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
|
Hip Full
Knee Full Ankle Decreased Achilles Length
|
| 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.