9.3 Acquired Brain Injury

Quick Answer: ABI is motor rehab through a cognitive–behavioural lens. Severity labels (GCS, PTA) inform but never replace functional assessment. Adapt cueing and dual-task load to cognition; manage behaviour and fatigue with environment and dosing; progress return-to-activity with proper clearances. In tumour/neurosurgical contexts, stop for raised-ICP red flags and escalate medically.

Acquired brain injury (ABI) refers to brain damage occurring after birth that is not primarily hereditary, congenital, or degenerative. For APC Written Assessment purposes, the big clinical clusters are traumatic brain injury (TBI) and non-traumatic ABI (hypoxic-ischaemic injury, infection, metabolic insults, and brain tumour related disability). Stroke is a major ABI subtype already covered in sections 9.1–9.2; this section focuses on TBI severity thinking, cognitive-motor and behavioural rehab implications, fatigue and return-to-activity, plus tumour-specific cautions relevant to Australian inpatient, community, and private settings.

TBI Severity Concepts (Without False Precision)

Severity is commonly framed using combinations of:

• Glasgow Coma Scale (GCS) at scene or admission (mild/moderate/severe bands historically linked to GCS ranges).
• Duration of loss of consciousness.
• Post-traumatic amnesia (PTA) duration—often one of the more useful prognostic and staging tools in rehabilitation; people in PTA may be confused, amnesic for ongoing events, and unsafe for complex independence.
• Imaging findings (contusions, diffuse axonal injury, haematomas, surgical intervention).

Entry-level physiotherapists should understand that “mild” TBI is not always mild in impact—post-concussion symptoms can include headache, dizziness, cognitive fog, mood change, and exercise intolerance. Conversely, some people with alarming early imaging make strong functional recoveries. Never reason from a single label alone. Assess current motor control, balance, cognition for therapy engagement, behaviour, fatigue, and participation restrictions.

In acute moderate–severe TBI, medical priorities include intracranial pressure (ICP) management, seizure control, systemic stability, and prevention of secondary brain injury (hypoxia, hypotension). Physiotherapy early roles resemble acute neuro care: respiratory support as indicated, passive/active movement within precautions, positioning, tone and contracture prevention, and carefully graded sensory-motor stimulation as consciousness recovers—always within neurosurgical/ICU parameters.

Cognitive-Motor Interaction

ABI rarely produces a “pure motor” problem. Cognition shapes every session:

• Attention: can the person sustain focus for a sit-to-stand set?
• Memory: will they remember the home exercise without written/carer support?
• Processing speed: are your cues too fast or multi-step?
• Executive function: can they plan a safe transfer sequence or problem-solve when the aid is on the wrong side?
• Insight and judgment: do they recognise deficits, or attempt unsafe independent mobility?
• Visuospatial skills: navigation, aid placement, doorway negotiation.

Practical therapy adaptations:

• One instruction at a time; demonstrate; use consistent language across the team.
• External aids: whiteboards, phone alarms, illustrated programs, supervised practice schedules.
• Errorless or supported learning early if severe memory impairment frustrates trial-and-error.
• Reduce dual-task load initially (no complex conversation during first gait trials), then reintroduce dual task as a trained skill because community life is dual-task.
• Session structure: predictable routines help people with executive dysfunction.

If a patient “fails” a motor task only when distracted, that is clinically important for discharge safety (kitchen mobility while talking, street crossing). Document dual-task cost and train it explicitly rather than blaming motivation.

Behavioural Considerations

Behavioural changes after ABI include agitation, aggression, impulsivity, disinhibition, emotional lability, apathy, and sleep–wake disturbance. Causes are multifactorial: lesion location (especially frontal/temporal), PTA/confusion, pain, infection, constipation, medication effects, overstimulation, and frustration at disability.

Physiotherapy contributions to behavioural safety:

• Environment: quiet space, limited visitors during high-agitation periods, remove unnecessary equipment hazards.
• Timing: treat when the person is most settled; avoid fighting peak agitation with maximal physical challenge.
• Predictability and choice: simple choices (“walk to the window or the chair first?”) can reduce confrontation.
• Team consistency: same transfer method, same cue words; mixed messages escalate behaviour.
• Safety staffing: extra assistance for impulsive attempts to stand; low bed, sensor mats per unit policy; never leave highly impulsive patients standing unsupported while you turn away for a chart.
• De-escalation: calm voice, reduce demands, do not argue facts during confusional states; involve behavioural supports/psychology as available.

Do not interpret all refusal as “non-compliance warranting discharge.” Reassess pain, fatigue, fear, sensory overload, and cognitive load. Conversely, do not ignore risk when insight is poor—use supervision plans and graded freedom. Australian multi-disciplinary rehab units and community ABI services expect consistent behavioural strategies across professions.

Fatigue and Dosing

Post-ABI fatigue is often central and disproportionate to the physical work done. People may perform well for ten minutes then crash for hours. Strategies:

• Schedule demanding motor-cognitive tasks at best times of day.
• Use distributed practice with planned rest; teach energy conservation without complete avoidance of activity.
• Watch for delayed symptom exacerbation (common in concussion pathways): headache, fogginess, irritability after sessions—if present, reduce intensity and coordinate with medical guidance.
• Educate families that fatigue is neurological, not laziness.

Return-to-Activity: Work, Study, Sport, Driving

Return-to-activity is graded and multidisciplinary:

• Physical activity: progress aerobic and strengthening as symptoms and medical status allow; monitor symptom-limited exercise in concussion-related ABI.
• Work/study: graded hours, reduced dual-task load, environmental adjustments, occupational therapy and vocational rehab liaison.
• Sport: stepwise return-to-play protocols after concussion are medical-led; physiotherapy supports exertion tolerance, balance/vestibular components when indicated, and must not clear elite return alone outside scope/protocol.
• Driving: medical and legal clearance pathways apply in Australia; cognitive, visual, and motor criteria matter—do not green-light driving based only on walking speed.

Always clarify seizure status, medication sedation, and visual deficits before community mobility goals that imply road use.

Brain Tumour Rehabilitation Cautions

People with primary or metastatic brain tumours present with progressive or fluctuating neurology: focal weakness, seizures, cognitive change, headache, and treatment effects (surgery, radiotherapy, chemotherapy, steroids). Rehab goals remain functional—mobility, falls prevention, upper-limb use, respiratory care, carer training—but prognosis and medical status reshape intensity and honesty of goal setting.

Raised intracranial pressure (ICP) red flags

Escalate urgently for features suggesting raised ICP or neurological deterioration, such as:

• Progressive severe headache, especially worse lying flat or morning headache with vomiting.
• New or worsening drowsiness, confusion, or reduced GCS.
• New pupillary change, acute diplopia, or other cranial nerve change reported in the vignette.
• Seizure activity.
• Rapidly progressive focal deficit.
• Cushing-type patterns in monitoring environments (hypertension with bradycardia—recognise as emergency context in acute settings).

If these appear during therapy, stop the session, position safely per acute protocol (often head elevation if ordered), do not provoke Valsalva/inverted postures, and obtain immediate medical review. Do not continue vestibular spinning drills or heavy isometric loading when raised ICP is suspected.

Medical liaison across treatment phases

• Pre/post neurosurgery: respect orders for bed rest, drain care, blood pressure, and wound/skull integrity; avoid pressure on craniectomy sites; helmet use if prescribed after decompressive craniectomy.
• Steroids: may temporarily improve function; watch for steroid side effects (proximal weakness, mood, glucose) that change rehab performance.
• Radiotherapy/chemotherapy: fatigue and cytopenia risk may limit intensity; infection control and bleeding risk awareness matter for hands-on techniques and gym exposure.
• Palliative-adjacent goals: when disease is advanced, prioritise comfort, safe transfers for care, positioning, and family education over aggressive restorative targets the person cannot sustain. That is competent, ethical practice—not “giving up.”

Putting ABI Reasoning Together for APC Cases

A high-quality answer usually:

1. Identifies safety/cognitive/behavioural constraints.
2. Adapts motor practice to cognition (cueing, dual-task, environment).
3. Doses for fatigue.
4. Plans graded return-to-activity with the right clearances.
5. For tumour/acute neurosurgical contexts, spots raised-ICP red flags and liaises rather than pushing generic neuro rehab.

Traps include treating ABI as pure hemiparesis identical to uncomplicated ischaemic stroke, ignoring PTA/confusion in independence decisions, using complex multi-step home programs for severe memory impairment without supports, and continuing high-intensity therapy through new vomiting headache and drowsiness in a tumour patient.

Interdisciplinary Reality

ABI rehab is team sport: medicine, nursing, occupational therapy, speech pathology, neuropsychology, social work, and recreation therapy often share goals. Physiotherapy owns mobility, motor control, balance, respiratory contributions, and physical activity progression—but shares cognition-behaviour strategies. Document functional baselines with enough cognitive context that the next clinician understands why assistance levels differ between quiet morning sessions and busy afternoon wards. Thresholds-aligned practice includes collaborative communication, culturally safe engagement with families, and scope-aware referral when mood, behaviour, or medical status exceeds physiotherapy-only management.

Closing Exam Anchor

ABI care is motor rehab through a cognitive-behavioural lens, dosed for fatigue, aimed at real-life return-to-activity, and—especially with tumour or acute neurosurgical patients—always subordinate to neurological stability and raised-ICP red flags.