Case Study: Traumatic Brain Injury in an Elderly Woman

*Not finished, currently in progress of editing.

Introduction

Traumatic brain injury is a major health condition, and one of the common causes is falls . More specifically, subdural hematomas have been identified as one of the most prevalent injuries in patients who presented to the emergency department due to a traumatic brain injury. Few studies have looked at the role of rehabilitation and its effects on the improvement of functional outcomes in patients who have undergone surgery for subdural hematomas. The purpose of this fictional case study is to explore the rehabilitation of an elderly woman with an acute traumatic brain injury, post-surgical intervention.

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Client Characteristics

A 65-year-old woman was getting groceries with her friend when she slipped on ice, hit her head and lost consciousness. An ambulance was called, and she was rushed to the hospital. The patient lost consciousness for one hour and remained in an altered state of consciousness for 24 hours. Diagnostic imaging confirmed right sided focal subdural hematoma. Her Glasgow Coma Score (GCS) score upon arrival was 9 (E5; M2; V2) and presented as a level III on the Ranchos Los Amigos Scale. The severity of her traumatic brain injury was classified as ‘moderate’.

The patient underwent a craniotomy the following afternoon. After 2 weeks in the ICU, the patient’s Functional Independent Measure (FIM) score improved from 20 to 60 and was deemed appropriated for the inpatient rehabilitation unit. The patient presents with 7 days retrograde amnesia, making the post-traumatic amnesia 7 days. Her pre-existing conditions include hypertension and osteoporosis, and the medications she is taking for these conditions include Perindopril (Coversyl) and Alendronate (Fosamax), respectively. She has limited range of motion and requires assistance with ambulation. Due to her FIM score, hospital protocol dictates the she is to enter in-patient rehabilitation which includes daily physiotherapy.

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Examination Findings - 2 Weeks Post-op: In-patient Rehabilitation Program

Subjective

During examination, information was collected from the patient’s chart, from members within the multidisciplinary team, and from the patient and her husband. As mentioned, diagnosing imaging confirmed right sided focal subdural hematoma. When speaking with the patient, she had complaints of dizziness and a headache earlier that morning. Prior to her fall, the patient was living with her husband in a bungalow located just South of Kingston, ON. She is a retired teacher, and her husband is a healthy 68-year-old retired farmer. Her husband reported that she was active and independent and did not use any walking aids prior to her fall. She enjoyed activities such as pickle ball, camping, hiking, baking and playing with her grandchildren. Her husband also stated that they had 4 steps to get into their house, with a railing on the right side. Her main goal is to return home and resume her regular activities. Upon gathering a subjective interview, her husband also explained that he was very concerned about his wife and that he is having difficulties coping with her changes in behaviour.

Objective

After the patient was admitted to in-patient rehabilitation, the patient’s screening results showed stable vital signs with a heart rate of 76bmp, blood pressure of 115/76, SpO2 of 97% and intact integuments. The physiotherapist proceeded to choose various outcome measures to obtain the patient’s mental status at baseline and monitor any changes over time. 

The Galvestron Orientation and Amnesia Test (GOAT) was used to evaluate patient’s orientation and ability to recall events before and after the incident. Her GOAT score was 60/100, which was below the cut-off of 66 suggesting impaired memory. Specifically, the patient has in depth current memory and remembers most events after she gained consciousness in the ICU; however, she shows sign of retrograde amnesia from events that happened 7 days before the incident. https://www.ncbi.nlm.nih.gov/pubmed/501342 

The Ranchos Los Amigos scale is a useful tool to rate the patient’s cognitive level after the patient regains consciousness from a TBI.  During initial assessment, she presented with level VI (Confused-appropriate) on the Ranchos Los Amigos scale. As such, the patient was ready for rehabilitation since she was able to consistently follow simple directions (i.e., one step commands), showed carry over for relearned familiar tasks (e.g., self-care), and could attend to highly familiar tasks for a certain period of time. However, the therapist must keep in mind that the patient requires maximal assistance in learning new tasks since the patient may show little carry over from previous sessions. Additionally, proper safety must be ensured (i.e., maximal supervision) since the patient may be unaware of her impairments and may be inconsistently oriented to person time and space. https://www.neuroskills.com/education-and-resources/rancho-los-amigos-revised/ 

The Moss Attention Rating Scale (MARS) measures the effects of impaired attention on cognitive and motor performance specific to patients with TBI in acute rehabilitation. Considering that patients at level VI on the Ranchos scale mostly benefit from learning tasks in a non-distracting environment; the therapist could use an observational rating scale such as MARS to assess patient’s daily attentional state and use the results to provide appropriate cueing to help the patient focus. https://www.archives-pmr.org/article/S0003-9993(02)04926-2/pdf 

• Total Raw Score: 62/110 
• Average MARS Item Score: 2.82 
• Factor 1 (Restlessness/ Distractibility) Score: 3.80 
• Factor 2 (Initiation) Score: 2.67  
• Factor 3 (Sustained/ Consistent Attention) Score: 2.33  

The Agitated Behavior Scale (ABS) was chosen to objectively measure the extent of agitation including levels of: disinhibition, aggression and liability, and is specific to the acute phase of acquired brain injury. The patient scored 20/56 upon initial assessment, which is considered borderline normal.Although patients at Rancho Los Amigos level VI tend to have decreased agitated behaviour, the ABS has been administered to monitor the extent of decrease over time.   https://www.sralab.org/rehabilitation-measures/agitated-behavior-scale

The Neurobehavioral Functioning Inventory (NFI) depression scale is used to measure post-injury depressive symptoms such as frustration, restlessness, loneliness, etc. Research shows that the NFI depression scale is highly reliable and valid, and is sufficient at identifying minimal, borderline and clinical depression in patients with a TBI. The patient scored 26/65 on the NFI depression scale. This score classifies her as 'minimally depressed', which means that the patient rarely experiences depressive symptoms, therefore immediate intervention is not required, but signs of depressive symptoms should be monitored throughout treatment. https://www.archives-pmr.org/article/S0003-9993(03)00270-3/fulltext 

1. Sensory integrity 

• Proprioception, light touch, and sharp/dull discrimination were intact on the right and left extremities.

2. Assistive and adaptive device

• Patient was using a standard wheelchair when arrived to in-patient rehabilitation. 

3. Gait, locomotion and balance:  

• Ambulation: Able to ambulate with a four wheeled walker with heavy assistance of one person for 50m using a 3 points step- to gait pattern. 
• Decreased gait speed: measured as 0.50m/s (normal range is 0.82+/- 0.16 to 1.60 +/- 0.16m/s)  
• Observational gait assessment with 4 wheeled-walker: ataxia, difficulty clearing left foot during initial swing due to decreased dorsiflexion, hikes her left hip to clear left foot from ground during swing phase, hyperextension of right knee during terminal stance 
• Sitting balance: able to sit on the edge of the bed and wheelchair – requires supervision 
• Berg balance scale: 40/56 – increased risk of fall *cannot do stairs*  

4. Motor function: Muscle tone graded on the Modified Ashworth Scale (MAS) 

• Left Lower Extremity 
  • Increased extensor tone in the following muscle groups:
    • left hip and knee extensors and ankle dor
  • Grade 2 on the MAS 

• Right Lower Extremity 
  • No increase in muscle tone was detected  
  • Grade 0 on MAS 

• Left Upper Extremity 
  • Increased flexor tone in the following muscle groups:  
    • Left elbow, wrist and finger flexors  
  • Grade 2 on MAS. 

• Right Upper Extremity 
  • Slight increase in flexor tone in the follow muscle groups 
    • Right shoulder, elbow, wrist and finger flexors 
  • Grade 1 on MAS 

• Patient was unable to isolate movement in the left upper and lower extremities but is able to isolate movement in the right upper and lower extremities.  
• Patient presented with active (AROM) dorsiflexion, knee flexion as well as finger, elbow and wrist extension on both right and left sides.  

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Physiotherapy Diagnosis

Patient presents with a moderate traumatic brain injury with imaging confirming an acute subdural hematoma affecting the frontal lobe of the brain, as well as a fracture of the distal radius of the right wrist. Patient demonstrates signs of increased tone, limited ROM, general weakness, and cognitive and behavioural deficits such as memory problems and mild agitation. Activities such as walking, sitting, ascending/descending stairs, and moving limbs in isolation are affected. Patient is currently unable to resume regular activities such as pickle ball, camping, hiking, baking, and playing with her grandchildren. However, she hopes to restore as much function as possible during rehabilitation so she can go back to doing things she enjoys. Patient is a good candidate for physiotherapy to help regain balance control, improve joint range of motion, reduce spasticity and overall restore physical function.

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Problem list

1. Reduced Level of Cognition

• Ranchos Los Amigos Level VI (confused–appropriate) - difficulties retaining new information, memory problems, unaware of safety concerns
• ABS scale = 29/56 - mild agitation
• Alpha FIM score = 60 - moderate alpha FIM rating, indicating that patient is not ready for community-based rehabilitation

2. Signs of Post-Injury Depression

• NFI score = 26/65 - minimal depression

3. Impaired Gait and Balance

• Left side hip hike & decreased dorsiflexion during swing phase

• Supervision to sit in wheelchair and on edge of bed
• Berg balance scale = 40/56 - increased risk of falls

4. Reduced ROM

• Contractures in the left side elbow, wrist, and finger flexors, as well as ankle plantarflexors
• Contractures in the right side elbow and finger flexors
• Reduced wrist extension and flexion

5. Environmental

• Four steps to get into house

6. Social Impacts

• Unable to resume regular activities – e.g. playing with grandchildren, hiking, camping, pickle ball
• Husband is concerned for her health and is having difficulties coping with his wife's changes in behaviour

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Intervention

Although the patient is currently at a level VI (confused-appropriate) of the Rachos Los Amigo scale, and may not be cognitively aware of her condition,  the focus of in-patient rehabilitation is to create a program based on not only the patient's goals, but also the facility's protocol on TBI rehabilitation, which typically includes restoring function and progressing the patient to a point where she safe to return home with her husband. Further, treatment will follow evidence-based clinical practice guidelines for TBI, specifically“Understanding Traumatic Brain Injury” by Ontario Neurotrauma Foundation and “Rehabilitation following acquired brain injury” by the British Society of Rehabilitation Medicine (BSRM). Therefore, in-patient rehabilitation will involve components of task-specific training, balance re-training, gait re-education, strength training and aerobic fitness training, all in the context of functional tasks where possible. 

Further, to maximize outcomes of treatment, the in-patient rehabilitation program will be adapted to use appropriate learning strategies based on the patient’s cognitive abilities. For example, treatment will begin with using distributed practice, explicit feedback, closed environments, clear and concise instructions, and having a structured routine. Further, as the patient shows improvements in cognitive and physical function, treatment will progress to using a more open environment, random practice schedule, implicit feedback and more complex cognitive tasks. In addition, treatment will be adapted based on the patient’s energy levels to avoid fatigue. For instance, lowering the frequency, intensity, and/or amount of exercises done during treatment sessions. Finally, segments of education for both the patient and her husband will be included in treatment as well. For example, educating them on physical, cognitive, behavioural and emotional impacts of TBI, as well as the prognosis and symptoms of TBI. In addition, it is important to educate her husband on areas of treatment that help with, and how he can support his wife throughout her prognosis. 

*NOTE: Treatment would occur daily, for 1-hr sessions. However, all of the exercises below would not be performed in a single treatment session. Each day of the week, treatment would involve a selection of these exercises, and parameters may vary, depending on the patient's tolerance. In addition, it is recommended that the patient works on these exercises outside of rehab as well, either with her husband or other staff .        

Balance and Mobility – Start treatment with basic static sitting and standing postures, and then progress to dynamic exercises if patient tolerates well. The idea of including these exercises in the program is to help the patient gain balance prior to introducing more dynamic, functional and complex movements, such as walking and/or ascending and descending stairs.    

Static sitting (With close supervision)
Exercise	Description	FITT principle
Educate on seating posture in wheelchair	Trunk upright, arms on the armrests, wide base of support with feet (I.e. feet shoulder width apart), back against chair, head & neck erect	N/A
Educate on seating posture on edge of bed	Trunk upright, arms placed on the bed beside her body, wide base of support with feet (I.e. feet shoulder width apart), head & neck erect	N/A
Hold posture sitting in wheelchair or on edge of bed	*Have patient practice seating posture whenever she is in seating position (e.g. during meals, sitting on edge of bed, sitting up in bed, etc.)	F – 3-4 days/week  I – quiet sitting, no movement   T – 3 sets holding for 1-minute, with 1-minute break in between sets   T – static sitting exercise

    

 {| class="wikitable" | colspan="3" rowspan="1" |Dynamic sitting: with close supervision, while maintaining proper seating posture  |- |Exercise  |Description   |FITT principle |- |Functional tasks involving shoulder flexion and abduction  |Reaching for a cup on a table, alternating the location of the cup throughout sets 

• Bringing utensils to/from mouth during eating  
• Ensure patient goes back to neutral position (e.g. hands on lap) after each reach 

|F – 3-4 days/week   

I – minimal intensity, to patient’s comfort  

T – 3 sets, 6 reps (1 rep = 1 reach for cup) with 1-minute break in between sets  

T – dynamic sitting exercise  |- |Knee extension  |Kicking outwards to aim for a target  |F – 3-4 days/week  

I – minimal intensity, to patient’s comfort  

T – 3 sets, 6 reps (alternating cup location) with 1-minute break in between sets  

T – dynamic sitting exercise  |}

Static standing: One assist in parallel bar
Exercise	FITT principle
Standing, eyes open	F – 3-4 days/week   I – quiet standing, no movement, to patient’s comfort   T – 3 sets holding for 30 seconds, with 1-minute break in between   T – static standing exercise
Standing, eyes closed	F – 3-4 days/week   I – quiet standing, no movement, to patient’s comfort    T –3 sets holding for 30 seconds, with 1-minute break in between sets   T – static standing exercise

Dynamic standing: One assist in parallel bar
Exercise	FITT principle
Weight shifting left to right	F – 3-4 days/week   I – minimal intensity, to patient’s comfort    T – 3 sets, 6 reps (e.g. 6 weight shifts) on each leg, 1-minute break in between sets   T – dynamic standing exercise
Standing, turning head to look at sticker on wall	F – 3-4 days/week   I – minimal intensity, to patient’s comfort   T – 3 sets, 10 reps (alternating location of sticker), 1 –minute break in between sets   T – dynamic standing exercise
Taking a step forward, backwards and to the side	F – 3-4 days/week   I – moderate intensity, to patient’s comfort   T – 3 sets, 3 reps (1 rep = step forward, backwards and to the side), with 1-minute break in between sets   T – dynamic standing exercise
Marching on the spot	F – 3-4 days/week   I – moderate intensity, to patient’s comfort    T – 3 sets, 3 reps on each leg (1 rep = lifting of one leg), with 1-minute break in between sets   T – dynamic standing exercise

  

Strength Training - Core strengthening and strengthening of the lower extremities will help improve coordination and efficiency of walking.  

• Core Strengthening - *find exercise*  

• Lower Extremity Strengthening

• Hip abduction
  • Clam shells in sitting, progress to resistance band in sitting
  • Progress to clam shells in side-lying against gravity, and then side-lying with resistance band

F - 2-3 days/week

I - with gravity, to patient's comfort level

T –  3 sets, 6 reps each leg, with 1-minute break in between sets

T – strengthening/resistance exercise

• Knee extension (in sitting, against gravity, done in balance/mobility section)
  • Progression: add ankle weight, use resistance band, or make it more functional by getting patient to extend her knee to put pants on

F - 2-3 days/week

I - against gravity, to patient's comfort level

T – 3 sets, 6 reps each leg, with 1-minute break in between sets 

T – strengthening/resistance exercise

• Knee flexion (in sitting, against gravity)
  • Progression: add ankle weight or use resistance band

F - 2-3 days/week

I - against gravity, to patient's comfort level

T – 3 sets, 6 reps each leg, with 1-minute break in between sets

T – strengthening/resistance exercise

• Ankle dorsiflexion (in sitting, against gravity)
  • Progression: add resistance band

F - 2-3 days/week

I - against gravity, to patient's comfort level

T – 3 sets, 6 reps each leg, with 1-minute break in between sets

T – strengthening/resistance exercise

Flexibility/ROM - Patient should focus on stretching muscle groups that have developed contractures or have tightened throughout hospital stay. 

• Plantar Flexor Stretch (e.g. dorsiflexion with band) 

F - 3-4 days/week

I - comfortable stretch, no pain should be felt

T - 3 sets, 3 reps (hold each rep for 20 seconds)

T - static stretching

• Finger & Wrist Flexor Stretch
  • Bring wrist and fingers into extension, patient places hands on bed beside their body (fingers facing forward) and push hands into bed. To increase stretch, face fingers backward.

F - 3-4 days per week 

I - comfortable stretch, no pain should be felt

T - 3 sets, 3 reps (hold each rep for 20 seconds)

T - static stretching

• Hip Extensor Stretch
  • In supine, bring one knee to chest. Repeat with other leg. 

F - 3-4 days per week

I - comfortable stretch, no pain should be felt

T - 3 sets, 3 reps (hold each rep for 20 seconds)

T - static stretching

Task-Specific Training

• Supine-to-Sit Transfers

• Sit-to-Stand Transfers     

*Encourage practicing with staff or PT whenever she needs/wants to get out of bed; can educate her husband on how to assist.

Gait Training - Ambulation is a common goal of many TBI patients, making gait training an important aspect of rehabilitation . However, the type of gait training varies depending on the severity of the TBI . The most common forms include range of motion activities, weight shifting, and lower extremity and core strengthening, which were addressed earlier in treatment . However, higher level exercises such as dual-task techniques can be introduced to make treatment more engaging and functional for the patient .

• Conventional gait training in parallel bars (with assistance)
  • Patient can walk with support of parallel bars
  • Therapist cueing to move joints appropriately throughout gait cycle
  • Work on reciprocal gait pattern & proper weight shifting

• Virtual reality (if available in rehab facility) - computer-generated virtual environment adds patient engagement, enhances motor learning, and makes gait training more task-oriented
  • Example: simulation of walking through grocery store, patient can pretend she is pushing cart through isles and grabbing food off shelves
  • VIDEO: https://www.youtube.com/watch?v=S7KHh530drM 
• Dual-task training
  • Walking slowly on treadmill with assistance or body weight support, asked to turn head to look at something on the wall
  • Progress by increasing speed

Aerobic Exercise Training - Exercise can improve cardiorespiratory fitness as well as cognitive function among patients with TBI .

• Arm cycling, progress to leg cycling and eventually treadmill walking

F - 3-4 days/week

I - 60-90% of age predicted max HR (~93-140bpm)

T - 20-40 min per session

T - aerobic exercise

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