Rehabilitation and Returning to Activity After Prolonged Moderate Traumatic Brain Injury

Traumatic brain injury (TBI) is a growing global health concern—by 2024, the World Health Organization (WHO) predicts it will be the third leading cause of death and disability worldwide. For many, the journey doesn’t end with initial treatment: 10–30% of people who survive head injuries face delayed symptoms like balance issues, headaches, or dizziness months to years later. But how can physical therapy help those with prolonged moderate TBI (mTBI) regain their independence? A 2021 case report from Qassim University offers a compelling example of recovery.

Dr. Norah M. Alsalamah, a physical therapist in the College of Applied Medical Sciences at Qassim University in Buraidah, Saudi Arabia, details the story of a 24-year-old Saudi woman who sought help 10 months after a life-altering road traffic accident. The crash caused a skull fracture and internal brain hemorrhage; she underwent surgery and spent 10 days in the ICU but still struggled with severe imbalance (she held walls to change direction), headaches, dizziness, double vision, and a “foggy” sensation. No other health conditions complicated her recovery.

Imaging revealed surgical skull defects in her occipital bone (the back of the skull) and residual brain changes in her frontal lobes and right cerebellum. A physical exam found tenderness in her neck muscles (suboccipital area) and upper cervical joints—touching these areas triggered dizziness and headaches. While her neck and limb movement ranges were normal, tests showed critical deficits:

Buffalo Concussion Treadmill Test: Measured her ability to safely do aerobic exercise (key for recovery without worsening symptoms).
Balance Error Scale System: Her score of 24 confirmed severe imbalance (higher scores mean more balance issues).
Y Balance Test: A dynamic stability tool—her composite scores (47% right leg, 47.5% left leg) indicated poor neuromuscular control, raising her risk of falls or lower limb injuries.
Post-Concussion Symptom Scale (PCSS): She rated her symptoms (headache, dizziness, fogginess) a 33 out of 132—moderate severity.

A Holistic Physical Therapy Plan

Dr. Alsalamah’s intervention focused on four core pillars to address both symptoms and long-term recovery:

Education: Explaining her limits, how exercises would help, and TBI prevention.
Rehabilitation: Over 30 in-clinic sessions (plus a home program) targeting balance, proprioception (awareness of body position), and lower limb strength. She practiced standing exercises (double-leg, single-leg, tandem) until she could hold each for 30 seconds. In the final weeks, she progressed to Nordic walking—using poles to engage her upper body and trunk, which boosted overall stability.
Vestibular Rehabilitation: Gaze stability and balance exercises reduced her dizziness.
Prevention & Return to Activity: A structured 6-stage plan (from light exercise to non-contact activities) helped her rebuild confidence safely. She learned warm-up routines, hip stability exercises, and how to avoid re-injury.

The Results: No Symptoms and Restored Function

By the end of the program, the patient reported no symptoms—not at rest, not during activity. She could stand on one leg or in a heel-to-toe “tandem” position with eyes open or closed. Her Y Balance scores jumped to 71.2% (right) and 67.5% (left)—a major improvement in her ability to move safely. Most importantly, she regained the confidence to return to daily life without fear of imbalance or pain.

Key Takeaways for TBI Recovery

This case highlights that prolonged mTBI symptoms don’t have to be permanent. A structured, patient-centered physical therapy program—combining education, rehabilitation, prevention, and gradual return to activity—can help even 10 months after injury. The key was holism: treating not just the body, but also the patient’s understanding of their recovery and how to stay safe long-term.

For anyone struggling with post-TBI symptoms, this story offers hope: recovery is possible with the right support.

Original research by Norah M. Alsalamah, Physical Therapy Department, College of Applied Medical Sciences, Qassim University, published in the Chinese Medical Journal (2021). Patient consent was obtained for the report.

doi: 10.1097/CM9.0000000000001403

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