Traumatic Brain Injury: Therapy, Rehabilitation, and Recovery

Of the 1.4 million people in the US each year who sustain a Traumatic Brain Injury (TBI), many need some type of therapy to reach full recovery. During the acute stage - shortly after the injury - moderately to severely injured patients begin to receive therapy as soon as possible, often in the intensive care unit of the hospital. Once they are able to leave intensive care, rehabilitation continues at the hospital or a rehabilitation center.

Patients with TBI might have a number of different problems. Physically, they might be unable to walk, get in and out of bed, get dressed, bathe, use the bathroom, and perform basic self-care. Their consciousness is often diminished as well, so they might have problems with communication and thought processes.

Therapy Begins with Assessment
Mark Klingbeil, MD, Medical College of Wisconsin Assistant Professor of Physical Medicine and Rehabilitation, serves as Medical Director of Neurorehabilitation Medicine at Froedtert Hospital.

He says that therapy for TBI patients is begun as soon as they are medically stable enough to tolerate it, usually in the intensive care unit. "Tightness and spasticity develops in the muscles rather quickly," says Dr. Klingbeil, "and patients need to be kept limber or they can have compromised movement when they do recover."

Within 24 to 48 hours of any severe brain injury, the patient's rehabilitation team is assembled, consisting of a speech therapist, a physical therapist, an occupational therapist, and a neurorehabilitation physician.

"Initially, we provide passive measures several times a day, such as range-of-motion exercises for the arms and legs to stretch out the muscles, and splinting of tight joints to keep them from developing contractures or tightness in the muscles," says Dr. Klingbeil. "As patients become more alert and can interact with their environment, we start to incorporate their own movements into the therapies. We build on things they can do, and help them incorporate the movement into self-care activities like bathing and dressing."

Once patients are alert, the speech therapist begins to work with them. "The speech therapist first assesses whether patients can swallow properly. If the swallowing study shows that they can't swallow well, they might need a feeding tube for a time," says Dr. Klingbeil.

The speech therapist also works on establishing communication. "Typically the kinds of problems we see from a cognitive standpoint include impaired short-term memory, attention span, and problem-solving abilities, as well as poor insight, judgment, and safety awareness," Dr. Klingbeil says. "The speech therapist works to help patients improve all those skills."

The physical therapist works primarily on movement of the lower extremities, such as transfers to and from a bed or wheelchair, transfers from sitting to standing, taking first steps, and helping the patient walk. "This might require the use of a walker initially," says Dr. Klingbeil, "or it might require splinting of an impaired extremity. For instance, if a patient's foot is dropping because of muscle weakness or paralysis, it will impede the patient's ability to walk."

The occupational therapist works mainly on patients' use of their arms. This helps them regain the ability to perform functional activities such as bathing and dressing, and fine motor activities with the hands.

Patients Continually Monitored
As therapists continue their work in the intensive care unit, the patients are monitored for pressure within the head. "If the pressure inside the head is too great, the therapy stops so medical recovery is not impeded," says Dr. Klingbeil. "If there is an acceptable intercranial pressure, therapy will continue."

Agitation is a typical problem at this stage, and patients are monitored for signs such as confusion, disorientation, and lack of understanding. "They might not understand what's going on around them, where they are, or why they're in this situation. The agitation is a natural response to this lack of control and understanding," says Dr. Klingbeil. "There are various measures, both medical and environmental, that we use to minimize problems with agitation that might cause harm to the patient."

"Medication can be used to calm patients, or to keep them less stimulated, but we prefer to try the environmental interventions prior to medication to sedate them," says Dr. Klingbeil. "Medication can be counterproductive if we're trying to get patients to be aroused and interacting with their environment." Putting patients in a quiet environment without noise or distractions will often help calm agitation.

Once patients are stable enough to be transferred out of the intensive care unit, ongoing rehabilitation needs are assessed. "If they're at a point where they're medically stable enough to handle therapy, the emphasis becomes getting them ready to be discharged from the hospital," says Dr. Klingbeil. "If there are cognitive problems, medication might be added to the therapy, to increase their attention span or level of arousal, so they can participate in therapies."

Depending upon the injury, patients might then be transferred to another unit of the hospital or an independent rehabilitation center.

Long-Term Consequences of TBI
Physical consequences are obvious. "If you damage the portion of the brain that controls movement, vision, hearing, or any of the other senses," says Dr. Klingbeil, "the body is not able to interact with that modality in the ways it did prior to injury." For instance, if there is weakness or tightness in a leg, the patient will need therapy to regain movement.

Cognitive consequences are often more of a long-standing problem. "Patients can get around with a brace, cane, or walker, but they must also be able to think clearly in order to function well in their environment and do the things they did prior to injury," says Dr. Klingbeil.

"Problems like short-term memory, problem-solving abilities, processing speed, insight, judgment, and control of emotions are primarily the responsibility of the frontal and temporal lobes," says Dr. Klingbeil.

The frontal lobe, the part of the brain behind the forehead, and the temporal lobe, beneath and behind the frontal lobe, are the most commonly injured areas of the head. Because of the shape and structure of the skull, even if there's a blow to the back of the head, the frontal and temporal lobes take the brunt of the impact.

Dr. Klingbeil says, "We try to find ways that patients can get around memory problems, ways they can understand their quick temper and low frustration tolerance. We show them how to remove themselves from situations where they might speak in a manner that would cause them to lose their jobs or have problems with friends or family."

The brain's frontal lobes are also a factor in the psychological consequences of TBI. "We work on the regulation of moods and other psychological issues," says Dr. Klingbeil. "Depression is commonly associated with head trauma, so psychotherapy and medication are often a part of the recovery process."

Continuing Rehabilitation Necessary
Dr. Klingbeil says that patients need continuing rehabilitation in all phases of recovery. "If rehabilitation is interrupted at any point in the process from intensive care unit to outpatient, patients can regress," he says. "If, for example, a patient has tightness in a muscle and needs therapy to range it several times a day, or needs to be gotten up to walk and do exercises, and those services are not available, this can lead to problems that might not be reversible."

While some patients with Traumatic Brain Injury go on to make a full recovery, more than five million Americans currently live with disabilities due to TBI. Direct medical costs of TBI, and indirect costs such as lost productivity, totaled an estimated $60 billion in the US in 2000.

"Traumatic Brain Injury is more common than most people think," says Dr. Klingbeil, "and many of these injuries and deaths are preventable."

P. J. Early
HealthLink Contributing Writer

This article includes information from the National Institutes of Health and the US Centers for Disease Control and Prevention (CDC).

For more information on this topic, see first part of this interview, Traumatic Brain Injury, Part I: Diagnosis and Treatment.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.