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.

---

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 and x-rays revealed a fracture of the distal radius. 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. 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)

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 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.

Objective

After the patient was admitted to in-patient rehabilitation, the patient’s screening results show 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 outcomes measures to obtain the patient’s mental status at baseline and monitor change 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 is 60/100, which is 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 7daysf 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 regain consciousness a TBI.  During initial assessment, she presents as level VI (Confused-appropriate) on the Ranchos scale. As such, the patient is ready for rehabilitation since she is able to consistently follow simple directions (i.e., one step commands), shows carry over for relearned familiar tasks (e.g., self-care), and can attend to highly familiar tasks for a certain period of time. However, the therapist musk keeps in mind that patient require maximal assistance in learning new tasks since the patient would show little carry over from previous sessions. Additionally, proper safety must be ensured (i.e., maximal supervision) since the patient can be unaware of her impairments and is still 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. The attention construct in the MARS scale includes. 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. Although patients at Rancho level VI has decreased agitated behaviour, the ABS has been administered to monitor the extent of decrease over time.  Score 20/56 – borderline normal. https://www.sralab.org/rehabilitation-measures/agitated-behavior-scale 

1. Sensory integrity 

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

2. Assistive and adaptive device

• currently uses a standard wheelchair 

3. Gait, locomotion and balance:  

• Able to ambulate with walker with assistance of one person for 50m using a 3 points step- to gait pattern. With 4 point walker 
• Decreased gait speed: 0.50m/s (normal range 0.82+/- 0.16 to 1.60 +/- 0.16m/s)  
• Observational gait assessment: ataxia, difficulty clearing left foot in initial swing due to decreased dorsiflexion, decrease right knee extension through swing phase and hip hikes left hip to clear foot 
• 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*  
• TUG (added): 35 seconds (later in treatment) 

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

• Left Lower Extremities 
  • increase extensor tone in the following muscle groups
    • left hip, ankle and knee extensors
  • Grade 2 on the Modified Ashworth Scale (MAS) 

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

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

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

• Patient is 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 does present with active (AROM) dorselfextion, knee flexion as well as fingers, elbow and wrist extension on both right and left sides  

---

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, 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

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

2. 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)

3. Reduced ROM

• Contractures on left side lower extremity - plantar flexors, knee flexors, hip flexors
• Reduced wrist extension and flexion

4. Environmental

• Four steps to get into house

5. Social Impacts

• Unable to resume regular activities – e.g. playing with grandchildren, hiking, camping, pickle ball

---

Intervention

Although our patient is currently at a level VI (confused-appropriate) of the Rachos Los Amigo scale, and is not cognitively aware of her condition,  the focus of in-patient rehabilitation is to create a program based on our patient’s goals to restore function and safely return home with her husband as soon as possible. Therefore, treatment will follow evidence-based clinical practice guidelines found in research, such as “Understanding Traumatic Brain Injury” by Ontario Neurotrauma Foundation and “Rehabilitation following acquired brain injury” by the British Society of Rehabilitation Medicine (BSRM). In particular, in-patient rehabilitation will be centered around gait, balance and mobility training, with a focus on functional tasks with the intent of discharge for home. 

With these guidelines in mind, to maximize engagement and outcomes of treatment, the rehabilitation program will be adapted to use appropriate learning strategies based on our patient’s cognitive abilities. For example, beginning treatment in closed environments, using extrinsic feedback, increasing repetitions, and using clear and concise instructions. Further, treatment will progress to open environments, intrinsic feedback and more complex cognitive tasks as our patient improves function. In addition, treatment will be adapted based on the patient’s energy levels to avoid fatigue. Finally, it is important that we include segments of education for both our patient and her husband. For example, educating 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 he can play a role in, and how he can help contribute to her overall well-being. 

---