Int J Physiother.

Vol 4(4), 241-245, August (2017) ISSN: 2348 - 8336

CASE STUDY
PHYSIOTHERAPY INTERVENTIONS FOR A TRAUMATIC
IJPHY
BRAIN INJURY PATIENT: A CASE STUDY

Saad Saleem
*1

²Muhammad Sarfraz Khan

³Varisha Kabir
⁴Nabeel Baig

ABSTRACT
Background: Traumatic brain injury (TBI) is one of the main reasons of death and disabilities globally, mainly in kids
and adolescence and is still being considered as an enduring issue in ICUs. There are no definite rehabilitation methods
for traumatic brain injury patients. The frequent techniques administered by physiotherapists in ICU are positioning,
mobilization, manual hyperinflation technique (MHT), percussion, vibrations, suction, cough, and breathing exercises.
Case Summary: This study was done in the Medical ICU at Liaquat National Hospital and Medical College, Karachi,
Pakistan.
The chief complaints of the patient was gunshot injury to the right temporal region. The patient was diagnosed with
right front parietal contusion with a fracture of the right temporal bone, subarachnoid edema, and midline shift. The
physiotherapy interventions given to the patient were Chest Physical Therapy (CPT) with Zero-pressure Manual Hy-
perinflation and percussions. Once the ICP issues were controlled, manual hyperinflation with 30 cm of H2O, modified
postural drainage, minimal–handling saline suctioning were applied. After extubation, CPT included Active Cycle of
Breathing Techniques (ACBTs), volume oriented incentive spirometry, motor relearning program, and mobilization.
The outcome measures were secretion status, modified rancho los amigos level of cognitive functioning scale, and ar-
terial blood gas analysis.
Results: The patient’s secretions status improved from P1 to M1, FiO2 was improved from 40% to 21%, chest wall vol-
ume was increased from 200 cc/sec to 600 cc/sec, and RLA level increased from I to VIII.
Conclusion: The case study presents that physiotherapy interventions used in intensive care units may prevent pulmo-
nary complications in sufferers with traumatic brain injuries. It also suggests that early mobilization should be done
to improve cognitive functioning and behavior. This study may also indicate that the earlier the patient is started with
mobilizations and rehabilitation, the less costly it will be for the patient.
Keywords: Traumatic brain injury, Chest Physical Therapy, Postural Drainage, Manual Hyperinflation, Mobilization,
Motor Relearning Program.

Received 02nd April 2017, revised 15th June 2017, accepted 03rd August 2017

10.15621/ijphy/2017/v4i4/154721

www.ijphy.org

²Assistant Professor, HOD, DUHS Fitness, CORRESPONDING AUTHOR

and Sports Rehabilitation Centre, *1
Saad Saleem
Dow University of Health Sciences.
³Lecturer, Baqai Institute of Physical Therapy Assistant Professor,
and Rehab Medicine. Ziauddin College of Physical Therapy,
⁴Assistant Professor, North Campus, Ziauddin University.
Ziauddin College of Physiotherapy. [email protected]
This article is licensed under a Creative Commons Attribution-Non Commercial 4.0 International License.

Int J Physiother 2017; 4(4) Page | 241

INTRODUCTION Table 1: Modified ramsey sedation scale
Brain injury may result because of an unswerving blow or Sedation
by rushing force. This causes series of events that happen Clinical Response
Score
during the particular time of the injury or days after the
0 Paralyzed, unable to evaluate
injury.
Resultant brain trauma occurs due to a reduction in ce- 1 Awake
rebral oxygen transport because of HTN, decrease oxygen
2 Lightly sedated
concentration in blood, cerebral inflammation, intracrani-
al HTN or irregularities in cerebral blood transport. Even 3 Moderately sedated, follows simple commands
though the impact of the initial brain trauma cannot be
decreased, resultant brain trauma can be lessened provided Deeply sedated, responds to nonpainful
4
suitable treatments are applied instantaneously. stimuli
The primary aims are to preserve the best outcome of pri- Deeply sedated, responds only to painful
5
mary brain trauma impacts and minimizing the resultant stimuli
brain damage. These aims can be achieved by:
Deeply sedated, unresponsive to painful
1. Maintaining the cerebral energy metabolism by preserv- 6
stimuli
ing the required systemic maintenance,
2. Maintaining cerebral perfusion pressure (CPP) within DIAGNOSIS AND ASSESSMENT
regular boundaries, Patient was diagnosed with right frontoparietal contusion
3. Maintaining ICP within regular limits as achievable [1]. with fracture of right temporal bone, subarachnoid edema
and midline shift for which he underwent surgical proce-
(TBI) Traumatic brain injury is one of the prime factors
dure of wound closure and drain placement
of death in the world. There are no definite rehabilitation
methods for traumatic brain injury patients [2]. In the ma- On the 1st post operative day and 0 day of intubation, pa-
jority hospitals, physiotherapy is seen as an essential ele- tient’s ventilator support parameters were: Mode of venti-
ment for the treatment of patients in ICUs. The frequent lation; Volume assisted control (A/C), Tidal Volume (Vt)
techniques administered by physiotherapists in Intensive 550, Positive End Expiratory Pressure (PEEP) 0, Fraction
Care Unit are positioning, mobilization, manual hyperin- of Inspired Oxygen (FiO2) 50%. When sedation was ta-
flation technique (MHT), cough, percussion, vibrations, pered off, GCS was calculated to be 7/10. His ABGs were
suction, and breathing exercises. Some physiotherapists found to be 7.35, 44, 110, 24, 100%, Slight increased PaO2,
normally care for the majority of ICU patients incorporat- interpreted [5] according to the following table:
ing all of the physiotherapy interventions above, irrespec- Table 2: Normal ABG values
tive of the patient’s disease, with the purpose of avoiding
pulmonary complications, whereas other physiotherapists pH 7.35-7.45
use such techniques selectively when they believe they are
PaCO2 35-45 mm Hg
specifically indicated [3]. This case study will discuss the
different physiotherapy techniques used in the rehabilita- PaO2  80-95 mm Hg
tion of a TBI patient.
PATIENT INFORMATION: HCO3  22-26 mEq/L
A 30 years old male patient came to the ER of Liaquat
O2 Saturation 95-99%
National Hospital, Karachi, Pakistan with a history of
gunshot injury to the right temporal region, Loss of con- His chest x-rays were clear. On auscultation, no added
sciousness, projectile vomiting (10-15 times), vertigo. CAT sounds were audible. On 4thpost Operative day and 3rd in-
scan showed right front parietal contusion with a fracture tubation day, patient’s GCS was improving from 7/10 to
of right temporal bone with subarachnoid edema and 8-9/10, but his secretion status was deteriorating from P1
midline shift. The patient had no previous history of any to P3 [6]. ABGs were 7.40, 48, 75, 26, 90% (Hypoxia, with
disease. The patient underwent the surgical procedure of uncompensated slight respiratory acidosis). He was also
wound closure and drain placement to decrease subarach- developing an infiltrate on right basal lobe suggestive of
noid edema. ventilator associated pneumonia (VAP). On auscultation,
PHYSICAL EXAMINATION fine crackles were audible in the right basal lobe. Since
his O2saturations were also deteriorating so, FiO2 was in-
The patient was kept on sedation and relaxation using 0
creased to 80%, along with an increase in PEEP from 0 to
score according to Modified Ramsay Sedation Scale as
10 cm of H2O. His Rancho Los Amigos (Level of Cognitive
shown in table 1[4]. Oro-Endo-Tracheal Tube (OETT) was
Functioning Scale) was Level IV as shown in table 3 [7].
placed as an artificial airway.

Int J Physiother 2017; 4(4) Page | 242

 Table 3: Modified (RLA) Rancho Los Amigos (level of extubation, along with the same CPT and Limbs mobiliza-
cognitive functioning scale) tion, the patient was mobilized from bed to chair [15,16].
I No Response: Total Assistance CPT was performed using Active Cycle of Breathing Tech-
niques with volume oriented incentive spirometry in-
II Generalized Response: Total Assistance creased to 600cc/min with 3 seconds hold. Limb mobiliza-
III Localized Response: Total Assistance tion was progressed to Motor Relearning [14]. Mobilization
was progressed from bed to chair to tilt table standing to
IV Confused/Agitated: Maximal Assistance
normal standing with support by the 4th post–extubation
Confused, Inappropriate Non-Agitated: Maximal day which markedly improved the cognitive functioning
V
Assistance of the patient [16,17]
VI Confused, Appropriate: Moderate Assistance DISCUSSION
Automatic, Appropriate: Minimal Assistance for The case study presents that physiotherapy interventions
VII used in intensive care units may prevent pulmonary com-
Daily Living Skills
plications in patients with traumatic brain injuries. Re-
VIII Purposeful, Appropriate: Stand-By Assistance search done by Khan F et al. postulated that rehabilitation
Purposeful, Appropriate: Stand-By Assistance on should be planned to decrease pain and improve activities
IX
Request of daily living in conjunction with cognitive, behavioral
and pharmacological therapies. These indications corrob-
X Purposeful, Appropriate: Modified Independent
orated with this case study [18].
On 10th post Operative day and 9thintubation day, the pa- The results of research conducted by Zhu XL et al. support-
tient was extubated, with a GCS of 15/15, maintaining ed our case study which proposed that physiotherapy in
SpO2 of 100% on five lit O2via face mask, which was later the early phases helps in improving the functionality of pa-
removed. His agitation had also improved from RLA Level tients with TBI which, therefore, enhances their capability
IV to RLA Level VII. The patient was able to move his right to early return to work. They also concluded that intensive
side spontaneously and on commands but was unable to care therapy increased the speed of recovery [19].
move left side.
Comparable to Stiller et al, this study indicated that while
INTERVENTIONS doing rehabilitation of TBI patients ICP should be kept
The patient was given passive Chest Physical Therapy below 20 mmHg, head should be kept at 30⁰ for all phys-
(CPT) inclusive of Zero-pressure Manual Hyperinflation iotherapeutic procedures while keeping the neck in mid-
[3,8,9] with manual percussions [3,9,10,11,12]. Once the line, sedatives can be given to prevent ICP raise due to any
ICP issues were controlled, Manual Hyperinflation with 30 physiotherapeutic interventions, manual hyperinflation,
cm of H2O, modified postural drainage, minimal–handling suctioning, or manual techniques to improve lung func-
saline suctioning were given as passive CPT. After extuba- tions, breathing mechanics and ADLs should be given for
tion, CPT included Active Cycle of Breathing Techniques shorter periods whereas percussions and compressions do
(ACBTs), volume oriented Incentive Spirometry[13], Mo- not increase ICP, PaCO2 should not be lowered than 30-
tor Relearning Program[14], and mobilization. 35 mmHg, and modified postural drainage should be used
FOLLOW – UP AND OUTCOME while treating any patient with TBI [3].
Chest Physical Therapy treatment is given included Ze- CONCLUSION
ro-pressure Manual Hyperinflation[3,8,9]with manual This case study helps in identifying the physiotherapy in-
percussions[3,9,10,11,12], Modified Postural Drainage, terventions used in intensive care units for patients with
keeping the ICP issue in view, followed by minimal–han- traumatic brain injuries. The study is suggestive of provid-
dling saline suctioning. Limbs mobilization included pas- ing early chest physiotherapy techniques to prevent the pa-
sive ROMs[3,9,11]with PNF (Patterns and Approxima- tient from respiratory complications and reduce the cost
tions)[3,9,11,12] implications in the ICUs. It also emphasizes the impor-
On 4thpost Operative day and 3rd intubation day, Manu- tance of early mobilization to improve the psychomotor
al Hyperinflation with 30 cm of H2O pressure, Modified functioning of the patient.
Postural Drainage and Aggressive manual percussions fol- REFERENCES
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Int J Physiother 2017; 4(4) Page | 244

 Appendix 1 : Assessment, investigations, and interventions at different intervals
1st post-op Day And 4th post-op day and 10th post-op day and
2nd Day of Extubation
Day 0 Of Intubation 3rd intubation day 9th intubation day

Ventilator: Ventilator:
Mode: Volume A/C Mode: Volume A/C Extubated: Extubated:
Mode Of Venti-
Vt: 550 ml Vt: 550 ml Face mask Room Air
lation
PEEP: 0 PEEP: 10
FiO2: 50% FiO2: 80%
GCS 7/10 8-9/10 15/15 15/15
ABGs 7.35, 44, 110, 24,100% 7.40, 48, 75, 26, 90% 100% O2 99% O2
Secretion
P1 P3 M1 M1
Status
Chest X-rays Clear Infiltrate Right Basal No infiltrates Normal
Auscultation Normal Localized Crackles. Localized Crackles Normal
RLA Level I IV VII VIII
Movement
Inability to move L side. Inability to move L side. Inability to move L side. Inability to move L side
present
Active Cycle of Breath-
CPT included Zero-pres- Manual Hyperinflation Active Cycle of Breath-
ing Techniques coupled
sure Manual Hyperinfla- with 30 cm of H2O pres- ing Techniques with
with volume oriented
tion with manual percus- sure, Modified Postural volume oriented incen-
incentive spirometry
sions, Modified Postural Drainage and manual tive spirometry at 600
at 200 cc/min volume
Interventions Drainage, minimal–han- percussions followed by cc/min. With 3 seconds
with 3 seconds hold.
given dling saline suctioning. 10 ml saline suctioning. hold.
Limbs mobilization in-
Limbs mobilization Limbs mobilization Motor Relearning
cluded Passive ROM for
included passive ROMs included passive ROMs started.
left side with PNF and
with PNF (Patterns and with PNF (Patterns and Tilt Table standing
strengthening exercises
Approximations) Approximations)
for the right limb

Citation
Saleem, S., Khan, M. S., Kabir, V., & Baig, N. (2017). PHYSIOTHERAPY INTERVENTIONS FOR A TRAUMATIC
BRAIN INJURY PATIENT: A CASE STUDY. International Journal of Physiotherapy, 4(4), 241-245.

Int J Physiother 2017; 4(4) Page | 245