2. PRESENTED BY
NIRUPOM BARDHAN
BSc in Physiotherapy
18th Batch
BHPI, CRP, SAVAR.

3. HEAD INJURY

4. CONTENTS…
 Definition
 Etiology
 Mechanism of injury
 Types
 Pathophysiology
 Clinical feature
 Progression
 Complication
 Diagnosis
 Treatment
 Physiotherapy intervention for head injury
 Prognosis
 Conclusion

5. DEFINITION
 Head injury means damage to any of the structures of the
head as a result of trauma.
 As defined by National Head Injury Foundation of America,
Head Injury is “a traumatic insult to brain capable of
producing physical, intellectual, emotional, social and
vocational changes.
 The term “Head Injury” is most often used to refer to an
injury to the brain, that may also involve the bones, muscles,
blood vessels, skin or other organs of the face or head.

6. ETIOLOGY
 Falls
 Road Traffic Accident
 Violent physical assault
 Stabbing
 Sports
 Shallow water diving
 Missile injuries
 Shaken baby syndrome.

7. MECHANISM OF INJURY
 Closed head injuries are due to:
1. Acceleration – deceleration
2. Coup - contra coup
 Open Head injuries due to:
1. Penetrations
2. Fractures

8. MECHANISM OF INJURY…
Acceleration:
 Direct blow to the head
 Skull moves away from force
 Brain rapidly accelerates from
stationary to in- motion state
causing cellular damage

9. MECHANISM OF INJURY…
Deceleration:
 Head impacts to a stationary object
 Moving skull stops motion almost
immediately
 However, brain, floating in cerebral
spinal fluid (CSF), briefly continues
moving in skull towards direction of
impact, resulting in significant forces that
damage cells

10. MECHANISM OF INJURY…
Injury resulting from rapid, violent
movement of brain is called coup and
contra coup.
 Coup: an injury occurring directly
beneath the skull at the area of impact.
 Contra coup: injury occurs on the
opposite side of the area that was
impacted.

11. TYPES
A. Depending on the severity of the injury:
1. Mild Head Injury
2. Moderate Head injury
3. Severe Head injury.
We use Glasgow Coma Scale to interpret the severity of the
head injury. Glasgow Coma Scale (GCS) is a neurological
scale which aims to give a reliable and objective way of
recording the conscious state of a person for initial as well as
subsequent assessment.

12. Glasgow coma scale

13. Glasgow coma scale…
Modified GCS for vocal responses from children under 5 years:
2-5 years Points <2 years
Words of any sort 5 Coos, smiles, cries
Monosyllables 4 Cries only
Cries or screams 3 Unstimulated screaming
Grunts 2 Grunts
None 1 None

14. TYPES…..
B. Depending on the structures involoved in the injury, there
are 5 types. They are:
1. Brain contusion
2. Brain concussion
3. Skull fractures
4. Diffuse axonal injury
5. Intracranial hematoma.

15. TYPES…
Brain Contusion:
 Contusion – bruising of brain tissue
on the impacted site.
 Has area of necrosis infarction and
hemorrhage
 Often from coup – contra coup
injury.

16. TYPES….
Brain concussion:
 The most common and least serious type of
traumatic brain injury is called a concussion.
The word comes from the
Latin concutere, which means "to shake
violently.“
 Here, the brain is pushed towards and against
the skull.

17. TYPES….
Skull fractures:
 Linear undisplaced
 Depressed
 Compound
 Basal skull fracture

18. TYPES…
Basal skull fracture is further
divided into:
 Anterior basal skull fracture
 Transverse Basal skull fracture
 Longitudinal basal skull
fracture.

19. TYPES…
Diffuse axonal injury:
 Diffuse axonal injury occurs when
shearing, stretching and/or
angular forces pull on axons and
small vessels.
 Impaired axonal transport leads to
focal axonal swelling and after
several hours may result in axonal
disconnection.

20. TYPES…
Intracranial hematoma:
Intracranial hematoma has some sub-types such as:
 Epidural hematoma
 Intracerebral hematoma
 Subdural hematoma
 Traumatic Subarachnoid hemorrhage

21. TYPES…
Epidural Hematoma:
 Comes from bleeding
between dura and inner
surface of the skull.
 Will be unconscious, then
awake, and then deteriorate
( lucid interval )

22. TYPES…
Intracerebral Hemorrhage:
Intracerebral hemorrhage (ICH), also
known as cerebral bleed, is a type
of intracranial bleed that occurs within
the brain tissue or ventricles.

23. TYPES…
Subdural hematoma:
 Hematoma between the dura
mater and the pia arachnoid
mater.
 Occurring in approximately
30% of severe head injuries

24. TYPES…
Traumatic Subarachnoid
Hemorrhage:
 Blood collects beneath the
arachnoid.
 Tear of veins in subarachnoid
space.
 Usually associated with types of
brain injury –commonly with
contusion.

25. PATHOPHYSIOLOGY
Decrease in venous return resulting in reduced ventricular filling
Increased sympathetic tone and hypercontractility of ventricles with under
filled chamber
Ventricular mechanoreceptor activation and feedback to Medulla(CNS) via
afferent vagus nerve
Sympathetic withdrawal, parasympathetic overdrive leading to bradycardia
and hypotension
SYNCOPE

26. CLINICAL FEATURES
Clinical manifestations come according to the area of damage of
the brain. Such as.
Damaged Frontal lobe:
 Problem in intellectual activities.
 Loss of ability to organize.
 Problem in personality, behavior and emotional control.
Damaged Temporal lobe:
 Problem in memory, speech and comprehension.

27. CLINICAL FEATURES…
Damaged Parietal lobe:
 Inability to read and write
 Difficulty to understand spatial relationship.
Damaged Occipital lobe:
 Problem in vision.
Damaged Cerebellum:
 Posture and trunk instability
 Loss of body equilibrium and co-ordination of movements.
 Change in rapid limb movements.

28. CLINICAL FEATURES…
Some features commonly found in head injuries:
 Anxiety, nervousness.
 Aphasia
 Dysphasia
 Dizziness
 Headache
 Seizures
 Vertigo
 Sleep difficulties

29. PROGRESSION
Symptoms typically progress through three successive stages-
1. Coma : Severe head injury results in coma, a loss of
consciousness.
2. Post – traumatic amnesia : It is a stage of acute confusion
and the hallmark of this stage is cognitive impairment.
3. Recovery : recovery is characterized by progressive
improvement in cognitive and behavioral functions.

30. COMPLICATIONS
 Deep venous thrombosis
 Heterotopic ossification
 Pressure ulcer
 Pneumonia
 Hydrocephalus
 Chronic pain
 Contractures
 Muscle atrophy
 Fracture
 Peripheral Nerve Damage

31. DIAGNOSIS
A complete neurological evaluation is performed to rule out
conditions requiring neurosurgical attention, such as
hematomas, depressed skull fractures, and elevated intracranial
pressure. Some diagnostic tools are used as:
Angiogram: A test to examine blood vessels in the brain.
ICP monitor: A device used to monitor intracranial pressure.
EEG: A test to measure electrical activity in the brain.
X-rays, MRIs, and CT Scans: to detect fractures, hemorrhages,
swelling and certain kinds of tissue injury.

32. TREATMENT
There are three stages of treatment for head injury.
 Acute – to stabilize the patient immediately after the injury.
 Sub-acute – to rehabilitate and return the patient to
community
 Chronic – to continue rehabilitation and treat the long – term
impairments.

33. TREATMENT…
ACUTE TREATMENT:
 Unblocking the airway
 Assisting breathing
 Keeping the blood circulating
 Cardiopulmonary resuscitation may be necessary.
 Surgery is indicated if any blood clot causes increased
intracranial pressure in case of subdural hematomas and
intracerebral hemorrhages.

34. TREATMENT…
Sub-acute treatment:
Sub – acute treatment is provided after stabilization. Which ranges from
medical stability to patient’s return to the community or admission to a chronic
facility. The main goals of sub-acute treatment are:
 Early detection of complications, such as:
1. Cranial nerve damage
2. Epilepsy
3. Spasticity
4. Heterotopic ossification
5. Diabetes insipidus.
 Facilitation of neurological and functional recovery
 Prevention of additional injury.

35. TREATMENT…
Chronic Treatment:
Disabilities from head injury may last a lifetime, and different
interventions may be appropriate even many years later.
There are two categories of chronic treatment .
 Community-based rehabilitation and return to work or school,
and
 Treatment of long term consequences of the injury.

36. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY
Plan of care:
The purpose of the plan of care is to maintain an optimal
physical condition, thus providing a basis from which learning
and relearning may be enhanced. The components of a plan of
care are:
 Respiratory care.
 Control of posture – in lying, sitting and standing.
 Maintenance of range of motion in joints.
 Encouragement of remaining ability.

37. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
Respiratory care:
The patient will have limited lung excursion due to loss of
function of respiratory muscle and poor postural control, and
this will predispose to chest infection. To prevent respiratory
complications, a physiotherapist can prescribe:
 Breathing exercises : Deep breathing exercise, Breathing
control exercise, Active cycle of breathing technique.
 Postural drainage.
 Encouraging active coughing.

38. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
Control of posture:
Posture while lying
Patients with asymmetrical, decerebrate posture and inability to
accept the support of the surface of the bed are vulnerable to
joint contractures, pressure sores and respiratory complications.
The presenting posture may be modified by providing
additional support such as pillows, wedges and foam rolls and
thus stability to the body segments.

39. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…

40. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…

41. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
Posture while sitting
There are three typical postural
patterns in sitting:
1. C – shaped posture: This is a
slumped kyphotic pattern.

42. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
2. Arched posture: The body is
arched backwards from the coccyx,
with an exaggerated lumbar
lordosis. Legs tend to flex, and
arms to extend. Inevitably the
buttocks will tend to lift and slide
forwards,

43. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
3. Asymmetrical posture: In this
posture the legs may be
windswept, the pelvis tilted and
rotate, and the trunk and the
side of the head flexed and
rotated.

44. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
The patient may display a combination of these
postures and most will adopt a preferred position in
sitting. If a patient is unable to provide own postural
support, it must be provided externally to provide
stable, balanced, symmetrical and functional position,
whilst relieving pressure and shearing forces.

45. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
Posture while standing:
Standing is achieved by the mechanical
support of a tilt-able or standing frame,
when the joint range of the lower
extremities allow this to be a safe and
achievable procedure.

46. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
Maintenance of Joint ROM:
Reduced ROM can lead to contractures and contribute to
asymmetrical posture and an unstable position. To maintain
ROM a physiotherapist can do to a patient:
 Passive movement
 Active facilitated and active movements.
 If contracture is developed then splinting and serial casting
can help to stretch the contracted tissues.

47. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
Encourage remaining ability:
Stimulating interest in task, providing an element of
competition and frequent repetition, may enhance
performance of even the most simple task. Leisure
activities are encouraged like swimming, archery and
table tennis. These activities will depend on the
patients ability to enjoy and/or take part in them.

48. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
Other Physical therapeutic interventions required for head injury:
 Inhibit abnormal patterns of reflex activity by :
1. Positioning
2. Reflex inhibiting
 Establish communication
 Increase sensory stimulus by:
1. Encouraging awareness of surroundings
2. Afferent cutaneous reactions
3. Encouraging motivation

49. PHYSIOTHERAPY INTERVENTION FOR
HEAD INJURY…
 Develop normal tone
 Develop normal reactions
 Facilitate voluntary movements
 Reeducate functional activities by:
1. Choice and adaptation of activities which do not conflict
with other principles of movements.
2. Choice and use of aids.

50. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
Trunk control
exercise with the
help of Theraband.

51. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
High Kneeling
exercise.

52. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
Knee walking
exercise

53. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
One limb high
kneeling
exercise

54. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
Balance exercise
in high kneeling

55. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
Walking in a
frame

56. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
Balance
exercise on
balance
board

57. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
Balance
exercise on
balance
board

58. HEAD INJURY PATIENTS IN
NUROLOGY UNIT of PT DEPARTMENT
Standing in a
frame

59. PROGNOSIS
Prognosis depends on several indicators to predict the level of
patient’s recovery during first few weeks and months after injury.
 Duration of coma
 Severity of coma in the first few hours after the injury.
 Duration of post-traumatic amnesia
 Location and size of contusions and hemorrhages in the brain
 Severity of injuries to other body systems sustained at the
time of the injury.
 Age of the patient.

60. CONCLUSION
The overall objective of a management programme
for the brain-injured patient with severe long-term
physical disability is to ensure that the patient enjoys
the best possible quality of life, in terms of general
wellbeing and control of adverse secondary
complications, whilst exploring to the full of any
independence available.

61. SHARING SESSION

62. SHARING SESSION