Treatment

Functional Training

Fitness or aerobic training

Serial casting, splinting

Treatment intensity

Sensory stimulation

Proprioception

Strength training

Modalities?

Physical Therapy Evidence Based Practice

Currently there are no standardized PT treatment recommendations for patients

with TBI’s

Lack of randomized controlled studies for patients with TBI

Possibly due to heterogeneity of the symptoms

Physical Therapy Evidence Based Practice

A systematic literature review was conducted by Hellwig & Johannes (2008)

regarding physiotherapy following TBI

Strong evidence exists for positive rehabilitation effects when early & intensive

functional and/or aerobic training was utilized

Better patient outcomes when:

Patient compliant

Family actively engaged

Good support system

Physical Therapy Evidence Based Practice

HVLA-T to TS as a possible adjunct treatment?

Patients with h/a’s, dizziness, anxiety, neck pain (TBI w/ PTSD)

Case series provides preliminary evidence suggesting supraspinal

mechanisms may be associated with thoracic thrust manipulation and

hypoalgesia (Sparks 2017)

Assessment Tools for Return to Duty (RTD)

Currently criteria for RTD in operational environment based primarily on sports

concussion literature

Transition readiness determination from impairment-based approach to

functionally oriented based approach

Something that will challenge sensorimotor, cognitive, and physical impairments

simultaneously and target higher-level functioning

Assessment Tools for Return to Duty (RTD)

Computer Assisted Rehabilitation Environment (CAREN)

RTD Testing Modules

Assessment of Military Multitasking Performance (AMMP)

Assessment Tools for Return to Duty (RTD)

• CAREN

• Pros: Assesses multiple performance domains

simultaneously

• Cons: Cost; Required tech support for

programming, running, and maintaining

system; immaturity of evidence for

generalization of readiness; availability to

facilities

• RTD Testing Modules

• Pros: Good face validity and favorable RTD

generalization

• Cons: Lacks precise measurement and

repeatability; requires significant resources;

costly technology; substantial logistics

support; a large clinical staff; increased staff

hours to coordinate and execute testing

Assessment Tools for Return to Duty (RTD)

AMMP

Novel battery of militarized dual tasks and multitasks designed to challenge known mTBI

vulnerabilities

Pros: Incorporates complex testing methods into RTD assessment & potential application

of standards-based assessment in clinical environment which can be performed in remote

clinics or in a deployed setting; less cost compared to VR

Cons: Ability to discriminate duty readiness in service members with mTBI has not been

validated with reliability of individual test tasks yet to be reported; training required to

solidify standardized testing procedure

Assessment Tools for Return to Duty (RTD)

AMMP DUAL TASK EXAMPLE

TASK: Illinois Agility Test

TASK DEMANDS: Memory, attention, dynamic stability, and agility

TASK DESCRIPTION: Single task (motor) running distance of 30 feet with rapid direction changes and navigation of serpentine obstacles; single task (cognitive) 7-word list memory task; Dual-task condition: agility task and the memory task are done at the same time

ASSESSMENT METRIC: Accuracy of memory recall and time to complete the agility task are measured in single and dual-task conditions. Dual-task costs for cognitive and motor components

TASK RATIONALE: Tests of walking with dual-task performance are unlikely to identify discernible dual-task costs. Service member demand for speed and agility during quick maneuvers while attending to other information supports this high-level balance, running, and working memory task.

Assessment Tools for Return to Duty (RTD)

AMMP MULTITASK EXAMPLE

TASK: SALUTE

TASK DEMANDS: Executive function, attention, memory, visual scanning, gaze stability, and exertion

TASK DESCRIPTION: Service member is challenged to gather information from video surveillance

recordings and radio communication recordings (SALUTE) while performing a continuous modified step

test at >65% of age-predicted max HR

ASSESSMENT METHOD: Accuracy/errors of SALUTE report; ability to maintain appropriate exertional

load

TASK RATIONALE: The ability to integrate and retain in ones working memory visual and auditory

stimuli that are operationally significant under exertion represents a high level of functional readiness in a

clinical environment in a task that is clearly relevant to a service member

Challenges in Rehabilitation with TBI Patients

Acute and Chronic Pain are common after TBI

Acute pain, usually associated with defined tissue damage, last up to several weeks

and is expected to resolve

Chronic pain tended not to be associated with tissue damage.

Reported as high as in 71% of patients 12 months after injury, typically in form

of headache followed by declining incidents in neck, shoulders, back, and upper

& lower limbs

NOTE: Female gender, prior h/a disorder, and family hx of h/a disorder were found to be

associated with increased risk for developing posttraumatic h/a

Challenges in Rehabilitation with TBI Patients

“Polytrauma Triad”

TBI, PTSD, and Chronic Pain

Stojonavic et al found perceived pain intensity was higher in patients diagnosed with

PTSD as opposed to mTBI, but subjects with both disorders had highest perceived pain

levels

Overlapping symptoms which characterize these conditions make accurate diagnosis

problematic

Cognitive impairments associated with TBI can adversely affect a person’s ability to engage in

therapies

Post-Traumatic Brain Injury (TBI) Rehabilitation

SUMMARY

TBI in U.S. Armed Forces

Provider Clinical Recommendations

Physical Therapy Evidence Based Practice

Assessment Tools for Return To Duty (RTD)

Challenges in Rehabilitation with TBI Patients

Post-Traumatic Brain Injury (TBI) Rehabilitation

References

TBI Basics. Retrieved from: https://dvbic.dcoe.mil/articles/tbi-basics

Defense and Veterans Brain Injury Center. (2013). DoD Worldwide Numbers for TBI Worldwide totals. Retrieved

from: http://dvbic.dcoe.mil

Chapman, J.C., Diaz-Arrastia, R. (2014). Military traumatic brain injury: A review. Alzheimers & Dementia (10),

94-104.

Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury: Guidance for the

Primary Care Manager in Deployed and Non-deployed Settings (2014). Retrieved from:

https://dvbic.dcoe.mil/system/files/resources/2014

Hellwig, S., Johannes, S. (2008). Physiotherapy after traumatic brain injury: A systematic review of the literature.

Brain Injury, 22(5), 365-373.

Scherer, M.R., et al., (2013). Returning Service Members to Duty Following Mild Traumatic Brain Injury:

Exploring the Use of Dual-Task and Multitask Assessment Methods. Physical Therapy, 93(9), 1254-1267.

Irvine, K., and Clark, D., (2018). Chronic Pain After Traumatic Brain Injury: Pathophysiology and Pain

Mechanisms. Retrieved from: https://academic.oup.com/painmedicine/article

References

Gironda, R.J., et.al. (2006). Pain among vetereans of Operations Enduring Freedom and Iraqi Freedom. Pain

Medicine, 7(4), 339-343.

Stojanovic, M.P., et. al. (2016). Influence of Mild Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder

(PTSD) on Pain Intensity Levels in OER/OIF/OND Veterans. Pain Med, 17(11): 2017-2025.

Sparks, C., Cleland, J., Elliott, J., Zagardo, M., & Liu, W. (2013). Using Functional MRI to Determine if Cerebral

Hemodynamic Response to Pain Change Following Thoracic Spine Thrust Manipulation in Healthy Individuals.

Journal of Orthopaedic & Sports Physical Therapy 43(5): 340-348