Case 1: TBI (Ranchos level II) (Occupational Deficits (Problem List…
Case 1: TBI (Ranchos level II)
2.8 million people experienced emergency department visits, hospitalizations, and deaths by TBI in the United States in 2013. (Centers for Disease Control and Prevention, 2017).
1.7 million individuals experience traumatic brain injuries each year (Padilla & Domina, 2016).
Traumatic brain injuries are attributed to a number of traumatic events including: motor vehicle accidents, falls, and sports injuries (Petersen & Sanders, 2015).
Diagnosed in over 282,000 hospitalizations for the year 2013 (CDC, 2017).
TBI accounted for approximately 2.5 million ED visits for the year 2013 (CDC, 2017).
TBI Ranchos Level II Symptoms (Generalized Response: Total Assistance)
Generalized reflex response to painful stimuli (Centre for Neuro Skills, 2018).
Responds to repeated auditory stimuli with increased or decreased activity (Centre for Neuro Skills, 2018).
Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization (Centre for Neuro Skills, 2018).
Responses may be significantly delayed (Centre for Neuro Skills, 2018).
Recovery from a TBI varies based on the individual and the brain injury, and recovery can be seen months even years after initial injury (Traumatic Brain Injury.com, 2004).
56 y.o. male
Referral for: PT/OT/SLP
Husband & father
Problems impacting function
Client's TBI is currently scaled at a Ranchos Level II. He inconsistently responds to light, sound, touch, and movement with delayed reactions to these simulations.
Time response-delayed time response
Turns toward stimulus provided but delayed response
Notices-responds to sound, light, touch, and movement with delayed reactions
Upper extremities 1+, lower extremities 2 on Modified Ashworth Scale
TBI (Ranchos level II)
Context & Environment
Aggitated and negative reactions to over stimulations (i.e. loud sounds, too much tv, too much light)
Has support from wife and daughter
Has recently been moved to a skilled nursing facility
Role of a father and husband
Routine of Skilled Nursing Facility care
Little change in responsiveness since being admitted
Presents with slight increase in muscle tone upper extremity, and more marked increase in tone in lower extremities
Delayed response to stimuli
No active ROM
Assess for current range of motion to determine amount of PROM to be administered to client (Centre for Neuro Skills, 2018).
Therapist Observations of Arousal Levels
Client was classified at a Ranchos Level II traumatic brain injury as indicated through generalized responses to external simuli (Centre for Neuro Skills, 2018). Therapist will observe client for other determinants of arousal.
Modified Ashworth Scale
"Slight increase in muscle tone, manifested by a catch, followed by minimal
resistance throughout the remainder (less than half) of the ROM" (Bohannon & Smith, 1987, p.1).
"More marked increase in muscle tone through most of the ROM, but
affected part(s) easily moved" (Bohannon & Smith, 1987, p.1).
Cognitive Recovery Scale - Revised (CRS-R)
Used for differential diagnosis, prognostic assessment and treatment planning with patients with disorders of consciousness (Parten, 2018)
Able to differentiate b/w vegetative state (VS) (renamed as unresponsive wakefulness syndrome-UWS) and minimally conscious state (MCS) and determine when a patient is emerging from a minimally conscious state (EMCS) (Parten, 2018).
Client scored a 5 on the CRS-R upon examination.
Preventative Care through ROM
PROM techniques are used with clients who have experienced traumatic brain injuries to prevent contractures from abnormal tone and static postures and to decrease change for heterotopic ossification (Powell, 2014). Severe contractures negatively impact mobility and function and benefit from range of motion techniques (Leung,Harvey, & Moseley, 2013).
Client will participate in PROM movements administered by therapist 1X/ day for 6 weeks. PROM in the upper extremities will begin with scapular mobility to facilitate normal scapular and humeral movement (Powell, 2014). Abnormal tone in the client's upper and lower extremities require inhibitory movements to be performed slowly with no sudden stretch (Powell, 2014).
Preventative Care through Caregiver education
Providing family with support and education regarding the recovery process for this point in the injury (Powell, 2014).
Experiencing grief is a normal and expected reaction for caregivers who's loved one has undergone a traumatic brain injury (Petersen & Sanders, 2015). Caregivers will be educated on the importance of maintaining their own self-care in order to provide their loved one with a high degree of care (Petersen & Sanders, 2015).
Provide caregiver with education over the importance of keeping stimulation at a tolerable level to reduce the risk of over stimulating the client. For example, the caregiver should understand that the television can stay on if it is on at a low level.
Restorative Care through Multimodal sensory stimulation (Padilla & Domina, 2016).
Client will participate in combined auditory and tactile stimulation activity involving family participation.
2X/day for 6 weeks, client's wife and daughter will sit in chairs at the head of client's bed facing client. Client's wife and daughter will greet client by name in their typical conversational tone. Client's wife will take the client's hand and state her name. Client's daughter will place her hand on her father's shoulder and state her name (Padilla & Domina, 2016).
Multimodal sensory stimulation increases engagement of higher order cortical functioning in the brain (Padilla & Domina, 2016).
Auditory and tactile stimulation was shown to increase patient consciousness as measured by Glasgow Coma Scale (Padilla & Domina, 2016).
Preventative Care through Positioning
Client will experience positioning routine to prevent pressure ulcers and contractures. Decubitus ulcers are one of the most common non-neurological complications of traumatic brain injuries (Omar et al., 2017). Positioning is used to normalize muscle tone and decrease chance for contractures in clients with traumatic brain injuries (Powell, 2014).
Client's position will be adjusted 3x/ day for prevention of muslce contractures (Königs, Beurskens, Snoep, Scherder, & Oosterlaan, 2018). Changes in facial expression and vocalizations will be monitored and reported. Changes in muscle tone from positioning will observed through direct observation.
Caregiver will be included in the positioning routine to learn appropriate ways to position client and learn the importance of positioning procedures.
Client will experience an increase in conscious response as recorded through the JFK Coma Recovery Scale - Revised (CRS-R).
In 4 weeks, client will increase awareness as evidenced by a CRS-R score of 14.
Client will experience increased auditory arousal.
In 4 weeks, client will orient toward an auditory stimulus using eyes or head turn, IND, with < 6 seconds delayed reaction, for 2 out of 3 attempts.
Caregiver will demonstrate understanding of client's care.
In 4 weeks, caregiver will verbalize and demonstrate understanding of client's care routine including positioning procedures and methods for creating a tolerable sensory environment for the client.
Person-Environment-Performance (PEOP) Model
The PEOP model will be used to provide quality interventions to the client. Aspects of the client's current environment and interactions with his family will be utilized to create treatments that will improve his current level of functioning as impacted from his neurological and physiological impairments.
This model takes in to account the client and how they engage within their environment including home and work, their occupational role within the environment, and their performance in that environment. (Cole & Tufano, 2008)
Client is currently living in a skilled nursing facility where he is receiving therapy services from an SLP, PT, & OT. Consistency or change in client's health, as well as goals achieved would be defined as progress.
The client's environment will be modified as necessary to create a tolerable atmosphere for the client and to increase arousal.
Toglia's Dynamic Interactional Approach
Domains of Toglia's Dynamic Interactional Approach will be used to address concern's in the client's orientation, attention, visual processing, and cognition and the impacts they pose on occupational engagement (Cole & Tufano, 2008).
Toglia's framework was designed for individuals with brain injuries and cognitive impairments (Cole & Tufano, 2008).
Toglia's approach will be used to address client's current level of cognition from recent TBI. Client currently presents with limited improvements in responsiveness since being admitted to SNF.
Allen's Cognitive Levels (ACL) Frame of Reference
ACL FOR will guide the implementation of interventions that will be most effective for the client's current level of functioning. ACL utilizes the "just right challenge" to incorporate evaluations and treatments that match the client's current capacities (Cole & Tufano, 2008). Client currently scores at a level 1 (automatic actions) on ACL. This FOR will guide responses and understanding of the client's sensory cues and motor actions (Cole & Tufano, 2008).
ACL FOR describes different limitations seen through various cognitive levels (Cole & Tufano, 2008).
ACL is a useful FOR in monitoring changes in brain chemistry, physiology, and plasticity (Cole & Tufano, 2008).
The results and improvements measured from ACL can be compared to the Ranchos Assessment as another method for measuring improvements (Cole & Tufano, 2008)
Biomechanical Frame of Reference
The Biomechanical FOR will be used to address ROM deficits impacting the client and for preventative measures regarding the client's positioning. This FOR will guide the implementation of PROM techniques to reduce muscle tone and prevent contractures and positioning modifications to prevent pressure ulcers and contractures.
This approach incorporates the principles of movement related to improving body functions (Cole & Tufano, 2008).
The biomechanical approach is associated with "remediation, improvements of strength, ROM, or endurance" (Cole & Tufano, 2008, p. 165).
Ashley Abrego, Nooreen Khalid, & Melissa Williams