Introduction:

Traumatic brain injury (TBI) is associated with a decreased level of consciousness, amnesia, and other disorders. The objective of this study is to describe the physical therapy management, within the International Classification of Functioning, Disability and Health framework, and the progress of a patient with neurological sequelae after three TBIs of different severities.

Case presentation:

A 31-year-old male, admitted through an outpatient visit on October 10, 2020, presented with balance and mobility impairment. As activity limitations and participation restrictions, the patient stated he had gait impairments, both indoors and outdoors, and impaired reactive postural adjustments. At admission, the Mini Balance Evaluation Systems Test (Mini-BEST) score was 14 points. Treatment included the following dual tasks: motor-cognitive, dynamic gait, trunk control, static balance, and reactive postural changes. The patient obtained a score of 19 points at reassessment.

Conclusion:

An improvement in mobility and dynamic balance was observed based on the dynamic gait items, measured by the Mini-BESTest.

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