Traumatic Brain Injury Case Study

Occupational profile – Goals

Santo was very active with his church, community, and his college. When Santo was injured he was a sophomore in college working toward a degree in computer science. He was also living in his apartment. Santo has expressed a desire to return to school and independent living. To return to college he feels that he needs to be able to move without relying on the wheelchair. Currently, Santo can ambulate for a distance of 40 feet with the assistance of a hemi-walker but is reliant on a wheelchair for longer distances.

Santo has demonstrated decreased retrieval skills including decreased recall, especially when presented with unfamiliar material. His reasoning is intact and he can generate multiple solutions to problems presented in a structured setting. He has psychomotor slowing, difficulty in shifting cognitive set and may perseverate on some tasks. He has impaired higher-order abstract thinking.

He also has decreased categorization of verbal material and mildly impaired short-term memory. He has an easier time categorizing and understanding written materials but is inefficient in his attempts to organize written materials. Verbal outbursts are noted when he is frustrated by abstract tasks, including cursing. He demonstrates excessive talking if he is trying to avoid difficult activities, requiring frequent redirection.

Due to these cognitive deficiencies, additional difficulties might be experienced when Santo can return to college.

Expected Performance Strengths and Deficits

Santo has shown improvement in several areas. These areas include reaching in multiple planes and the ability to extend fingers and pick up and release lightweight objects. He has almost accomplished consistent lateral prehension and release. His LLE demonstrates Brunnstrom stage 4/5. He can perform knee flexion past 90 in sitting with his foot sliding backward on the floor. He has active dorsiflexion with his heel on the floor and the knee flexed to 90. He demonstrates hip extension with knee extension in standing.

Santo still has several deficits. He remains unable to demonstrate hip and knee extension with ankle dorsiflexion. In addition he demonstrates N strength in his RLE except for ankle movements, which are all in the G/G+ range with dynamic combined movement patterns most affected by the residual orthopedic problem. In addition while Santo’s static standing balance is intact, the dynamic standing balance demonstrates mild deficits to the left on a flat, stable surface.

Evaluation

The treatment plan will focus on the following three long-term goals as well as the short-term goals that are associated with them.

1. To improve hip and knee extensions with ankle dorsiflexion

  • To report pain that is less than 3/10
  • To show an improvement in movement as determined through an increase in the ROM measurements of hip and knee extensions

2. To improve ankle movements when performing dynamic combined movement patterns.

  • To report pain that is less than 3/10
  • To show an increase in movement as determined through an increase in the ROM measurements of Santo’s ankle movements

3. To improve Santo’s dynamic standing balance demonstrates mild deficits to the left on a flat, stable surface

    1. To increase Santo’s sense of balance
    2. To increase Santo’s stability

The first treatment plan will focus on improving Santo’s sense of balance. This will be done through the use of intensive physical therapy that is specifically designed to improve and strengthen his sense of balance. The forms of rehabilitation that will be used in this session are forms of vestibular rehabilitation. Vestibular rehabilitation is a technique that is designed to create brief periods when the patient experiences a loss of balance in a controlled setting. This is important because Santo is experiencing periods where he has lost his balance. These exercises will assist in increasing his sense of balance as well as provide the muscle memory that could prevent a serious injury during these episodes of instability.

This session will focus on the Cawthorne Cooksey Exercises. These exercises were chosen because they start with the patient in a sitting position and progress to the patient moving around obstacles in the treatment room under their own power.

The second step of this exercise involves the following motions described below while Santo is sitting in a chair. Santo will be asked to move his eyes up and down, side by side and then focus on a moving finger that is one foot away from his eyes. He will be asked to do this twice once slowly and then quickly. He will then be asked to move his head forward and back and then turn the head in a side to side motion. He will be asked to do this twice once slowly and then quickly. If there are no problems with this portion of the exercise he will be asked to shrug his shoulders and then to bend forward to pick up objects off of the floor. Depending on how well Santo is able to perform these actions will determine the level of difficulty for the next therapy session.

In order to increase the amount of movement Santo can perform. He will be asked to do basic stretching exercises to ensure that the muscles and tendons are fully warmed up. After this warm-up period he will be asked to perform calf raises and other strengthening exercises. The strengthening exercises will include squats, leg curls and front and back lunges. He will also be asked to walk on a treadmill. These exercises will be performed with the aid or assistance of the therapist to maximize Santo’s safety and the effectiveness of the treatments. These muscles, tendons and bones must be stretched and strengthened to create an increased range of motion.

Evidence-Based Practice

Through many years of research more information about the parts of the brain, how they interact with the other parts and with areas of the body has been collected by researchers (Kaas, Jon H, and Florence, Sherre L, 1996). Through this research, it has been discovered that the brain through various forms of treatments and therapies can in a sense rewire itself after a traumatic injury. This ability to rewire itself makes it possible for individuals who have suffered a traumatic brain injury to regain some of the functions that were disabled during the impact (Kaas, Jon H, and Florence, Sherre L, 1996). The result of this increased understanding of the human brain has allowed researchers to develop several theories and treatments that have allowed individuals who have experienced a traumatic brain injury to recover much of the functionality that was lost.

Occupational therapy is effective at improving an individual’s ability to care for them and to increase their range of motion. Through these comprehensive therapy programs, the patient can increase the quality of life that they are experiencing. Several different therapies are used by occupational therapists when designing therapies for their patients. Those therapies include the compensatory approach and the adaptive skills theory (Turner, Foster, and Johnson, 2002). When treating Santo it was decided that the compensatory approach would be the best treatment method. In this approach the fact that humans can adapt their functionality for any situation that is presented to them with any limitations that might arise.

There is a large amount of research that shows that this is a very effective form of therapy. Several benefits of this therapy include ease of understanding by the patient, involves the patient in the treatment plan and the setting of goals and other forms of therapy can be used at the same time to maximize the results seen by the patient and the therapist (Turner, Foster and Johnson, 2002). There are some potential problems with this therapy as well but with proper planning and communication, those problems can be minimized. Due to the increased desire of hospitals and insurance companies the occupational therapist might be pressured to choose the form of treatment by financial constraints rather than the best needs of the patient (Turner, Foster and Johnson, 2002). When this happens the patient is denied the ability of personal choice. With this lack of personal choice, the patient might not experience the full value of the treatment. This therapy can be used for both long and short-term disabilities.

In the compensatory approach, the goal of the patient and the therapist is to find a way to complete an activity. Due to this being the primary consideration the ability to complete the task or activity is the focus rather than the physical or anatomical features of the patient (Turner, Foster and Johnson, 2002). There are several basic assumptions that this theory requires. The first assumption is that any individual that is experiencing a physical disability can learn alternative methods to perform and complete daily activities. The second assumption is that if the disability is considered to be a short or long-term disability those daily actions still need to be performed (Turner, Foster and Johnson, 2002). Due to this some form of alteration to the task would allow the patient to perform the tasks. Through this theory, it may be possible for the patient to see an increased quality of life that might not be seen through other forms of treatment.

With the above assumptions in place, the therapist will work with the patient to discover the extent of their capabilities and find alternative methods of performing daily tasks. These might include the use of mechanical devices or aids, adopting some or all of the steps that are required to complete the task or creating brain-storming sessions that will increase the patient’s problem-solving skills (Turner, Foster and Johnson, 2002). Through this intervention, the individual will be involved in their treatment plan and instrumental in the creation of activities and methods for conducting the activities of their daily life. Through this interaction of the patient and the therapist the well-being of the patient will be increased leading to a greater quality of life for them and their family members (Turner, Foster and Johnson, 2002). Because of the above considerations and Santo’s desire to regain the ability to perform those activities that he has not been able to do since the accident.

References

  1. Kaas, Jon H and Florence, Sherre L. (1996). Brain Reorganization and Experience. Peabody Journey of Education. 71(4), 152-167.
  2. Turner, A., Foster, M., Johnson, S.E.(2002), Occupational Therapy and Physical Dysfunction. Principles Skills and Practice. Edinburgh. Churchill Livingston. (Turner, Foster and Johnson, 2002)