The role of physiotherapy in
managing intracranial
haemorrhage in an otherwise fit
and well 20 year old male: A case
study
Patient Characteristics
Presentation 15/01/22 in QE Hospital:
20 year old male, RTC, trauma to head,
stabbed in abdomen
PMH - none
QE Hospital 15/01/22:
- Diagnosed traumatic sub arachnoid
haemorrhage and subdural
haematoma in left hemisphere
- Underwent decompressive
craniotomy
- GCS 11/15
MHH Hospital 13/03/22:
- Medically stable and undergoing
rehabilitation
SHx
- Lives with parents and siblings
in Birmingham
- Unemployed and no
qualifications
- Indep ADLs
- Listens to the quaran
- Likes takeaways, cereal,
cheese on toast
DH
No known drug allergies
Enoxoparin (Anticoagulants)
Dexane (VTE prophylaxis)
Fortisip Protein (dieatary
supplement)
Lansoprzole (prevents gastric
issues from NSAID’s)
Levetiracetam (anti-epileptic)
Senna (consitptation)
Initial Ax
- Established visual prompts and simple verbal commands as method of
communication.
- AVPU – Pt was alert
- ROM and Power Ax was completed bilaterally (PROM in R UL due to
hemiplegia and AROM in L UL in the movements that the patient could
understand)
- Bed mobility assessed and T/F method established (AO2 lying to sitting
and able to do Sara Stedy AO2)
- Identified patient has lack of hazard awareness, therefore safety
considerations were made
Plan
Physio review 3-4
times per week
Impairmenet List
Goal
Dense R sided weakness
(grade 0 power)
Regain muscle activity in R
side.
Incr tone throughout body. PROM stretching in R UL to
Particularly in biceps
reduce tone
Communication
impairment
Ensure pt can engage with
Rx by adapting
communication styles.
Movements are abrupt
Movement education.
Reinforce correct rolling
and standing technique
OT input:
- Cognitive assessment
- Completing personal care tasks
S&L input:
- to improve expressive and receptive aphasia
Intervention
Focus on task orientated exercises to help with functional tasks, ADLs and improve attention. As communication level improved,
movement specific exercises were used, such as bed exercises. Progressed task difficulty as pt demonstrated mastery of tasks
throughout Rx. Postual facilitation during Rx. Applied the principles of nueroplasticity in Rx.
Recieved approx 3x 1 hour Rx sessions per week.
- Verbal and tacticile cueing to support attention tasks thorughout Rx
- STS practice with reducing assistance over time and developing eccentric control.
- Bed mobility practice (rolling, lying to sitting)
- Dual task training to facilitate motor performance of basic task automaticity
- Positional awareness, attention to R side limbs during Rx
- Use of UL during grooming, eating and dressing tasks (OT). Encouraging to use R limb in these.
- Sensory work – hot/cold, textures
- Weight bearing exercises (standing reaches with upper limb)
- Sequencing tasks and movements. Started off with simple one-step commands and progressed complexity as appropriate
Outcome
Physio:
-
We have been measuring progress by assessing how well particular movements and exercises are performed and considering progression compared
to previous sessions
-
Increased acitvity tolerance
- Patient no longer on 15 minute checks as safety concerns are considerably less
-
H is understanding more complex commands and instructions such as “roll over to side”). He is more reliable with communication and less visual
promts need to be used. Pt able to verbally respond with single words such as “side” “can’t feel” “cold” “hot”. Yes/no inconsistency has improved
-
Progressed to being able to walk on pulpit max AO2. Lacks hamstring activity therefore compensating with hyperextended knees
- Pt R knee activity grade 2. R hip flexion strength improvement as pt can straight leg raise indep. Adductor grade 2 power. Patient not able to hip adbuct
- Tone has reduced in R LL and R UL although R bicep tone still present
-
Pt showed flicker in distal finger
- Pt able to isometrically contract some R UL and LL muscles when forcefully using L side to complete bilateral slide sheet heel slides (knee flexion and hip
flexion)
OT: AO1 with washing and dressing. Mostly indep with eating and grooming
SLT: picture chart Rx has helped his ability to understand things
Physical Therapy in Patients After Subarachnoid Haemorrhage. Clinical and
Social Study W. Kulinski, K. Symczyk (March 2021)
DOI:10.36740/ABal202101101
Aim – to assess a 1-year long physical therapy programme in 29 patients with SAH
Method: Study patients underwent physical therapy and rehabilitation, which included sitting training,
standing up training, gait improvement, speech therapy, PNF, NDT-Bobath, neuromuscular electrical
stimulation, feedback, and physiotherapy procedures.
PNF = Proprioceptive Neuromuscular Facilitation
NDT-Bobath = Neuro-developmental treatment
Results after 1-year of physical therapy treatment:
• 81.2% females and 100% males shows pronounced improvement in signs and symptoms
Conclusions (Blue = learning points / reflections)
1. Most SAH patients with neurological deficits require LT rehabilitation – patient H will require LT physio
input in community
2. Outcomes achieved depend on time from stroke onset to treatment (the earlier the patients started physio
therapy the better) – how could we ensure earlier physio input In future SAH patients? Earlier physio input
in H’s case could have been beneficial.
3. Effectiveness of rehabilitation required simultaneous monitoring of existing cardiological and metabolic
disorders - highlights that the management of SAH should consider multiple systems
My learning points from this case are:
• Leading physio sessions with a patient who has difficulty
communicating
• Physio ax and Rx of patient – progression of exercises used to recruit
automatic activity.
• Causes of traumatic brain injury (TBI)
• Impacts of TBI to an individual and wider society
• Wider MDT role in patients care – Medical, surgical, OT, SLT,
Psychology, Dietician, HCA, Nurse, Physio
References
• https://pubmed.ncbi.nlm.nih.gov/2406101/#:~:text=The%20pathoph
ysiology%20and%20treatment%20of,%2C%20nuchal%20rigidity%2C%
20and%20photophobia.