1. Core concepts and classification
   • Head injury vs traumatic brain injury (TBI)
   • Primary vs secondary brain injury
   • Severity: Glasgow Coma Scale, post-traumatic amnesia, Rancho Los Amigos levels
   • Focal vs diffuse injury, open vs closed injury
2. Site of injury and resulting impairments
   • Frontal, temporal, parietal, occipital, brainstem, cerebellar, diffuse axonal injury
   • Typical motor, cognitive, behavioural, sensory, visual and vestibular findings
3. Acute medical and ICU phase
   • Red flags and precautions
   • Positioning, respiratory care, prevention of secondary complications
   • Early mobilization criteria and monitoring
   • Prevention of contracture, pressure injury, DVT and chest complications
4. Physiotherapy assessment
   • Consciousness, tone, reflexes, ROM, strength, balance, gait, cognition, vision, vestibular symptoms, functional outcome measures
5. Stage-wise physiotherapy procedures
   • Coma/low-response phase
   • Confused-agitated phase
   • Rehabilitation phase
   • Community and vocational return phase
6. Problem-specific rehabilitation
   • Spasticity and weakness
   • Postural control, balance and gait
   • Upper-limb function
   • Dysphagia and respiratory issues as part of team management
   • Vestibular dysfunction, post-concussion symptoms, fatigue, headache and autonomic symptoms
7. Current techniques
   • Task-specific and high-intensity practice
   • Body-weight-supported treadmill training and robotic gait training
   • Functional electrical stimulation
   • Virtual reality and exergaming
   • Tele-rehabilitation and wearable sensors
   • Vestibular and oculomotor rehabilitation
   • Non-invasive brain stimulation, with cautious evidence-based use
8. Outcome measures, prognosis and full recovery
   • Glasgow Outcome Scale-Extended, Functional Independence Measure, Community Integration Questionnaire, balance and gait measures
   • Return to school/work/sport and caregiver education

Stage-wise Physiotherapy Management Plan for Traumatic Brain Injury

Safety screen before every session

• Neurological status is stable: no fall in GCS, new pupillary asymmetry, seizure, or new focal deficit.
• No uncontrolled intracranial pressure, unstable haemodynamics, severe hypoxaemia, active bleeding, or unstable spine/fractures.
• Review craniectomy precautions. Use prescribed helmet for out-of-bed activity if bone flap has not been replaced.
• Check lines, drains, EVD, tracheostomy, ventilator, weight-bearing restrictions, and DVT status.
• Stop and escalate urgently for worsening headache, repeated vomiting, seizure, decreasing consciousness, new weakness, CSF leak, new agitation with neurological decline, or significant vital-sign deterioration.

Stage 1: Acute emergency, ICU, and coma phase

Main physiotherapy goals

1. Prevent secondary respiratory and musculoskeletal complications.
2. Maintain skin integrity, joint range, muscle length and circulation.
3. Provide safe sensory-motor input without increasing physiological stress.
4. Prepare for early mobilization when stable.
5. Educate family and coordinate care with ICU staff.

Assessment

• GCS, pupillary response, sedation level and Rancho Los Amigos level, when applicable.
• Vital signs, oxygen saturation, ventilator parameters, secretions, chest expansion and cough.
• Tone, reflexes, posture, ROM, pain behaviours, oedema, skin condition.
• Presence of contractures, heterotopic ossification, pressure injuries, DVT risk and associated orthopaedic injuries.
• Arousal response to voice, touch, movement and meaningful stimuli.

Physiotherapy procedures

Progression criteria

Stage 2: Early mobilization and emergence from coma

Goals

• Improve tolerance to upright posture.
• Develop head and trunk control.
• Initiate active movement and basic functional mobility.
• Reduce complications of prolonged bed rest.
• Establish a calm, structured environment.

Procedures

1. Graded verticalization
   • Head-up bed progression, tilt table, supported sitting, then supported standing.
   • Monitor BP, heart rate, oxygen saturation, symptoms, fatigue and neurological response.
   • If orthostatic symptoms occur, lower the angle, use compression/medical strategies as prescribed, and progress more slowly.
2. Bed mobility
   • Rolling, bridging, moving from supine to sit, edge-of-bed balance.
   • Use manual facilitation at trunk and pelvis, but encourage active participation rather than doing the movement for the patient.
3. Postural control
   • Supported sitting with midline orientation.
   • Controlled weight shifts in anterior-posterior and lateral directions.
   • Reaching within safe limits and maintaining head alignment.
4. Active motor retraining
   • Active-assisted to active movement in functional patterns.
   • Repetitions of reaching, grasp-release, bridging, sit-to-stand components and stepping preparation.
   • Use short instructions, one command at a time, demonstration and repetition.
5. Management of agitation
   • Low-stimulation environment, consistent routine, reduced noise and crowding.
   • Short therapy sessions with predictable tasks.
   • Avoid arguing, physical confrontation and unnecessary restraints.
   • Identify triggers: pain, fatigue, overstimulation, hunger, bladder/bowel need or communication failure.

Key viva point

Stage 3: Inpatient rehabilitation or post-traumatic amnesia phase

Goals

1. Achieve independence in transfers and basic mobility.
2. Restore walking, balance and endurance.
3. Improve upper-limb use and bilateral integration.
4. Prevent falls.
5. Improve participation while accounting for cognitive deficits.
6. Train caregivers.

Assessment measures

• Rancho Los Amigos Cognitive Functioning Scale.
• Post-traumatic amnesia measures as used locally.
• Modified Ashworth Scale, ROM, strength and selective motor control.
• Berg Balance Scale, Functional Gait Assessment, Timed Up and Go, 10-Metre Walk Test, 6-Minute Walk Test.
• Functional Independence Measure or local functional measure.
• Observation of dual-task interference, neglect, visual field problems, dizziness and fatigue.

Procedures

Session structure for a patient in PTA

1. Orient the patient: name, place, date, therapist and activity.
2. Give one simple task.
3. Demonstrate it.
4. Allow practice with feedback.
5. Include a functional task such as transfers or walking.
6. End before significant fatigue/agitation.
7. Document triggers, performance and safety needs for the next therapist.

Stage 4: Outpatient rehabilitation and community reintegration

Goals

• Return to home, education, work, driving assessment pathway, recreation and social roles.
• Restore physical activity and fitness.
• Prevent falls and secondary deconditioning.
• Develop self-management, pacing and risk-awareness skills.

Physiotherapy programme

1. Aerobic exercise
   • Individualized cycling, treadmill walking, swimming or outdoor walking.
   • Begin at tolerable intensity and progress duration, frequency and intensity according to symptoms, vitals and goals.
   • Include warm-up, cool-down and monitoring for headache, dizziness, fatigue and autonomic symptoms.
2. Advanced gait and balance
   • Uneven terrain, crowds, slopes, curbs, public transport simulations, carrying objects, multitasking and reactive balance.
   • Falls education and home/environmental safety review.
3. Dual-task training
   • Walking while counting, route-finding, conversation, carrying items or responding to visual cues.
   • Start with simple cognitive loading; reduce task difficulty if gait safety deteriorates.
4. Sport/work conditioning
   • Job-specific lifting, prolonged standing, stair climbing, transfers, floor recovery, manual handling, simulated work circuits.
   • Coordinate graded return-to-work with employer, OT, neuropsychology and medical team.
5. Home programme
   • Written, simple and illustrated plan.
   • Include aerobic activity, strengthening, balance, gait/step practice, stretching only where needed, and symptom-management strategy.
   • Train family to supervise only as necessary, avoiding unnecessary dependence.

Stage 5: Mild TBI or concussion pathway

First 24-48 hours

• Relative physical and cognitive rest.
• Education about red flags and expected recovery.
• Sleep, hydration, reduced alcohol/recreational drug exposure, and avoidance of re-injury.
• No return to contact sport, hazardous work or driving until medically cleared.

After initial rest

• Start symptom-limited, graded activity.
• Light walking or stationary cycling may be progressed if symptoms remain mild and settle promptly.
• Treat specific persisting impairments:
  • Vestibular rehabilitation for dizziness/balance dysfunction.
  • Cervical assessment and treatment if neck pain/headache has a musculoskeletal component.
  • Oculomotor/visual referral for convergence, accommodation or visual-motion problems.
  • Graduated aerobic exercise for exertional intolerance.
  • Pacing and cognitive load management for fatigue and reduced concentration.

Stage 6: Long-term follow-up and full recovery

Criteria for discharge from physiotherapy

• Safe independent mobility at the required home/community level.
• Functional gait, transfers, stairs and floor recovery appropriate to the person’s role.
• Individualized balance and endurance goals met.
• Patient and family understand falls prevention, pacing, exercise progression and warning signs.
• Equipment/orthoses reviewed.
• Community exercise, vocational rehabilitation and follow-up referrals in place.

Long-term outcome measures

• Glasgow Outcome Scale-Extended.
• Functional Independence Measure or equivalent.
• 10-Metre Walk Test, 6-Minute Walk Test, Timed Up and Go, Functional Gait Assessment.
• Community Integration Questionnaire.
• Goal Attainment Scaling.
• Return-to-work, school, recreation and physical-activity participation.

Latest techniques and their appropriate role

Viva answer in one line

TBI Physiotherapy Viva Cheat Sheet

1. Definition and classification

• Severity by GCS: Mild 13-15 | Moderate 9-12 | Severe ≤8
• Types: Closed/open; focal/diffuse; primary/secondary injury
• Useful scales: GCS, Rancho Los Amigos Cognitive Functioning Scale, Modified Ashworth Scale, GOS-E, FIM, Berg Balance Scale, TUG, 10-Metre Walk Test.

2. PT assessment

• Medical stability: BP, HR, SpO₂, ICP concerns, seizures, lines/drains, fractures, craniectomy precautions.
• Consciousness and cognition: GCS, orientation, attention, agitation, ability to follow commands.
• Chest status: secretions, cough, chest expansion, ventilatory support.
• Motor: tone, reflexes, ROM, strength, coordination, sensation, pain.
• Function: bed mobility, transfers, sitting/standing balance, gait, stairs, ADL participation.
• Vestibular/visual: dizziness, gaze instability, BPPV, convergence, visual neglect.
• Participation: family support, home barriers, work/sport/school goals.

3. Red flags: stop treatment and inform medical team

• Falling GCS or worsening consciousness
• New unequal pupils, seizure, new focal weakness
• Severe/worsening headache, repeated vomiting
• New CSF leak, significant hypertension/hypotension, desaturation
• Suspected DVT, unstable fracture, uncontrolled ICP
• Post-craniectomy patient without prescribed helmet for out-of-bed activity

4. Stage-wise management

5. Problem-specific treatment

Spasticity and contracture

• Identify triggers: pain, infection, constipation, bladder issues, poorly fitting splints.
• Prolonged positioning, slow ROM, weight-bearing, active task practice.
• Splints, serial casting, AFO if indicated.
• Refer for botulinum toxin or medication when spasticity prevents function, hygiene, positioning, or gait.

Balance and gait

• Progress: sitting balance → standing → weight shift → stepping → turns → obstacles → stairs → uneven terrain.
• Use gait belt, close guarding, harness or assistive device when required.
• Practice meaningful walking tasks with sufficient repetition.

Vestibular/visual symptoms

• Screen for BPPV, gaze instability, motion sensitivity and convergence difficulty.
• Use gaze-stabilization, habituation, balance and walking exercises as tolerated.
• Coordinate with neuro-ophthalmology/optometry and OT. Head injury may produce combined vestibular, visual and cognitive impairments, so vestibular rehabilitation should be part of multidisciplinary management.

Cognition and behaviour during PT

• One command at a time.
• Demonstrate before asking the patient to perform.
• Use repetition, visual cues, consistent routine and short sessions.
• Reduce noise, crowding and unnecessary stimulation.
• Use external memory aids and involve family.

Fatigue and headache

• Pacing: plan activity-rest cycles.
• Increase one variable at a time: duration, intensity, complexity, or environment.
• Do not use a “no pain, no gain” approach for post-concussion symptoms.

6. Current rehabilitation techniques

• Task-specific high-repetition training: transfers, reach, gait and stairs.
• Body-weight-supported treadmill training: when weakness or poor balance limits stepping.
• Functional electrical stimulation: selected muscle activation, especially foot drop.
• Virtual reality/exergaming: supervised balance, reaching and gait practice.
• Robotic gait devices: adjunct for high stepping repetitions, not a replacement for functional overground practice.
• Wearables/tele-rehabilitation: activity monitoring and home-programme progression.
• Graded aerobic exercise: key for deconditioning and selected persistent mild-TBI symptoms.

7. One-line viva answer

8. Evidence update

TBI Physiotherapy: Goals and Interventions

Universal precautions