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 DorsiFlexion with Knee Ext. -10°	Hip Full Knee Full Ankle Decreased Achilles Length DorsiFlexion with Knee Ext. -5°
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.