Case Study: Traumatic Brain Injury and Intimate Partner Violence (IPV)

Abstract

This fictional case study was created with the purpose to shed light on the possible mechanism of injury, symptoms, resultant deficits and possible rehabilitation program of an individual with a traumatic brain injury (TBI) acquired through domestic violence.  This case documents the patient from initial inpatient care at the hospital through to discharge to home care.  Included in this case presentation is a background overview of TBI acquired through intimate partner violence (IPV), our fictional client characteristics, the examination findings, the intervention and rehabilitation program and the outcomes.  

The fictional client is a 33-year old female presenting with a moderate traumatic brain injury acquired through intimate partner violence on the same day of admission to the hospital. Damage was sustained to the right parietal and temporal lobes. Patient lost consciousness for approximately 40 minutes and could only remember events from about 1 week before the injury. Patient scored a 12 on the Glasgow Coma scale (GCS) and a 2 (moderate injury) on the Abbreviated Injury Scale at intake to hospital.  Upon initial assessment, beginning after day 3 of intake, patient presents with left sided hemiparesis, high tone in both extremities on left side, with greater range of motion loss and strength deficits, as well as increased spasticity in the left upper extremity (UE). Sensation examination found positive upper motor neuron tests and abnormal reflexes on the left side. Cortical sensations are also diminished on the left side. The patient scored a Stage 3 of motor recovery on the Chedoke McMaster Stroke Assessment (CMSA) and requires supervision with activity according to the Activity Inventory.  Balance and gait show great deficits as the Timed Up and Go test indicates she is at an increased risk of falls. In terms of a cognitive assessment, the patient scored a 66 on the Galveston Orientation and Amnesia Test (GOAT) administered by a neurologist, indicating she is still experiencing memory deficits. The patient displays preservation and confabulation and some uncharacteristic aggressive behaviour, however patient does present with a history of depression. The patient was determined to be at level 4, confused-agitated according the Ranchos Los Amigos, Level of Cognitive Functioning (LOCF) Scale, four days after initial intake to inpatient care.   

Patient rehabilitation began day 4 after intake into hospital. Her LOCF increased to a level 5, confused inappropriate when rehab commenced. She receives 3 hours of therapy every day, 5 days a week with a rehab team including physiotherapists, physiotherapy assistant, nurses and occupational therapists. With the goal of improving activities of daily living and functional ambulation, her treatment program consists of gait and balance training, range of motion exercises, contracture prevention techniques, and functional strength training. As her physiotherapist, working daily with the patient, her mental health and cognitive functioning will be monitored and taken into consideration for what type of treatment is warranted on a day to day basis. 

OUTCOME MEASURES 

During inpatient rehabilitation, the patient will also be cared by a social worker and psychologist to help cope with the effects of the intimate partner violence and she will be educated and supported on her options for support groups, safety planning and return to home life. After 42 days of inpatient care, the patient improved in her physiotherapy related outcome measured and is safely discharged to her mother’s house with help from the occupational therapist to determine her specific needs. She will continue to receive home physiotherapy care to improve her independent functioning. As well as support from the social worker and psychologist to assist her in managing her mental health as a result of domestic abuse.      

Examination Findings

Subjective  

• Patient reports frequent headaches and dizziness 
• Speech is mildly slurred (dysarthria)-- speech returns to normal 1 week post TBI (swelling) 

History of Present Illness  

Medical Dx: Moderate TBI with cerebral contusion in parietal/temporal area sustained through blunt trauma on March 29. Admitted to KGH on March 29, ~6 hours after injury. 

Saw a physiotherapist off and on in the last 5 years for neck pain and headaches. 

Medications 

Setraline (Zoloft)  

Aspirin (for frequent headaches)  

Current status 

Current status was determined by both the patient and the caregiver (the patient's mother) due to the altered cognitive/behavioural state of the patient.

Pain 

With use of her right arm, the patient pointed to her left arm to indicate where she feels pain and points to her head and neck. Using a VAS scale with pictures, she complains ofedmoderate to severe pain in her head and neck and mild pain throughout her left arm that intensifies with any movement attempts of the left arm. 

Movement 

The patient’s mother indicates that all movements of her UE have been with her right arm since she was admitted to the hospital, rarely attempting to use her left hand or arm. The patient also reports frequent mild dizzy-spells with movements of her head. The patient had been able to sit on the edge of the bed and stand with minimal assist since she had been admitted to the hospital.

Behaviour  

The patient’s mother reports the patient speaking somewhat non-sensically and repeating words or phrases and frequently interrupting the nurses or physician with unrelated information. She reports her daughter being unable to remember the names of the nurses, the hospital and why exactly she is in the hospital. This was reported as atypical behaviour from the patient's caregiver.

Other Medical History  

The patient was seen for a concussion 3 years ago. Her mother reports that the patient has been battling depression for several years now and is on anti-depressant medication.  No other comorbidites were present. The patient is a non-smoker and occasional drinker.

Social Hx:  

The patient lives with her husband and does not have any children. She works full time as a daycare manager. Prior to injury she walked 5km a day, practices yoga and enjoys playing with the children in her daycare. Mother lives down the road in the same neighborhood. 

Functional Status/Activity  

Frequent headaches prior to the TBI limited her activity to walking and playing with the children. She avoided higher intensity exercises due to headaches and occasional dizziness. Patient did not use any mobility aids prior to TBI.  The patient is right-handed.

Medications 

Setraline (Zoloft)  

Aspirin (for frequent headaches)

Patient Goals/ or caregivers 

Patient reports a desire to have less pain, to be able to use her left arm for daily activities and to return home without needing too much help. For more detailed goals, the mother was questioned about what the patient may want to achieve from treatment. The mother reported that she really enjoys going on her walks and yoga practice and they help a lot with the her ession and keep her active for her kids. She also reports that the patient loves her job and would want to return to work with limited restrictions (a.k.a being able to pick up the children at daycare or get down on the floor to play with them). 

Clinical Impression

Patient admitted to hospital after sustaining a TBI as a result of IPV. Imaging results show a small contusion in the right parietal/temporal lobe area where the blow is suspected to have occurred. Patient presents with left sided hemiparesis with spasticity that is worse in the UE, post traumatic amnesia, cognitive behavioural changes (confabulation, confusion, perseverance, attention deficit) and cortical sensation deficits which are affecting mobility and performance of ADL’s and recreation activities such as yoga and walking. 

Intervention

Short-Term Goals 

1. Incorporate use of 4 wheeled walker to immediately improve posture, balance and decrease TUG to 18s. 
2. Maintain/improve ROM to prevent contractures within the upper and lower extremities until decreased is observed. 
3. Increase L shoulder and elbow flexion MMT to a 3 within 3 weeks. 
4. Educate patient and mother about safe transitions and proper guarding during ambulation within 1 week. 
5. Educate patient and mother on proper positioning and posture while seated and laying within 1 week. 

Long-Term Goals 

1. Independent with ADLs within 5 weeks 
2. Able to ambulate independently with a quad cane within the home/patient room within 5 weeks 
3. Able to ambulate for 10mins at a community level pace with 4ww within 5 weeks 
4. Improve postural to be able to sit without support from pillows within 5 weeks 
5. Improve L shoulder flexion MMT to a 3+ within 6 weeks 
6. Be able to return to modified yoga practice in the community within 6 weeks 

Management 

The patient will be receiving therapy from a PT, nurses, PTA, and OT while in inpatient rehab. The aim will be to complete 3 hours of therapy 5 days per week, keeping patient fatigue and LOC at the forefront of this decision. The focus of the rehabilitation will be allowing patient to become independent with ADL’s and to ambulate with a gait aid independently within the home. Considering the patient’s cognitive state (I.e. previous depression and anxiety) will be vital while working daily with the patient. In addition to PT and OT treatment the patient will be working with a social worker and a psychologist to help with these symptoms. When treating a patient with a TBI related to IPV, there are many factors to keep in mind. The ABI Research Lab has developed a tool kit to guide practitioners in the assessment and treatment of these patients. Little things such as completing activities in a quiet room, listen to and validate their feelings, keepings meetings short and incorporating breaks can make a big difference in the patient’s comfort level and treatment outcomes (https://abitoolkit.ca/service-provision/make-a-difference). Patient will be given the choice between 3 activities when needing to switch, and they will be performed in a closed environment. OT treatment will be focusing on hand and sensation improvement in the patient, and PT treatment will focus on ambulation, posture, balance and gross movements of the arm. The social worker and psychologist will be attending to help mental health needs and processing the effects of her trauma. 

Gait 

• Ambulate with rollator walker for 10mins daily with rests as needed, progress to using a quad cane as the patient’s balance and endurance improves throughout treatment.  
• Minimal physical and verbal cueing for posture used 

Balance 

• For standing balance, the Romberg test will be used. As the patient progresses and can complete the Romberg test, the Berg Balance Scale will be administered, and weak areas will be used in the patent’s treatment. 

• Seated balance will be practiced in conjunction with upper extremity ROM activities acting as internal perturbations 

Flexibility 

• The PT will perform ROM activities daily with a focus on regaining movement in the right upper extremity and maintaining/improving the ROM in the lower extremity as well as work to prevent contractures and address the shoulder pain she is experiencing 
• As the patient’s ability to follow directions and focus on a task improves, a ~10 min chair yoga video is added to her program to be completed as a warm-up for the beginning of her therapy session 

• https://www.youtube.com/watch?v=89wkSAJYKEU 

Strength 

• Lower body strength: 

• • Kitchen sink exercises 1x daily 
  • Sit to stand practice 
  • Included with walking practice 

• Upper Body Strength 

• • Starting with active assisted (with the left arm) seated flexion on a physio ball, with progression to an angled AA slide and finally working towards AROM against gravity 
  • There will be a focus on high repetitions and using the same height dimensions as the cupboards in her mother’s house for task-specific training (PLOS systematic review, L8, slide 16) 

• Hand function 

• • The OT will be focusing on the patient’s hand function, and will be using the Constraint Induced Therapy technique. It will include 2 hours of intensive practice per day. 

Outcome

The patient was in the inpatient hospital unit for a total of 42 days (5 weeks) and experienced a number of improvements over the course of their stay. They progressed to using a quad cane while on stable ground, and can now ambulate for 5 minutes without needing to break. They will be using the rollator walker while out in the community and while using the walker she is able to ambulate for 15 minutes. Her TUG score while using a quad cane improved to 15s (down from an initial score of 22s unaided). 

The patient exhibited improvements in strength and range of motion in both the upper and lower extremity on the right side as exhibited in the chart below:  

Upper Extremity			Lower Extremity
AROM	Initial Score	Discharge Score	AROM	Initial Score	Discharge Score
Shoulder Flexion	60°	120°	Hip flexion	100°	120°
Elbow Extension	-30°	-4°	Hip Extension	5°	15°
Supination	50°	76°	Ankle DF	-5°	11°
Pronation	75°	90°	Ankle PF	45°	56°
MMT Scores			MMT Scores
Shoulder flexion	2+	3+	Hip Flexion/Ext	3+/2+	4-/4
Elbow flexion	2+	4	Knee Flex/Ext	2+/2+	3+/4
Wrist flexion	2+	3+	Ankle DF/PF	3+/3+	4/4-
Grasp	2+	4

Upon discharge the patient scored a 6.2 on the CMSA activity scale (up from an initial score of 4.8). The patient will continue to work on upper extremity ROM and strength while in home physio to help with her return to work goal.  

The patient's posture has improved requiring cueing to sit without a lean only when she is tired. With walking, posture improved immediately with the addition of a walking aid. 

For balance, the patient has improved greatly, she is now able to complete a Romberg test and can maintain tandem stance for 17s with eyes closed. Once balance improved a Berg Balance was completed. Her baseline score was 37/56, and she improved to 49/56.  

Over the course of the 5 weeks the patients cognitive functioning improved greatly as well. It was reported that she moved into Stage 6 of the Ranchos Los Amigos LOCF. Additionally, she was scored on the GOAT twice more before discharge receiving a score of 76 and 78, signaling and end to post traumatic amnesia which was confirmed subjectively from the interdisciplinary team. 

Discharge Plan 

Discharge planning is a vital step when considering where a patient who has experienced IPV, due to safety concerns regarding sending the patient back to where they were living previously. This is an interdisciplinary task requiring the expertise of the PT, OT, Social worker, psychologist, and the patient. Within this case study, the interprofessional team observed that she was able to ambulate safely, was functional with many ADLs and her cognitive functioning was at a level that they felt confident to discharge. She was discharged to her mother’s home, where she would have a home assessment completed by an OT to help the patient function in her new environment and while coping with her continued deficits. To address physical deficits, the patient will be completing home physio care, and attending chair yoga sessions once a week at her local YMCA. The patient will continue to work with a social worker from the hospital who connected her to the “WomenattheCentrE” facility, with the goal of enrolling the patient into a group meetings which are created for women who have experienced IPV, such as the C6 program. With the social worker she has also completed a safety planning booklet. The patient will also continue working with a psychologist and will be receiving a therapy dog to help manage her depression and anxiety and help around the house,