Case presentation (TBI)

Name : Pramanik Mohammad Basher

Age : 27
Gender : Male
Date of assessment : 12/8/2019
Diagnosis: Severe head injury with temperoparietal extradural haemorrhage.
:Lt temporal bone and zygomatic bone fracture.
: Multiple facial bone and skull vault fracture
: Hospital acquired pneumonia.
Motor deficit : left
Medical hx
Patient was involve in MVA 21/3/2019. The patient was sent to Hospital
Tengku Ampuan Rahman Klang(HTAR). At HTAR, patient GCS was E1 V2 M3
(6/15) with pupil 3/3 reactive. The patient was then intubated for airway
protection and CT brain was done. CT show left frontotemporal extradural
haemorrhage with multiple facial bone fracture and skull vault fracture.
Patient received ICU care (10 days), suture of bleeding scalp wound, blood
transfusion, tracheostomy 29/3/2019, repeated CT scan and intravenous
antibiotic at HTAR. Patient refer to CAECH for rehab.
Social / family Hx
-unknown

Medication
- Sy epilin 200mg
- T. Brahexine 8mg
- T. Thiamine 100mg
- T. Ferrous Fumarate 200mg
- T. Folic acid 5mg
- T Multivitamin 2 daily
- Pravacid 30mg daily
Dominant hand : right
Cognitive impairment : NO
Communication impairment: Yes( language barrier and slurred speech)
Visual deficit : No
Hearing deficit : No
Proprioception : intact
Splint : AFO
DVT sock : not required
Functional analysis
Transfer : required 1 pax help
Supine to side lying : independent ( supervision)
Side lying to sitting : independent ( supervision)
Static sitting balance : Yes
Dyanamic sitting balance : No
Sit to stand : dependent
Standing : dependent
Eating : independent
Grooming : independent
Range of motion
Movement Left Right Muscle power Muscle power
(left) (right)
Shoulder flexion Limited at outer range FAROM -3 4
(d/t muscle tightness)

Shoulder abduction Limited at middle range FAROM -2 4

(d/t muscle tightness)

Elbow flexion Limited at middle range FAROM 0/5 5

Elbow extension Limited at middle range FAROM 0/5 4

Wrist flexion FPROM FAROM 0/5 4

Wrist extension Limited at outer range FAROM 0/5 5

Finger flexion FPROM FAROM 0/5 5

Finger extension Limited at middle range FAROM 0/5 4

( rt thumb has
limited of rom)
Forearm pronation FPROM FAROM 0/5 5

Forearm supination Limited at outer range FAROM 0/5 4

Movement Left Right Muscle power Muscle power
(left) (right)

Hip adduction FAROM FAROM 3 4

Hip abduction FAROM FAROM -3 -4

Hip flexion FAROM FAROM -4 -4

Knee flexion FAROM FAROM -4 5

Knee extension FAROM FAROM -4 5

Plantarflexion FAROM FAROM -4 4

Dorsiflexion Limited at outer range FAROM -2 5

Inversion FAROM FAROM -4 5

Modified Ashworth scale
Muscle Left Right
Shoulder flexor 4 0
Shoulder abductor 4 0
Elbow flexor 4 0
Elbow extensor 4 0
Wrist flexor 4 0
Wrist extensor 0 0
Finger flexor 4 0
Finger extensor 0 0
Forearm pronator 4 0
Forearm supinator 4 0
Hip adductior 0 0
Hip abductor 0 0

Hip flexor 0 0
Muscle Left Right
Knee flexor 0 0
Knee extensor 0 0
Plantarflexor 4 0
Dorsiflexor 0 0
Invertor 0 0
 MRMI
Component Score
Turning over 3
Lying to sitting 3

Sitting balance 2

Sitting to standing 2

Standing 2
Transfer 2
Walking indoor 2
Stair n/a

Total :16/40
 Problem identified
• Reduce left upper limb range of motion due to muscle tightness.
• Reduce in left dorsiflexion at outer range due to muscle tightness.
• Reduce in left lower limb muscle power generally -4/5.
• Reduce in right thumb extension at outer range.
• Reduce in right upper limb and lower limb strength of generally 4/5.
• Increase in left upper limb muscle tone of generally 4/5.
• Increase in plantar flexor muscle tone of 4/5.
• Fair dynamic sitting balance
• Poor standing balance
• Poor dynamic standing balance
• Dependent in sit to stand.
• Require one person to transfer
• No heel strike while walking
• Scissoring gait
Short term goal
• Increase left shoulder rom to inner range by 2-3/52.
• Increase left elbow, wrist rom to middle range by 2-3/52.
• Increase left foot dorsiflexion from outer range to middle range by 1/52.
• Increase the right thumb extension to middle range in 2/52.
• Increase the right upper limb and lower limb muscle power from 4/5 to 5/5 with 2/52.
• Improve dynamic sitting balance in 1/52.
• Improve standing balance in 2/52
• Improve dynamic standing balance in 3/52.
• Enable pt to sit to stand with supervison within 2/52
• Enable pt to transfer wc to bed with minimal help within 2/52
• Improve heel strike within 1/52.
Long term goal
• Enable patient to transfer independently.
• Enable patient to walk independently with quadripod.
• Improve MRMI to 23/40
Treatment plan
• Stretching
• Upper limb strengthening
• Lower limb strengthening
• Balance exercise
• Transferring
• Gait training
Intervention
• Passive stretching ~ 10reps with 20sec hold
• Standing in tilt table ~30min.
• Pully exercise 5 set of 10 reps.
• Weight bar 5 set of 10 reps.
• Half squat in tilt table 5 set of 10 reps.
• Sit to stand 5set of 10reps.
• Reaching exercise : putting the cone on the floor.
• 3 point gait with quadripod.
Follow up
21/8/2019
Movement Left Right Muscle power Muscle power
(left) (right)
Shoulder flexion Limited at outer range FAROM 3 5
(d/t muscle tightness)

Shoulder abduction Limited at middle range FAROM 2 5

(d/t muscle tightness)

Elbow flexion Limited at middle range FAROM 0/5 5

Elbow extension Limited at middle range FAROM 0/5 5

Wrist flexion FPROM FAROM 0/5 5

Wrist extension Limited at middle range FAROM 0/5 5

Finger flexion FPROM FAROM 0/5 5

Finger extension Limited at middle range FAROM 0/5 4

Forearm pronation FPROM FAROM 0/5 5

Forearm supination Limited at outer range FAROM 0/5 4

Movement Left Right Muscle power Muscle power
(left) (right)

Hip adduction FAROM FAROM 3 5

Hip abduction FAROM FAROM -3 4

Hip flexion FAROM FAROM 4 5

Knee flexion FAROM FAROM -4 5

Knee extension FAROM FAROM -4 5

Plantarflexion FAROM FAROM -4 5

Dorsiflexion Limited at middle range FAROM -3 5

Inversion FAROM FAROM -4 5