Case study 2
Mark is a 25 year old male who sustained a head injury in a motor vehicle accident two years ago.
His initial hospital course is significant for prolonged ICU admission requiring mechanical ventilation. Three months after the accident, he was transferred to a rehabilitation center for six months. He was discharged nine months after the accident and was able to transfer with assistance of 1 and walking frame at that time. He since continued rehabilitation services. Since returning home, he has required some assistance with tasks and prompting. He was previously very physically actively and worked as a landscape gardener. He is able to walk independent without aid outside for one mile but has poor balance on uneven ground or at night, walking with a wide-based, ataxic gait. He has reduced single leg stance, right greater than left, and reduced step length, right greater than left. He has spasticity in the right hemi-body, worse with fatigue and postural instability. He has leg length discrepancy on the right leg. He has difficulty with fine motor movements in the right arm but is able to use it for some gross movements. He feels that the arm is “tight” with reduced supination and extension. Finally, he has ataxic speech with poor volume control, poor memory, and poor planning. He has behavioral and anger issues. He is highly motivated to improve
Below is a problem list for Mark:
|1||Balance issues on uneven ground or at night|
|2||Wide-based, ataxic gait|
|3||Right leg length discrepancy|
|4||Right hemi-body spasticity|
|5||Decreased fine motor movements in right hand|
|6||Ataxic speech and poor volume control|
|8||Behavioral changes, anger outburst|
The long-term goal for Mark is to walk 150 feet on an uneven surface independently with good balance. This goals was chosen for a number of reasons. Firstly, it accomplishes the patient’s goal of restoring some functions of his life before his brain injury. Secondly, it allows Mark to address a number of his other problems related to his gait, balance, and walking. Finally, it is measurable in terms of successfully completed attempts over a given amount of time and for a particular distance.
The role of the carer and multi-disciplinary team (MDT)
In addition to the physiotherapist, the carer and wider MDT can assist Mark in his rehabilitation.
Carer – Mark lives with his father, who can be considered his carer. He can attend appointments with Mark where he can be educated on how to assist his son in the areas he struggles in. Care giver fatigue is also of concern and he can be educated on how to manage his own feelings throughout this process. He can also provide additional reporting on Mark’s condition and history, which will help the team make better decisions for Mark’s care and keep track of his progress. Finally, he can also provide valuable emotional support for Mark throughout this journey.
TBI nurse – have specialized experience with brain injury patients. They can assist with the management of medication, and educate Mark and his father on how to live with a brain injury. They can also facilitate with the coordination of care amongst all team members.
Consultant (Neurologist) – meets with Mark throughout his rehabilitation to assess his condition and diagnose any additional problems that will require treatment. Makes referrals to other MDT members and can also prescribe further medication if necessary.
Occupational therapist (OT) – can help Mark manage his activities of daily living (ADL) in an easier, efficient fashion. Specifically, Mark needs help with fine motor movements, like buttoning. An OT can make recommendations to facilitate in these tasks and employ certain equipment or techniques that may be necessary.
Physical therapist (PT) – will assist in improving his balance, gait, and fine motor function. Home assessments can be carried out to make navigation around the house easier and reduce the risk of falls. While this is of lower concern for Mark, it is still important to maximize his safety in the home while he continues to struggle with his gait and leg length discrepancy. Specialist techniques or equipment can be implemented for tasks that Mark struggles with such as walking on uneven ground or at night.
Speech & Language therapist (SLT) – can assist with volume regulation and ataxic speech.
Recreational therapist (RT) – can offer recreational activities to improve mental and emotional wellbeing. These activities can also help Mark to recover some of his fine motor activities and memory skills. It will also allow him to socialize and build confidence.
Clinical psychologist – can help with any mental issues such as depression or anxiety that come with TBIs. Mark has behavioral changes and feels like he is losing relationships because of his injury. The injury in and of itself puts him at risk for depression, as does the loss of relationships and decrease in physical function.
Social worker – assist patients who may have difficulty in social aspects of their life. Social worker can help Mark’s father find funding sources, if that is an issue, and coordinate outpatient care if that is necessary on discharge.
Long term goal: to walk 150 feet on an uneven surface independently with good balance.
In order to help Mr Walker achieve his long-term goal, there are three short-term (ST) goals he will be given.
1st ST goal – walk on an even surface independently for 20 minutes. Before we begin to assess his ability to walk on uneven surfaces, we need to be sure it is safe to progress, especially in the setting of his ataxic gait and leg length discrepancies. If he can perform this task well, it will allow us to progress.
2nd ST goal – ambulate over and around obstacles in a path without loss of balance or hitting objects. Mark will be able to focus on balance training in this short term goal. An 18-item obstacle course is a validated means of quantifying gait, balance, and functional mobility (Rubenstein et al, 1997). In patients with intellectual disabilities, the number of falls decreased by 82% after completing obstacle course training (Van Hanegem, 2014).
3rd ST goal – ambulate 100 feet on an uneven surface with good balance on four out of the five attempts. After completing obstacle course training, it would be appropriate to move on to a more natural uneven surface that Mark may encounter. An example of this would be a brick road. Because this is still a goal on the way to full progression, we hope to see him perform this task on the majority of his attempts.
Goal attainment scale (GAS)
The GAS will be used to measure the progress of Mr Walker regarding the second ST goal (completing an obstacle course).
|Attainment level||Description||Relation to short-term goal|
|+2||Much better than expected||Can complete the obstacle course with no instability and no encounters with objects.|
|+1||Better than expected||Can complete the obstacle course with no instability and <20% encounters with objects.|
|0||Goal attainment||Can complete the obstacle course with no instability and <50% encounters with objects.|
|-1||Less than expected||Can achieve the obstacle course with noticeable instability and frequent encounters with obstacles in course.|
|-2||Baseline||Unable to complete the obstacle course independently and requires manual assistance.|
The Goal Attainment Scale, or GAS, is a means of quantifying progress on personal goals (Krasny-Pacini, 2013). With the assistance of the physiotherapist, both Mark and his carer (dad) would both be involved in establishing what the GAS scale looks like.
Rubenstein LZ, Josephson KR, Trueblood PR, Yeung K, Harker JO, Robbins AS. The reliability and validity of an obstacle course as a measure of gait and balance in older adults. Aging (Milano). 1997 Feb-Apr;9(1-2):127-35. doi: 10.1007/BF03340138. PMID: 9177596.
Van Hanegem E, Enkelaar L, Smulders E, Weerdesteyn V. Obstacle course training can improve mobility and prevent falls in people with intellectual disabilities. J Intellect Disabil Res. 2014 May;58(5):485-92. doi: 10.1111/jir.12045. Epub 2013 Apr 19. PMID: 23600491.
Krasny-Pacini A, Hiebel J, Pauly F, Godon S, Chevignard M. Goal attainment scaling in rehabilitation: a literature-based update. Ann Phys Rehabil Med. 2013 Apr;56(3):212-30. doi: 10.1016/j.rehab.2013.02.002. Epub 2013 Feb 28. PMID: 23562111.