Traumatic Brain Injury - Case Study Part 2

Presenting Condition

For background information go to

Traumatic Brain Injury - Case Study Part 1

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	N	Decreased	N
Power	Unable to participate in manual muscle testing - spontaneous movements are uncoordinated.
Sensation	Unable to participate in formal testing, does react to some tactile stimulation.
Co-ord	Unable to Assess Spontaneous Movements Impaired
Proprioception	Unable to Assess
Reflexes	Decreased	N	Decreased (Plantar - Upgoing)	N (Plantar  - Downgoing)
ROM	Active - No Response to Cues, Spontaneous Movements observed  Passive Within Normal Limits
Behaviour	Restless ++

Assessment at 2/12 Post Injury

Tracheostomy Removed, Self ventilating on room air. 

PEG remains in situ for feeding.

Can attend Gym for Rehabilitation

Currently using wheelchair for mobility

GCS 10 (E₄ V₂ M₄) Not following commands, No speech but 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

Repetitive non purposive movements of RLL 

Subluxation of  Left GHJ (Two Fingers Breadth)

	Upper LImbs		Lower Limbs
	Left	Right	Left	Right
Tone		N		N
Power	0/5	4/5	0/5 Ankle 1/5 Hip 1/5 Knee (Not to Command)	4/5
Sensation	Unable to Assess
Coordination	Unable to Assess - During Spontaneous Movements Cordination Impaired
Proprioception	Unable to Assess
Reflexes		¯		¯
ROM  Muscle Length	Glenohumeral Joint (GHJ); 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 Decreased Achilles Length DorsiFlexion with Knee Ext. -10°	Hip Full Knee Full Decreased Achilles Length DorsiFlexion with Knee Ext. -5°

Function

	Staticic	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

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. Go to Discussion.