Impact Of Early Cognitive Rehabilitation On Functional Outcomes Following Moderate Traumatic Brain Injury
Phase: NA
Conditions: TBI (Traumatic Brain Injury)
Sponsor: Amany Saadallah Hassan Mobarez

 
 
 
 
 
 
 
 
Official Title : Impact  of  early cognitive  rehabilitation on functional outcomes 
following moderate traumatic brain injury 
 
 
 
 
 
 
 
BY 
 
Amany saadallah hassan mobarez 
 
 
 
 
 
 
Submitted For Partial Fulfillment Of The Requirements Of 
Doctoral Degree  
In Department Of Physical Therapy For Neurology  
Faculty Of Physical Therapy 
Cairo University 
2023
 
Document 
Date: 1 
December 2023 
 
NCT Number: 
Not yet 
assigned 
 
 

1 
 
Chapter I 
Introduction 
Traumatic brain injury occurs from violent blows or objects, 
causing physical and psychological effects. Signs may appear 
immediately or days later, affecting the brain's function and 
functioning (Plass et al ., 2019) . Traumatic Brain Injury (TBI) 
impacts health and quality of life, with unpredictable prognosis. 
Exercise is crucial for neuroplasticity and brain rewiring ( 
Kiwanuka et al .,2023). 
 Moderate to severe traumatic brain injuries may cause 
physical symptoms such as loss of consciousness, persistent 
headaches, vomiting, nausea, seizures, eyelid dilation, and 
coordination issues. Cognitive symptoms include profound 
confusion, unusual behavior, slurred speech, and coma. These 
symptoms may appear within hours or days of the injury (Breting 
et al., 2023). 
Intensive care unit (ICU) hospitalization saves lives but often 
costs ICU survivors, who often experience cognitive impairment 
and 
physical 
and 
functional 
disabilities. 
Early 
physical 
rehabilitation improves chances of regaining pre-hospital 
functional status, but early cognitive rehabilitation for these 
patients remains unexplored (Muradov et al ., 2021) 

2 
 
The Glasgow Coma Scale, published in 1974, measures 
impaired consciousness in acute medical and trauma patients 
using eye-opening, motor, and verbal responses. It provides a 
clear, communicable picture of a patient's state (Yee et al., 2023). 
The Rancho Los Amigos Scale (RLAS) is a medical 
assessment tool for individuals recovering from closed head 
injuries, including traumatic brain injuries. It evaluates cognitive 
and behavioral presentations as they emerge from coma, 
comparing patients' state of consciousness and reliance on 
assistance (Palatinus , 2018). 
The Functional Independence Measure (FIM) is an 18-item 
assessment tool for evaluating patients' functional status in 
rehabilitation after stroke, traumatic brain injury, spinal cord 
injury, or cancer. It evaluates self-care, continence, mobility, 
transfers, communication, and cognition, with each item rated 1-7 
(Lee et al ., 2022). 
Passive range of motion exercises are very important if you 
have to stay in bed or in a wheelchair. ROM exercises help keep 
joints and muscles as healthy as possible. Without these exercises, 
blood flow and flexibility (moving and bending) of the joints can 
decrease. Passive ROM exercises help keep joint areas flexible 
(Hosseini et al ., 2019). 

3 
 
Statement of the problem: 
Is there an effect of early cognitive rehabilitation on length 
of stay and functional outcomes in patients following moderate 
traumatic brain injury. Purpose of the study: 
The aim of this study is to detect the impact of early 
cognitive rehabilitation on functional outcomes and length of stay 
with patients following moderate traumatic brain injury 
Significance of the study: 
Neurocognitive consequences can last for months to years 
and possibly become chronic, affecting survivors' quality of life 
(QOL). However, neurocognitive deficits following intensive care 
unit (ICU) admission have only lately attracted scholarly and 
therapeutic attention. The purpose of cognitive rehabilitation 
following a TBI is to improve the person's ability to receive and 
interpret information, as well as to perform mental activities 
(Ramnarain et al., 2013).  
Cognition covers all aspects of perception and action. As a 
result, cognition displays itself in system behaviour. Cognition 
influences behaviour. The cognitive apparatus and brain are 
shaped through behaviour (Kaufman et al ., 2020). 
Bender et al (2014) proposed an early interval rehabilitation 
programme to improve Functional Independence Measure (FIM) 
at discharge, which is translated into improved daily activities. 

4 
 
Rehabilitation has been shown to play a key role in enhancing 
functional outcomes following discharge. According to previous 
research, the FIM is the most often used functional assessment 
instrument for inpatient rehabilitation (Stuck et al ., 2022) . 
Hypothesis: 
There 
is 
significant 
difference 
of 
early 
cognitive 
rehabilitation on functional outcomes and length of stay with 
patients 
following 
moderate 
traumatic 
brain 
injury.                      
.   
  Basic assumptions: 
   It will be assumed that: 
Safety  precautions and environmental aspects will be the 
same for all patients during the study. 
 
Delimitations: 
This study will be delimited to: 
1. Thirty  four  patients with moderate  traumatic brain 
injury of both sex. 
2. The age over 18 years old. 
3. Patient’s with GCS (9-12). 
 

5 
 
Chapter II 
Review of literature 
 A traumatic brain injury (TBI) can be caused by a forceful 
bump, blow, or jolt to the head or body, or from an object that 
pierces the skull and enters the brain. Not all blows or jolts to the 
head result in a TBI.Some types of TBI can cause temporary or 
short-term problems with normal brain function, including 
problems with how the person thinks, understands, moves, 
communicates, and acts. More serious TBI can lead to severe and 
permanent disability, and even death. Some injuries are 
considered primary, meaning the damage is immediate. Other 
outcomes of TBI can be secondary, meaning they can occur 
gradually over the course of hours, days, or appear weeks later. 
These secondary brain injuries are the result of reactive processes 
that occur after the initial head trauma (Overman ., 2022). 
A traumatic brain injury (TBI) can cause problems with 
consciousness, 
awareness, 
alertness, 
and 
responsiveness. 
Generally, there are four abnormal states that can result from a 
severe TBI : Minimally conscious state—People with severely 
altered consciousness who still display some evidence of self-
awareness or awareness of one's environment (such as following 
simple commands, yes/no responses).Vegetative state—A result of 
widespread damage to the brain, people in a vegetative state are 

6 
 
unconscious and unaware of their surroundings( Joshua et al ., 
2022).  
However, they can have periods of unresponsive alertness 
and may groan, move, or show reflex responses. If this state lasts 
longer than a few weeks, it is referred to as a persistent vegetative 
state. Coma—A person in a coma is unconscious, unaware, and 
unable to respond to external stimuli such as pain or light. Coma 
generally lasts a few days or weeks after which the person may 
regain consciousness, die, or move into a vegetative state. Brain 
death—The lack of measurable brain function and activity after 
an extended period of time is called brain death and may be 
confirmed by studies that show no blood flow to the brain 
(Gosseries et al., 2022). 
Traumatic brain injuries may be emergencies. In the case of 
more-severe TBIs, consequences can worsen rapidly without 
treatment. Doctors or first responders need to assess the situation 
quickly (Lulla et al., 2023) . Glasgow Coma Scale ; This 15-point 
test helps a doctor or other emergency medical personnel assess 
the initial severity of a brain injury by checking a person's ability 
to follow directions and move their eyes and limbs. The coherence 
of speech also provides important clues. Abilities are scored from 
three to 15 in the Glasgow Coma Scale. Higher scores mean less 
severe injuries (Basak,et al .,2023). 

7 
 
A moderate or severe TBI is caused by a bump, blow, or jolt 
to the head or by a penetrating injury (such as  to the head. In the 
United States, severe TBIs are linked to thousands of deaths each 
year. For those who survive, a moderate or severe TBI may lead 
to long-term or life-long health problems that may affect all 
aspects of a person’s life. These health problems have been 
described as being similar to the effects of a chronic disease 
(Kraus et al., 2023). 
Computerized tomography (CT) scan. This test is usually the 
first performed in an emergency room for a suspected traumatic 
brain injury. A CT scan uses a series of X-rays to create a detailed 
view of the brain. A CT scan can quickly visualize fractures and 
uncover evidence of bleeding in the brain (hemorrhage), blood 
clots (hematomas), bruised brain tissue (contusions), and brain 
tissue swelling (Yue et al ., 2023). 
The Rancho Los Amigos Scale (RLAS), also known as the 
Ranchos Scale, is a widely accepted medical scale used to describe 
the cognitive and behavioral patterns found in brain injury 
patients as they recover from injury. It was originally developed 
by the head injury team at the Rancho Los Amigos Hospital in 
Downey, California to assess patients emerging from a coma 
(Joshua et al ., 2022). It is often used in conjunction with the 
Glasgow Coma Scale during the initial assessment of a brain 

8 
 
injury patient. However, unlike the Glasgow Coma Scale, it is 
used throughout the recovery period and not limited to the initial 
assessment. It takes into account state of consciousness as well as 
their reliance on assistance to carry out their cognitive and 
physical functions. This activity describes the clinical use of the 
Ranchos Los Amigos scale to assess patients with a head injury 
(Margagliotti ., 2023). 
The Functional Independence Measure (FIM) was developed 
to address the issues of sensitivity and comprehensiveness that 
were criticized as being problematic with the Barthel Index 
(another measure of functional independence). The FIM was also 
developed to offer a uniform system of measurement for disability 
based on the International Classification of Impairment, 
Disabilities and Handicaps for use in the medical system in the 
United States (McDowell & Newell, 1996). The level of a patient’s 
disability indicates the burden of caring for them and items are 
scored on the basis of how much assistance is required for the 
individual to carry out activities of daily living. The FIM assesses 
six areas of function (Self-care, Sphincter control, Transfers, 
Locomotion, Communication and Social cognition), which fall 
under two Domains (Motor and Cognitive) ( Manik et al ., 2022). 
Shiel et.al., 2001 in his study emphasis that increase in 
rehabilitation reduces the length of stay in hospital (Level 1b 

9 
 
evidence). There is Level 4 evidence that patients with a long 
length of stay who receive high-intensity rehabilitation fair better 
on the Rancho Los Amigos Scale at discharge than those who 
receive low-intensity rehabilitation(Goodwin et al ., 2016). 
          Passive exercises are largely preventive in nature and are 
used to; maintain range of motion, maintain joint and connective 
tissue mobility,  minimizes the effects of and the formation of 
contractures, enhances synovial movement, maintain mechanical 
elasticity of muscles, assist circulation and vascular dynamic and 
help maintain the patient’s awareness of movement (Alaparthi et 
al.,  2021). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

10 
 
Chapter III 
Subjects, materials and methods 
Study Design: 
Randomized Control Trial Pre-test- post-test control study 
design. 
 
Subjects: 
Subjects selection: 
Thirty four patients of both sex  medically diagnosed with 
moderate  traumatic brain injury using CT and GCS. 
The patients will be divided randomly into two groups: 
 Study 
group: 
Seventeen 
Patients 
in 
study 
group will receive early cognitive  therapy program in 
addition to Control group: Seventeen Patients in 
control group will receive selected physiotherapy 
program only (Chest care exercise, passive movement 
of the four limbs). 
G*Power and sample size calulations 

11 
 
 
Inclusion criteria: 
1. Both Genders. 
2. Moderate  traumatic brain injury patients will be 
included with GCS score 9-12. 
3. Patients’ age 18 years old and more . 
4. All patients must be medically stable post trauma.  
Exclusion Criteria: 
1. children under 18 years old . 
2.Previous cerebral infarction and intracranial space-
occupying 
lesions.  
3.Patients with cancer and major underlying illnesses.  
4.Patients with diffuse axonal damage.  
5. Incomplete clinical and imaging data 
6.Patient with other neurological deficits or orthopedic 

12 
 
abnormalities  that causing disability. 
7.Patients with serious psychiatric pathology or mentally. 
Materials: 
Clinical history will be taken and data collection ( Name, 
Age, ,  job, mechanism of injury,  vital signs , head injury 
severity , GCS , CT scan findings, Intensive Care Unit (ICU) 
length of stay (LOS) ). 
Place of application: 
Patient will be assessed and treated in Neurotrauma ICU in 
emergancy hospital   kasr al aini medical school. 
Evaluation Methods and Procedure: 
         Each patient will be evaluated three times; pre-treatment, 
post first week and post tow weeks   of ICU  stay. 
A. Glasgow Coma Scale: 
The patient’s level of consciousness will assessed with  the GCS, 
and 9 - 12 points indicates moderate injury as indicated in 
(APPENDIX I) . 
 
B. Rancho Los Amigos Revised Scale (RLAS-R) (Tölli et al ., 
2019) 
The RLA Scale measures the levels of awareness, cognition, 
behavior, and interaction with the environment after TBI. 
Level I – no response (total assist) to Level X – purposeful, 

13 
 
appropriate (modified independent) as indicated : 
Level I: No Response: Total Assistance 
 No response to external stimuli 
Level II: Generalized Response: Total Assistance 
 Responds inconsistently and non-purposefully to 
external stimuli 
 Responses are often the same regardless of the 
stimulus. 
Level III: Localized Response: Total Assistance 
 Responds inconsistently and specifically to external 
stimuli 
 
 Responses are directly related to the stimulus, for 
example, patient withdraws or vocalizes to painful 
stimuli 
 Responds more to familiar people (friends and family) 
versus strangers 
Level IV: Confused/Agitated: Maximal Assistance 
 The individual is in a hyperactive state with bizarre 
and non- purposeful behavior 
 Demonstrates agitated behavior that originates more 
from internal confusion than the external environment 
 Absent short-term memory 
 

14 
 
Level V: Confused, Inappropriate Non-Agitated: Maximal 
Assistance 
 
 Shows increase in consistency with following and 
responding to simple commands 
 Responses 
are 
non-purposeful and
random to more 
complex commands 
 Behavior and verbalization is often inappropriate, 
and 
individual 
appears 
confused 
and 
often 
confabulates 
 If action or tasks is demonstrated individual can 
perform but does not initiate tasks on own 
 Memory is severely impaired and learning new 
information is difficult 
 Different from level IV in that individual does not 
demonstrate agitation to internal stimuli. However, they 
can show agitation to unpleasant external stimuli. 
Level VI: Confused, Appropriate: Moderate Assistance 
 
 Able to follow simple commands consistently 
 
 Able to retain learning for familiar tasks they 
performed pre-injury (brushing teeth, washing face) 
however unable to retain learning for new tasks 
 Demonstrates increased awareness of self, situation, 

15 
 
and environment but unaware of specific impairments 
and safety concerns 
 Responses may be incorrect secondary to memory 
impairments but appropriate to the situation 
Level 
VII: 
Automatic, 
Appropriate: 
Minimal 
Assistance for Daily Living Skills 
 Oriented in familiar settings 
 
 Able to perform daily routine automatically with 
minimal to absent confusion 
 Demonstrates carry over for new tasks and learning 
in addition to familiar tasks 
 
 Superficially aware of one’s diagnosis but unaware of 
specific impairments 
 Continues to demonstrate lack of insight, decreased 
judgment and safety awareness 
 Beginning to show interest in social and recreational 
activities in structured settings 
 Requires at least minimal supervision for 
learning and safety purposes. 
Level VIII: Purposeful, Appropriate: Stand By Assistance 
 Consistently oriented to person, place and time 
 Independently carries out familiar tasks in a non-

16 
 
distracting environment 
 Beginning to show awareness of specific impairments 
and how they interfere with tasks, however, requires 
standing by assistance to compensate 
 Able to use assistive memory devices to recall daily 
schedule 
 Acknowledges other’s emotional states and requires 
only minimal assistance to respond appropriately 
 Demonstrates improvement of memory and ability to 
consolidate the past and future events 
 Often depressed, irritable and with low frustration 
threshold 
Level IX: Purposeful, Appropriate: Stand By Assistance on 
Request 
 Able to shift between different tasks and complete
them independently 
 Aware of and acknowledges impairments when they 
interfere with tasks and able to use compensatory 
strategies to cope 
 Unable to independently 
anticipate 
obstacles that may 
secondary to impairment 
 With assistance able to think about consequences of 

17 
 
actions and decisions 
 Acknowledges the emotional needs of others 
with stand by- assistance. 
 Continues to demonstrate depression and low 
frustration threshold 
Level X: Purposeful, Appropriate: Modified Independent 
 Able to multitask in many different environments 
with extra time or devices to assist 
 Able to create own methods and tools for memory 
retention 
 Independently anticipates obstacles that may occur 
as a result of impairments and take corrective actions 
 Able to independently make decisions and act 
appropriately but may require more time or 
compensatory strategies 
 Demonstrate intermittent periods of depression and 
low frustration threshold when under stress 
 Able to appropriately interact with others in social 
situations. 
C.  Functional Independence Measure (FIM)(Figure 2)( Naghdi, 
et al ., 2016). 
The FIM scores are a combined physical and cognitive 
measure which ranges from 18 to 126. It evaluates 18 items (13 

18 
 
motor and 5 cognitive) with 1 point (total assistance) to 7 points 
[fully independent]). The difference between FIM at admission 
and FIM at discharge from inpatient rehabilitation is the actual 
functional gain or FIM gain and is a measure of functional 
recovery. 
 FIM efficiency is defined as FIM gain divided by number of 
days in hospital. It reflects the mean gain in scores per day. The 
functional limitations based on FIM Score have been divided into 
three groups as high (FIM score <40), moderate (FIM 40–79), and 
low (FIM ≥80) 
 
Treatment Methods and Procedure: 
 
 All these exercises  for each group were given to patients for 
around 30-45  minutes every six days . 
 Control group: Fifteen patients in control group will 
receive selected physiotherapy program only (Chest 
care exercise, passive movement of the four limbs). 
 Study group: Patients in study group will receive 
early cognitive  therapy program in addition to 
selected physical therapy program (Chest care 
exercise, passive movement of the four limbs). 
 

19 
 
 
 
A. Passive range of movement for all four limbs and positioning 
for head injury patients (Osti et al ., 2017). 
 The patient was placed in a comfortable position with a 
head-up position to increase venous drainage and a head-up 
position that is a semi-recumbent position of 30 degrees to 
reduce increased intracranial pressure. 
 The patients who are unable to keep the head upright was 
stabilized by hard cervical collar (ambulance collar) but also 
saw to that it is not causing venous obstruction. 
 The therapist took an appropriate position and effective 
stance ,  the area has been freed from restrictive closures, 
linen, splints and bandages and the patient was flexed and 
covered as necessary. 
 All range of motion  exercises were performed smoothly and 
gently. We never force, shake, or over-extend the muscles. 
 The range of motion  exercise for each limb  was repeated 
from 5 to 10 repetitions, with a time rate equal to the 
performance time and the rest time, according to the 
patient’s condition and response, in order to give the patient 
an opportunity to respond. 

20 
 
B . Chest clearance intervention (Ntoumenopoulos et al ., 2018). 
 The chest care included percussion and positional drainage. 
.C.Procedure for cogntive therapy 
 All these exercises had  given to patients  with study group 
around 20-30 minutes six days /weak . 
 
1.The coma stimulation incorporated with cognition training such 
as : 
i. Multimodal Sensory stimulation, research suggests that 
sensory modalities are more effective when in concert with 
each other (Norwood et al ., 2023) including : 
a. Visual- Administered by using a flashlight, bright-
colored objects, a mirror, and pictures of various 
shapes and sizes. The patient is encouraged to track 
these objects. 
b. Auditory- Uses taped voice recordings of family and 
friends, favorite music, or sounds from nature. 
c. Olfactory- Uses perfume, spices, or the aroma of food 
items. 
d. Gustatory- Spices, popsicles. Swabs of appropriate 
items can be touched on the patient’s tongue to 
stimulate the taste sensation. 

21 
 
e. Tactile- Administered by rubbing different textures 
like satin, silk, fur, smooth metal, sandpaper, or cool or 
warm items over the patient's body surfaces. 
ii. Calling out their names, using patient’s relatives help for 
transferring etc were used for improving the cognition and 
conscious levels. 
 
2.Kinesthetic Stimulation (Thomas et al ., 2018) 
a. Passive movements to prevent contractures, deformities 
and to maintain muscle properties, active assisted exercises 
and facilitation techniques to improve the muscle tone. 
Positional changes from supine to sit, sitting in chair and 
standing with support/tilt table given to improve the 
arousal mechanism. 
b. Joint approximation by weight bearing on hands, leg 
support on high stools, positioning changes, slow rocking 
in high sitting position, tactile stimulation by tapping on 
muscle bellies to facilitate movements, quick stretches to 
initiate muscle contractions all Should be  added to 
improve the brain stem arousal. 
 Each movement two times, allowing 1 minute to respond. This 
will be performed either on bed or on wheelchair, one extremity 
at a time. 

22 
 
 Red flags : 
Patients who are not maintained the systolic pressure of more 
than or equal to 110 and SPo2 below 90% must We prevent 
patients from  sitting upright and the chair mobilization(Thomas et 
al ., 2018). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

23 
 
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Puccio, A. M., ... & Investigators, T. T. T. (2023). Neuroworsening 
in the Emergency Department Is a Predictor of Traumatic Brain 
Injury Intervention and Outcome: A TRACK-TBI Pilot 
Study. Journal of Clinical Medicine, 12(5), 2024. 

 
Appendix (II) 
 
Glasgow Coma Scale (Reith et al ., 2016). 
 
 
 
 
 
 
 
 
 
 

1 
 
 
Appendix (III) 
 
 
 
 
 

2 
 
 
 
 
 
 
 
 
Statistical Analysis: 
Official Title : Impact  of  early cognitive  rehabilitation on functional outcomes 
following moderate traumatic brain injury 
 
 
 
 
 
 
 
BY 
 
Amany saadallah hassan mobarez 
 
 
 
 
 
Submitted For Partial Fulfillment Of The Requirements Of Doctoral Degree 
In Department Of Physical Therapy For Neurology 
Faculty Of Physical Therapy 
Cairo University 
 2023 
 
Document 
Date: 1 
December 2023 
 
NCT Number: 
Not yet 
assigned 
 
 

3 
 
 
 
 

4 
 
Statistical Analysis: 
 Data will be statistically analyzed to compare the differences between 
the groups. The statistical package for social sciences (SPSS) will be 
used for data processing. Data will be statistically analyzed. 
 Descriptive statistics: including the number and percentage for all 
variables. 
 MANOVA: to compare between the different changes in GCS and 
Rancho los amigos cognitive scale through the three tested periods. 
 ANOVA: to compare between two distinctive testing periods. 
 Significant level: All statistical analyses were significant at P ≤0.05. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

5 
 
 
 
 
 
 
Consent form 
Official Title : Impact  of  early cognitive  rehabilitation on functional outcomes 
following moderate traumatic brain injury 
 
 
 
 
 
 
BY 
 
Amany saadallah hassan mobarez 
 
 
 
 
 
 
 
Submitted For Partial Fulfillment Of The Requirements Of Doctoral Degree 
In Department Of Physical Therapy For Neurology  
Faculty Of Physical Therapy 
Cairo University 
 2023 
 
 
 
Document 
Date: 1 
December 2023 
 
NCT Number: 
Not yet 
assigned 
 
 

6 
 
 
Consent form 
I acknowledge /                     
My relationship  to the patient/  
I agree to share the patient /                  In the research program under the 
direction of the researcher/ Amany S.H. Mobarez .  
A through description of the procedures has been explained and I understand 
that, I may withdraw my consent and discontinue participation in this 
research at any time without prejudice to me. 
 
Date :     /   / 202                                        
Participant: