Traumatic Brain Injury - Case Study Part 3

Presenting Condition

For background information go to

Traumatic Brain Injury - Case Study Part 1

Traumatic Brain Injury - Case Study Part 2

Assessment

6 Months Post Injury

Upper Limb Lower Limb
Left Right Left Right
Tone Increased NAD Increased NAD
Power 2/5 4/5 2/5 Ankle

3-/5 Hip

3-/5 Knee

4+/5
Coordination Impaired
Range of Movement

Muscle Length

Shoulder:  

Flexion 110°

Abd 90°

IR 40°

ER 50°

Elbow:

Full ROM

Wrist:

Full ROM

Shoulder:

Full ROM 

Elbow:

Full ROM

Wrist:

Full ROM

Hip:

Full ROM

Knee:

Full ROM

Ankle:

Decreased ROM

DF with Knee Ext -5°

Hip:

Full ROM

Knee:

Full ROM

Ankle:

Decreased ROM

DF with Knee Ext 0°

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

Current Function

  • No use of oxygen 

  • Blood pressure within normal limits 

  • Supervision with mat mobility 

  • Contact guard with stand turn transfers 

  • Contact guard to minimal assist of 1 & supervision of another for gait 1200m

  • Minimal assist of 1 & supervision of 1 on 20 steps reciprocally with a handrail 

  • Minimal assist of 1 & supervision of 1 on 6 inch curb 


Discharge Planning Considerations

  • Family support
  • Environment 

  • Equipment 

  • Further rehabilitation needs 


Discussion

What treatment goals would you select for James? What considerations would you make towards James discharge planning? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can.