Traumatic brain injury is a type of injury that often results from an accident. It involves a long recovery process way past physical healing. This type of brain injury requires a lot of patience as well as persistence from all parties involved. 

This is a case of 64-year-old Traumatic Brain Injury(TBI) survivor who made significant progress to achieve his near normal function with aggressive rehabilitation, nursing, and respiratory therapy.  

History and Examination :

A 64-year-old male was admitted to my facility in March 2015 from a recent hospitalization with a 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 a ventilator at night. His cuff was inflated at all time, unable to tolerate deflation of the cuff, or unable to tolerate capping or PMV. Due to 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 unable to tolerate any weight-bearing activities like standing or weight shifting. One of the major concerns was a potential flexion contracture development in the right wrist, fingers and right knee.

Mr. M’s past medical history was significant for intracranial hemorrhage s/p left craniectomy in 11/2014, multiple hospitalizations with aspiration pneumonia, hypertension, anemia, and tachycardia. 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. 

Treatment Approach TBI:

He received PT, OT, and ST five days a week since 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 improve his participation in the functional task. He was receiving proper nursing and respiratory care along with regular rehab for his medical 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 for TBI:

Currently, Mr. M. is independent in functional tasks like bed mobility, transfer, short-distance ambulation (20 feet), wheelchair mobility, dressing, hygiene, grooming, and feeding! 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 very good teamwork which included nursing as well as the respiratory department.

 

functional task	At evaluation	After 6 months of rehab	Current  status
Bed mobility	total dependent	Min A	Independent
sit to stand	unable	Mod A	Independent
functional transfer	total dependent	Mod A	Independent
ambulation	unable	Min A	Independent for short distance, supervision for long-distance
diet	NPO	puree trials	Regular
liquid	NPO	honey-thick trials	Thin
communication	unable	unable to speak/can communicate via  gestures or facial expression	Able to communicate independently
participation	poor	moderate	No skilled services required
feeding	NPO	total dependent	Independent
UE dressing	total dependent	Mod A	Independent
LB dressing	total dependent	Max A	Independent

 

Conclusion:

This case seems like very slow progress, but we are talking about traumatic brain injury here! It’s like teaching an infant or baby to sit up, stand and to walk!! As kids take around 11 months to a year to learn to walk and so do TBI patients!!  Slow, steady and consistent rehab is the key.  This is one of my favorite cases so far as it is a successful example of the importance of working as a team. Together, we can achieve amazing results and a near-normal life for our patients.

We physical therapists usually do not give enough credit to ourselves.  Physical Therapists are usually the one who helps people to walk, take their first step after surgeries like total hip and total knee replacement.  We are the one spreading smiles across the patient’s face after relieving pain through therapy.  It’s the physical therapist who listens to patients like their own family members and suggests a variety of treatment methods to “fix the problems”. Additionally, We are the last finishing workers without whom the full outcome of results will never be the same – just like a cherry on top!

References

 

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