TRAUMATIC BRAIN

INJURY
SHRI ABIRAMI VASUDEVAN
MPT 1ST YEAR
 CONTENTS
 INTRODUCTION

 MECHANISM OF INJURY

 PATHOPHYSIOLOGY OF INJURY

 CLINICAL FEATURES

 TYPES AND CLASSIFICATION

 SPEECH AFFECTION

 PHYSIOTHERAPY

 Prognosis and Diagnosis

 Assessment

 Management
 INTRODUCTION
Defined as “An alteration in brain function or other evidence of brain pathology caused by external
force.”
Occurs when a sudden trauma causes damage to the brain
The damage ca be due to either :
 A closed head injury – a blow to the head that doesn’t penetrate the skull
 A penetrating head injury – an object piercing the skull and entering brain tissue
The patient with a brain injury is treated across a wide continuum of care, which includes the
intensive care unit (ICU), acute hospital, inpatient rehabilitation center, skilled nursing facility
(subacute rehabilitation), and long-term care facility.
Additional services may include outpatient services, community reintegration programs,
comprehensive day treatment, and residential programs for assisted living and neurobehavioral
services.
 Traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of
the brain. Not all blows or jolts to the head result in a TBI. The severity of such an injury may range from mild—a brief change
in mental status or consciousness— to severe—an extended period of unconsciousness or amnesia after the injury.
 A TBI can result in short- or long-term problems with independent function.
MECHANISM OF TBI
• Mechanisms of Traumatic Brain Injury (TBI)
• TBI occurs when an external force disrupts the normal function of the brain. These forces
can be categorized into several main types:
1.Impact Injuries (Blunt Trauma):
1. These result from a direct blow to the head, or the head striking a surface with sufficient force.
2. Skull fractures: The impact can fracture the skull, potentially leading to bone fragments penetrating
the brain tissue.
3. Closed head injuries (non-penetrating): The skull remains intact, but the brain is damaged due to
the force of the impact.
1. Coup injury: Damage occurs at the site of impact.
2. Contrecoup injury: Damage occurs on the opposite side of the brain from the impact, due to the brain's
movement within the skull.
3. Diffuse axonal injury (DAI): Shearing forces from the impact can damage the brain's white matter, disrupting
communication between brain regions.
4. Contusions: Bruising of the brain tissue.
4. Subdural hematoma, and epidural hematoma are also injuries that can occur from impact.
2. Acceleration/Deceleration Injuries (Inertial Injuries):
•These occur when the head undergoes rapid acceleration or deceleration without direct impact.
•Shaken baby syndrome (abusive head trauma): Violent shaking of an infant can cause severe brain
damage due to the shearing forces on the brain tissue.
•Whiplash type injuries, from car accidents are also in this category.
•This type of injury is also a major cause of DAI.
3. Blast Injuries:
•These are complex injuries caused by the pressure wave from an explosion.
•Primary blast injury: Damage is caused by the direct effect of the blast wave on the brain.
•Secondary blast injury: Damage from shrapnel and other flying debris.
•Tertiary blast injury: Damage from being thrown by the blast.
•Quaternary blast injury: all other blast related injuries.
•These injuries are particularly prevalent in military settings
4. Penetrating Injuries:
• These occur when an object pierces the skull and enters the brain tissue.
• Gunshot wounds: High-velocity projectiles can cause severe and extensive brain
damage.
• Knife or other sharp object injuries.
• Damage is direct, and can cause cellular and vascular damage.
• Injuries to the face and neck can also disrupt blood flow to the brain, leading to
secondary brain damage.
 PATHOPHYSIOLOGY OF TBI
 Injuries can occur through various mechanisms such as acceleration, deceleration, rotational forces, or
penetrating objects, leading to different types of primary and secondary damage to the brain.
 Initiates with primary damage, followed by a cascade of secondary injuries that exacerbate the initial insult.
• A. Primary Damage (Direct Injury)
• Primary damage occurs at the moment of impact or force application. It results from the direct mechanical
disruption of brain tissue and blood vessels.
• 1. Contusions: Bruises or bleeding in the brain caused by impacts, either from an object hitting the head or
the head striking an object. The occipital region is more susceptible to contusions than other areas.
2. Epidural Hematomas: Blood collects between the skull and dura mater, often due to torn meningeal
vessels, commonly associated with skull fractures and can cause loss of consciousness and be fatal if
untreated.
3. Subdural Hematomas: Result from torn veins due to acceleration-deceleration injuries, leading to blood
build-up and symptoms like weakness and lethargy, which can be life-threatening.
4. Diffuse Axonal Injuries: Common in brain trauma, these occur when brain tissues experience differing
forces, leading to axonal damage, coma, or various cognitive difficulties.
5. Penetrating Injuries: Caused by high-velocity objects, these can inflict severe damage on the brain and
tissues beyond the point of impact.
6. Blast Injuries: Result from explosions, leading to rapid pressure changes that can cause injuries, including
tympanic membrane ruptures and potential brain damage from shearing forces.
• B. Secondary Damage (Delayed Injury)
• Secondary damage develops after the initial injury and contributes to further brain dysfunction.
Arise mainly from oxygen deprivation in the brain and may include:
• 1. Increased Intracranial Pressure (ICP): Swelling or hematomas can cause dangerous pressure
changes in the skull leading to brain herniation and poor outcomes.
2. Cerebral Hypoxia or Ischemia: Blocked or damaged blood vessels disrupt oxygen flow to the
brain.
3. Intracranial Hemorrhage: Can lead to tissue hypoxia and increased pressure, causing cell
death due to toxic effects.
4. Electrolyte and Acid-Base Imbalances: This may lead to secondary cell death weeks after the
initial injury.
5. Infections: Can occur due to open wounds or invasive procedures, potentially causing swelling
and cell death.
6. Seizures: Common post-injury, offering additional damage risks due to their high demands for
oxygen and glucose.
 CLINICAL FEATURES
• TBI can manifest in a wide range of clinical features, affecting consciousness, autonomic function,
motor, sensory, cognitive, and behavioral domains.
• 1. Disorders of Consciousness (DOCs)
• DOCs reflect varying degrees of impaired arousal and awareness.
• Coma: A state of unresponsiveness with closed eyes and no reaction to stimuli, lacking sleep-
wake cycles.
• Vegetative State (VS): Wakefulness without awareness, where the patient shows minimal
responses but does not communicate. If lasting over a month, it’s termed Persistent Vegetative
State (PVS).
• Minimally Conscious State (MCS): Evidence of some awareness with inconsistent responses,
indicating potential recovery.
• Posttraumatic Confusion: Patients are awake but confused, with memory issues and slower
responses.
•Autonomic Nervous System (ANS) Changes
•ANS dysfunction is common, especially in moderate to severe TBI.
 Shift from parasympathetic to sympathetic dominance.
 Impaired orthostatic responses.
 Symptoms:
o Heart rate and respiratory rate variability.
o Irritable bowel syndrome.
o Temperature elevations.
o Blood pressure changes.
o Excessive sweating, salivation, tearing, sebum secretion.
o Dilated pupils.
o Vomiting.

• Anxiety, panic disorder, PTSD.

•Motor, Sensory, Perceptual, and Functional Changes
 Motor impairments:
o Paralysis/paresis (monoplegia, hemiplegia).
o Cranial nerve injuries (eye movement, facial paralysis, dysarthria, dysphagia).
o Incoordination, abnormal reflexes, abnormal muscle tone (flaccidity, spasticity, rigidity,
decorticate/decerebrate posturing).
o Loss of selective motor control, poor balance, bowel/bladder incontinence.
 Sensory/perceptual impairments:
o Hypersensitivity to light/noise.
o Hearing/vision loss, visual field changes.
o Numbness, tingling, somatosensory loss.
o Dizziness, vertigo.

• Visuospatial abnormalities, agnosia, apraxia

•Cognitive, Personality, and Behavioral Changes
 Cognitive changes:
o Intellectual dysfunction, memory loss (retrograde, anterograde), shortened attention span.
o Concentration problems, confusion, motivation changes.
o Executive function loss, reduced problem-solving, lack of initiative.
o Poor abstract thinking, working memory deficits.
 Behavioral changes:
o Agitation, aggression, irritability, substance abuse, legal issues.
o Apathy, decreased goal-oriented behavior.
o Depression, anxiety, PTSD, obsessive-compulsive disorder, psychosis.
o Suicidal ideation/attempts.
•Other Complications
 Iatrogenic injuries from medical procedures.
 Infections, contractures, skin breakdown, thrombophlebitis, pulmonary problems, heterotopic
ossification.
 Posttraumatic epilepsy.
 Depression (common and impactful).
 Locked-in syndrome (consciousness intact, but severe motor paralysis).
 Communication disorders (aphasia, dysarthria, etc.).

•Secondary Impairments and Medical Complications:

•High risk due to immobility and other injuries.
•Gastrointestinal, genitourinary, respiratory, cardiovascular, and dermatological problems.
•DVT, heterotopic ossification, pressure ulcers, pneumonia, chronic pain.
 TYPES AND CLASSIFICATION
•TBI severity is categorized primarily based on the Glasgow Coma Scale (GCS), loss of consciousness (LOC), and post-traumatic amnesia
(PTA- The duration of time between injury and the return of continuous memory).
•. The Rancho Los Amigos Levels of Cognitive Functioning (LOCF) scale is used to track cognitive and behavioral recovery.
1. Severity Classification:
 Mild TBI (mTBI):
o GCS: 13-15.
o LOC: 0-30 minutes.
o PTA: 0-1 day.
o Symptoms: Brief or no LOC, headache, dizziness, nausea, vomiting, fatigue, sleep disturbances, and memory problems.
o Often referred to as a concussion.
 Moderate TBI:
o GCS: 9-12.
o LOC: 30 minutes to 24 hours.
o PTA: 1-7 days.
o Symptoms: Prolonged confusion, significant cognitive deficits, and neurological signs on imaging (contusions, hematomas).
 Severe TBI:
o GCS: 3-8.
o LOC: >24 hours (coma).
o PTA: > 7 days.
o Symptoms: Prolonged coma, significant neurological deficits, and obvious structural brain damage on imaging.

2. Glasgow Coma Scale (GCS):

 A standardized neurological scale used to assess level of consciousness.
 Evaluates eye-opening, verbal response, and motor response.

• Scores range from 3 (deep coma) to 15 (fully conscious).

3. Rancho Los Amigos Levels of Cognitive Functioning (LOCF):

 A descriptive scale of cognitive and behavioral recovery after TBI.
 Describes eight levels of recovery:
SPEECH AFFECTION IN HEAD INJURY
• Depending on the area of the brain affected, head injuries can cause difficulties
with language acquisition and speech, as well as cognitive impairments and
personality changes.
• The left hemisphere is more susceptible to language damage than the right,
leading to slower language acquisition.
• Individuals with left-sided damage may have trouble understanding or
expressing language, along with issues like alexia, agraphia, and naming
difficulties.
• Those with mild traumatic brain injury might exhibit unclear speech
(dysarthria) and cognitive issues, such as poor attention and concentration,
problem-solving difficulties, and personality changes.
PHYSIOTHERAPY
• GOALS : Physiotherapy in TBI can help to:
• Prevent or improve the respiratory distress to minimise/ prevent secondary brain damage
• Prevent the skin, soft tissues, joints dysfunction while unconscious or bed ridden
• Reduce muscle spasms, pain and stiffness
• Increase strength
• Retrain normal patterns of movement
• Increase affected arm and leg function
• Initiate the ability & do independent ADLS from roll / move in bed / sit to stand and walk
• Improve balance and walking
• Increase energy levels
• Increase independence and quality of life
• Decrease risk of falls
• Physiotherapy Process:
• Thorough Examination: A comprehensive physiotherapy examination is essential before any intervention to
accurately assess the patient's condition.
• Individualized Interventions: Interventions are tailored to the patient's specific deficits, which may include motor
control impairments, cognitive challenges, behavioral issues, or other problems.
• Interdisciplinary Team Collaboration:
• Enhanced Understanding: Working within an interdisciplinary team allows the physiotherapist to gain a holistic
understanding of the patient's needs.
• Optimal Functional Recovery: Combining the expertise of various professionals leads to more effective
rehabilitation and better patient outcomes.
• Effective Communication: Open communication and a willingness to learn from each other are vital for team
success.
• Shared Knowledge: Physiotherapists contribute their expertise in motor control while remaining open to learning
from other team members.
• Consistent Approach: Collaborative learning ensures a consistent and comprehensive approach to patient care.
• Variable Roles: The prominence of each team member's role may vary depending on the patient's specific deficits
and stage of recovery.
DIAGNOSIS
• Glasgow Coma Scale (GCS):
• The most widely used tool to classify TBI severity.
• Assesses motor, verbal, and eye-opening responses.
• Scores range from 3 to 15:
• Severe: 8 or less.
• Moderate: 9 to 12.
• Mild: 13 to 15.
• It is important to remember that even mild TBI can have long lasting effects.
• Imaging:
• CT scans and MRIs are used to identify brain damage (hematomas, contusions, etc.).
PROGNOSIS
•Factors Associated with Poor Outcomes:
•Low initial GCS scores (especially motor score and pupillary reactivity).
•Older age.
•Lower education level.
•Specific CT scan findings (petechial hemorrhages, subarachnoid bleed,
midline shift, subdural hematoma).
•CRASH Study Calculator:
•A web-based tool to predict 14-day mortality and 6-month unfavorable
outcomes.
•Considers demographic and clinical information.
•Unfavorable outcome: death, vegetative state, severe disability.
• Post-Traumatic Amnesia (PTA):
• The duration of time between injury and the return of continuous memory.
• A strong predictor of long-term functional outcomes.
• Measured using the Galveston Orientation and Amnesia Test (GOAT), revised GOAT, or
Orientation Log (O-Log).
• Shorter PTA duration is associated with better outcomes (higher FIM scores, employment,
independent living).
• PTA is a stronger predictor of discharge FIM scores than GCS scores or time to follow
commands.
 ASSESSMENT
• First step is to review their case paper thoroughly as it
helps to determine their medical stability and any
complications that may arise during the examination
and treatment.
• Since a patient's condition can change, it is essential to
consult with healthcare professionals like the intensivist
or nurse before starting treatment.
• Due to the risk of infections, physiotherapists should
wear protective gear while treating the patient.
• During the initial observation, focus on the patient's
response to stimuli to gather the following information:
Key Points Summarized:
•Case Paper Review:
•Essential first step to understand the patient's medical history, complications, and precautions.
•Crucial for safety and effective treatment planning.
•Medical Stability:
•Patient's condition can be dynamic, requiring constant communication with medical staff (intensivist,
anesthetist, surgeon, nurse).
•Ensures patient safety and prevents exacerbation of injuries.
•Infection Control:
•Strict adherence to infection control protocols (gowns, gloves, masks) due to the risk of various
infections.
•Initial Observation:
•Focus on the patient's response to stimuli to determine:
•Posture and presence of abnormal reflexes.
•Eye status (open/closed).
•Responsiveness to auditory and visual stimuli.
•Vocalization abilities.
•Presence and nature of active movements (purposeful/non-purposeful).
•Reaction to tactile/painful stimuli.
•Vital sign changes in response to stimulation.
•Respiratory State:
•Respiratory distress can arise from:
•Airway obstruction (blood, vomitus, foreign objects, tongue, jaw fractures).
•Depression of the respiratory center in the brainstem.
•Associated chest injuries.
•Neurological Examination:
•Consciousness level assessment is critical.
•Glasgow Coma Scale (GCS) is the standard tool.
•Monitoring for changes in GCS scores, limb movements (lateralizing/focal signs), and pupillary
light reflex.
•Cardiovascular State:
•Pulse and blood pressure monitoring.
•Hypotension can lead to reduced cerebral perfusion and neurological deterioration.
•Attempting assisted sitting at the edge of the bed (if medically cleared) while monitoring vital
signs, muscle tone, and head/trunk control.
•Associated Injuries:
•Head injury patients often have other injuries (chest, abdominal, cervical spine, facial, rib
fractures).
•Prioritize and address urgent injuries.
•Progress Monitoring:
•Comprehensive examination may require multiple sessions.
•Careful monitoring and documentation of progress or regression.
•Severity Assessment:
•The examination helps determine the severity of the head injury.
Important Considerations:
•Multidisciplinary Approach: Effective management of head injury patients requires collaboration
among various healthcare professionals (physicians, nurses, therapists, etc.).
•Individualized Assessment: The assessment should be tailored to the individual patient's specific
condition and needs.
•Dynamic Nature of Recovery: Recovery from head injury is a dynamic process, and ongoing
assessment is essential to guide treatment.
•Early Intervention: Early and appropriate intervention can significantly improve outcomes.
•Safety First: Patient safety is paramount. All assessments and interventions should be performed
with caution and careful monitoring.
PATIENT CARE : PHYSIOTHERAPY
MANAGEMENT
Can be in
two stages

ACUTE SUBACUTE
STAGE STAGE
 ACUTE STAGE
• Primary aim – To stabilize the medical condition while preventing potential secondary complications to
improve recovery outcomes.
 Proactive Management is Paramount:
o Emphasize early intervention to prevent secondary issues like increased intracranial pressure (ICP), respiratory
compromise, and contractures is crucial for better long-term outcomes.
 Treating the Whole Person:
o Reminder to see the unconscious patient beyond just joints and muscles highlights the importance of holistic
care, including sensory stimulation and awareness of their potential for perception.
 Balancing Chest Care and ICP:
o Chest care is essential to avoid hypoxia that may damage the brain.
o Delicate balance should be done between maintaining airway patency and avoiding interventions that could
elevate ICP.
o Caution against head-down tipping and nasal suction in the presence of CSF rhinorrhea are vital safety
o Regular monitoring and appropriate positioning help in this regard.
 Early Mobilization and Tone Management:
o Initiate passive range of motion (PROM) exercises and careful positioning early as it is essential to combat
spasticity and prevent contractures, which can significantly hinder later rehabilitation efforts.
 The Role of Sensory Stimulation:
o Controlled multisensory stimulation helps increase arousal in a coma or vegetative state
o Check for warnings about overstimulation and the need to monitor for adverse reactions.
 Family Education and Support:
o Family involvement is essential for support and education about recovery stages, allowing them to be active in
their loved one's care.
o Education for family members includes managing mobility skills and understanding the patient’s progress and
possible outcomes in recovery.
o Recognize the stress on families regarding patient recovery and connect them with support resources as they
are vital components of holistic patient management.
 Transition to Rehabilitation:
o The mention of long-term rehabilitation centers for slow-to-recover patients and the need for ongoing
education and counseling for both the patient and family as they progress is a realistic and important
consideration.
SUBACUTE STAGE
• Goals and Outcomes:
• Preserve the neuro musculoskeletal system to avoid muscle shortening and contractures.
• Manage abnormal tone and spasticity.
• Offer appropriate sensory stimulation.
• Enhance motor and postural control for improved function.

• Care Settings:
• Patients recovering from coma may receive therapy in hospitals, long-term care homes, or rehabilitation
centers.
• The cognitive and behavioral abilities affect functional levels, thus requiring assessment by a
neuropsychologist.
• • Post-Traumatic Agitation:
• Patients often experience confusion, memory loss, and agitation, leading to aggressive or noncompliant
behaviors.
• Consistent communication and familiar routines are essential for stabilization.

• Therapeutic Approaches:
• Monitoring functional mobility, balance, strength, tonus, sensation, and cognitive aspects is crucial.
• Therapy can include passive movements, proper positioning, and possibly medications to manage
symptoms.
• Physical therapy aims to maintain soft tissue length and prevent pain, especially around sensitive areas like
shoulders.

• Management of Spasticity:
• Treatment approaches involve therapeutic stretching, strengthening exercises, and positioning.
• Methods like cryotherapy, serial casting, and the use of medications target tone abnormalities.
• Both compensatory and restorative strategies are employed based on patient needs.
• • Importance of Upright Positioning:
• Maintaining an upright position supports organ function and enhances alertness.
• Early sitting and mobility training are vital for recovery.
•Specific Neuro-Physiotherapeutic Techniques:
 Developmental sequence training (progressing through postures).
 Proprioceptive Neuromuscular Facilitation (PNF) for initiating mass movements.
 Neuro Developmental Therapy (NDT) focusing on alignment and movement analysis (task-oriented
approach).
 Body Weight Support (BWS) with treadmill for gait training.
 Constraint Induced Movement Therapy (CI/CIMT) and Modified CIMT (MCIMT) to promote affected
upper extremity use.
 Hand Arm Bimanual Intensive Training (HABIT) for bilateral hand use in ADLs.
•Functional Training: Start with simple daily activities. Use visual aids. Expect poor carryover and require
daily recall. Therapist needs to be aware of patient's emotions and behavior. Family and caregiver attitude is
important. Egocentricity and limited attention are common.
PHYSICAL REHABILITATION
• The main goals of physiotherapy during this rehabilitation stage focus on improving function, preventing
complications, and aiding reintegration into daily life.

Key Points
• Encourage active movement that helps with daily activities.
• Prevent secondary deformities and harmful compensatory movements.
• Maximize respiratory function.
• Support social and vocational reintegration.
• Advise family, caregivers, and the care team about patient management.
• Educate family on the patient’s condition and goals.

When a patient shows improvement in consciousness or awareness and is able to breathe independently,
they may be in a rehabilitation center or receiving outpatient therapy.
Based on evaluation, two levels of intervention
 At the impairment level- basic components of performance that are faulty and are
contributing to lack of performance are addressed
 At the disability level- substitutions for loss of function such as bracing, wheelchairs,
functional electrical stimulation, ambulation devices and environmental changes such as
ramps, chairs, bath benches, padding for skin care and reachers provide immediate change
and improve the disability almost immediately
Areas of intervention
 Motivation, cognition and memory
 Working on clients goals helps to establish motivation
 Client goal that seem unrealistic should not to be dismissed as inappropriate
 Giving time out of therapy to experience everyday life at home and work helps them
determine and readjust goals and skills and set a new priority
 Early on techniques to increase attention span includes removing distracting stimuli from
clients environment, including auditory, tactile and visual distractions. Later, can be
reintroduced and maintain attention.
• Muscle tension is increased and decreased by the number of motor units firing and
the rate at which they are fired
• Functional electrical stimulation (FES)for recruitment of more nerves and muscle
fibers and changing type 1 to type 2 appears effective. When applied to the peroneal
nerve for improving dorsiflexion in gait it also improves force production
• Resistance in eccentric and concentric contractions and movement through varying
amplitude effectively strengthen clients with neurological injury
• Functionally oriented tasks such as stepping up and down small and progressing to
larger steps with proximal body weighting changes force production
• Changing lever arm length
• Over hear throwing of ball at different speeds
• Prevent overwork
 Flexibility:
• Joint mobilization, stretching, and dynamic splinting as well as serial casting
• Electrical stimulation is extremely effective in improving flexibility especially in
dorsiflexon, but is contraindicated in unconscious and agitated patients.
 Reaction time:
• It can be done in sitting and standing
• In a pilot study done by Winkle, exercise performed while standing on foam pad
(10 inches thick and medium density) significantly improved reaction time
during weight shifting to a visual stimulus in a group of 8 clients with
neurological deficits
 Endurance and fatigue:
• Use of repetition, increasing duration and intensity can improve endurance
• Upper extremity ergometry can enhance cardiovascular conditioning in clients
who r unable to walk or ride bicycle
 Somatosensory :
• Clients with poor tactile function can perform activities such as manipulation of
objects, first in view and then out of view
• Using tactile discrimination to pick out objects from other objects eg; safety pins
in a bowl of rice
• To isolate the proprioceptive and muscle force system, gloves can be used, light
thin gloves can be changed for heavier thicker gloves
• Rough to smooth to slippery objects
• One hand to two hand tasks for interlimb coordination
• Proprioception at the shoulder and elbow level can be improved by having the
patient practice writing and drawing on paper or blackboard sitting or standing
• For lower limb use targets with and without vision with shoes on and off
 Tone :
• Electrical stimulation
• Strengthening exercise

 Vestibular system :
• Clients with sensory mismatch may require treatment that enhances input from
the two normally functioning systems
• Eg; client who is dizzy when moving the head may need increased somatosensory
input to provide information of the specific body motion
• Clients can perform head movements while supine or sitting with feet and arms
well supported and eyes open progression decrease the additional input till the
client is finally in standing position
• In clients who's vestibular system is no longer functioning enhancing vestibular
and proprioceptive system is important
 Visual system :
• Looking from a near object to a far object or tracking
• Occipital lobe injuries generally result in more perceptual problems

 Balance :
• Moving the extremities, adding weight to the extremities during movement
• Pulling and pushing activities
• Ball activities pushing, catching, throwing, and kicking activities with weighted
and regular ball
 Gait :
• Locomotor training with body weight supported system and treadmill
• If the problem is with balance modify the environment ask the patient to walk in
parallel bar
• Walking on mats

 Disability (functional) level of intervention :

• Mobility and prehension are the most frequent disability losses after brain injury
• Functional devices are provided to substitute functional loss
• Functional task such as transfer, cooking, and self care activities with assistive
devices are taught
REFERENCES
• Physical Rehabilitation - Susan B. O’Sullivan (7th edition)
• Umphred’s Neurological Rehabilitation – Rolando T Lazaro, Sandra G Reina –
Geura (7th edition)
• NeuroRehabilitation A Multidisciplinary Approach – Dr. VC Jacob, Alok Sharma
(2012)