It's never too late improving function several years post Traumatic Brain Injury: 2 case studies

Transcription

1 It's never too late improving function several years post Traumatic Brain Injury: 2 case studies PROF DOROTHÉE DEBUSE, PHD JUNE 2018, HETI CONGRESS, DUBLIN LU:NEX University

2 Definition Traumatic Brain Injury (TBI) Non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and/or psychosocial functions, with an associated diminished or altered state of consciousness. (Dawodu 2017)

3 LU:NEX University Background - general evidence that recovery is better with rehabilitation within the first six months of TBI, than if rehabilitation is initiated later in the recovery process, rehabilitation interventions are still effective even if delivered after 12 months of injury (High et al 2006; Micklewright et al 2011)

4 Background case studies Real life - not initially intended as case studies! Goals were set according to what mattered to these clients, and not necessarily amenable to being captured by validated outcome measures Video recording & analysis of objective markers before and after hippotherapy Self-reported functional ability and participation was documented and analysed

5 Definition Hippotherapy One-to-one physiotherapy intervention with and on a well-trained horse makes use of the horse s unique three-dimensional movement impulses in order to facilitate movement and postural responses in the client on horseback Client-specific variations in the horse s movement are the primary impulse (not assuming various postures on horseback) - very precise tool! The horse is long-reined (Debuse 2015)

6 Case Study 1: Kerry 17-year-old nine years post TBI (road traffic accident) Lived at home with family Difficult socio-economic / socioeducational background College for IT Attended Ax and Rx sessions with a support worker

7 Assessment: ICF impairment/activity R-sided hemiparesis, UL > LL involvement Slow gait Strong backward propulsion on talking: had to sit or stand with her back against something if she wanted to speak Hypertone R>L UL and LL with ++ associated reactions ( R ) on any kind of effort (speaking/walking) Very limited fine motor skills (e.g. no selective opposition thumb-fingers) Impaired sitting and standing balance Slurred, slow speech

8 Assessment: ICF participation Loved walking but slow gait meant family and most friends wouldn t go out with her backward propulsion: unsafe if out in traffic. Could walk or talk but not both family and most friends wouldn t go out with her Unable to do up buttons or zips: required help with dressing; always wore tracksuit bottoms, so that she could manage toileting independently Social isolation

9 Goals 1) To improve trunk control 2) To improve sitting and standing balance 3) To improve the fluency and speed of gait 4) To decrease tone and improve function in R UL 5) To improve functional mobility and participation

10 Delivery 30-minute sessions incl. mount/dismount HT sessions on three consecutive days with breaks of betw. 1 wk and 8 wks in between. Patient stayed over-night in neighbourhood as she lived 1.5 hours away 12 sessions in total

11 Notes Very sensitive client Quite anxious Things had to be predictable for her to feel at ease Less = definitely more! (people, instructions)

12 Intervention Horse Equipment Mounting

13 Intervention Movement: Progression from Straight lines bends stop-&-go lateral work First all holding on, then some without.

14 Therapeutic Outcome no more episodes of backwards propulsion when talking functional mobility improved considerably (normal speed!) right upper limb fine motor skills improved considerably

15 Impact Greater independence (mobility and dressing!) Able to go walk and talk Going out with peers and family! Not socially isolated any more participation! Much increased self-esteem

16 Case Study 2: Lucy 41-year-old 2 years post TBI (road traffic accident) 2/12 in coma (GCS 1) Lived at home with husband and 2 teenage children Very supportive home environment Attended Ax and Rx sessions with her husband

17 Assessment: ICF impairment/activity Increased tone L UL and LL Decreased ROM and function L UL Gait lacked L arm swing and trunk rotation Gait very insecure over uneven ground or on slopes Sitting < standing balance considerably impaired

18 Assessment: ICF participation Needed support for household chores and outdoor mobility Used trekking poles outdoors, but preferred linking arms with another person Several falls made her feel quite anxious about going out on her own. Unable to ride a bike

19 Goals 1) To improve trunk control / core stability 2) To improve sitting and standing balance 3) To improve the fluency and speed of gait 4) To improve functional mobility and participation

20 Delivery 30-minute sessions incl. mount/dismount HT sessions on three consecutive days with break of 6 weeks in between. Patient and husband stayed over-night in neighbourhood as she lived 2.5 hours away 6 sessions in total Husband acted as side-walker / helper for mounting

21 Notes Very positive and motivated client and husband Very supportive husband an excellent team Very body-aware Had been a rider before her accident and had begun having 30 mins 1:1 lessons again at her local riding school Noticed a considerable difference between riding on a saddle and having HT with the sheepskin

22 Intervention Horse Equipment Mounting

23 Intervention Movement: Progression from Straight lines stop-&-go bends lateral work Facilitation: Completely hands-off Use of images: soles of feet smiling at the ground Smiling shoulder blades Tapping into client s excellent body awareness Encouragement to feel

24 Outcome From 1 st session: whole L side feels alive again! After 2 nd session was able to use a hairdryer with her L hand for the first time since her accident Gait much more fluent due to L arm swing and trunk rotation Trunk control and balance much improved: Able to walk in deep sand without aids or holding on to somebody for the first time since accident Able to bend down and then throw stick for dog for the first time since accident

25 Impact Greater confidence in own balance and independent mobility Much improved participation (very outdoorsy family) Able to do more household chores independently (e.g. peg up clothes, empty dishwasher) regaining role Now cycling again!

26 Summary The example of the two case reports shows that a) adults several years post (severe) TBI can benefit significantly from Hippotherapy in the ICF domains of Impairment/activity, and Participation b) the delivery option of 3 consecutive days followed by a several-week break is effective c) 3 to 6 high quality hippotherapy interventions were enough to result in lasting and meaningful change in these adults with TBI

27 Thank you for your attention

28 References Dawodu ST (2017) Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology. Debuse D (2015) Die Hippotherapie im Rahmen des aktuellen Konzepts von Gesundheit und Rehabilitation. In D Debuse (ed). (2015). Hippotherapie - Grundlagen und Praxis. Munich: Ernst Reinhardt Verlag. High, W. M., Roebuck-Spencer, T., Sander, A. M., Struchen, M. A., & Sherer, M. (2006). Early versus later admission to postacute rehabilitation: Impact on functional outcome after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 87(3), Micklewright, J. L., Yutsis, M., Smigielski, J. S., Brown, A. W., & Bergquist, T. F. (2011). Point of entry and functional outcomes after comprehensive day treatment participation. Archives of Physical Medicine and Rehabilitation, 92(12),

29 Sources of images Horse Power for Ability (Hippotherapy practice) all pictures and videos taken and used in this presentation with the agreement of the depicted persons =300&h=300