Rehabilitation post brain injury occurs in a variety of setting with multiple team members. Regardless of timing, goal-directed care is important. Each individual sustaining brain injury presents with unique mobility and cognitive challenges; therefore, no single intervention is recommended for everyone. Periodic reevaluation of functional status is required to align goals and the plan of care to maximize the patient’s return to independence. It is critical to incorporate the entire interdisciplinary team, including the patient and family, in developing the rehabilitation plan.
The entire rehabilitation team should work toward common patient-centered goals in a transdisciplinary approach that benefits the patient by providing the most comprehensive approach to rehabilitation. Open communication assists with identifying possible complications such as normal pressure hydrocephalous (NPH), seizures, infections, and neuroendocrine dysfunction.
Individuals post brain injury recover at different rates and to different extents. Rehabilitation interventions should include efforts to prevent sequalae that may impair future function and recovery, such as periarticular calcification resulting from prolonged immobilization. In survivors of traumatic brain injury (TBI), time of posttraumatic amnesia—along with several other factors time factors, such as inflammation, timing of neurotoxic events, and neurorestorative events—may affect recovery timelines. , For survivors of acquired/nontraumatic brain injuries (such as stroke and anoxic injuries), initial severity of motor deficits followed by early return of motor function tend to be the best predictor of functional return. In this chapter, we explore current trends and highlight key concepts in rehabilitation and therapeutic exercises post brain injury.
Motor control
Literature based on animal studies reveals timing, intensity, and frequency of rehabilitation post brain injury are important factors to consider with recovery. Rehabilitation can both promote and inhibit neural plasticity based on timing, frequency, and intensity. Animal model findings suggest that the window of opportunity to start symptom-specific, skilled rehabilitative training is early (within days) but not immediately (within hours). , There is a dearth of human studies on this subject; therefore, best practice continues to evolve, but current literature supports early intervention to promote mobility and decrease sequelae of immobility.
Longitudinal studies suggest that recovery from hemiparesis proceeds through a series of fairly stereotypical stages over the first 6 months poststroke, irrespective of the kind of therapeutic intervention. Biernaskie and colleagues found that rehabilitative training was more effective in improving functional outcomes when initiated at 5 days rather than 30 days after stroke.
Therapeutic interventions to promote motor recovery are derived from different therapeutic approaches, such as exercise and functional-based activities, proprioceptive neuromuscular facilitation (PNF), and neurodevelopmental therapy (NDT). The Brunnstrom approach is another philosophy that breaks down motor recovery into six phases: flaccidity, spasticity and synergies emerge, increased spasticity, decreased spasticity and synergies, able to move freely through complex movement combinations, spasticity is no longer apparent, and normal motor function returns. Based on current literature, no one approach is best, and often the mixed approach is needed to maximize function. ,
Therapeutic concepts such as task-oriented training, progressive practice to increase movement speed and precision, compensatory adaptations, strengthening, and cardiovascular fitness are ingrained in the rehabilitation goals for patients with most neurological diseases. The frequency, timing, intensity, and environmental conditions of practice are critical to consider when developing plans of care for patients with brain injuries. Following TBI, use of the Rancho Los Amigo Scale-Revised (RLAS-R) can guide the progression of therapeutic interventions according to phases of recovery.
For example, in cognitive level III, the family should be speaking with the patient in a normal tone and performing passive range of motion (PROM). In contrast, at cognitive level VI RLAS-R, the family and providers shift focus toward patient-initiated movements with assistance to complete task as needed. Sessions may include route finding, task-specific training, and higher-level balance retraining. The ability to layer physical, cognitive, and behavioral expectations changes as a person progresses through the stages of recovery, and the team can adapt rehabilitation strategies to maximize recovery.
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Consider frequency, intensity, and timing when prescribing activities.
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A mixed approach to therapeutic intervention offers the best recovery. Knowing how and when to layer on cognitive and behavioral expectations with physical activity can help the team formulate the strategy to maximize recovery.
Mobility and range of motion
Mobility is important to recovery no matter the severity or type of brain injury. Key considerations are medical stability, impaired balance, range of motion (ROM), muscle weakness, and premorbid motor skills. Providing early intervention can reduce complications such as contractures, pressure sores, heterotrophic ossification, and deconditioning. Inclusion of therapy services early after injury can assist with initiating family education on PROM and positioning and promote multiple benefits, including early participation in therapeutic exercise. Functional mobility tasks such as transfers and standing can double as therapeutic exercise in the early stages of recovery. Therapy can assist with maintaining functional strength and improving cardiovascular function, which may decrease consequences of immobility.
Spasticity and tone changes can occur over time after a brain insult and must be monitored and used to adjust the treatment plan accordingly. A limb that at one time was flaccid may progress to hypertonicity, and incorporating therapeutic exercise as tone changes throughout recovery is assessment dependent.
Mobility changes throughout recovery. It is imperative to assess and update treatment plans periodically to align with the patient’s abilities.
Strength and endurance
Strength and endurance training is vital to the prevention of secondary complications and promotion of a healthy lifestyle. Most physical therapy interventions focus on physical impairments that are a direct result of the injury, such as gait kinematics, spasticity, flexibility, muscle performance, balance, and functional skills. However, not all brain injuries result in primary physical impairments. Adapting strategies to accommodate other impairments, including cognitive, behavioral, and motivational deficits, is important to focus on and plays a key role in strength and endurance training. Physical capacity and endurance are key components to focus on during recovery for not only the health benefits but also the reduction of secondary complications. ,
The promotion of a healthy lifestyle is critical to reduce secondary complications. Addressing cognitive, behavioral, and motivational factors that may inhibit strength and endurance training should be considered.
Exercise and activity
Based on physical activity guidelines recommended by the US Department of Health and Human Services, adults should participate in at least 150 to 300 minutes a week of moderate-intensity or 75 to 150 minutes a week of vigorous-intensity aerobic physical activity—or an equivalent combination of moderate- and vigorous-intensity aerobic activity, preferably spread throughout the week. Adults with disability and chronic conditions should also strive for the 150 minutes of moderate to vigorous activity per week, incorporating an exercise plan that accommodates their abilities.
Prescribing exercise to meet the recommend intensity, frequency, and duration is important in survivor’s overall health. Educating patients on exercise and its benefits is an important role of the rehabilitation team. Monitoring progression using the modified Borg scale—reported as rate of perceived exertion (RPE)—is a simple way to monitor exercise intensity. Combining aerobic, muscle strengthening, bone strength, flexibility, and balance activities is needed to maximize the health benefits.
Rehabilitation specialists have multiple therapeutic modalities available to achieve the recommended guidelines. The timing and progression of activities are important to overall recovery. Access to therapeutic exercises, technology (for example, exoskeletons, functional e-stim, virtual reality equipment), and knowledge in promoting mobility despite impairments allows patients to remain active. Providers need to set the expectation that exercise is possible after brain injury and to assist survivors of a brain injury to identify a mode of exercise that accommodates their level of function.
Adults with disability and chronic conditions should strive for the 150 minutes of moderate to vigorous activity per week. Prescribing an exercise plan that accommodates their abilities and incorporates intensity, duration, and frequency is most beneficial.
Mobility AIDS, orthoses, casting, and splinting
In many cases, mobility aids may enhance mobility after brain injury. More options become available as technology advances; understanding the device function and the needs of your patient is vital to prescribe the appropriate device ( Table 43.1 ). Early orthosis use may improve kinematics but must be monitored to maximize functional mobility outcomes and prevent complications. Frequent evaluation of impact and benefit of technology is required in the absence of technology gold standards after brain injury.
| Types of Aids | Examples |
|---|---|
| Aids to support independent living | Kitchen adaptations, bathroom adaptations, ramps, stairlifts, handrails, lift chairs |
| Seating and positioning aids | Wheelchair: power base or manual base |
| Transfer aids | Hoyer lift, sliding board, gait belts |
| Mobility aids | Cane, crutches, walker, rollator, scooter |
| Orthotics | Spinal, ankle-foot orthotics, knee-ankle-foot orthotic, dynamic splints, functional e-stim |
| Rehabilitation tools | Exoskeletons, body weight support devices, robotics, standing frames |
| Casting and splitting | Dynamic splints, serial casting |
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