When Should I Start Treatment After TBI
In order for rehabilitation to be maximally effective following a concussion, it would be ideal to know exactly when the optimal time is to start rehabilitation after your injury. Having the answer to this question would seemingly enhance the recovery of individuals with a concussion. (1) Although there are studies that have attempted to answer this question, (2,3) animal models have played a significant role in what we know today. The majority of these studies have primarily been addressed in animal models of stroke and applied to the rehabilitation of both stroke and concussion patients. The difficult challenge with this is that a stroke is not a concussion and animals are obviously not humans which makes extrapolating this data a little less than ideal.
Most would agree that rehabilitation is more effective when started earlier as opposed to later. Reach training following a stroke in a rat that starts 4 days post-stroke enhances recovery, while the same training started at 25 days post-stroke is ineffective. (4) Similarly, in monkeys, reach training that begins within 1 week post- stroke but not 30 days post-stroke leads to more favorable outcomes. (5,6) In TBI patients, studies show that outcomes were better if patients received rehabilitation within the first year (7) following TBI. (8)
The available evidence indicates that early onset neurorehabilitation and more intensive neurorehabilitation promotes functional recovery of patients with moderate to severe TBI compared with usual care. (9)
Although all of these studies point to the idea that earlier is better, the definition of early differs, and there is no definitive guideline that points to a particular time point post-injury during which rehabilitation is maximally effective. Also, I can tell you from my own personal experience I have seen numerous patients with injuries that occurred many years and sometimes even decades prior that are able to make a significant amount of progress. In addition, animal models demonstrate that different rehabilitation strategies seem to have different time points during which they are maximally effective, suggesting that the optimal rehabilitation time point may differ depending on what therapy is prescribed.
Although starting rehabilitation early seems to be beneficial, it has also been demonstrated that care needs to be taken to not initiate rehabilitation too early. Most individuals will no longer feel symptomatic after a few weeks to a month post injury. Notice I did not use the word recover because feeling symptomatic and actually recovering are not synonymous. Check the blog article "Is it Possible to Fully Recover after TBI?" to learn the difference betweem asympotomcatic and recovered. If you refer back to the article titled “What Happens During a Concussion” you will learn how there is a metabolic cascade of events that occurs after a concussion. This cascade of events leads to a disruption in the sodium, potassium, and calcium levels. When all of these ions end up in the incorrect location the brain has to use a lot of energy to restore all of the ions back to neutrality. Therefore, when you start a neuro-rehabilitation program, especially at Peak Brain Performance Centers, you will be performing seemingly simple tasks that will require a lot of brain power. Now if your brain is still in the process of restoring everything back to normal while simultaneously going through an intense individualized treatment program it can make it very difficult for you to achieve the results we are both in search of in a relatively quick manner. In a recent study done on rats who had undergone a concussion, forcing the use of the impaired limb creates contusions that correspond structurally to an area of increased glucose metabolism, (10) suggesting that an over-activation may occur when one doesn’t have enough resources to fuel that specific activation.
At Peak Brain Performance Centers we look at each case as a unique individual and make the recommendation on when its an appropriate time to start care based on the severity of the injury, symptom presentation, metabolic factors, neurological findings, and the patient’s lifestyle/needs. If you or someone you know has recently experienced a head injury and are wondering when should I start seeking out treatment options, schedule a free phone consult with the doctor by clicking the contact us button at the top of the page. There are answers, and I hope to talk to you soon!
References:
1. Horn SD, Corrigan JD, and Dijkers MP. Traumatic brain injury rehabilitation comparative effective- ness research: Introduction to the traumatic brain injury-practice based evidence archives supplement. Archives of Physical Medicine and Rehabilitation. 2015; 96: S173–7.
2. Lang CE, Lohse KR, and Birkenmeier RL. Dose and timing in neurorehabilitation: Prescribing motor therapy after stroke. Current Opinion in Neurology. 2015; 28: 549–55.
3. Wahl AS and Schwab ME. Finding an optimal reha- bilitation paradigm after stroke: Enhancing fiber growth and training of the brain at the right moment. Frontiers in Human Neuroscience. 2014; 8: 381.
4. Hsu JE and Jones TA. Time-sensitive enhancement of motor learning with the less-affected forelimb after unilateral sensorimotor cortex lesions in rats. European Journal of Neuroscience. 2005; 22: 2069–80.
5. Nudo RJ, Wise BM, SiFuentes F, and Milliken GW. Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science. 1996; 272: 1791–4.
6. Barbay S, Plautz EJ, Friel KM et al. Behavioral and neurophysiological effects of delayed training fol- lowing a small ischemic infarct in primary motor cortex of squirrel monkeys. Experimental Brain Research. 2006; 169: 106–16.
7. Griesbach GS, Kreber LA, Harrington D, and Ashley MJ. Post-acute traumatic brain injury rehabilitation: Effects on outcome measures and life care costs. Journal of Neurotrauma. 2015; 32: 704–11.
8. Turner-Stokes L, Pick A, Nair A, Disler PB, and Wade DT. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. The Cochrane Database of Systematic Reviews. 2015; 12: CD004170.
9. Königs M, Beurskens EA, Snoep L, Scherder EJ, Oosterlaan J. Effects of Timing and Intensity of Neurorehabilitation on Functional Outcome After Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2018 Jun;99(6):1149-1159.e1. doi: 10.1016/j.apmr.2018.01.013. Epub 2018 Feb 8. PMID: 29428344.
10. Kozlowski DA, Lee SM, and Hovda DA. Use- dependent degeneration following fluid percussion injury corresponds to areas of increased glucose metabolism. Society for Neuroscience Abstracts. 1997.