Traumatic Brain Injury - Case Study Part 3

Presenting Condition

For background information go to

Traumatic Brain Injury - Case Study Part 1

Traumatic Brain Injury - Case Study Part 2

Assessment

6 Months Post Injury

	Upper Limbs		Lower Limbs
	Left	Right	Left	Right
Tone		N		N
Power	2/5	4/5	2/5 Ankle 3-/5 Hip 3-/5 Knee	4+/5
Sensation	Unable to Assess
Coordination	Impaired
Reflexes		¯		¯
ROM  Muscle Length	GHJ  Flexion 110° Abd 90° IR 40° ER 50° Ext 40° Elbow Full ROM Wrist Full ROM	Full all joints	Hip Full Knee Full ¯Muscle Length TA DF with Knee Ext.-5°	Hip Full Knee Full ¯Muscle Length TA DF with Keee Ext. 0°

Current Function

•   No use of oxygen 


•   Blood Pressure within normal limits 


•   Supervision with Mat Mobility 


•   Contact Guard with Stand Turn Transfers 


•   Contact Guard to Minimal Assist of 1 & Supervision of another for Gait 1200’


•   Minimal Assist of 1 & Supervision of 1 on 20 steps reciprocally with a Handrail 


•   Minimal Assist of 1 & Supervision of 1 on 6 Inch Curb 


Discharge Planning Considerations

• Family Support

• Environment

• Equipment 
• Further Rehabilitation Needs 

What treatment goals would you select for James? What considerations would you make towards James discharge planning? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can. Go to Discussion