Rehabilitation and Returning to Activity After Prolonged Moderate Traumatic Brain Injury

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Rehabilitation and Returning to Activity After Prolonged Moderate Traumatic Brain Injury

Traumatic brain injury (TBI) is a significant public health concern characterized by disrupted brain function following a blow to the head or body. Classified as mild, moderate, or severe based on the Glasgow Coma Scale (GCS), TBI severity depends on motor responses, verbal abilities, and eye-opening capacity. Moderate TBI (mTBI) often presents with prolonged symptoms, including balance deficits, dizziness, and cognitive impairments, which can persist for months or years. Globally, TBI is projected to become the third leading cause of disability by 2024, with an estimated annual incidence of 2.8 million cases. In Saudi Arabia, the prevalence is 116 cases per 100,000 individuals, underscoring the urgency for effective rehabilitation protocols.

This case report details the physical therapy intervention for a 24-year-old Saudi woman with prolonged post-mTBI symptoms following a road traffic accident. Ten months prior to rehabilitation, the patient sustained a skull fracture and internal hemorrhage, requiring surgical intervention and a 10-day intensive care unit stay. Upon presentation, she reported persistent headaches, dizziness, diplopia, and a “foggy” sensation, alongside significant balance impairments. Magnetic resonance imaging (MRI) revealed surgical cranial defects in the occipital bone and residual hypodense areas in the frontal lobes and right cerebellum, indicating unresolved brain injury.

Clinical Assessment and Baseline Findings
A comprehensive physical examination evaluated cervical muscle tenderness, range of motion, strength, and aerobic capacity. The patient exhibited tenderness in the suboccipital muscles and upper cervical joints, though cervical range of motion remained normal. Manual muscle testing revealed no significant weakness in the neck or lower extremities. Aerobic capacity was assessed using the Buffalo Concussion Treadmill Test, a validated tool for measuring exercise tolerance in TBI patients. Heart rate and perceived exertion were monitored to establish a safe exercise threshold.

Balance deficits were quantified using the Balance Error Scoring System (BESS), which evaluates postural stability during six stances (e.g., single-leg, tandem). The patient scored 24/60, indicating severe imbalance. Further assessment with the Y Balance Test, a dynamic stability measure, yielded composite scores of 47% (right limb) and 47.5% (left limb), reflecting poor neuromuscular control and elevated injury risk. Symptom severity was captured via the Post-Concussion Symptom Scale (PCSS), a self-reported tool rating headaches, dizziness, and cognitive fog on a 0–6 Likert scale. The patient’s baseline PCSS score was 33, classified as moderate impairment.

Intervention Strategy
The rehabilitation program, spanning over 30 in-clinic sessions, integrated four pillars: education, neuromuscular rehabilitation, injury prevention, and structured return-to-activity progression. Each session concluded with a customized home exercise program to reinforce gains.

  1. Education and Symptom Management
    The patient received detailed explanations of her impairments and the rationale behind each intervention. Emphasis was placed on symptom monitoring, particularly headaches and dizziness, using the PCSS checklist before and after aerobic exercise.

  2. Neuromuscular Rehabilitation

    • Balance and Postural Control: Exercises progressed from static holds (double-leg stance) to dynamic challenges (single-leg stance on unstable surfaces, tandem walking). Each exercise required maintaining positions for ≥30 seconds.
    • Vestibular Rehabilitation: Gaze stabilization drills, such as focusing on a stationary object during head movements, were employed to reduce dizziness.
    • Aerobic Conditioning: Graded treadmill walking began at sub-symptom thresholds, gradually increasing speed and incline to improve cardiovascular endurance without exacerbating symptoms.

  3. Preventive Strategies
    A prevention protocol included lumbo-pelvic stabilization exercises, warm-up routines, and education on avoiding high-risk activities. Core strengthening targeted the transverse abdominis and multifidus muscles to enhance trunk stability during dynamic tasks.

  4. Return-to-Activity Progression
    A six-stage protocol guided the patient’s reintegration into daily activities:

    • Stages 1–3: Light aerobic exercise, gradual reintroduction of work/school tasks, and non-contact sport-specific drills.
    • Stage 4: Full participation in non-contact activities with monitored exertion.
    • Stages 5–6: Gradual return to contact sports under medical supervision.

In the final three weeks, Nordic walking—a technique using poles to engage the upper body and core—was introduced to improve gait symmetry and functional endurance.

Outcomes and Follow-Up
Post-intervention, the patient achieved symptom-free rest and activity. BESS scores normalized, and Y Balance composite scores improved to 71.2% (right limb) and 67.5% (left limb), reflecting enhanced neuromuscular control. She demonstrated proficient single-leg and tandem standing with eyes open/closed and regained confidence in jumping tasks. The PCSS score decreased to 0, indicating resolution of headaches, dizziness, and cognitive fog.

Discussion
This case highlights the efficacy of a holistic, phased rehabilitation approach for prolonged mTBI. Key success factors included:

  • Individualized Progression: Regular reassessments ensured exercises matched the patient’s evolving capabilities.
  • Multimodal Interventions: Combining balance training, aerobic conditioning, and vestibular drills addressed overlapping deficits.
  • Preventive Education: Empowering the patient with injury-prevention knowledge reduced recurrence risk.

Notably, the delayed initiation of rehabilitation—10 months post-injury—underscores the potential for functional recovery even in chronic mTBI cases. The integration of Nordic walking, though unconventional in TBI protocols, proved effective in enhancing gait stability and upper-limb coordination.

Conclusion
This report demonstrates that structured physical therapy, anchored in education, neuromuscular retraining, and preventive strategies, can restore function and quality of life in patients with prolonged mTBI. Future research should prioritize randomized trials to validate these interventions and establish standardized protocols for this understudied population.

doi.org/10.1097/CM9.0000000000001403

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