Traumatic brain injury (tbi) affects people indiscriminately, with an increasing incidence over the past decade. According to the Centers for Disease Control (CDC), the combined rates of TBI-related deaths, emergency department (ED) visits, and hospitalizations have increased from 521 per 100,000 in 2001 to 823 per 100,000 in 2010.¹ Physiatrists with expertise in brain injury medicine often manage patients with brain injuries in various medical settings. The purpose of this assessment is multifold but in essence aims to maximize function, provide additional insight into active medical and neurologic issues, and then assist with rehabilitation planning for the postacute setting. There are three main clinical settings in which assessment for TBI occurs by rehabilitation professionals: in the acute care hospital, in inpatient rehabilitation facilities, on the sideline of athletic events, and in the ambulatory setting. This chapter will describe aspects of the physical examination that are common to all three and highlight unique features that differ by venue.

When providing a physiatry consultation in an acute care setting, a thorough chart review and fact-finding mission is essential to piece together coherent recommendations. Basic information such as preexisting medical conditions, date of injury, initial Glasgow Coma Scale (GCS) score, dates and nature of any neurosurgical interventions, seizure history, and medical complexities are among the first things to be identified. From there, a current and recent medication list can be scrutinized for centrally acting agents that may impair cognition, arousal, or behavior. Analysis of recent imaging allows correlation of brain injury location with aspects of behavior, cognition, and communication issues.

It is also important to learn the nature of a patient’s current sleep-wake cycle, elimination schedule, and behavioral patterns. These issues are often neglected by the primary team, who may be more focused on managing the most active neurologic or medical problems. When assessing a patient, it is important to determine how such patterns may affect a patient’s future rehabilitation course or even their candidacy for acceptance into a rehabilitation program. For example, a patient whose sleep-wake cycle is inverted at the time of transition to an inpatient rehabilitation setting may sleep during several days of valuable therapy and cause unnecessary disruption on the unit overnight. Additionally, daily assessments in such patients may be more challenging and inaccurate. This common scenario often leads to anxiety on the part of the patient’s family and can negatively affect the relationship with health care providers.

At the time of discharge from the acute care setting, it is sometimes the case that a plan for rehabilitation has not yet been formulated, or must be formulated quickly to correspond with pressures of increasingly regulated hospital-length-of-stay guidelines. From the time of initial physiatric consultation, careful attention to unique patient characteristics and psychosocial restraints should be factored into all planning. The goal of the physiatric assessment in the acute care setting is to ensure that each patient gets the rehabilitation they require in the most appropriate setting. Often it is not possible to determine what the most appropriate rehabilitation environment will be from the initial assessment. Because of rapid changes in functional and medical status, patients with brain injury may require frequent assessments to accurately determine the discharge plan.

The environment of care in an acute care setting may negatively affect functional recovery from a brain injury. A physiatrist is well positioned to suggest strategic environmental modifications, which may improve the sleep-wake cycle, general safety, and sense of emotional well-being. Modifying the patient surroundings can also help to reduce triggers for agitated behavior. Following implementation of these environmental and behavioral strategies, it may be appropriate for a consulting physiatrist to suggest use of neuropharmacology to target various deficits in behavior or arousal, or to address changes in mood or behavior resulting from the brain injury.

Establishing contact with the family members of a patient should be considered part of an initial patient assessment. In addition, patient and family education should begin as soon after the injury as possible to both improve outcomes and align expectations.

The physical exam performed by a physiatrist can provide very valuable information and insight to help guide care of the patient with acute brain injury. The most notable example of this is in the setting of patients with a disorder of consciousness. The differentiation of a patient in the minimally conscious state from the vegetative state is often conducted by a physiatrist in collaboration with a rehabilitation therapist trained in the administration of the revised JFK-Coma Recovery Scale (CRS) (see Chapter 21 for details). Serial administration of the CRS-Revised can help gauge the effectiveness of neurostimulant trials and other interventions.

During a hospital assessment of a patient with brain injury, early identification of common sequelae, like spasticity, reduction in joint range of motion, or heterotopic ossification, can minimize their future impact on recovery. Additionally, response to early rehabilitation efforts can help gauge the patient’s future rehabilitation potential (Fig. 22–1).

Head injuries are common in contact sports, with concussions comprising more than 10% of reported injuries among high school athletes from 2008 to 2010.² The head-injured athlete should be quickly assessed on the field for stability and spinal injuries, and then on the sideline by a trained clinician to assess whether their symptoms represent a concussion or possible catastrophic injury (subdural hematoma, epidural hemorrhage, second impact syndrome) requiring urgent imaging and further evaluation. Many validated tools are available to aid in this decision-making process and should be used in conjunction with medical evaluation in deciding the course of care. Caregivers of head-injured athletes must be aware of postinjury warning signs, management options, and appropriate referrals prior to return to play.³

Suspicion for head injury while at play is typically raised when an athlete does not immediately get up after contact or if there is presence of confusion or unsteadiness. An athlete who is unable to get up should be immediately evaluated on the field prior to being moved to ensure no catastrophic spinal injury is present.^4,5 Primary survey for level of consciousness and vital signs should be taken. Secondary survey for signs of trauma should be done as well, searching for tenderness or deformity of the extremities, neck, and head. An unconscious athlete who cannot be quickly roused should be assumed to have an unstable spinal injury and immobilized and transported for imaging and evaluation. If awake and able to answer questions, mental status, cranial nerves, strength, and sensation should be assessed for focal deficits. GCS <13, any focal deficits, neck spasm, severe pain/tenderness, or visible/palpable deformity should be similarly assumed to be an unstable cervical fracture and immobilized for transport.⁴

If stable, the athlete should be assisted to a relatively quiet and less distracting area for further assessment. A more detailed physical exam should be performed with attention to red flags such as worsening confusion, increased somnolence, new focal neurologic deficits, and signs of basilar skull fracture (raccoon eyes, Battle’s sign, cerebrospinal fluid [CSF] from the nose/ears and hemotympanum) (Fig 22–2).

Attention should be paid to signs of concussion: loss of consciousness, anterograde or retrograde amnesia, poor coordination, a vacant stare, altered mental status, or signs of facial trauma. Any athlete suspected of concussion should not return to play and be continuously supervised on the sideline.³ Any sign of neurologic deterioration should lead to immediate transport for imaging and neurosurgical evaluation (Table 22–1).

Table 22–2 discusses clinical guidelines for obtaining head computerized tomographies (CTs) and sensitivity and specificities for detecting significant brain injury and need for neurosurgery. These guidelines include the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and the National Emergency X-Radiography Utilization Study II (NEXUS II) Rule.⁶