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REVIEW
Abstract
Primary objectives: At present there are no standardized recommendations concerning physiotherapy of individuals with
traumatic brain injury (TBI) resulting in a high variability of methods and intensity. The aim of this literature review is to
develop recommendations concerning physiotherapy in the post-acute phase after TBI on the basis of scientific evidence.
Method: literature review: data bases: PubMed, PEDro, OT-Seeker, Cochrane and Cinahl. Keywords: brain injury
(in PEDro, OT-Seeker, Cochrane), brain injury AND physical therapy (in PubMed and Cinahl).
For personal use only.
Results: Fourteen studies met the inclusion criteria and were grouped into sub-groups: sensory stimulation, therapy
intensity, casting/splinting, exercise or aerobic training and functional skill training. While for sensory stimulation evidence
could not be proven, a strong evidence exists that more intensive rehabilitation programmes lead to earlier
functional abilities. The recommendation due to casting for the improvement of passive range of motion is a grade B,
while only a C recommendation is appropriate concerning tonus reduction. Strong evidence exists that intensive
task-orientated rehabilitation programmes lead to earlier and better functional abilities.
Conclusion: Although some recommendations for the effectiveness of physical therapy interventions could be expressed,
there are many questions concerning the treatment of humans with TBI which have not been investigated so far.
Especially on the level of activity and participation only a few studies exist.
Correspondence: Stephanie Hellweg, Rehaklinik Bellikon, CH 5454 Bellikon, Switzerland. Tel: +41 56 485 5168. Fax: +41 56 485 5257.
E-mail: stephanie.hellweg@rehabellikon.ch
ISSN 0269–9052 print/ISSN 1362–301X online ß 2008 Informa UK Ltd.
DOI: 10.1080/02699050801998250
366 S. Hellweg & S. Johannes
This investigation did not address issues relating to Here reliance was placed on existing, well proven
mild TBI. instruments. The PEDro Scale as developed by
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be achieved.
specialist literature in the professional journals and Studies that achieve a score of 9–10 points set
books on this subject. In addition, the reference lists a gold standard that is almost never achieved in the
of the pertinent literature were browsed in order to practical realization of therapeutic intervention.
identify additional publications. A score of 8/10 or 7/10 points corresponds to a
methodologically well designed study. Scores of 6/10
Key words and 5/10 correspond to moderate quality.
The searches commenced with the search term A score of 4/10 is rated as acceptable in this review
‘traumatic brain injury’. Since very few results were study. Studies with a score less than 4/10 were
obtained with this search strategy, the umbrella term excluded.
or mesh term ‘brain injury’ was entered. Due to the For the evaluation of review articles, six questions
clarity of the Cochrane, PEDro and OT-Seeker were adopted from the Centre for Reviews and
databases, the search was not narrowed by adding Dissemination of the University of York, UK,
more search terms. The searches in PubMed and in page 6, Box 0.3 [2]. The more questions that can
the Cinahl database were conducted as follows: be answered and that are manageable, the higher the
‘brain injury’ AND ‘physical therapy’ OR quality rating for the review. The inclusion criterion
‘physiotherapy’. for the present study was that at least four of the six
Many of the studies found are contained in several questions were answered and that manageability
databases, whereby there was a great deal of overlap was given.
for PEDro and OT-Seeker, in particular, with the
result that only six new studies were found in
Level of evidence and grades of recommendation
OT-Seeker.
The abstracts of the identified studies were then An additional tool to facilitate adequate assessment
scrutinized on the basis of specific inclusion and of study outcomes is the classification of evidence.
exclusion criteria. The SIGN scale was implemented due to its
simplicity and the clarity of its divisions [3].
Inclusion and exclusion criteria After classification of the level of evidence of each
study, the grades of recommendation were derived
The inclusion criteria were defined as follows:
by application of the SIGN scale (see Table I).
. investigates the efficacy of a physiotherapeutic This is presented in table form with sub-divisions
method, from A to D and their precise definitions
. makes statements about treatment intensity, (see Table II).
Physiotherapy after TBI: A systematic review of the literature 367
Level of evidence
1þþ High quality meta analysis, systematic review of RCTs or RCTs with a very low risk bias for systematic errors.
1þ Well conducted meta analysis, systematic review of RCTs or RCTs with a very low risk bias for systematic errors.
1 Meta analysis, systematic review of RCTs or RCTs with a high risk bias for systematic errors.
2þþ High quality systematic reviews of case-control or cohort studies. High quality systematic reviews of case-control or cohort
studies with a low risk of systematic errors, e.g. confounding with a high probability that the relationship is causal.
2þ Well conducted case control or cohort studies with a low risk of systematic errors, e.g. confounding with a high probability
that the relationship is causal.
2 Case control or cohort studies with a high risk of systematic errors, e.g. confounding with a high probability that the
relationship is causal.
3 Non-analytical studies, e.g. case report, case series.
4 Expert opinions.
Grade of recommendation
A At least one meta analysis, systematic review, or RCT rated as 1þþ and directly applicable to the target population and
yielding overall consistency of results.
B A body of evidence including studies rated as 2þþ and directly applicable to the target population and yielding overall
consistency of results; or extrapolated evidence from studies rated as 1þþ or 1þ.
C A body of evidence including studies rated as 2þ and directly applicable to the target population and yielding overall
consistency of results; or extrapolated evidence from studies rated as 2þþ.
D Evidence level 3 or 4; or extrapolated evidence from studies rated as 2þ.
For personal use only.
. Sensory stimulation;
. Treatment intensity; Treatment intensity
. Serial casting, splinting;
. Fitness or aerobic training; and A total of five studies on this subject were included,
. Functional training: namely a systematic review by the Cochrane
. Sit-to-stand training, Collaboration (Turner-Stokes level of evidence
. Gait training, and 1þþ) [6], two simple blinded RCTs (Zhu level of
. Arm ability training. evidence 1þþ and Slade level of evidence 1-) [7, 8],
one non-blinded RCT (Shiel level of evidence 1þ)
[9] and one systematic review (Watson level of
Sensory stimulation
evidence 2þþ) [5]. Two of the three RCTs had
A particular difficulty with the comparability of already been integrated into the systematic overviews
studies on this subject is the inconsistent use and of Turner-Stokes and Watson.
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For personal use only.
368
Sensory stimulation
[5] Sensory stimulation Not identifiable SR 2þþ Recommendation grade A: no
verifiable evidence of the effi-
cacy of sensory stimulations
programmes
[4] Sensory stimulation programme vs. standard n ¼ 68, 3 studies SR 1þþ
rehabilitation
Treatment intensity
[6] Multidisciplinary rehabilitation vs. routine pro- n ¼ 2564, 14 studies SR 1þþ Recommendation grade A: more
grammes, Comparison of different treatment intensive rehabilitation pro-
settings and intensities grammes lead to early func-
tional skills
[8] Comparison of conventional rehabilitation vs. n ¼ 36 RCT 1þþ TBI
intensified treatment (additional 1 hour PT/ET
per day)
[7] Comparison experimental group: on average 67% n ¼ 141 RCT 1
more therapy than the control group
[9] Standard therapy vs. additional therapy as n ¼ 51 RCT 1þ
requested by the rehab team
[5] Treatment intensity Not identifiable SR 2þþ
[12] 1 week cast treatment with stretching vs. 1 week n¼9 CT 1 TBI
without cast treatment and without stretching
[13] 1st group: standard PT, 2nd group: cast treatment n ¼ 35 RCT 1
with injection of salt solution, 3rd group: cast
treatment combined with botulinum toxin
[11] Routine therapy: 5/week. 30 min individual motor n ¼ 28 RCT 1þþ Recommendation grade A: no
training programme for the upper extremities, verifiable clinical improvement
2 30min stretching of the upper extremities after night splints in functional
5/week for 5 weeks; Intensive group: additional position
hand splint worn for 12 hours a day for 4 weeks
Strength training
[5] Strength and fitness training SR 2þþ Recommendation grade A:
Improvement in cardiovascular
fitness after strength training
[15] Intervention group: 330 min/week. Individual n ¼ 38 RCT 1þ
strength training on the ergometer bicycle for
12 weeks; Control group: individual relaxation:
breathing exercises, progressive relaxation,
autogenous training, visualization
Functional training
[16] Intensive group: For 4 weeks intensive sit-stand and n ¼ 24 RCT 1þ TBI Recommendation grade A: for the
step-up training 5 days a week; Control group: efficacy of intensive task-
no additional training oriented training programmes
[17] Intensive group: Gait training with partial weight n ¼ 38 RCT 1þ TBI Recommendation grade A: Gait
bearing 2/week for 8 weeks; Control group: training with partial weight
standard PT, whereby treatment time was bearing is not superior to phy-
identical for both groups siotherapeutic gait training
[18] 3 groups: (1) no AAT (functional arm training), n ¼ 60 RCT 1þ Recommendation grade A: proof
(2) AAT, (3) AATþ knowledge of results of efficacy for AAT
Physiotherapy after TBI: A systematic review of the literature
369
370 S. Hellweg & S. Johannes
Conclusion. The levels of evidence for the identified was found for transfer of the improved cardiovas-
studies are very high. The results of these studies are cular parameters to the activity/participation level.
uniform so that an A recommendation grade is
appropriate with regard to the statement that more Functional training
intensive rehabilitation programmes lead to
A total of three RCTs that referred to functional
improved functional skills. There is also a large
training were found. Since the validity of the Watson
body of evidence to show that persons with
study on this subject is very low, that study was not
moderate-to-severe brain injury benefit from formal
taken into account. Two of the three studies
interventions. Finally, there is limited evidence to
(Canning evidence level 1þ, Wilson evidence
show that specialist settings lead to additional
level 1þ) [16,17] exclusively included persons who
improvements in function.
had suffered TBI, whereas the study by Platz et al.
A ceiling effect was not observed as a result
[18] also included persons with acquired brain
of more intensive therapy in any of the studies.
injuries of various aetiologies (evidence level 1þ).
Cost-benefit analysis is not available for any of these
programmes. Two studies report a reduction in Sit-to-stand training conclusion. The improvements in
inpatient stay. However, there is only moderate the experimental group are statistically significant in
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evidence for this effect since length of stay is often terms of number of repetitions in 3 minutes (62%),
dependent on external factors such as the follow-on although the control group also achieved
solution. improvements. From this it was deduced that
intensive, task-oriented, repetitive training can
be recommended as an important part of
Serial casting, splinting (botulinum toxin) rehabilitation—recommendation grade A.
Five studies were found that met the inclusion Gait training conclusion. This study concludes that
criteria. These included two systematic reviews both gait training with partial body-weight support for
rated as evidence level 2þþ (Watson, Mortenson) persons with TBI is not superior to conventional
For personal use only.
[5,10] and three randomized controlled studies physiotherapeutic gait training. Recommendation
(Moseley evidence level 1-, Verplancke evidence grade: A.
level 1-, Lannin evidence level 1þþ) [11–13]. Arm ability training conclusion. The conclusion is that
Since four studies addressed the subject of serial arm ability training for persons who have suffered
casting, these studies are summarized in the stroke or TBI can improve function relevant to
conclusion. Splinting will be discussed separately. activities of daily living. The efficacy of arm ability
Conclusion. Only a recommendation grade B for training was proven in this study—recommendation
serial casting to improve passive range of motion grade A—but its superiority in comparison to other
(PROM) can be awarded because of the lack of high concepts was not.
quality studies, whereas a C recommendation is
appropriate with regard to reduced muscle tone.
Overnight splinting in a functional position does Discussion
not produce clinical improvements in adults with an
acquired brain injury, recommendation grade A. Investigation of the scientific literature revealed a
A more recent study by Harvey et al. [14] supports few subject areas within which recommendations for
the recommendation that overnight splinting does physiotherapeutic and/or treatment intensity are
not lead to a reduction in contractures. made and which can be confirmed on the basis of
the currently available literature. Although the
re-learning of functional skills after brain injury is
Fitness or aerobic training
essentially one of the main tasks of physiotherapy,
In addition to the sub-group fitness or aerobic/ only three studies addressing the subject of
fitness/aerobic training in the systematic review by ‘functional training’ were found. These are all
Watson (evidence level 2þþ), a randomized recent studies so that there is hope that research
controlled study by Batemann et al. [15] was also will focus more on activity and participation levels in
taken into account (evidence level:1þ). The study by future rather than on body function and structure.
Batemann et al. is, however, already included in Furthermore, the ERABI working group
the review. (evidence-based review of moderate-to-severe
acquired brain injury) set itself the objective of
identifying those areas of rehabilitation for which
Conclusion. Both studies confirm an improvement there is currently no proof of efficacy and, therefore,
in cardiovascular fitness after fitness or aerobic require research [19]. By November 2007 the
training. Recommendation grade A. No evidence working group had drawn up a very comprehensive
Physiotherapy after TBI: A systematic review of the literature 371
literature overview of evidence-based rehabilitative show superiority of the intensive group over the
methods for persons with acquired brain injury conventional group. In particular, comparison of the
(revised three times), whereby the results of that groups at the 2- and 3-month follow-up assessments
literature overview correspond largely with the were significant, whereas the differences after a
results of this study. full 6 months had decreased and there was an
Fourteen studies were included in this investigation. approximation of the two groups. If further
The specific recommendations are summarized consideration is given to the basic differences
according to sub-groups: sensory stimulation, treat- between the rehabilitation of persons with stroke
ment intensity, serial casting or splinting, fitness or and those with TBI, then heterogeneity and
aerobic training and functional training. spontaneous remission are important factors.
clinical care. One can attend to patients in coma or Moseley [12] finds that mechanical factors are
in a minimally conscious state therapeutically and responsible for changes in the soft tissues that are,
control secondary problems as far as possible, but in turn, associated with shortening of muscles and
one has no influence over the ‘speed of the waking tendons, sarcomere loss and an increase of
process’. Specifically, this may mean that the time to connective tissue in the muscles and muscle fibres,
conduct high intensity therapy needs to be other authors support the hypothesis that
questioned very critically. hyperactivity of the stretch reflexes is an important
contributing factor that leads to morphological
Treatment intensity changes in the soft tissue.
In contrast, patients who are already at a high level In all the studies, the primary reason for serial
of alertness benefit significantly from intensive casting was loss of passive range of motion. None of
treatment programmes. the studies differentiated further as to which
Although there is a large body of evidence for the structures were primarily responsible for the loss.
efficacy of more intensive treatment programmes, Experience in clinical practice shows that by far
the studies, with the exception of the study by not all patients are suited to treatment with serial
Zhu et al. [8], must be criticized for a lack of casting. Regrettably, there are no reliable assessment
transparency with regard to precise data on the tools currently available to facilitate the decision-
increase in treatment intensity and the nature of making process.
the treatment, which makes the implementation of The Verplancke et al. [13] study demonstrates this
the study conclusions in routine practice difficult. indirectly. In their group 2 ‘serial casting and
It is important that the availability of strong injection of salt solution’, four of 12 patients
evidence is to be viewed with caution since it is continued to deteriorate and had to be given
essentially based on three studies. Of these three additional injections of botulinum toxin.
studies only Zhu et al. [8] exclusively recruited Overnight splints in functional position applied to
persons with TBI. In this prospective randomized adults with acquired brain injury do not lead to
controlled study, conventional rehabilitation clinical improvement, for example, improvement in
consisting of 1 hour of physiotherapy and 1 hour of the range of passive motion. This statement
ergotherapy in the morning was compared with an corresponds very closely with clinical experience.
intensive programme that took twice the time. The In addition, patients often perceived splints as very
Glasgow Outcome Scale (GOS) and the Functional upsetting. Furthermore, a critical view must be taken
Independence Measure (FIM) were employed as as to whether or not splinting actually encourages
outcome parameters. The outcomes from the GOS non-use of the affected arm.
372 S. Hellweg & S. Johannes
Functional training exclusively TBIs had been recruited and to take this
into account in the analysis.
In the area of functional training, proof of efficacy
Furthermore, it is important to scrutinize the key
was obtained for sit-to-stand transfer and arm ability
words carefully. ‘Brain injury’ was deliberately not
training, although the experimental group was
modified for searches in the PEDro, OT-Seeker and
compared with a control group that had not received
Cochrane databases in order to locate as many
any training so that conceptional superiority could
studies as possible and to avoid selection bias from
not be proven.
the outset. Due to the sheer size of the database
With regard to arm rehabilitation it is surprising
For personal use only.
while also taking into account individual expertise 10. Mortenson P, Eng J. The use of casts in the management of
and the preferences of the patient. joint mobility and hypertonia following brain injury in adults:
A systematic review. Physical Therapy 2003;83:648–658.
11. Lannin N, Horsley S, Herbert R, McCluskey A, Cusick A.
Splinting the hand in the functional position after brain
Declaration of interest: The authors report impairment: A randomised controlled trial. Archieve of
no conflicts of interest. The authors alone are Physical Medicine and Rehabilitation 2003;84:297–302.
responsible for the content and writing of the paper. 12. Moseley A. The effect of casting combined with stretching on
passive ankle dorsiflexionin adults with traumatic head injury.
Physical Therapy 1997;77:982–983.
13. Verplanke D, Snape S, Salisbury C. A randomised controlled
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