Traumatic Brain Injury

Traumatic brain injury (TBI) is most often caused by motor vehicle accidents or by falls and violence.² Because of the nature of the injury, the brain trauma may be associated with fractures, dislocations, lacerations, and the like. The groups most commonly affected are children (from bicycle accidents) and young adults (from car accidents and violence); TBI is the most common cause of death and disability in these age groups. Early management is focused on preservation of life and prevention of further damage. The diffuse nature of the brain injury usually results in problems with multiple brain functions and mechanisms. A complex picture is common, with varying deficits in motor and sensory capabilities, intellectual and cognitive functions, and emotional and psychological functions. Because of the complexity and variability of problems that may be encountered with each patient, management and treatment require an individualized plan and a multidisciplinary team approach in which each member plays a specific and significant role. Early physical therapy involvement has been shown to be beneficial. As with stroke, physical therapy intervention focuses on facilitating functional recovery. TBI is an area in which prevention through education is crucial. Wearing a helmet when riding a bike and using a seat belt when riding in a car can make the difference between life and death.

Spinal Cord Injury

Spinal cord injury (SCI), like TBI, most often results from motor vehicle accidents, falls, violence (especially gunshot wounds), and sports (diving and football). The age group most often affected is 16 to 30 years of age, and men are affected four times as often as women.³ Spinal cord damage can also be precipitated by other diseases and conditions, and in these instances older patients are affected more commonly. Depending on the level of injury, all limbs may be affected (tetraplegia), or the lower part of the trunk and legs may be affected (paraplegia). If the lesion is complete, no residual sensory or motor function can be found below the level of the lesion (“-plegia”). The injury may also result in an incomplete lesion in which some distal motor and sensory functions may be preserved (“-paresis”).

As with TBI, SCI may be accompanied by multiple injuries, and the early goal of management is preservation of life and prevention of further damage to neural tissue. Further damage is prevented through internal immobilization of the area, by fusing the vertebrae with bone grafts, rods, and wires, or external immobilization with devices such as braces or casts. Medications are used to prevent further damage to neural tissue and enhance repair and recovery.

While this healing process occurs, it is important to maintain mobility in the joints of the extremities, strength in the unaffected muscles, cardiorespiratory capacity, and endurance. Figure 9-3 illustrates one of the types of braces used to provide stability. The patient is working on strengthening the upper extremity and trunk muscles. Once medical and orthopedic clearance is obtained, more vigorous functional training is begun.

In Figures 9-4 and 9-5 the patients are learning mat table–to-wheelchair transfers and wheelchair manipulation skills. Identification of equipment requirements and environmental adaptations is needed for each patient. For example, most patients use a wheelchair as a primary means of mobility, and they must be custom ordered for each patient with specific size and adaptation requirements. Figure 9-6 shows a patient with tetraplegia using an electric wheelchair for mobility and a special device that allows him to write. The home will have to be made wheelchair accessible with ramps and other modifications. Thus the therapist plays a major role not only in the treatment, but also in the rehabilitation of patients with SCI by providing family education and consultation on many related issues such as environmental modifications and assistive technology

Vestibular Disorders

The vestibular system helps detect head position and movement. It consists of two components: (1) the peripheral apparatus, which includes the semicircular canals in the inner ear, and the central component, which includes the vestibular nuclei, and (2) the connections between the peripheral and central components, which include the vestibular nerve, and the central connections between the vestibular nuclei and various brain regions. The vestibular system, in conjunction with other systems, allows us to maintain our orientation in space, control our posture, and maintain our balance. The most common symptoms of vestibular disorders are dizziness, unsteadiness, vertigo, and nausea. According to the National Ambulatory Medical Care Survey for 1991,⁴ dizziness or vertigo is among the 25 most common reasons Americans visit their doctors. U.S. physicians report a total of more than 5 million dizziness or vertigo visits a year. Vestibular disorders can occur as a result of trauma, infections, toxicity from large doses of antibiotics, and pathologic changes underlying other conditions such as MS and stroke. Common vestibular diagnoses include benign paroxysmal positional vertigo, labyrinthitis, vestibular neuritis, and Meniere’s disease.

Over the past two decades, the knowledge and understanding of vestibular function and related disorders have improved tremendously. This has resulted in better diagnosis based on history, examination, and differential tests to pinpoint the specific disorder and underlying mechanisms. Improved diagnosis allows therapists to better target the treatment, management, and rehabilitation of affected patients.