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From Ventilation to Ambulation: A Brain Injury Rehab Case Study

April 3rd, 2017 in  Allied Health
by Bijal Shah

Here, at NGPT, we often keep it clinical and career-oriented. Here's an inspiring case study that serves as a reminder of why we do what we do.

History and examination:

A 64 year old male was admitted to my facility in March, 2015, following a recent hospitalization with change in mental status and traumatic brain injury. Due to HIPAA, we are going to address him as a patient (pt) or Mr. M.

At the time of evaluation, he was on ventilator at night. His cuff was inflated at all times, and he was unable to tolerate deflation of cuff, and unable to tolerate capping or Passy Muir Valve (PMV). Because of this, he was not able to communicate at the time of evaluation.

During PT and OT evaluations, he demonstrated hypotonicity on bilateral upper and lower extremities. He was unable to perform any active movement, unable to follow one step simple commands verbally, visually or with tactile cues. He was unable to communicate with any device or unable to mouth words.

Functionally, he was totally dependent for all daily activities. His sitting balance was poor, and he was unable to tolerate any weight bearing activities, like standing or weight shifting. One of the major concerns was potential flexion contracture development in right wrist, fingers, and right knee.

At the hospital, he was intubated due to lung abscess. Due to his multiple aspirations, his PEG tube was converted into J tube in hospital.

Brain injury rehab treatment approach:

Mr. M. received PT, OT and ST five days a week, following his evaluation in the facility. The plan of care for PT and OT included increasing or normalizing tone, increasing strength, improving balance, contracture management and improving his participation in functional tasks. He was receiving proper nursing and respiratory care, along with regular rehab for his functional needs.  The treatment approach included bracing/splinting, mat exercise, bed mobility and transfer training, gait training, electrical stimulation and functional electrical stimulation for neuro reeducation, swallowing techniques etc.

Outcomes:

He requires supervision for stair climbing and for long distance uneven surface ambulation.  Thus, we saw amazing treatment results with Mr. M with just consistent rehabilitation and a very good team work which included nursing as well as respiratory department.

Functional task: bed mobility

At evaluation - Total
After 6 months - Min A
Current status - Indep

Functional task: sit to stand

At evaluation - Unable
After 6 months - Mod A
Current status - Indep

Functional task: functional transfer

At evaluation - Total
After 6 months - Mod A
Current status - Indep

Functional task: ambulation

At evaluation - Unable
After 6 months - Min A
Current  status - Indep for short distances, Sup for long distances

Diet:

At evaluation - NPO
At 6 months - puree trials
Current status - regular

Liquids:

At evaluation - NPO
At 6 months - Honey thick trials
Current status -  Thin liquids

Communication:

At time of eval - Unable
At 6 months - Unable to speak, but communicated via gestures or facial expressions
Current status - Able to communicate independently

Participation in therapy:

At time of eval - Poor
At 6 months - Moderate
Current status - No skilled services required

Feeding:

At time of eval - NPO
At 6 months - Total dependent
Current status - Indep

UE dressing:

At time of eval - Total dependent
At 6 months - Mod A
Current status -  Indep

LB dressing:

At time of eval - Total dependent
At 6 months - Max A
Current - Indep

Conclusion:

This case seems like very slow progress, but we are talking about traumatic brain injury here! It's like teaching infants or babies to sit up, stand up, and walk!!

Kids take around 11 months or a year to learn to walk, and so do TBI patients!! Slow, steady, and consistent rehab is key.  This is one of my favorite cases so far, as it is a successful tale teller for importance of working as a team. Together, we can achieve amazing successes and bring near normal life to our patients.

We physical therapists usually do not give enough credit to ourselves. We are usually the ones who help people to walk, helping them to take their first steps after surgeries like total hip and total knee replacements. We are the one spreading smiles across patients' faces after relieving the pain. It's physical therapists who listen to patients like their own family members, suggesting a variety of treatment methods to “fix the problems.”

References

1. Injury Prevention & Control: Traumatic Brain Injury & Concussion. Centers for Disease Control and Prevention. January 22, 2016. Available at: http://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed February 13, 2016.
2. Office of Communications and Public Liaison. NINDS Traumatic Brain Injury Information Page. NINDS. February 11, 2016. Available at: http://www.ninds.nih.gov/disorders/tbi/tbi.htm.
3. Get the Stats on Traumatic Brain Injury. Injury Prevention & Control: Traumatic Brain Injury & Concussion. January 22, 2016. http://www.cdc.gov/traumaticbraininjury/pdf/bluebook_factsheet-a.pdf. Accessed February 13, 2016.
4. Starosta M, Niwald M, Miller E. The effectiveness of comprehensive rehabilitation after a first episode of ischemic stroke. Polish Medical Journal. 2015;XXXVIII(227):254-257.
5. Guoqing Y, Huiying L, Tiebin Y. Functional electrical stimulation early after stroke improves lower limb motor functionl and ability in activities of daily living. NeuroRehabilition. 2014(35):381-389.
6. Kawahira K, Shimodozono M, Etoh S, Kamada K, Noma T, Tanaka N. Effects of intensive repetition of a new facilitation technique on motor functional recovery of the hemiplegic upper limb and hand. Brain Injury. 2010;24(10):1202-1213.
7. Mang C, Campbell K, Ross C, Boyd L. Promoting Neuroplasticity for Motor Rehabilitation After Stroke:Considering the Effects of Aerobic Exercise and Genetic Variation on Brain-Derived Neurotropic Factor. Physical Therapy. 2013;93(12):1707-1716.
8. Lannin N, Herbert R. Is Hand splinting effective for adults following stroke? A systematic review and methodological critique of published research. Clinical Rehabilitation. 2003;17:807-816.
9. Lannin N, Horsley S, Herbert R, McCluskey A, Cusick A. Splinting the Hand in the Functional Position After Brain Impairment: A Randomized, Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2003(84):297-302.
10. Accelerated Care Plus. Available at: http://www.acplus.com/sports/Pages/Products.aspx. Accessed February 14, 2016.
11. Bakas T, Clark P, Kelly-Hayes M, King R, Lutz B, Miller E. Evidence for Stroke Family Caregiver and Dyad Interventions – A Statement for Healthcare Professionals From the American Heart Association and American Stroke Association. Stroke. 2014;45:2836-2852.
12. Lannin N, Cusick A, McCluskey A, Herbert R. Effects of Splinting on Wrist Contracture After Stroke A Randomized Controlled Trial. Stroke. 2007;38:111-116.
13. Koh G, Ong P. Caregiver Factors in Stroke: Are they the Missing Piece of the Puzzle? Archives of Physical Medicine and Rehabilitation. February 2016(10.106).

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