Traumatic Brain Injury - Case Study Part 2

Presenting Condition

For background information go to

Traumatic Brain Injury - Case Study Part 1

Assessment

Initial Physiotherapy Assessment in the ICU

  • GCS             6 (Eyes 1 Voice 2 Motor 3)
  • Pupils             Right 6+, Left 5+
  • BP                    116/84 Supine
  • Pulse                 114 bpm 
  • O2 Saturation   94% on 30% O2
Upper Limb Lower Limb
Left Right Left Right
Tone Decreased NAD Decreased NAD
Power Unable to participate in manual muscle testing

Spontaneous movements are uncoordinated

Coordination Unable to Assess

Spontaneous Movements Impaired

Range of Movement Active - No Response to Cues, Spontaneous Movements observed 

Passive - Within Normal Limits

Sensation Unable to participate in formal testing

Does react to some tactile stimulation

Proprioception Unable to Assess
Reflexes Decreased NAD Decreased

Plantar - Upgoing

NAD

Plantar  - Downgoing

Behaviour Restless ++

2 Months Post Injury

  • Tracheostomy Removed, Self ventilating on room air. 
  • PEG remains in situ for feeding.
  • Can attend Gym for Rehabilitation
  • Currently using a wheelchair for mobility
  • GCS 10 (E4 V2 M4) Not following commands, No speech but an occasional physical aggressive outburst
  • Mask like expression of face, wide open eyes and constantly raised eyebrows giving an alarmed or surprised impression, consistent with abnormal tone and sensation
  • Poor eye contact
  • Flexed posture with poor trunk and head control
  • Subluxation of Left GHJ (Two Fingers Breadth)
Upper Limb Lower Limb
Left Right Left Right
Tone Increased NAD Increased NAD
Power 0/5 4/5 0/5 Ankle

1/5 Hip

1/5 Knee

(Not to Command)

4/5
Coordination Unable to Assess

During Spontaneous Movements Coordination Impaired

Range of Movement Glenohumeral Joint:

External Rotation 45°

Internal Rotation 40°

Flexion 90°

Abduction 60°

*Painful Grimace at End of Range GHJ Movement

Elbow Full Range of Movement

Wrist Full Range of Movement

Full Range of Movement

All Joints

Hip Full

Knee Full

Ankle Decreased Achilles Length

  • DorsiFlexion with Knee Ext. -10°
Hip Full

Knee Full

Ankle Decreased Achilles Length

  • DorsiFlexion with Knee Ext. -5°
Sensation Unable to participate in formal testing

Does react to some tactile stimulation

Proprioception Unable to Assess
Reflexes Increased NAD Increased

Plantar - Upgoing

NAD

Plantar  - Downgoing

Behaviour Restless ++
Static Dynamic
Sitting Balance Assist x 2 Unable - Tends to Extend
Standing Balance Max Assist x 2 Unable - Tends to Extend
Bed Mobility Assist x 2
Lie to Sit Assist x 2
Sit to Stand Max Assist x 2 - Tends to Extend
Gait Unable to Initiate
Wheelchair Dependant - Currently in Tilt in Space
ADLs Dependent for All

Discussion

Considering what we now know, outline the key impairments and activity limitations for James. What outcome measures might you use with James and why? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can.