traumatic brain injury ( tbi ) is one of the most common causes of mortality and disability 
 worldwide , especially among children and young individuals .
the annual number of tbi cases 
 is considerably increasing , and tbi is the third leading cause of all injury - related 
 deaths1 , 2 .
the distribution of people who sustained a tbi according to gender is similar across the 
 world .
the male - to - female ratio is 3:1 
 in many countries worldwide , as well as in lithuania3,4,5 .
traffic accidents have been reported to be the most common cause of 
 tbi . among the elderly ,
severe tbi is characterized by an extended period of unconsciousness , which can last for 
 numerous days or even months , and coma , especially long - term , is an indicator of poor 
 prognosis7 , 8 .
tbi has been noted to cause movement , emotional , cognitive , and 
 behavioral impairments9,10,11,12,13 , 38 .
the relevance of treatment of patients who have sustained a tbi is increasing in all 
 developed countries .
however , to date , no effective and efficient treatment has been 
 established that could prevent secondary brain damage caused by the inflammatory response at 
 the site of injury14 .
rehabilitation during the early period of the disease ( acute rehabilitation ) remains a main 
 part of treatment for patients with tbis .
the application of physical therapy in these 
 patients during the early inpatient period of rehabilitation ( post - acute rehabilitation ) is 
 of paramount importance to ensure physical activity and the recovery of cognitive 
 functions15 .
physical therapy is a 
 constituent of rehabilitation directed to the prevention of various complications 
 ( pneumonia , contractures , thromboembolism , etc . ) , improvement of motor function , training of 
 balance and movement coordination , and improvement of cognition .
physical therapy covers 
 patients follow - up and assessment by using various standardized and nonstandardized tests 
 and scales and the evaluation of the results obtained . in the literature
, emphasis is placed on coma duration in the recovery of motor and 
 cognitive functions .
some authors have pointed out that the recovery of motor and mental 
 status depends on the coma duration , while others have stated that prolonged coma only 
 extends the period of rehabilitation , which is very practical regarding a financial 
 aspect16 , 17 .
the aim of this study was to evaluate the impact of physical therapy on the recovery of 
 motor and mental status in patients who sustained severe traumatic brain injuries , according 
 to coma duration in acute and post - acute rehabilitation .
this study was conducted in the brain injury and neurorehabilitation units of the hospital 
 of lithuanian university of health sciences .
patients with severe tbi are typically treated 
 first in acute medical settings , where the patient is medically stabilized and enrolled in 
 acute rehabilitation , and then discharged to post - acute rehabilitation .
the study was approved by the bioethics center of lithuanian university of health sciences 
 ( no .
all of the participants provided their written informed consent prior to 
 their participation in the study , in accordance with the ethical principles of the 
 declarations of helsinki . for the study , 52 patients ( 39 males and 13 females )
were randomly enrolled during the 
 acute rehabilitation , of whom 16 ( 11 males and 5 females ) were referred to the 
 neurorehabilitation unit during the post - acute rehabilitation .
the level of their consciousness ranged from 3 to 8 according to glasgow coma scale scores . 
 according to coma duration ,
the patients were divided into 2 groups as follows : the first 
 group comprised patients who were in a coma up to 1 week ( group 1 ) , and the second group 
 included patients who were in a coma for more than 2 weeks but not longer than 4 weeks 
 ( group 2 ) .
no 
 significant gender- and age - related differences were observed between the two groups 
 ( p>0.05 ) . in the neurorehabilitation unit ( post - acute rehabilitation ) , 10 patients in 
 group 1 and 6 patients in group 2 were admitted .
no sex- and age - related significant 
 differences were found between the two groups ( p>0.05 ) .
rehabilitation covered two periods as follows : an acute period from injury to condition 
 stabilization ( in the brain injury unit ; acute rehabilitation ) and from condition 
 stabilization to the recovery of functions ( in the neurorehabilitation unit ; post - acute 
 rehabilitation ) .
the patients in both groups underwent four assessments of functional and 
 mental status . during the acute rehabilitation ,
the patients were assessed in the brain 
 injury unit before the physical therapy procedures ( assessment 1 ) and before discharge 
 during the last physical therapy procedure ( assessment 2 ) . during the post - acute 
 rehabilitation ,
assessments were 
 performed before physical therapy procedures ( assessment 3 ) and before discharge during the 
 last physical therapy procedure ( assessment 4 ) .
each procedure performed twice a day usually took 3060 
 minutes to complete . in the brain injury unit , during the acute rehabilitation , the patients 
 underwent 14.6  4.3 procedures .
in the neurorehabilitation unit , during the post - acute 
 rehabilitation , the patients underwent 78.7  2.8 procedures . in post - acute rehabilitation , 
 an individual rehabilitation plan
is tailored to each patient . after a comprehensive patient 
 examination , the physical therapist considered the impairment of the patient s motor ( muscle 
 tone , muscle strength , balance , movement coordination , and proprioception ) and cognitive 
 ( memory , perception , and motivation ) functions in creating an individual physical therapy 
 plan .
the duration of the physical therapy procedures and complexity , repetition number , and 
 intensity of exercises were tailored individually , considering the patient s state of 
 consciousness , age , and physical status .
the physical therapy program consisted of 
 positioning , and passive and active physical therapies to strengthen the limb and trunk 
 muscles , to increase the range of motion , to improve the coordination of movements and 
 balance , and to train functional movements .
the 
 patients were taught to concentrate their attention to a movement being performed , motivated 
 to remember and perceive verbal information , and count the movements performed17 .
motor recovery was assessed according to the motor assessment scale ( mas ) , and the recovery 
 of mental status was evaluated according to the mini - mental state examination ( mmse)19 , 20 .
activities according to the mas were evaluated based on the 
 patient s abilities to perform them .
the minimal score according to the mas was 0 , and the maximal score was 54 .
the following 
 functions were assessed : supine to side lying , supine to sitting over side of bed , balanced 
 sitting , sitting to standing , walking , upper arm function , hand movements , advanced hand 
 activities , and general muscle tone .
mental status was evaluated according to the mmse , which tests orientation to time and 
 place , recall , attention , short - term memory , language , comprehension , writing , reading , and 
 ability to copy a drawing .
mmse scores ranged from 0 to 30 . a score of 0 to 10 indicates 
 severe cognitive impairment ; 11 to 20 , moderate ; 21 to 24 , mild ; and 25 , no cognitive 
 impairment .
the excel 2007 for 
 windows program was used to graphically depict the results of the study .
differences between the means of the 
 independent samples were evaluated with the student t - test ; those between the means of 
 dependent samples , with the paired t - test .
the nonparametric criteria for two independent or 
 dependent samples were determined by using the mann - whitney u test or wilcoxon test , 
 respectively .
during the acute rehabilitation , the motor function of the patients in group 1 before 
 physical therapy was severely impaired .
the application of various physical therapy methods 
 and special means resulted in an improvement in the motor function at the beginning of the 
 acute period ( 3.3  1.7 vs. 4.0  1.8 , p<0.05 ) . in group 2 , the motor function
was rated 
 with a score of 1.6  1.3 before physical therapy and 2.7  1.7 after physical therapy 
 procedures ( p<0.05 ) according to the mas .
the evaluation of motor recovery during the 
 acute rehabilitation according to coma duration revealed that the patients in group 1 showed 
 significantly better motor recovery after the physical therapy sessions than their 
 counterparts in group 2 ( p<0.05 ; table 
 1table 1.motor recovery evaluated by using the motor assessment scale in patients who 
 sustained severe traumatic brain injuries , according to coma duration during the acute 
 rehabilitationgroup 1group 2assessment 1assessment 2assessment 1assessment 2supine to side lying3.54.61.93.2supine to sitting over side of bed3.44.51.63.1balanced sitting3.254.051.42.8sitting to standing2.53.60.82.2walking2.153.30.451.45*upper arm function2.54.21.552.85*hand movements3.454.051.32.5*advanced hand movements3.03.451.02.0*general muscle tone4.64.54.04.25**p<0.05 , comparison of the groups before ( assessment 1 ) and after physical therapy 
 ( assessment 2 ) ) .
moreover , a trend toward a positive impact of faster improvement of motor 
 functions on the faster motor recovery was observed during the post - acute 
 rehabilitation .
* p<0.05 , comparison of the groups before ( assessment 1 ) and after physical therapy 
 ( assessment 2 ) the abilities that showed significant differences between the groups during the acute 
 rehabilitation according to coma duration were analyzed more thoughtfully .
the evaluation 
 and comparison of walking ability according to the mas at the end of the acute 
 rehabilitation revealed significant differences between the groups ( p<0.05 ) .
the recovery 
 of functions in the patients in group 1 was better ( i.e. , they were able to perform more 
 complex tasks ) than that in the patients in group 2 .
the application of special physical therapy measures resulted in a significant improvement 
 in the upper arm function in both groups after physical therapy at the end of acute 
 rehabilitation ( p<0.05 ) .
comparison of the results between the groups showed a better 
 recovery of upper arm function in the patients of group 1 ( p<0.05 ) .
this shows that coma 
 duration influenced the recovery of movements . at the end of the acute rehabilitation ,
most of the patients in group 1 could perform 
 independently tasks such as moving items from one side of the body to another , whereas the 
 patients in group 2 could only perform wrist movements such as supination and pronation . 

after physical therapy during acute rehabilitation , the patients in group 1 could perform 
 more - complex tasks than their counterparts in group 2 ( p<0.05 ) . at the beginning of the post - acute rehabilitation ,
the patients in groups 1 and 2 scored 
 3.4  1.2 and 2.9  1.2 on the mas , respectively .
after physical therapy , a significant 
 improvement in motor function was observed ( mas scores , 4.1  1.4 and 3.7  1.4 , 
 respectively ; both p<0.05 ) . the evaluation and comparison of general muscle tone according to the mas at the beginning 
 of the post - acute rehabilitation revealed that the patients who were in a coma for a shorter 
 period had significantly better general muscle tone than those who were in a coma for more 
 than 2 weeks ( p<0.05 ) .
however , at the end of the post - acute rehabilitation , no 
 significant difference between the groups was observed ( p>0.05 ) . in summary ,
the results of this study indicate no significant differences in motor recovery 
 between assessments 2 and 4 ( p>0.05 ; table 
 2table 2.changes in motor function evaluated by using the motor assessment scale during 
 acute and post - acute rehabilitation in patients who sustained severe traumatic brain 
 injuriesassessment 1assessment 2assessment 3assessment 4supine to side lying2.73.93.95.0supine to sitting over side of bed2.53.83.7 * 4.7balanced sitting2.23.53.2 * 4.3sitting to standing1.72.82.53.6walking1.22.51.9 * 2.9upper arm function2.53.43.23.9hand movements2.33.133.5advanced hand
movements2.02.82.12.9general muscle tone4.24.14.04.0*p<0.05 , comparison between assessments 1 and 3 ) , and only a trend toward improved motor function was observed . *
p<0.05 , comparison between assessments 1 and 3 in the acute rehabilitation , mental status as assessed by using the mmse before physical 
 therapy was severely impaired in both groups ( mmse scores , 1.4  0.8 and 0.8  0.8 , 
 respectively ) . at the end of the acute rehabilitation after physical therapy ,
a significant 
 improvement in mental status was observed in both groups as follows : the patients in the 
 groups 1 and 2 scored 2.2  0.6 and 1.7  0.8 on the mmse , respectively , with the 
 differences between the periods being significant ( p<0.05 ) .
after the physical therapy procedures , the orientation to time improved significantly in 
 all the evaluated patients ( p<0.05 ) .
the comparison of the results between the groups 
 revealed that the patients in group 1 had significantly better orientation to time than 
 those in group 2 ( p<0.05 ) .
the evaluation of orientation to time after physical therapy 
 revealed significantly better results in group 1 than in group 2 ( p<0.05 ) .
moreover , a 
 significant difference between the groups was observed in the evaluation of attention 
 according to the mmse ( p<0.05 ) .
after physical therapy , during which the patients were asked to recognize the means of 
 physical therapy , they were named significantly better by the patients of the group 1 
 ( p<0.05 ) . at the beginning of acute rehabilitation , of the 20 patients who sustained 
 severe tbis in group 1 ,
a comparison of the ability to repeat these words after physical therapy 
 at the end of the acute rehabilitation revealed that the patients in group 1 performed this 
 task significantly better that the patients in group 2 ( p<0.05 ) .
after physical therapy , the recovery of mental status significantly differed between the 
 groups ( p<0.05 ) .
the patients in group 1 performed significantly better than those in 
 group 2 on the tasks associated with orientation to time and place , attention , naming a 
 pencil and a watch , and repetition of some words ( table 
 3table 3.recovery of mental status in patients who sustained severe traumatic brain 
 injuries , according to coma duration during the acute rehabilitationgroup 1group 2assessment 1assessment 2assessment 1assessment 2orientation to time2.64.20.9***2.75orientation to place2.34.20.8***2.7recall2.22.91.92.6*attention2.153.21.12.3**short - term memory1.02.20.61.7subject naming1.652.01.41.8**word repetition0.20.800.4**folding a sheet of paper0.82.50.62.0accomplishment of written command0.751.00.60.9sentence writing0.71.00.60.85copying a drawing0.50.90.4*p<0.05 , comparison between the groups during assessment 1 ( before physical 
 therapy ) * * p<0.05 , comparison between the groups during assessment 2 ( after 
 physical therapy ) * * * p<0.05 , comparison between the groups during assessment 1 
 ( before physical therapy ) and assessment 2 ( after physical therapy ) ) . at the post - acute rehabilitation ,
the mental status of the patients in the 
 group 1 was 1.4  0.6 according to the mmse before physical therapy .
the application of 
 special physical therapy methods resulted in a significant improvement in mental status that 
 was rated with a score of 2.1  0.6 at the end of post - acute rehabilitation ( p<0.05 ) . in 
 group 2 , the mental status before and after physical therapy were rated with scores of 1.9  
 0.8 and 2.4  0.6 , respectively ( p<0.05 ) , according to the mmse .
* p<0.05 , comparison between the groups during assessment 1 ( before physical 
 therapy ) * * p<0.05 , comparison between the groups during assessment 2 ( after 
 physical therapy ) * * * p<0.05 , comparison between the groups during assessment 1 
 ( before physical therapy ) and assessment 2 ( after physical therapy ) at the post - acute rehabilitation , the evaluation of mental status and the comparison of the 
 results between the groups revealed no significant differences in the evaluation of the 
 following tasks : to read and do what was written (  close your eyes  ) , to write a sentence , 
 and to copy a drawing .
while performing other tasks , significantly better results according 
 to the mmse were achieved by the group of patients who were in a coma for a shorter period 
 ( p<0.05 ) . according to the results of this study , no significant differences in the 
 evaluation of mental status after physical therapy
were documented in the comparison between 
 the groups ( p>0.05 ) . during the study , the recovery of motor and mental status and whether these variables were 
 interrelated were analyzed .
a correlation analysis revealed a direct linear relationship 
 between almost all the parameters of motor evaluation .
significant positive correlations 
 between walking and sitting to standing ( r=0.835 , p<0.05 ) , between 
 walking and balanced sitting ( r=0.878 , p<0.05 ) , and between orientation 
 to time and place ( r=0.669 , p<0.05 ) were observed . by analyzing the recovery of cognitive functions , whether a relationship exists between 
 short - term memory and attention in patients who sustained severe tbis was determined .
the 
 analysis revealed a significant linear relationship between short - term memory and attention 
 ( r=0.675 , p<0.05 ) .
the evaluation of motor parameters and mental status revealed that a significant moderate , 
 positive relationship prevailed ( p<0.05 ) . a linear relationship was observed between 
 motor parameters and orientation to time and place , attention , recall , and the tasks such as 
 folding a sheet of paper in half and putting it down on the knees , sentence writing , and 
 copying a drawing .
a linear relationship was observed between attention and walking 
 ( r=0.451 , p<0.05 ) and between orientation to time and sitting to 
 standing ( r=0.569 , p<0.05 ) . while analyzing the recovery of motor and mental status separately during the acute 
 rehabilitation before and after physical therapy , a weak significant correlation between 
 these parameters
was found both in group 1 ( r=0.245 , p<0.05 ) and group 2 
 ( r=0.265 , p<0.05 ) . during the post - acute rehabilitation , a significant 
 weak correlation
meanwhile , 
 in group 2 , the correlation between mental status and motor recovery was moderate 
 ( r=0.488 , p<0.05 ) .
evaluation and comparison of motor recovery at the end of the post - acute rehabilitation and 
 mental status recovery at the end of the acute rehabilitation revealed a moderate 
 significant correlation both in the patients who were in a coma up to 1 week 
 ( r=0.378 , p<0.05 ) and those who were in a coma for more than 2 weeks 
 ( r=0.488 , p<0.05 ) .
tbi is one of the most common causes of death and disability , especially among children and 
 young persons , worldwide , which can cause movement , cognitive , and behavioral 
 impairments9,10,11,12,13 , 38 .
early rehabilitation interventions seem to be essential for 
 successful patient recovery after a severe brain injury .
physical therapy plays an important role in the recovery of impaired functions , during 
 which the patient s functional status is assessed and appropriate methods and measures are 
 tailored to individual patients21 . in 
 this study ,
the mas was used to evaluate patient functional status as patients with tbi 
 develop paralysis , muscle spasticity , and balance , coordination , and sensory impairments . 

the results of this study showed that among all 8 motor abilities , the worst improvement 
 was observed in walking ability .
walker and pickett reported that gait impairment is a 
 common problem in patients who sustained tbis22 .
therefore , other authors suggested paying special attention to 
 walking , balancing , and stair climbing in the improvement of mobility of patients with tbi 
 during physical therapy23 .
presented the case of a patient who sustained tbi and regained the abilities 
 to walk , speak , perform daily activities , and undertake outdoor leisure activities 
 independently after a 7  year rehabilitation24 .
this shows that motor functions can recover even after a long 
 period and that every period is important for recovery .
williams and goldie conducted a 
 study that compared 40 subjects ( 20 runners and 20 nonrunners ) who sustained tbis .
they had 
 to perform 4 specific motor tasks , including to bound onto a leg , walk on toes , step 
 backward up a step , and balance on one leg .
the results showed that all these 4 tasks were 
 the factors that influenced the ability to run , but coma duration did not have any impact in 
 either the runners or the nonrunners16 . 

based on the present data , coma duration was associated with recovery of walking 
 ability .
investigated head control and turning , visual fixation and pursuit , and 
 trunk movement and control in patients with tbis and reported that significantly better 
 results were achieved by the patients who were in a coma for a shorter period25 .
the evaluation of hand movements according to the mas revealed that the smallest 
 improvement in recovery was documented while performing advanced hand movements both in the 
 patients who were in a coma up to 1 week and in those who were in a coma for more than 2 
 weeks . only at the end of the acute rehabilitation did the patients who were in a coma for 
 the shorter period showed significantly better recovery results for hand movements .
based on 
 the present data , in the patients with tbis , advanced hand movements were the most impaired , 
 and upper hand function was the least impaired .
cho et al . emphasized that the individual 
 training of hand movements is an effective physical therapy method to recover the movements 
 of the affected hand of patients with tbis26 .
the findings of this study indicated that in the recovery of mental status , coma duration 
 was associated with orientation to time and place , attention , naming a pencil and a watch , 
 and word repetition .
meanwhile , lammi et al . do not recommend making prognostic statements 
 on the recovery of mental status based on coma duration18 .
these results suggest that more - extensive studies involving later 
 rehabilitation stages should be conducted .
literature sources report that with an improvement in the balance of patients with 
 neurological impairments , gait improves as well .
this study shows a significant positive 
 correlation between walking and sitting to standing , as well as between walking and balanced 
 sitting .
some studies suggest that gait should be trained in patients who sustained a tbi , 
 and various gait training methods such as treadmill walking with self - support using the 
 upper limbs improve the effectiveness of rehabilitation27 .
tappan conducted a study that was aimed at determining if attention and cognitive function 
 training had an impact on balance training in patients who had sustained head injuries . a 
 16-year - old patient who sustained a head injury underwent physical therapy , which aimed to 
 improve patient s balance in a quiet , nondistracting environment and then in a distracting 
 environment .
losses of balance became more frequent in distracting environments when the 
 patient diverted his attention to a distraction .
his physical therapy plan of care included 
 balance training and improvement of cognitive functions .
after 11 weeks of outpatient 
 therapy , no losses of balance occurred , and the patient returned to school activities .
the 
 author reported that besides balance training , perception and cognitive function training in 
 patients with head injuries is needed as well28 .
, the 
 effectiveness of training of these functions can be limited by agitation behavior and 
 decreased concentration span29 . moreover
, 
 other authors reported that the effectiveness of physical therapy was reduced not only by 
 complications such as contractures , spasticity , and impaired balance , but also by attention 
 and behavior disorders , lack of motivation , and depression30 . the data from the study by kollen et al .
showed that improvement in standing balance was 
 more important than improvement in leg strength in order to achieve improvement in walking 
 ability , and attention and spatial perception were directly related to gait31 .
the results of this study are in line 
 with those of the abovementioned study ; a moderate correlation was found between attention 
 and walking both in the patients who were in a coma up to 1 week and in those who were in a 
 coma for more than 2 weeks .
based on the results of the study by franckeviit and kriinas , cognitive functions in 
 patients who had sustained tbis recovered slower than motor functions while applying 
 physical therapy32 .
meanwhile , schiff 
 reported that cognitive recovery could be strongly dissociated from motor recovery33 .
however , more comprehensive studies with 
 a larger number of patients conducted at the late rehabilitation stage are needed to 
 evaluate associations between the lack of motivation and recovery of motor and cognitive 
 functions .
no doubt , the recovery period can be influenced by certain factors related to postoperative 
 complications , patient s motivation , emotional state , and so on .
however , this study did not 
 investigate the impact of these factors on recovery , and additional studies should be 
 conducted .
the number of patients with coma who are undergoing post - acute rehabilitation is 
 low , and this limitation did not allow the formation of sufficiently homogeneous groups and 
 perform a comprehensive statistical analysis .
experts in the field believe that 
 comprehensive multidisciplinary post - acute rehabilitation is the best approach for 
 addressing impairments from severe tbi , although access to these services can be 
 problematic .
health insurance reimbursement policies may limit the degree to which patients 
 can participate in rehabilitation programs34 .
patients who were in a coma for a long time could be clinically 
 healthy and could have recovered motor functions , but severely impaired cognitive functions 
 limit the application of physical therapy16 , 21 , 37 . in summary ,
the recovery of motor and mental status of the patients in the acute 
 rehabilitation was significantly better for those who were in a coma for a shorter period , 
 although this study did not reveal associations between coma duration and recovery during 
 post - acute rehabilitation .
 [ purpose ] the aim of study was to evaluate the impact of physical therapy on the recovery 
 of motor and mental status in patients who sustained a severe traumatic brain injury , 
 according to coma duration in acute and post - acute rehabilitation . [ subjects and methods ] 
 the study population comprised patients with levels of consciousness ranging from 3 to 8 
 according to glasgow coma scale score . 
 the patients were divided into 2 groups based on 
 coma duration as follows : group 1 , those who were in a coma up to 1 week , and group 2 , 
 those who were in a coma for more than 2 weeks . 
 the recovery of the patients motor 
 function was evaluated according to the motor assessment scale and the recovery of mental 
 status according to the mini - mental state examination . 
 [ results ] the evaluation of motor 
 and mental status recovery revealed that the patients who were in a coma up to 1 week 
 recovered significantly better after physical therapy during the acute rehabilitation than 
 those who were in a coma for longer than 2 weeks . [ conclusion ] 
 the recovery of motor and 
 mental status of the patients in acute rehabilitation was significantly better for those 
 in a coma for a shorter period . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION