NPTE - TBIs

Types of TBI

Open (penetrating)

Closed (non-penetrating)

Coup - Contrecoup

Diffuse Axonal Injury

Concussion

Open TBI

Skull fx/object enters brain

Closed TBI

Brain injured within skull (MVA, fall)

Coup-Contrecoup TBI

Injury at site of impact and opposite side

Diffuse Axonal Injury

Widespread axonal damage

Often due to acceleration-deceleration

Concussion

Mild TBI

temporary cognitive sxs

TBI Severity classifiation

Mild

Mod

Severe

Mild TBI

GCS 13-15

LOC <30mins

PTA <24hrs

Mod TBI

GCS 9-12

LOC 30min-24hrs

PTA 1-7d

Severe TBI

GCS <8

LOC >24hrs

PTA >7d

GCS

3-15

Eye, motor, verbal

Rancho Los Amigos Level I

No response

Unresponsive

Rancho Los Amigos Level II

Generalized response

non-purposeful, inconsistent

Rancho Los Amigos Level III

Localized response

Responds to stimuli; may follow simple commands

Rancho Los Amigos Level IV

Confused-Agitated

Bizarre behavior, limited attn

Rancho Los Amigos Level V

Confused-Inappropriate

Random responses, lacks goal-directed behavior

Rancho Los Amigos Level VI

Confused-Appropriate

Some goal-directed behavior, needs cueing

Rancho Los Amigos Level VII

Automatic-Appropriate

Routine OK, judgement impaired

Rancho Los Amigos Level VIII

Purposeful-Appropriate

Aware of environment

may need MinA

Common impairments post-TBI

Cognitive deficits (attention, memory, executive function)

Behavioral changes (aggression, impulsivity, apathy)

Motor impairments (paresis, abnormal tone/posture)

Sensory deficits (vision, hearing, proprioception)

Dysphagia and communication issues

Impaired balance and gait

PT Interventions in Acute Stage

Prevent complications, promote arousal

PROM, sensory stimulation, bed mobility

PT interventions in subacute stage

Improve function, begin mobility

Transfers, postural control, and balance training

PT interventions in chronic stage

Maximize I, community re-entry

Task-specific training, cognitive strategies

PT Focus Areas

Neuroplasticity principles: repetition, specificity, salience

Dual-task training for higher level ftn

Visual-vestibular rehab if dizziness/balance issues

Behavioral management strategies: structure, cueing, reward systems

TBI Outcome measures

GCS: initial severity of brain injury

Rancho los amigos scale: cognitive ftn monitoring

Disability rating scale: global disability from coma —> community

FIM: ADL and ftnal assessment

Community Balance and Mobility Scale: high-level balance post-TBI

TBI complications and red flags

Increased ICP: monitor for HA, nausea, LOC changes

Seizures: know seizure precautions/emergency response

Heterotopic Ossification (HO): watch for swelling, p!, decreased ROM

Agitation/impulsivity: use structured environments, limit distractions

Decorticate posture: lesion above BS

Decerebrate posture: lesion @/below BS

Board tips Pt 1

Rancho IV = agitated/confused —> short, simple sessions in calm setting

Use external memory aides for cognitive deficits (notebooks, calendars)

Expect a delayed carryover in motor learning

Vestibular rehab is effective post-concussion

Avoid overstimulating environments in early recovery

Monitor vitals closely in acute care - ICP, HR, BP may fluctuate

Treat Heterotopic Ossification conservatively - avoid overstretching if suspected

PT Strategies for Rancho Levels I-III

Speak slowly, calmly, and clearly

Use short, simple commands

Focus on sensory stimulation (touch, smell, sound)

PROM to prevent contractures

Be consistent and document subtle responses

PT Strategies for Rancho Level IV

Limit Language - use short commands

Use (+) reinforcement; avoid arguing

Non-task-specific movement is best (walking, gross motor)

Use familiar activities (ball toss, simple games)

Don’t challenge memory - they won’t retain it

Prioritize safety - they may be impulsive/combative

PT Strategies for Rancho Level V

Use simple, structured instructions

Provide frequent orientation (time, place, name)

Begin structured tasks (basic transfers, reaching)

Use repetition and cues

Expect some carryover, but limited memory

PT Strategies for Rancho Level VI

Give simple explanations and feedback

Provide external memory aids (written HEP, whiteboard)

Begin goal-directed tasks (gait training, ADLs)

Use structured progression (blocked —> random practice)

May begin responding to emotional tone and peer interactions

PT Strategies for Rancho Level VII

Begin using normal social interaction

Reinforce appropriate behavior

Increase community-based tasks (stairs, uneven surfaces, obstacles)

Promote dual-task training (walk while talking)

Needs supervision for judgment and safety

PT Strategies for Rancho Level VIII

Use normal conversation

Provide constructive feedback

Focus on returning to full I

Emphasize high-level balance, endurance, and problem-solving

Still may have mild cognitive/emotional limitations under stress/in complex settings

Board Tips Pt 2

Rancho IV = safety risk: structure, redirection, limit stimulation

Rancho V-VI = improving memory and attn: use repetition, simple tasks

Rancho VII-VIII = working on I: focus on judgement, planning, and real-world ftn