Traumatic Brain Injury (TBI)

• Traumatic Brain Injury (TBI) involves conditions like concussion, contusions, and seizures.

Concussion (mTBI)

• A mild TBI with functional changes but no structural damage.
• The neurometabolic cascade should normally resolve within 4-6 weeks (30 days).
• Persistent post-concussion syndrome (PPCS) symptoms develop in 20-30% of concussed patients if symptoms persist beyond 4-6 weeks.

Concussion Treatment

• 5mg of creatine may be recommended.
• Coup injury occurs under the site of impact.
• Contrecoup injury occurs on the opposite side of the impact.
• Rotational force is most likely to cause loss of consciousness and persistent post-concussion symptoms.
• Concussion and whiplash often occur together.
• Imaging (MRI, CT scans) can rule out structural damage.

Concussion-mTBI

• Caused by a direct blow to the head, neck, or body, resulting in an impulsive force transmitted to the brain.
• Initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change, and inflammation.
• Symptoms may present immediately or evolve over minutes or hours.

Post-Concussion Syndrome

• Occurs after a concussion has occurred.
• Signs and Symptoms include autonomic dysfunction, headaches, dizziness, loss of concentration and memory, ringing in the ears, emotional and psychological changes, sleep changes, and vision changes.

Concussion Treatment

• Rest, including sleep at night and naps during the day.
• Avoiding vigorous activity.
• NSAIDs to control headaches.
• Avoid bright lights and electronics.
• Limit activities that require heavy concentration or intense focus.
• Light activity like walking can be resumed during the initial 24-48 hours.
• Reduced screen use in the first 48 hours.
• Physical therapy, speech therapy, recreation therapy, and occupational therapy may be required.

Classification System for TBI

• Mild: Duration of unconsciousness < 30 minutes, Glasgow Coma Scale 13-15, Post-Traumatic Amnesia < 24 hours.
• Moderate: Duration of unconsciousness 30 minutes-24 hours, Glasgow Coma Scale 9-12, Post-Traumatic Amnesia 1-7 days.
• Severe: Duration of unconsciousness > 24 hours, Glasgow Coma Scale 3-8, Post-Traumatic Amnesia > 7 days.

Glasgow Coma Scale

• Used to objectively describe the extent of impaired consciousness in all types of traumatic brain injuries.
• Lower score indicates a worse injury.
• 15: Fully awake, responsive, and no problems with thinking ability or memory.
• 13-14: Mild head injury.
• 9-12: Moderate head injury.
• 3-8: Coma and severe brain injury-immediate emergency care required.

Massage Considerations for Concussion and PPCS

• Remove noxious stimuli like bright lights and noise.
• Position and pillow for comfort, being aware of dizziness and/or onset of symptoms with neck movement (cervicogenic dizziness).
• Avoid rocking/shaking.
• Promote relaxation.
• Encourage and support light aerobic exercise.
• Refer to chiro/physio/MD trained in concussion assessment and treatment (BTT, VOM).

Contusions

• More serious than a concussion - bruising or bleeding along the brain surface.
• Damage depends on size and location.

Seizure Disorder (Epilepsy)

• Explosive episodes of uncontrolled and excessive electrical activity in the brain, leading to sudden changes in behavior or level of consciousness.

Two Main Types of Seizures

Focal (Partial) Seizure

• Limited to a single area of the brain, accounting for 60% of cases.
• Two categories: without loss of consciousness and with impaired awareness.
• Without loss of consciousness: May experience changes in how things look, feel, smell, taste, or sound; can result in involuntary movements or abnormal sensations like dizziness.
• With impaired awareness: Change or loss of consciousness; blank stare or repetitive movements; start walking in circles.

Generalized Seizure

• Involves more of a diffuse area; approximately 30% of cases.
• Two types: Absence (petit mal) and Tonic-clonic (grand mal).
• Absence (petit mal): Brief loss of awareness and often facial movements lasting up to 10 seconds; often no memory of the event.
• Tonic-clonic (grand mal): Intermittent contract-relax pattern in muscles and associated with loss of consciousness; can last for several minutes; if longer than 5 minutes, call 911.

Treatment of Seizures

• Antiseizure medication and cannabinoids are used.
• Mild sedatives.
• Understanding and removing triggers, such as flashing lights or smells/odors.

Massage Considerations for Seizures

• Follow first aid if seizure occurs.
• Use gentle, relaxing massage techniques.
• Adjust face rest for comfort.
• Limit position changes if client is experiencing dizziness.
• Establish a form of communication if the client has difficulty communicating.
• Avoid techniques that cause rocking or shaking.

Special Tests for TBI

• Spurlings or decompression test
• Neck ROM assessment.
• Cognitive ability assessment.
• TrP referral.
• VAT test.
• BP assessment.
• Postural assessment.

Additional Recommendations for Seizures

• Warm bath for 10-15 minutes for sleep.
• Aerobic exercise.
• Changing ADLs to avoid triggers.
• Stretching neck muscles.
• Journaling symptoms.

Cerebral Palsy

• A group of non-progressive, irreversible motor disorders caused by brain damage to an immature brain.
• Brain damage may occur in utero (from 2nd half of pregnancy onwards), during the birth process, or in early childhood (usually the first 3 years of life).
• Usually due to hypoxia, which may occur via very premature birth, intrauterine virus (TORCH), or ischemic insults, in utero or postpartum hypoxia or ischemia, in utero or postpartum trauma.

Hypoxia & Ischemia Causes

• Kink in the umbilical cord or the cord wrapping around the fetus's neck, maldevelopment of the placenta, or shock in the mother from an accident.
• Due to Suppression of the respiratory centers b/c of overmedication of the mother, or pneumonia, a collapsed lung or drowning of the infant

Presentation of Hypoxia

• Trauma to, or rupture of cerebral blood vessels, separation of the placenta, difficult or prolonged delivery, and postpartum head injury from an accident or abuse.
• Strokes can result of dehydration

4 Main Types of Cerebral Palsy

• Spastic, Athetoid, Ataxic, & Mixed
• There is a very wide spectrum of presentations in cerebral palsy from mind to very profound

Spastic

• Increased tone; accounts for 75% of all cases - most common.
• monoplegia - 1 arm or leg
• Diplegic - usually both legs, m/c of spastic form, fully ambulatory scissor gait
• Hemiplegic - 1 side of body, usually most ambulatory
• Quadriplegic-all 4 limbs

Athetoid

• Uncontrolled movement, slow & writhing (dyskinesia).

Ataxic

• Poor coordination, least common.
• Due to damage to cerebellum.

Mixed

• Usually spastic & athetoid.

Symptoms of Cerebral Palsy

• Early signs are delayed milestones, persistence of primitive reflexes, in toddlers not walking or forming sentences.
• Spasticity, Athetoid Movements.
• Choreiform movements are quick, uncontrolled, and without purpose; do not stop with sleep.
• Ataxia is the lack of coordination and clumsiness of movements; ataxia in the face causes grimacing.
• Development reflexes not integrated.
• May be present in the 1" year or two then change to spasticity or athetoid movements
• Pain resulting from muscular, neurological, and bony changes; can be acute or chronic.

Postural Dysfunctions

• Scoliosis (can lead to respiratory difficulties), hyperlordosis, hyperkyphosis
• Contracture formation, such as equinus deformity (short Achilles) and internal rotation of hip, hip flexion.
• Toe walkers
• Permanent skeletal changes and arthritis.
• Stenosis of C-spine.
• Osteoporosis because they aren't weight bearing
• Epilepsy, mental development delay, and emotional disturbances.
• Compromised tissue health such as disuse atrophy and edema can be > decubitus ulcers
• Peripheral nerve compression due to postural imbalances.
• Variety of sensory losses, decreased proprioception, though the perception of pain, temperature, and pressure is not affected.
• Speech - dysarthria; can be difficulty swallowing and inability to control saliva.
• Hearing impairmentcan occur
• Bowel and bladder function compromised.
• Frustration and anger.
• Vision can be normal or limited
• Intellect may or may not be affected.

"Scissors Gait"

• Due to adductor spasticity, causing the knees to be drawn together; legs can be swung forward only with great effort.

Treatment

• There is no cure
• Treatments that can be taken include physical and occupational therapy, speech therapy, drugs to control seizures, relax muscle spasms and alleviate pain
• Surgery to correct anatomical abnormalities or release tight muscles.
• Braces and other orthotic devices
• Wheelchairs and rolling walkers
• Communication aids

Massage Considerations

• People w/ CP non-verbal or non-communicative, in these cases a carer can establish a method of communication
• Providing Comfortable positioning (often in a wheelchair)
• May need to accommodate high amounts of salivary secretions.

Massage

• you must inform your patient that it can be fatiguing

Outcome

• Decrease mm tightness
• Increase ROM
• Improve proprioceptions
• Help w/inhalation and rib function
• Indicated Treatment
• PNF strengthening, core PNF
• Help w/ gastrointestinal motility
• Promote relaxation and comfort

Assessments

• Decreased edema
• Decrease contracture formation
• Breathing assessment
• Peripheral nerve compression tests
• Walking gait assessment
• Functional assessment

Other considerations

• Check for decubitus ulcers.
• What are challenges, secondary conditions?
• Who are working with if assistance is needed
• How often are people looking at bony prominences
• Prev massage history
• Drooling - modify positioning
• Assess if there are issues w/ swallowing
• Note patient's comfortable Sleeping position.

Note

• NO PRONE - FOR CEREBRAL PALSY, CONCUSSION, SEIZURES