Case Study: Traumatic Brain Injury in an Elderly Woman
Introduction[edit | edit source]
Traumatic brain injury is a major health condition (Bell), and one of the common causes is falls (Brazinova) (Heydari). 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 (Heydari). Few studies have looked the role of rehabilitation and its effects on the improvement of functional outcomes in patients who have undergone surgery for subdural hematomas (Carlisi). 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.
Client Characteristics[edit | edit source]
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 and x-rays revealed a fracture of the distal radius. Her 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’ (link to physiopedia classification of TBI).
The patient underwent a craniotomy the following afternoon. After 2 weeks in the ICU, the patient’s FIM score improved from 20 to 60 and was deemed appropriated for the inpatient rehabilitation unit. The patient presents with 7 days retrograde amnesia. Her pre-existing conditions include hypertension and osteoporosis, and her medications include coversyl and alendronate (Fosamax). 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.
Examination Findings - 2 Weeks Post-op (In-patient Rehabilitation Program)[edit | edit source]
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 and x-rays revealed a fracture of the distal radius. When speaking with the patient, she said that she had pain in her right wrist, and 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 his wife’s changes in behaviour.
Physiotherapy Diagnosis[edit | edit source]
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, mild agitation and mild depression. Activities such as walking, sitting, climbing 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 loves. Patient is a good candidate for physiotherapy to help regain balance control, improve joint range of motion, reduce spasticity and restore physical function.
Problem list[edit | edit source]
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, inpatient rehab) Impaired Gait and Balance Left side hip hike during swing phase Supervision to sit in wheelchair and on edge of bed Berg balance scale = 40/56 (increased risk of falls) Reduced ROM Contractures on left side lower extremity - plantar flexors, knee flexors, hip flexors Reduced wrist extension and flexion Environmental Four steps to get into house Social Impacts Unable to resume regular activities – e.g. playing with grandchildren, hiking, camping, pickle ball
