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Rehabilitation after traumatic brain injury (TBI)
The duration of post-traumatic amnesia (PTA) is the best clinical predictor of outcome after brain injury — the longer it lasts, the more severe the injury; in the confused, agitated stage the environment is treated first, and drugs that slow recovery are avoided.
Why it matters in the exam
The exam asks about the definition of severity, measurement of PTA, the Rancho Los Amigos scale, the mechanism of axonal injury and the treatment of agitation. Severity is set by GCS (13–15 mild, 9–12 moderate, 3–8 severe), how long consciousness was lost and how long PTA lasted. Mild injury is defined (by ACRM) as GCS 13–15, loss of consciousness up to 30 minutes and PTA up to 24 hours. PTA is measured by a daily test such as the GOAT; a score of 75 or more on two consecutive days marks emergence from PTA.
Diffuse axonal injury (DAI) is caused by rotational acceleration-deceleration forces that stretch axons in the white matter, at the grey-white junction, in the corpus callosum and in the brainstem; CT can be almost normal, and MRI (blood-sensitive sequences) shows small foci. The Rancho Los Amigos scale describes the stages of cognitive-behavioural recovery: from no response, through generalised and localised response, a confused and agitated stage (stage IV), confused inappropriate, confused appropriate, up to automatic and purposeful.
Agitation after brain injury: first exclude pain, infection, sleep disturbance, constipation, urinary retention and drugs; arrange a quiet environment, a floor bed instead of restraints, and consistent staff. Among drugs, beta-blockers (propranolol) have the best evidence; haloperidol and benzodiazepines may slow recovery and are avoided as far as possible. Amantadine improves arousal, and methylphenidate improves attention and processing speed. After mild injury most symptoms resolve within weeks; graded return to activity, sport and work, and treatment of headache, sleep and anxiety. Visual problems are common after injury: convergence insufficiency and cranial nerve 4 palsy.
Key points
- PTA is the best clinical predictor.
- Mild: GCS 13–15, loss of consciousness up to 30 minutes, PTA up to 24 hours.
- DAI — rotational forces, CT almost normal.
- Agitation — environment first; propranolol; not haloperidol.
- Rancho Los Amigos describes recovery stages.
Summary table
| Measure | Mild | Moderate | Severe |
|---|---|---|---|
| GCS | 13–15 | 9–12 | 3–8 |
| Loss of consciousness | Up to 30 minutes | 30 minutes to 24 hours | Over 24 hours |
| PTA | Up to 24 hours | 24 hours to 7 days | Over 7 days |
| Imaging | Usually normal | Focal findings possible | DAI, haematomas, oedema |
A free exam question
על פי מה נקבעת החומרה של פגיעת ראש טראומטית (בחר ו בתשובה ה מדויקת.)ביותר? (the question as examined, in Hebrew)
- א. GCS , PTA , משך LOC
- ב. GCS , כאב ראש עם VAS>7 ו- PTA
- ג. משך LOC , GCS ו- FIM<100
- ד. PTA , משך LOC, כאב ראש עם VAS>7
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Sources
- Brain Injury Medicine: Principles and Practice, 3rd edition (2021) — Severity classification, post-traumatic amnesia and recovery
- VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury, 2021 — Symptom management and return to activity
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.