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Sudden Collapse with Loss of Consciousness www.huntercombe.com
Introduction Ms H was initially referred to the Murdostoun Brain Injury Rehabilitation Centre from the local neurosurgical services. She was a lady in her sixth decade. She had presented with sudden collapse with loss of consciousness, subsequent generalised headache and neck pain.
On admission she was not confused and neurologically intact, but her condition deteriorated with an episode of collapse with subsequent right arm weakness and dysphasia. Urgent CT of head revealed an acute intracranial bleed. She had an EV shunt inserted but her recovery was complicated by a CSF infection requiring intravenous and intrathecally antibiotic treatment. She also suffered a gastrointestinal bleed secondary to nonsteroidal anti-inflammatory drugs. She required coil embolisation and craniotomy. She suffered other secondary complications including vasculitis and hydrocephalus. Initial assessment prior to transfer to our unit revealed that she was very drowsy but able to nod/shake her head in response to questions. Her responses were not consistent and she was unable to follow basic instructions. She smiled appropriately and demonstrated some active movement of the left arm. At that time she had not been able to sit in a chair and had not been supplied with a wheelchair.
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At initial assessment after transfer to this Centre I found her to have significantly increased tone in the right upper limb and possible cogwheel-type rigidity.
There was also reportedly improved alertness and interaction over the preceding several weeks. She was PEG fed and had an indwelling catheter. She was nursed in bed and required the support of 2 for all activities of daily living. She had been diagnosed as positive for clostridium difficile. She had a supportive husband and 2 sons who visited regularly. She had a past medical history of hypertension and osteomyelitis and had previously held a professional role. At initial assessment after transfer to this Centre I found her to have significantly increased tone in the right upper limb and possible cogwheel-type rigidity. Mildly increased tone in the right lower limb and relatively normal tone in the left upper lower limbs. Reflexes were generally brisk. This lady found it difficult to cooperate fully with the examination but she was able to obey simple commands but not 2-stage commands. Her speech was quiet and unclear. Her responses were not clear and not appropriate to the question posed.
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Power was globally slightly reduced but more markedly so on the right than the left. This lady received multi-disciplinary assessment and rehabilitative input. At initial assessment from a nursing standpoint she was found to be at risk of choking when eating and drinking, so required constant observation. Skin integrity had to be monitored closely with regular pressure area care. Nursing and care staff had to encourage verbal communication.
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Goals were: • To have PEG tube removed in view of the fact that she was taking diet and fluids • To have medications changed into tablet form now that she was able to swallow • To toilet on a 2-hourly basis to encourage improvement of problems relating to continence. • To inform staff when she has passed urine to ensure skin maintenance of skin integrity.
Speech and language therapy assessment revealed reduced oral sensation, especially on the left when eating and drinking, a tendency to overfill her mouth before swallowing, requiring prompting to swallow/chew her food regularly. She was able to safely manage a pureed diet and small sips of thin liquid. No visible signs of aspiration pre/post swallow. She was unable to manipulate more textured foods safely and there was evidence of marked oral residue post swallow.
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She was able to process one and some 2-part instructions, although experienced perseveration after the first two items, making all other answers inaccurate. She required extra time to achieve success and was adversely affected by external distraction/fatigue. Thus, her processing ability was variable. She was more likely to process information successfully when auditory and verbal information were provided together.
She could read at single word level as long as she was not excessively fatigued or distracted. She became less consistent at basic phrase level and breakdown occurred with longer sentences and instructions. She was able to indicate basic needs via gesture and facial expression. She was very frustrated by her language difficulties. She experienced significant word finding difficulties in all tasks. Her speech volume was very low, affecting intelligibility. She was unable to consistently write the names of everyday objects; there was evidence of perseveration after the first one to two items. She had been a proficient computer user; assessment identified similar difficulties in typing as with writing/ speaking, particularly with perseveration.
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Problems were:
Goals were:
• • • • • • •
• To name 6 family members and their relationship to her • To generate the names of items required for a short shopping list and write them down with minimal support • To read and understand a short shopping list • To read the TV listings page and find 3 favourite programmes, with support • To use a combination of speech, gesture and writing to communicate at least 3 points clearly during a 5-minute conversation • To follow five functional instructions containing 2 key points • To type 10 functional words accurately on the computer • To write her name and address accurately and legibly • To eat a small sandwich safely
Fatigue Attention/ concentration Perseveration Processing speed Comprehension Communication Reading and writing
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Physiotherapy assessment Physiotherapy assessment suggested that she had significantly reduced visual field on the right; on the left a moderate loss was noted. It was uncertain as to whether some of this deficit related to cognitive abilities in understanding the test. She exhibited reduced coordination in both upper and lower limbs. She was unable to complete a 9-hole peg test with her right hand and took a significantly increased length of time with her left hand. She exhibited reduced coordination.
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She exhibited reduced sensation throughout the right upper limb. Proprioception appeared reduced in both left and right upper limbs; similarly, it was reduced in both lower limbs but, again, cognitive understanding may have affected the results. At the time of initial assessment she required a full hoist for all standing transfers. During physiotherapy sessions she was able to stand in an Encore stand hoist and achieved safe transfers using that piece of equipment. A Modified Rivermead Mobility Index revealed a score of 5/40 demonstrating severe impairment. She had reduced sitting balance, tending to lean backwards and to the right side. She used her left hand to hold onto the bed to maintain a sitting position. She made steady improvements with this until she could maintain independent sitting balance. She scored 1 /56 on the Berg Balance assessment scale indicating severe impairment.
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Problems were:
Goals set:
• • • • • • •
• To have grade 3 pain free functional range of movement in right upper limb. • To do up a button using both hands. • To have grade 3 strength throughout right lower limb. • To roll to left and right independently. • To move from supine lying to sitting with supervision. • To transfer using banana board with assistance of one. • To type 5 words on the lap top using both hands. • To stand with assistance of 2 for 2 minutes (limb power is graded on a 0–5 scale, 5 being full and zero no power).
Right upper limb weakness Reduced sensation right upper limb Right lower limb weakness Reduced dynamic sitting balance Full hoist transfer Dependent for all bed transfers Inattention to right side
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This lady was assessed as low scoring in orientation and perception, visual motor organisation and thinking operations. She became easily become fatigued during sessions, demonstrated some perseveration over tasks and required a significant amount of time to process information. She demonstrated difficulties with symbolic actions and spatial perceptions of objects. She had difficulty sorting shapes into colour categories. She could not verbally tell the time but was able to correctly identify the time from written options.
She was able to correctly sequence self-care tasks and complete basic 3-stage sequencing tasks. She was not always consistent in achieving the correct order in more complex tasks. She followed one stage commands consistently. In quieter environments she was able to attend well in sessions but found difficulty in busier environments and could become easily distracted. Limited range of movement at the right shoulder, reduced grip and strength in the right hand, impacting on functional use, resulting in inability to write with the right hand. She required the support of 2 for self-care tasks but participated well. Difficulty with moving from lying to sitting but with support of 2 could achieve sitting over the edge of the bed and maintain sitting balance for washing and dressing. She was able to consistently choose items of clothing to wear. Difficulty washing and combing her hair and applying deodorant. Required shower chair. Required support for grooming tasks but could attempt to place toothpaste on her brush and apply face moisturiser with prompting.
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She was catheterised and incontinent of faeces with no real awareness of when she required to use the toilet.
She was catheterised and incontinent of faeces with no real awareness of when she required to use the toilet. She was taking a modified diet with support of one for eating and drinking to maintain safety. She was able to feed herself using a teaspoon and standard cup with the right hand. She enjoyed watching the television and was able to consistently choose preferred programme Problems to be addressed were: • • • • • • • •
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Reduced range of movement at shoulder Attention Information processing Self-care tasks Toileting Right hand function Sequencing Spatial perceptions
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Goals set: • • • • • • • • •
To wash hair using both hands To apply deodorant to left arm independently To use right hand to write her name legibly To complete a hand circuits exercise programme daily with support of one in the lounge To use a commode chair for a toileting programme each day To achieve lying to sitting with minimal support To correctly complete 8 stage sequencing cards 100% of the time To prepare a sandwich and soup with support of one To use right hand consistently to feed self
She was an in-patient for 11 months. By the time of discharge she was able to: • • • • • • • • • • • • •
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Independently lift right arm for dressing upper body Consistently step right leg on/off stand hoist Stand with assistance of 2 for 2 minutes Transfer with stand hoist or banana board with minimal assistance of 2 Roll left and right independently Wash hair using both hands Apply deodorant to left arm independently Complete a hand circuits exercise programme daily with support of one in the lounge Read the TV listings page and find 3 favourite programmes with support Type ten functional words accurately on the computer Write her name and address accurately and legibly using right hand Prepare a sandwich and soup with support of one Eat a small sandwich safely
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• Consistently use right hand to feed self • Order a drink/snack at a café with minimal support • State 2 pieces of information about herself to an unfamiliar listener using communication wallet • Express opinion about a topic of interest using communication wallet • Eat a meal with distant supervision only • Move from lying to sitting with supervision • Mobilise 10m with gutter frame and minimal assistance of one • Stand to pull trousers up • Groom self using a checklist and minimal prompting • Make a sandwich with physical support at her right elbow only • Participate in meal preparation twice a week • Initiate choosing a topic to discuss with minimum support • Use a combination of buzzer, speech and gesture to indicate needing the toilet 60% of the time • Manage all transfers with wheeled zimmer frame and supervision • Mobilise 20m with wheeled zimmer frame and supervision • Mobilise over a threshold/ small step to access outdoors • Pull up trousers with assistance of one person in standing
• Write a shopping list with assistance • Tidy her room with assistance each week • Participate in outdoor bird watching and identify birds using her bird book • Mobilise around the centre with wheeled zimmer frame independently • Use her right arm to reach for an object above her head 5 times consecutively • Complete a weekend at home with her family • Walk 10m outdoors with wheeled zimmer frame and assistance of one • Thread a lace using right hand • Complete a basic word search with minimal support • Tell therapist 2 things about her day using diary with minimal support • Write own timetable in diary with minimal support • Locate correct time and name on timetable with support of one • Pull up trousers with minimal assistance
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• Fasten trousers independently • Groom self independently when items laid out on table • Make a microwave meal each week with minimal assistance • Write a short letter to a friend or family member • Be continent through the day
She had been initially assessed using the Barthel ADL Index and attained a score of 3, indicating very severely disability. However, at discharge the score had increased to 18, indicating that she was mildly disabled. Continence improved slowly. She was prescribed Oxybutynin, which helped this. She became independently continent throughout the day but still suffered occasional bouts of urinary incontinence at night. She was prompted to use the toilet on 2 occasions overnight to help address this. She had suffered tonic clonic seizures since her brain injury and was commenced on anti-epileptic medication to reduce the risk of seizures. Guidelines were put in place and given to the family. She participated in regular shopping trips with supervision and was able to push a light trolley around the supermarket but tired after 20 – 30 minutes. She identified a list of leisure interests which she enjoyed participating in at home and in the community. A laminated copy of these was supplied to her.
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She did continue to have difficulty processing longer or more complex instructions and short paragraph level texts as she became overloaded with information.
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She made significant progress as regards comprehension and became able to remain alert throughout the day. She could sustain her attention for a 20-30 minute period and perseveration became much less of a problem. She became able to process everyday conversation and instructions containing 2 pieces of information consistently and could often retain this information from one session to the next. She did continue to have difficulty processing longer or more complex instructions and short paragraph level texts as she became overloaded with information. She made good progress with reading and became able to select an item from a word list containing 5 items, to express her needs. She could read at short phrase level consistently but had difficulty accessing information from instructions or text containing 2 or more key points.
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Her writing improved and she became able to write her own name, address, family names and other functional words.
She made good progress with communication and became able to express most basic needs verbally and had a communication wallet to get more complex ideas across. Her output became more fluent with louder volume but continued to contain many jargon or non-words. She exhibited improved self-monitoring but continued to require support to use alternative strategies such as writing information down and using her diary/communication wallet. Follow up therapy input was arranged for her on discharge to the community. She was also referred to the Chest Heart and Stroke communication group for social contact and support. Her writing improved and she became able to write her own name, address, family names and other functional words.
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She was supplied with a general exercise programme to follow upon discharge and was referred to a local community rehabilitation team for follow-up physiotherapy and occupational therapy, particularly as regards balance and outdoor mobility. FIM/FAM on assessment 57/210 and at discharge 177/210.
Overall, this lady’s problems with particularly urinary continence were resulting in her being unable to return home. Her communication issues meant that she could not tell people when she required to go to the toilet and her mobility issues meant that she was unable to go to the toilet by herself. Our team worked on her communication and mobility, as is detailed within this short report. As a result of these her continence improved significantly and she was able to be discharged home to her family.
Dr A M Weir Consultant in Rehabilitation Medicine Murdostoun Brain Injury Rehabilitation and Neurological Care Services www.huntercombe.com/murdostoun
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