•   Sensory impairments may include deficits in light touch, temperature sensation, deep pressure, pain sensation, proprioception, and vibratory sensation. Testing may be limited by communication and cognitive impairments.

•   Decreased range of motion (ROM) or contracture may develop secondary to decreased mobility, suboptimal positioning, and spasticity. Evaluation includes the use of goniometry and visual observation.

•   Motor control impairments present as weakness, decreased coordination, impaired initiation, motor restlessness, and movement disorders. Evaluation includes use of manual muscle testing and observation of antigravity movement, assessment of heel to shin and rapid alternating movements, and use of standardized tests such as those described by the American Physical Therapy Association’s (APTA) TBI EDGE group [6].

•   Changes in tone may present in a hemiparetic pattern, tetraparetic pattern, or may be localized. It may manifest as spasticity, spasms, or localized dystonias. Objective assessment of spasticity uses the Modified Ashworth Scale or the Tardieu Scale [7].

•   Balance impairments will be present in 30% to 60% of patients with TBI and require specific assessment by the PT [2,8]. Highly reliable and valid assessments have been identified by the APTA TBI EDGE group and should be selected as appropriate to the patient’s abilities [6]. When the exam is limited by cognitive deficits, observation, and description using assist levels should be utilized.

•   Up to 80% of TBI patients will present with some variety of vestibular pathology, including benign paroxysmal positional vertigo (BPPV), peripheral hypofunction, and central dysfunction. [9,10]. Symptoms may include dizziness, vertigo, nausea, disequilibrium, imbalance, visual disturbances, headache, and hearing loss. Assessments include use of positional testing, examination of oculomotor control, and the vestibular-ocular reflex, and are best completed with use of Frenzel lenses or video goggles. Temporal bone fractures may cause damage to cranial nerve VIII and indicate the need for examination of vestibular function. The examination will often be incomplete due to physical and cognitive deficits, limiting it to include observation of postural and oculomotor control. Examination should include specific outcome measures as appropriate to the patient’s cognitive and physical abilities, including the Dynamic Gait Index, Functional Gait Assessment, or Clinical Test of Sensory Integration and Balance (Foam and Dome) [9]. Location of the lesion, determined through clinical testing, will dictate appropriate treatment.

•   Fractures and soft tissue injuries are often comorbid diagnoses that the therapist must consider and that may impact treatment.

•   Functional mobility is often the area of greatest focus with TBI patients.

        Bed mobility assessment should include rolling and supine to-and-from sit transitions. Rolling assessment will provide the PT with information on possible vestibular deficits, trunk ROM, and strength. Supine to-and-from sit transitions may provide information on trunk ROM and strength, as well as general upper and lower extremity ROM and strength.

        Transfer assessment, including assist level, may incorporate use of mechanical lifts, squat pivot transfer, lateral or sliding board transfers, and stand pivot or stand step transfers. Choosing the appropriate transfer requires the clinical assessment, observation, and judgment of the PT. This assessment provides the therapist with further insight into strength, ROM, coordination, spasticity, and balance skills.

        Ambulation assessment is not always appropriate with moderate to severe TBI patients. The PT’s clinical judgment will dictate whether to proceed with this activity. Gait assessment is typically initiated in a highly supported environment, such as the parallel bars or a body weight supported ambulation system, and will provide further observational evidence of strength, ROM, balance, spasticity, and coordination.

•   Sensory stimulation within the context of physical therapy will include weight bearing activities in sitting and standing and change of position—including sidelying, prone, and upright. Equipment such as a tilt table and standing frame will be beneficial for the patient with significant mobility restrictions or disordered state of consciousness.

•   ROM and stretching programs have been considered a standard of care in physical therapy; however, current evidence does not support long-term changes or improvements in ROM secondary to these interventions [12]. Clinicians must carefully consider the amount of treatment time that is spent in these interventions based on the lack of evidence for effectiveness, and they should include education for families and caregivers to perform these skills outside of therapy. Static or dynamic orthoses are available commercially or custom devices may be fabricated by an orthotist. Prescription of appropriate orthoses may facilitate positioning, prevent skin breakdown, and be used to address ROM goals although evidence is sparse [12,13].

•   Spasticity is often a limiting factor for TBI patients, impacting positioning in bed and wheelchairs, setup and positioning for transfers, and limiting motor control. When left untreated, spasticity leads to muscle and soft tissue shortening and eventual contractures [14]. Physical therapy management will include stretching and ROM programs, strengthening of the antagonist muscles, orthoses, and serial casting. An effective program to treat spasticity requires the PT to work closely with the medical team for comprehensive management.

        Evidence is mixed on the effect of serial casting on reducing spasticity; however, there is good evidence to support ROM gains from serial casting. Average gains in the ankle ranged from 10° to 26°, and at the knee improvements of 15° to 27° were demonstrated [15].

        PTs should consider how ROM gains will be maintained and determine a strategy for ongoing spasticity management when casting is discontinued. The functional goals that may be achieved following casting should be weighed against the risks inherent to casting when initiating a serial casting protocol.

•   Strengthening programs are important to allow progression of functional mobility skills. TBI patients are often not able to participate in traditionally structured progressive resistive strengthening programs. In these instances, patients can benefit from strengthening within the context of functional mobility. When patients present with less than antigravity strength, using slings to suspend the extremity or friction-free surfaces can allow the patient to more effectively activate very weak muscles.

•   Balance training will likely start in sitting, initially working on static sitting balance and head control, progressing as appropriate to dynamic standing balance. Therapists may include use of compliant and mobile surfaces, altered base of support, altered sensory inputs, distracting environments, and dual tasking to progress balance training dependent on patient-specific impairments. Mirrors, vertical lines, and external supports may be used to orient patients to midline. Limited high-quality studies have addressed balance training in TBI populations and have utilized varying interventions; however, it appears that a wide range of approaches including the use of virtual reality training may facilitate improvements in balance [2,8,16].

•   Vestibular rehabilitation programs will incorporate the use of adaptation exercises including gaze stabilization, habituation exercises, corrective maneuvers for BPPV, compensatory training, and progressing functional mobility as appropriate [9]. TBI patients will often require modifications to the vestibular rehabilitation program, including hand-over-hand assist for cervical rotation when performing gaze stabilization exercises, using modified positioning for the canalith repositioning maneuver, or simply utilizing position changes and mobility training for habituation for patients who are unable to participate in a formalized treatment program.

        Patients with central dysfunction can make improvements with vestibular rehabilitation, although full resolution of symptoms and balance impairments may not be achieved [17].

        As many as 20% of cases of BPPV are due to trauma, and traumatic BPPV required significantly more repositioning maneuvers compared to idiopathic BPPV for resolution [18,19].

•   Functional mobility training should include bed mobility, transfers, and sitting, and progress to standing and ambulation as appropriate. Current literature supports the use of task-specific training for improved skill acquisition: A recent systematic review of the literature found high-level evidence to support the use of task-oriented and repetitive training [11]. This would support training patients by performing specific functional mobility skills multiple times sequentially during a session. However, this may be challenging for TBI populations with poor attention or problems with agitation; therefore, therapists may need to consider the use of varied practice throughout their sessions.

        Recovery of ambulation is frequently a high priority for patients and family members. Traditional gait training is often initiated in the parallel bars and progresses to an assistive device such as a walker or cane as patients improve their balance and strength. Body weight–supported treadmill training (BWSTT) has been shown to be highly effective in stroke populations, but research with TBI patients has not demonstrated significantly greater improvements due to treadmill training when compared to overground gait training [20–22]. However, in clinical practice, BWSTT may be useful with TBI patients who are not following commands or who may have poor attention, for initiation for ambulation, for those with impaired safety awareness, poor balance, or coordination, or for those who require a significant amount of physical assistance. BWSTT can be a safer, more successful, and earlier intervention to initiate gait training and increase intensity and volume of training. A variety of body weight supported gait training systems are available commercially to assist overground or treadmill-based training.

•   Orthoses are used by many clinicians to improve ambulation, although others avoid it because of concerns that an orthosis may disrupt normal gait kinematics and lead to disuse atrophy of the muscles that control the joint [23].

        A systematic review of the literature on the use of ankle foot orthoses (AFO) to improve ambulation concluded that there is good evidence that the AFO increased walking speed, increased stride length, increased cadence, and decreased energy expenditure during ambulation. Conflicting evidence was found on increasing or decreasing muscle activation of the anterior tibialis and gastrocnemius/soleus complex [5,23].

        The use of AFOs is often beneficial to facilitate early ambulation in brain injury patients; however, timing/appropriateness of prescription must be based on clinical judgment.

•   Specialized seating and positioning is often required to prevent skin breakdown, decrease risk of secondary complications, maintain patient safety, optimize positioning, and allow patient mobility when ambulation is not an appropriate goal. Power wheelchair mobility should be considered for TBI patients with very low-level mobility but minimal cognitive deficits.