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Disorders of Consciousness www.huntercombe.com
Introduction Mr A is a 25 year old man who was involved in a road traffic accident over 7 years ago. He suffered severe traumatic brain injuries, requiring decompressive craniotomy with evacuation of intracerebral haematoma.
Following initial emergency treatment this gentleman was admitted to an NHS rehabilitation facility and was communicating using thumbs up/thumbs down. He was able to spontaneously move himself about his bed and appeared alert. He then gradually deteriorated and became almost completely unable to communicate and, at his worst, only remained able to blink, yes/no. At all times he remained cooperative. He had a very supportive family. He required full nursing care and was PEG fed; he had initially been taking spoonsful of oral diet however, due to his deterioration, became unable to do so. He was receiving physiotherapy for about one hour on one or 2 occasions per day. He was receiving occupational therapy input and speech and language therapy input. There were significant problems controlling his oral secretions. It was considered that his deterioration may have coincided with repeated injections of Botulinum toxin to manage focal spasticity issues. He gradually recovered over an approximately 3 month period following discontinuation of the Botulinum toxin therapy.
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He was transferred to Murdostoun Brain Injury Rehabilitation Centre for further assessment and neuro-rehabilitation input.
At the time of admission to our Centre, there were still markedly restricted movements and severe difficulties with speech.
Our assessment found that GCS of 3 was recorded at the scene of the accident. He was flexing as a best motor response with bilateral unreactive pupils. His initial CT scan had revealed right acute subdural haematoma with an underlying intracerebral haematoma. Depressed right frontal fracture, base of skull fracture and right zygomatic complex. He required insertion of a tracheostomy. His injuries were considered to represent a very traumatic brain injury and diffuse axonal injury was also diagnosed. At the time of admission to our Centre, there were still markedly restricted movements and severe difficulties with speech. Thus, simple verbal responses were appropriate as these had to be spelt out from a letter board.
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Tests administered • Cognitive Screen: Addenbrookes Cognitive Examination — Revised (ACER) • Memory: Doors and People Test • Intelligence: WAIS-III (Picture Completion, Matrix Reasoning, Arithmetic, Information and Digit Span Sub-tests) • Visuospatial: Sub-tests from the above battery, Line Bisection Test
It was also noted that his mood fluctuated in relation to pain/ discomfort and also low mood was related to thoughts about his condition.
Mr A was considered to have been depressed and anxious in the months following the brain injury but this no longer appeared to be a problem. He was considered to be in the average range of intellectual premorbid functioning level.
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The battery of tests indicated intact verbal working memory, intact recall of information from long-term store, encoding of new verbal memory was in line with premorbid functioning, encoding of new visual memories was impaired, there being a constellation of visuospatial deficits. These manifested in tasks involving visual scanning, serial search and abstraction of information from verbal stimuli.
There was no evidence of visual field neglect. Fatigue impacted significantly and quickly on sustained attention and motivation. It was also noted that his mood fluctuated in relation to pain/ discomfort and also low mood was related to thoughts about his condition. There was slowed scanning noted as a visuospatial deficit. Goals were set as follows: • To communicate that he would like to start an interaction • To access mentally stimulating materials with support • To communicate the nature, location and severity of his discomfort • To communicate thoughts associated with depressed mood • To communicate longer term hopes Nursing assessments revealed that he was dependent for selfcare, incontinent, at risk of chest infections and a goal was set to participate in self-care.
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Speech & language therapy assessment Speech and language therapy assessment revealed no speech output, no oral intake, inability to indicate basic needs without the support of a communication partner and limited use of facial expression, gesture and writing to communicate information.
Goals were again set, including:
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Medical Case Study: Disorders of Consciousness
• To voice on command at least once per week • To use a point and select computer aid consistently three times per week • To communicate through writing at single word level • To reciprocate greetings at least once per day • To make four clear gestures with prompting • To indicate toilet needs 50% of the time • To identify swallow safety via videofluoroscopy
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Physiotherapy assessment Physiotherapy assessment revealed a further set of problems, including risk of aspiration, significantly reduced head, neck and trunk control, poor postural control; increased flexor tone of upper limbs with adaptive shortening and contracture development; reduced activity of upper limbs, increased lower limb extensor tone with stiffness of hips and pelvis with windswept posture; flexion contractures of both knees; contracted right foot in equinovarus position; significant pain when sitting, with reduced tolerance; inability to sit unsupported.
A wide range of goals were set relating to these issues, particularly:
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Medical Case Study: Disorders of Consciousness
• To maintain head and trunk control, with upper limb support, for 1 minute, in sitting with close supervision and verbal prompts. • To increase ranges of motion in upper limbs • To increase ranges of motion in the lower limbs • To improve positioning in bed with the use of support • To refer for orthopaedic review of right foot • To sit in more upright position • To tolerate splints as required Occupational therapy assessment revealed impairments essentially as previously noted. Goals related to activities of daily living, including leisure and outings in the Centre’s minibus.
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This gentleman spent a total of 17 months in the Centre and at the time of discharge had achieved a huge majority of his goals. He had received a comprehensive neuro-rehabilitation assessment and then continued to work on neuropsychological assessment, reassessment as regards vocational issues, adjustment issues, assertiveness training and nocturnal enuresis. His consistent recovery potentiated the idea of continued recovery and he eventually found the idea of leaving the Centre difficult. Preparatory work on opportunities and choices in the wider world aided his exploration of fears and excitements regarding discharge. He made very positive changes to his assertiveness as an aid to self-expression. Motivational interviewing was used to explore a return to academic pursuits. Areas of work, including mathematics, problem-solving, visuospatial design and interaction with people were suggested and discussed. He went on to identify an introductory computer course and planned to continue to gain experience in web design.
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He became able to manage any foods and drinks as he wished.
He became able to transfer from his bed and mobilise around his room. He became fully independent with all aspects of grooming.
He demonstrated a greater awareness of communication, resulting in increased effort to generalise speech strategies into everyday communication. He exhibited increased facial expression, tone of voice, use of gesture and pitch. He also began to initiate conversation naturally with others and became an engaging communication partner. He was encouraged to continue giving clear guidance during his transfer manoeuvres.
He became able to safely prepare basic snacks independently and was making all lunches and evening meals for himself prior to discharge. He increased his time spent in the lounge with staff members, engaging in leisure activities. He then engaged in groups with other patients. He went on to develop friendships with other patients and would engage in conversations with patients and staff.
He became fully independent with washing and dressing, having required 2 people to meet his self-care needs and hoist for transfers on admission.
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He had been supplied with an indoor/outdoor electric wheelchair. He was able to use this quite safely. He enjoyed accessing the local community but continue to require support to do this. He was supported in arranging his own tenancy and was keen to pursue further education opportunities. He went on to score 37/40 on the modified Rivermead Mobility Index Score. He also finally scored 50/56 on the Berg Balance Scale.
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Since discharge he has visited Murdostoun on many occasions and has been happy, along with his mother, to speak to selected groups as regards his injuries, recovery and present situation.
Overall his gait significantly improved and he became able to ascend stairs independently using a rail. He received phenol injections to the left biceps, brachioradialis and pectorals, requiring to be repeated. These injections helped to reduce his tone. He participated in stretches and active exercises and was supplied with an elbow splint. He required bilateral Achilles tendon lengthening surgery due to longstanding contractures. He was eventually discharged to his local district general hospital. Since discharge he has visited Murdostoun on many occasions and has been happy, along with his mother, to speak to selected groups as regards his injuries, recovery and present situation. He now lives completely independently, drives and has a job. He also has a girlfriend.
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Our services include an independence flat within the Centre, an ADL kitchen where patients are able to practice making their own meals.
I believe that Mr A’s rehabilitation and recovery were very significantly helped by his stay at Murdostoun Brain Injury Rehabilitation Centre. We were able to offer him an extended stay, during which he received in-depth and repeated neurorehabilitative assessment/ reassessment involving medical, nursing, physiotherapy, occupational therapy, speech and language therapy and neuropsychology input. He also received dietetic input. There were close ties with local services and he was referred for orthopaedic management and also for highly specialised spasticity management in the form of phenol motorpoint blocks. Our services include an independence flat within the Centre, an ADL kitchen where patients are able to practice making their own meals. Community access is encouraged and supported as appropriate, including days out locally, trips to the library, shops, restaurants, garden centres etc as interests the patient.
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Vocational opportunities are explored and supported. Thus, we work with an interdisciplinary neuro-rehabilitation team. SMART assessments and also WHIM are routinely used. There is a hydrotherapy pool within the Centre, which is used by the physiotherapists for appropriate patients. We have strong associations with local wheelchair and special seating services, including bioengineering, environmental control services and orthotic services. All patients are encouraged to participate in goal setting and, in addition to assessment and discharge reports, there are regular update reports throughout the patients’ stay. There are family meetings and support groups available.
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There is also a willingness to offer novel therapies as appropriate to and as wished by the patients themselves. In all, our approach is holistic and patient-centred and offers a very significant breadth and depth of neuro-rehabilitation experience.
Dr A M Weir Consultant in Rehabilitation Medicine Murdostoun Brain Injury Rehabilitation and Neurological Care Services www.huntercombe.com/murdostoun
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