Rehabilitation of the Elite Athlete After TBI Suzanne Carr, DPT Margaret Fuller, MA, OT/L February, 2015
Outline Case study medical history Initial Evaluation Status, Treatment problems Treatment approaches Treatment tools, techniques
Introduction Over 2 million TBI s each year A large percent have residual deficits/disability after completing the rehabilitation process Many do not return to regular participation in fitness activities or recreation
Patient History Pt is a 28 y.o. female s/p TBI with L basal ganglia ICH s/p assault with resultant R hemiparesis Pt had course of acute care followed by inpatient rehabilitation, outpatient BI Day Treatment, and finally traditional outpatient therapies
Hemiparesis AROM: Occupational Therapy Initial Evaluation Shoulder flexion, scapular plane 0-95 deg. Shoulder IR: 0-20 Shoulder ER: 0-10 Elbow flexion, extension 90 to -20 Supination, Pronation 0-45 Wrist, Hand 0
Occupational Therapy Initial Evaluation Abnormal muscle tone Modified Ashworth Scale: 3 out of 4 in hand and wrist Brunnstrom level: Fugl-Myer score
Occupational Therapy Initial Evaluation Flexion and extension synergy patterns: Shoulder abduction, flexion, extension w/ internal rotation Elbow flexion with shoulder abduction and IR, forearm supination, wrist, finger and thumb flexion and adduction Elbow extension with shoulder adduction, forearm pronation, wrist/finger and thumb flexion
Occupational Therapy Initial Evaluation Sensation: intact sharp/dull; impaired light touch and proprioception MVPT, Vertical : 36/36 Right inattention/ neglect Right homonymous hemianopsia
Occupational Therapy Initial Evaluation RUE Learned Non-Use Total lack of RUE use in ADLs or IADLs for any bilateral activities for support, protection or propulsion object stabilization, holding, carrying, manipulation
Occupational Therapy Cognition Impaired Initial Evaluation Digit Symbol Modality test -1.5 SD Minimally impaired short term memory and immediate recall Moderately impaired working memory Impaired dual tasking or divided attention: completes 2 step working memory task with 70% accuracy and decreased processing speed
OT Medical Management Abnormal Muscle Tone Multiple Botox injections to wrist, thumb and finger flexors
UE Orthotics Wrist support brace Neuro-IFRAH WHO to maintain wrist/hand ROM Oval 8 splints for finger and thumb IP NMES to wrist/ finger extensors Assessed, tried Hand Ness Not indicated or helpful
Physical Therapy Initial Evaluation RLE strength: Hip flexors: 2+/5, --Quadriceps: 3-/5 Hamstrings: 1/5, --Glut med 2/5 Tib anterior 0/5 Tone/Spasticity: Quadriceps 1+ on MAS (supine worse with standing/upright) Plantar flexors 2 on MAS (became worse with time to 3
PT R custom articulated AFO initially Ambulating 200 with mod A for balance and balance recovery Impaired motor control and increased tone with R pelvic retraction and R knee hyperextension in stance Decreased stance time on R, decreased R weight shift Mod/max manual verbal cues to correct
PT Transfers SBA for squat pivot with vc to incorporate R side COM shifted to L in sit/stand Balance Firm NBOS EO/EC x 30 seconds Foam: unable SLS/Sharpened romberg: Unable
PT Visual fields intact Negative diplopia Bilateral gaze nystagmus Initial motion sensitivity Impaired Dynamic visual acuity Impaired dual task ability
Physical Therapy Traditional Initial interventions for gait/mobility/balance EKSO (after 5 sessions, 10% increase in gait speed) Bioness neuroprosthesis Blue Rocker carbon fiber AFO with return to sport
EKSO
Home program Return to Swimming Posterior humeral extension External rotation Lat pull downs Elbow extension Motor control relearning
Return to Swimming Swim adaptive equipment Forearm based wrist extension Swim paddle
Return to Swimming No therapeutic pool Spouse used Go-Pro to video OT/PT able to view and provide feedback/recommendations Initial use of float belt in conjunction with orthotics no float belt open water swim with float belt
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Return to Bicycling Use of R arm for support, steering Wrist taping to prevent hyperextension at wrist Bike modifications: Moved brakes controls to L side Used only L hand gears Cognitive dual tasking
Return to Cycling Mount/dismount practice Initial use of stationary trainer Clip in shoes and Blue rocker AFO to manage Plantar flexor spasticity Practice unclipping shoe Vestibular training/tolerance of visual streaming
Return to Cycling Initial Overgroung Cycling: Grass straight large turns narrow turns flat trails continues progressions With increased dose of botox, pt did have some difficulty maintaining grip on difficult terrain
Trike
Cycle Straight on Grass
Working on Turns
First Trails
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Return to Run/Jog Gait remained impaired Primary limitation: plantar flexor spasticity Pre run drills, coordination, agility, RAM, bounding, SLS, plyometrics (on mini tramp then over ground) Use of Blue rocker for athletic activities Alter G (anti-gravity treadmill)
Return to Run/Jog Initial attempts 1-3.0 mph with short intervals of increased velocity Currently 85-90% body weight and able to sustain 3.7-3.8 mph x >10 minutes Max speed to date: 4.3 mph
First attempts
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Baclofen Medical Management Minimal change noted Pt declined continuation of Baclofen Pt just received initial dose of Botox to R posterior tibialis Mild improvement in ability to stretch and sustain increased ROM Mild Decrease in inversion component Potential larger subsequent dose next
Concerns/Risk Factors Return to Sport brings associated risk factors Work in conjunction with neurologist, medical team Educate patient/family Gradual progressions Safety (helmet, float belt, supervision)
Peer Mentorship Resources Challenged Athlete Foundation Participated in Para-triathlete Camp 2014 Access to gym and professionals Peer mentorship Available grants/scholarships Achilles Running Club