Move Forward Guide

    Physical Therapist's Guide to Traumatic Brain Injury

    Traumatic brain injury (TBI) occurs when a trauma causes damage to the way the brain functions. The most common causes of TBI are falls, car crashes, and blows to the head. Approximately 1.7 million TBIs occur each year in the US, resulting in 52,000 deaths and 275,000 hospitalizations.

    Approximately 80% of individuals with TBI are treated and released from the emergency department because their injury is classified as a concussion or mild traumatic brain injury. TBI can occur at any age, to anyone, but certain groups are more likely to experience a brain injury. Children under the age of 4 are at risk of injury from falls and child abuse. Adolescents aged 15-19 are at an increased risk due to sports and car crashes. People aged 75 years and older are at risk from falls.

    Physical therapists help people with TBI regain their physical abilities, re-learn daily tasks, and improve their strength and overall fitness.


    What is Traumatic Brain Injury?

    Traumatic brain injury (TBI) occurs as the result of extreme force exerted on brain tissue. Common causes are falls, car crashes, or blows to the head. Movement of the brain that causes damage even though the skull is intact is called a closed injury. Damage caused by a wound that breaks through the skull, such as a gunshot or a puncture by a sharp object, is called a penetrating injury.

    Those who sustain moderate-to-severe TBI require specialized hospital and rehabilitative care to address the serious physical, cognitive, and emotional changes that result from injury to the brain. Nearly half (43%) of those who need hospitalization for TBI will have some form of disability 1 year after the injury.

    Severe TBI often causes a period of unconsciousness, called a coma, when the patient's eyes remain closed, and he or she is not responsive to outside stimulation. Consciousness may gradually improve, but many brain functions can be affected by the injury, including those guiding thought, movement, sensation, and behavior.


    Signs and Symptoms

    Because the brain controls our ability to move, think, sense, and socialize, the symptoms that result from TBI can vary widely. They may include:

    • Physical symptoms, which can include weakness or difficulty moving the arms, legs, body, and head. The affected person may have difficulty sitting, standing, balancing, walking, or lying down and changing in bed.
    • Cognitive symptoms, which can include difficulty remembering, paying attention, or solving problems. The affected person may have a reduced awareness of these difficulties, which can cause safety concerns.
    • Sensory symptoms, which can include changes in vision, hearing, or the sense of touch. Balance senses that are aided by the inner ear may also be impaired.
    • Emotional and behavioral symptoms, which can include difficulty in controlling emotions, or a change in personality. If cognitive deficits are significant, the affected person's inability to understand what has happened may result in significant emotional agitation.

    How Is It Diagnosed?

    Upon the patient's arrival at the hospital, an attending doctor will diagnose the level of the TBI by assessing factors such as the ability to open the eyes, to speak, and to move in response to a command.

    In moderate or severe injuries, imaging studies will be conducted (such as MRI, CT scan) to determine what parts of the brain are injured or if there is any bleeding or fluid that could be pressing on the brain tissue. A physical therapist (PT) often works with the medical team to understand what areas of the brain are injured so that the PT evaluation can focus on potential problem areas.

    With a severe injury, the patient may be in a coma; the eyes are shut and there is no response to external stimuli. Over time, the patient will likely be able to open his or her eyes. Sometimes eye opening is accompanied by rapid recovery of other abilities such as talking and physical movement. For other patients, recovery is slower.

    When a patient is said to be in a vegetative state, some basic brain functions resume, such as eye-opening on a regular sleep/wake cycle, breathing, and digestive functions, but he or she is unaware of surrounding activity. During this phase, a physical therapist will help with positioning and equipment that will ensure proper posture and flexibility, reduce the likelihood of any problems such as bed sores, and encourage responsiveness to the environment.

    When a patient is said to be in a minimally conscious state, he or she shows beginning signs of awareness (the ability to do purposeful things) but these responses are often not consistent. During this phase, a physical therapist will help with stretching, positioning, and equipment use while trying to increase consistent responses to commands for movement and communication.


    How Can a Physical Therapist Help?

    By working with the patient and his or her family, goals are developed to improve physical independence. Physical therapists help patients with TBI regain functions such as getting in and out of bed and changing their position in bed, sitting down, rising to stand, walking, and using a wheelchair.

    The physical therapist uses exercise and task-specific training to help the patient improve:

    • The ability to maintain alertness and follow commands
    • Muscle and joint flexibility that may be reduced after inactivity
    • The ability to move around in bed, to sit without support, and to stand up
    • The ability to balance safely when sitting, standing, or walking
    • The ability to move by strengthening and the practicing of functional activities
    • Balance and coordination
    • Strength and energy, reducing any feelings of fatigue that occur from inactivity or the injury to the brain itself
    • A return to sports and fitness activities

    If limitations prevent the return to pre-injury activities, a physical therapist can help the patient improve mobility and master the use of equipment such as an ankle brace, a walker, or a wheelchair.


    Can this Injury or Condition be Prevented?

    Traumatic brain injuries can be prevented by taking steps to protect the head when engaged in risky activities, and by lessening participation in those activities. Awareness of the signs and symptoms of injury can help quicken response time should a TBI occur.

    • Always use an appropriate helmet when taking part in activities that increase the risk of falling, such as biking, rock climbing, motorcycling, skateboarding, skiing, or skating.
    • Always use your car's seatbelts; infants must be secured in an appropriate car seat according to safety requirements and instructions.

    For small children:

    • Provide appropriate adult supervision in fall-prone areas such as playgrounds.
    • Use child barriers to prevent home-based falls around areas such as stairs and second-story windows.

    For adolescents:

    • Educate teens about the many factors associated with death and brain injury in car crashes, including the use of alcohol or other substances, speeding, or texting or phone use while driving.
    • Educate teens about mild TBI (see concussion guide) or severe injuries related to sports.

    For older adults:

    • Educate older loved ones about the risk of falls in the home related to daily mobility and to housework activities that carry a greater risk of brain injury, such as using a ladder or footstool, walking on a wet floor, or vacuuming stairs.

    Real Life Experiences

    Ryan, a 20-year-old college student, sustained a severe brain injury with facial wounds and a broken left arm when the car in which he was a passenger rolled over in an accident. He was unresponsive at the scene of the accident and was taken by ambulance to the nearest trauma center. On the way to the hospital, Ryan needed help breathing. His initial diagnosis showed a severe injury: he was not opening his eyes, could not speak, and was unable to move his arms or legs.

    Ryan remained in a coma for several days, but eventually resumed breathing on his own, opened his eyes, and was moving the right side of his body. Although groggy and confused, he was able to begin physical therapy. Ryan's physical therapist worked with him each day on sitting and moving in bed, standing at the side of the bed, and taking a few steps with the help of a walker. His left-sided weakness was an important focus, so strengthening and coordination exercises were part of his routine.

    After his condition improved, Ryan was transferred to a rehabilitation center. Ryan clearly had problems with important skills such as paying attention, memory, and the ability to plan and problem-solve.

    At the rehabilitation center, his physical therapist’s main focus was on helping Ryan to improve control of the left side of his body in order to perform important skills safely and independently. At first, he needed physical help to stand up, walk more than a short distance, and climb stairs. As he progressed in therapy, he began to walk with a cane and build his endurance by exercising on a treadmill. He and his therapist developed a fitness workout that was similar to what he used to do at the college fitness facility.

    Ryan was discharged from the center and continued to see a physical therapist on an outpatient basis to work more on the remaining weakness in his left ankle that affected his endurance, balance, and ability to jump and run. Ryan's goal is to resume playing intramural basketball.

    During rehabilitation, Ryan's speech-language pathologist and neuropsychologist completed specific testing to determine the extent of his cognitive problems. While his ability to pay attention, remember, and problem-solve improved gradually, upon leaving rehab Ryan still wasn’t ready to go back to the cognitive challenges of college. Further outpatient therapy was planned in speech pathology and physical therapy to address the goals he had yet to achieve.


    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat TBI.   However, you may want to consider:

    • A physical therapist who is experienced in treating people with neurological conditions/injuries. You may find these therapists affiliated with rehabilitation centers that commonly serve individuals with stroke, brain injury, and spinal cord injury.
    • A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in neurologic physical therapy and uses the designation NCS. This therapist has advanced knowledge, experience, and skills that may apply to this condition.
    • Sometimes therapists with a strong interest in brain injury have the credential of Certified Brain Injury Specialist (CBIS), from the Brain Injury Association of America.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have traumatic brain injury.
    • During your first visit with the physical therapist, be prepared to describe the physical issues and symptoms that are causing the most difficulty following the brain injury.
    • Plan to talk about what goals are most important to help increase the patient's independence performing daily activities, and ensure a healthy future.

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

    The following articles provide some of the best scientific evidence related to physical therapy treatment of traumatic brain injury. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Bragge P, Chau M, Pitt VJ, et al. An overview of published research about the acute care and rehabilitation of traumatic brain injured and spinal cord injured patients. J Neurotrauma. 2012;29:1539-1547. Article Summary on PubMed.

    Mossberg KA, Amonette WE, Masel BE. Endurance training and cardiorespiratory conditioning after traumatic brain injury. J Head Trauma Rehabil. 2010;25:173-183. Article Summary on PubMed.

    Weightman MM, Bolgla R, McCulloch KL, Peterson MD. Physical therapy recommendations for service members with mild traumatic brain injury. J Head Trauma Rehabil. 2010;25:206–218. Article Summary on PubMed.

    Ontario Neurotrauma Foundation. Guidelines for mild traumatic brain injury and persistent symtpoms. Published 2009. Article Summary on PubMed.

    Acquired Brain Injury Knowledge Uptake Strategy (ABIKUS) Guideline. Evidence-based recommendations for rehabilitation of moderate to severe acquired brain injury. The Evidence-Based Review of Moderate To Severe Acquired Brain Injury. August 2007. Free Article.

    McCulloch K. Attention and dual-task conditions: physical therapy implications for individuals with acquired brain injury. J Neurol Phys Ther. 2007;31:104-118. Article Summary on PubMed.

    Belmont A, Agar N, Hugeron C, et al. Fatigue and traumatic brain injury [article in English, French]. Ann Readapt Med Phys. 2006;49:283-288. Article Summary on PubMed.

    Maskell F, Chiarelli P, Isles R. Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Inj. 2006;20:293-305. Article Summary on PubMed.

    *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Authored by Karen McCulloch, PT, PhD, NCS. Reviewed by the MoveForwardPT.com editorial board.