THE PT GUIDE TO TRAUMATIC BRAIN INJURIES

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.

THE QUICK GUIDE TO CEREBRAL PALSY (CP)

Cerebral Palsy (CP) is a general term used to describe a group of disorders that affect the normal development of movement and posture. CP is caused by an injury to the brain—such as infection, stroke, trauma, or the loss of oxygen to the brain—that occur before, during, or after birth or within the first 2 years of life. The injury to the brain is "nonprogressive," meaning that it does not get worse after the initial injury. However, the day-to-day activities that can be affected by the injury during an individual's childhood can worsen throughout the individual's life.

Difficulties from CP can range from mild to severe. Individuals with CP may have trouble seeing, hearing, feeling touch, thinking, or communicating. They may also experience seizures.

CP affects approximately 3.6 infants per each 1,000 born in the United States. The number of children diagnosed with CP has grown in recent years as a result of the increased survival rates of premature babies and those born with low birth weights. The average life expectancy of adults with CP has increased as well. People with CP can benefit from physical therapy throughout all the stages of their lives.

Physical therapists are experts in helping people with CP improve their physical functions. They can help them stay active, and healthy, and perform day-to-day tasks such as walking, operating a wheelchair, and getting in or out of a wheelchair to and from a bathtub, bed, or car.

What is Cerebral Palsy?

Cerebral palsy is a broad term used to describe the effects on the development of motor skills caused by nonprogressive injuries to the developing brain. Types of CP are given different names based on the type of movement problem and the areas of the body affected:

• Spastic involves increasing spasm of the muscles as the person moves faster.
• Ataxic involves decreased coordination and unsteadiness throughout the body.
• Dyskinetic involves unpredictable changes in muscle tone and movement that create unstable posture.
• Mixed describes a combination of the movement problems noted above (spastic, dyskinetic, or ataxic).
• Quadriplegia describes CP that affects both arms and legs, the neck, and the trunk.
• Diplegia affects either both legs (the most common form of the disorder) or both arms (less common).
• Hemiplegia affects just one side of the body.

Signs and Symptoms

Symptoms of CP differ from one person to the next. Symptoms might appear as early as 2 months of age and are usually seen before a child is 2 years old. Parents usually notice early signs that their child is not able to hold his or her head up as well as other babies, or easily reach, roll, sit, crawl, or walk.

Other symptoms of CP related to movement can include:

• Tight muscles that worsen with stress, illness, and time
• Tight joints that do not bend or stretch all the way, especially in the hands, elbows, hips, knees, or ankles
• Muscle weakness, or a decline in movements that the child had already been performing
• Lack of efficient movement of the legs, arms, trunk, or neck
• Lack of coordination
• "Floppy" muscles, especially in the neck or trunk
• Muscle tremors

Other symptoms of CP can include:

• Difficulty speaking or being understood
• Learning disorders (even though the child has normal intelligence)
• Vision problems
• Hearing problems
• Seizures
• Pain in joints that is often caused by tight muscles or poor posture
• Decreased mouth muscle strength or coordination leading to problems with eating and/or increased drooling
• Constipation
• Difficulty holding urine
• Slower-than-normal growth

How Is It Diagnosed?

Although a child's pediatrician may identify a delay in movement development and refer the child to a physical therapist, physical therapists are often the first medical professionals to identify signs and symptoms of CP. The therapist will:

• Conduct a medical history, asking questions about the parents' concerns, the pregnancy, birth, and the general health of the child
• Perform a thorough evaluation that includes:
  • observing the child in different positions to assess movement patterns
  • hands-on assessment of the child's muscle tone, strength, flexibility, and reflexes
  • determining developmental milestones (how well he or she can sit, stand, or grasp objects)

Your therapist will collaborate with your child’s physician, who may order further tests—such as blood work, magnetic resonance imaging (MRI), or computerized tomography (a CT Scan)—to reach a final diagnosis.

How Can a Physical Therapist Help?

A physical therapist is an important partner in health care and fitness for anyone diagnosed with CP. Therapists help people with CP gain strength and movement to function at their best throughout all the stages of life.

The physical therapist will provide care at different stages in the individual's development, depending on his or her unique needs. Therapy may be provided in your home or at another location such as a community center, school, or a physical therapy outpatient clinic. The physical therapist will work with other health care professionals, such as speech/language pathologists or occupational therapists, to address all the individual's needs as treatment priorities shift.

Physical Therapy in the Early Years: Birth to Age 4

Physical therapists can help caregivers support their child's movement development by providing hands-on training for positioning, movement, feeding, play, and self-calming. Your therapist will also suggest changes at home to encourage movement development, as well as communication, hearing, vision, and play skills. It is important to remember that it is through play that young children learn many skills. Your therapist will develop an individual program of play activities that match your child's specific needs—to improve strength, movement, and function. At this age, physical therapy is generally provided at home, in a daycare center, or in an outpatient clinic.

Physical Therapy in the School Years:  Ages 5 to 12

Physical therapists train caregivers to help the child with CP accomplish functional goals and promote the highest quality of life through all stages of development. The treatment plan and goals will change as your child ages. Pre-school and school bring challenges for your child to navigate new environments each year. At this age, children also experience growth spurts, requiring adjustments to therapy and equipment used to help the child. Care priorities can focus on walking, transfers, personal hygiene, play, socialization, and adaptive equipment needs to meet the social and physical changes that occur during this time period. Physical therapy may be provided in outpatient and/or school settings. School-based therapy focuses on accommodations and modifications to ensure your child has the best possible learning environment.

Physical therapy benefits the adolescent with CP by focusing on prevention of posture problems and joint limitations. This is done by encouraging mobility and fitness, managing muscle and/or joint pain, and recommending braces and other helpful equipment to maintain health and function. The physical therapist will educate parents about self-care, maintaining daily routines, socialization, physical activity, and plans for the child's schooling and future careers.

It is important to note that lifelong health habits are formed at this age—and developing an individual fitness program can improve the person’s health and function for the remainder of his or her life. Children with CP are at a greater risk than the general youth population of not exercising enough and becoming sedentary, which can lead to weight issues and medical complications. These issues progress gradually but can have a significant impact on the quality of life of the child and of the caregivers. Physical therapists are skilled in developing individual exercise programs that use each child's strengths and abilities. For instance, a therapist might recommend adaptive sports such as bowling, swimming, cycling, volleyball, tennis, and basketball to promote physical fitness and socialization with peers.

Physical Therapy in Adulthood: Age 18+

Many individuals with CP live highly functional lives as adults. Many have careers and families. In adulthood, people with CP often focus on pain management, conserving energy, adaptive equipment, and environment modifications to promote independence at work and at home. Physical therapists can help with managing these concerns. Like many adults, individuals with CP have muscle and joint pain in adulthood. Physical therapists can prescribe an exercise routine that enables the individual to stay strong and minimize joint issues.

Physical therapists are skilled in all of these areas, and they partner with people with CP and their caregivers to address their individual goals for realistic, positive outcomes.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients with cerebral palsy. However, you may want to consider:

• A physical therapist who is experienced in treating people with CP
• A physical therapist who focuses on treating infants and children
• A physical therapist who is a board-certified clinical specialist or who has completed training in pediatric or neurologic physical therapy, meaning he or she has advanced knowledge, experience, and skills

You can find physical therapists that 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 cerebral palsy.
• During your first visit with the physical therapist, be prepared to describe the symptoms in as much detail as possible, identify what makes the symptoms worse or better, and discuss your goals.