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 Limb		Lower Limb
	Left	Right	Left	Right
Tone	Increased	NAD	Increased	NAD
Power	2/5	4/5	2/5 Ankle 3-/5 Hip 3-/5 Knee	4+/5
Coordination	Impaired
Range of Movement Muscle Length	Shoulder:   Flexion 110° Abd 90° IR 40° ER 50° Elbow: Full ROM Wrist: Full ROM	Shoulder: Full ROM  Elbow: Full ROM Wrist: Full ROM	Hip: Full ROM Knee: Full ROM Ankle: Decreased ROM DF with Knee Ext -5°	Hip: Full ROM Knee: Full ROM Ankle: Decreased ROM DF with Knee Ext 0°
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

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 1200m

• 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 


Discussion

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.