6 P H Y S I O T H E R A P Y D E C E M B E R  ig 77

THERAPY IN THE EARLY STAGES FOR A 
HEAD-INJURED PATIENT*

H . P. M A R E E , B.Sc. (Physio.) (R and), C.T.P. (Cape

W a a m e m in g  en evaluering vorm  die belangrikste deel 
van behandeling in die vroee stadium  na hoofbeserings. 
P re-operatief behoort die pasient so gem aklik m oont- 
lik gem aak te word en by die hantering van so 'n 
pasient m o e t die bew usw ording van die totale liggaams- 
beeld in ag geneem  en beklem toon word. Post-operalief 
o f  post-traum aties behoort alle aspekte van die pasient 
se toestand, hi. die sosiale, sielkundige, fisiese en em o- 
sionele problem e, aandag te geniet. D ie verskillende 
stadia van bew ustheid w ord bespreek en daar word 
veral klem  gele op die fe it dat personeel op normale 
toon m e t die pasient m o et praat.

Evaluering m o et sistem aties geskied en voortdurende, 
noukeurige w aam em ing is noodsaaklik. Posisionering, 
passiewe bewegings en die beperking van hiperaktiwi- 
teit m o et volgens die pasient se toestand bepaal en 
toegepas w ord om  op tim u m  voordele vir die pasient in 
te hou. Verw aarlosing m ag plaasvind as daar geen sig- 
bare verbetering teenw oordig is nie en dit ly k  asof die 
pasient nie saam w erk nie. N ogtans m o et vroee be­
handeling daarop gem ik wees om  die pasient voor te 
berei vir latere behandeling. D oeltreffende, voldoende 
en effektiew e behandeling is dus die hoofdoel.

T his p ap er w as intended as a m eans o f provoking 
p a rtic ip a tio n  by the course m em bers by inviting th em  
to  take p a rt in discussion and a ir th e ir points o f view, 
w hich they did to som e extent. H ow ever, only the 
b asic ideas are  included in  this article.

In  any discussion o f P h y sio th erap y  in  th e early 
stages o f head injury, th e  w ord “ early ” m ust first be 
defined. D oes it include the acute and sub-acute 
stages o f recovery, a n d /o r th e en tire stage o f “com ing 
u p ”, o r only p a rt o f this?

Should the length o f tim e since th e dam age occurred 
be m easured, o r the length o f tim e since the dam age 
was surgically rep aired ? O r should o u r yardstick be 
th e  level o f consciousness reached or th e  degree of 
th e p a tie n t’s to ta l response to all stim uli?

T he p erio d  o f tim e m eant by th is term  w ould seem 
to be quite varied, totally in d iv id u a l and only 
m easurable in  retrospect.

T h e  period designated “early ” b y  the N eurosurgical 
D e p a rtm e n t at G ro o te  S chuur H o sp ital includes “all 
fe atu res o f p rim ary  adm ission fo r th a t p a tie n t” w hich 
includes com plications occurring during th a t period.

W e all know  th a t any first treatm en t is a p erio d  o f 
assessm ent, an d  a p atien t ad m itted  fo r surgery will 
have pre- as well as p ost-operative assessm ent and 
treatm ent.

Pre-operative Considerations

A s a general rule, when a p atien t is ad m itted  for 
neuro-surgery, in th e few days p rio r to surgery the 
p a tie n t is m ade as com fortable as possible. I f  neces­
sary h e  is catheterized and sedated in  o rd er to m in i­
m ize his distress.

* L ecturer, U n iv ersity  o f Cape Town, 
t  A dapted fro m  a pap er delivered at a postgraduate 

course o n  “E a rly  T reatm en t of th e H ead  In ju red  
P a tie n t” held a t the U niversity o f C ape T ow n, July 
1976.

Town)*

D u rin g  th is period the p hysiotherapist has an oppor. 
tu n ity  to establish stim uli to w hich she w ill expect the 
p a tie n t to respond a fte r surgery. In  establishing a re­
sponse at this stage, she is aim ing at eliciting an 
au to m atic response to th a t sam e stim ulus w hen the 
p a tie n t is less consciously responsive. F o r example 
the p atien t w ill becom e accustom ed to com m ands and 
handling and w ill come to know  how  h e is expected 
to respond in th a t situation.

In  introducing the p atien t to positions w hich we 
find m ost useful fo r treatm en t purposes w e may, at 
th e  sam e tim e, stim ulate his conscious aw areness of 
b ody im age in fav o u rab le patterns. A s fa r as possibly 
we should position and m ove b o th  sides o f his bod 
in o rd e r to stim ulate to tal bod y  aw areness, and in so" 
doing give th e p a tie n t som ething definite to do and 
think about, thus inculcating interest in, an d  responsi­
b ility  for, his own im provem ent. In any position in 
w hich he is being left fo r a p erio d  o f tim e he should 
be encouraged to  be aw are o f the correctness of the 
p o sitio n  and to reposition him self as fa r as he is able 
to do so.

The Post-operative Period

P ost-operatively, o r fo r em ergency o r trau m atic ad­
m ittance, the th e ra p ist’s first duty is to notice, and to 
be constantly aw are of, change o r lack o f change in all 
situ atio n s relevant to all aspects o f th e p a tie n t’s well­
being; including social, m ental, physical and emotional 
aspects.

H ow ever, w e m ust a d a p t o u r treatm en t to the situa­
tio n  as a w hole because associated injuries o r other 
conditions m ay take precedence.

F o r p relim in ary  in fo rm a tio n  w e refer to th e ward 
charts and check, am ong o th er things, drug intake, 
tem perature, pulse rate, d rips and drains, neurological 
responses; we note the trend o f the p a tie n t’s condition 
and establish w hy this should be so, as this will affect 
th e  p a tie n t’s response to  physiotherapy. ^

Should th e p atien t be w o rried  ab o u t his private 
affairs, he could n o t be expected to respond readily ok 
concentrate on his treatm en t and arrangem ents should 
be m ade to help him .

Levels of Consciousness

As a guide to  th e p a tie n t’s progress an d  his ability 
to  fesp o n d  to stim uli, we m ust consider his level of 
consciousness. T w o useful ways o f charting this are 
show n below :

(a) the academ ic, (o rd in ary  type) w hich is precisely 
w orded, and w hich aids o n e ’s general under­
standing o f the total picture; and

(b) th e clinical way, (italics) w hich is the m ost use­
fu l fo r p ractical purposes.

T h e clinical m ethod assesses the p a tie n t’s response 
to a p ain fu l stim ulus, b u t we have no w ay o f know ing 
w h at o th er stim uli are being received, registered and 
associated w ith the p ainful stim ulus.

W e cannot tell th e level o f acceptance <jf stim uli or 
necessarily the q u ality  o f the response, thus we must 
rem em ber th a t there a re  m any form s of afferent stim uli 
an d  be aw are o f o u r attitudes tow ards th e patient.

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pgSEMBER 1977

ALTERED STATES OF ALERTNESS OR CONSCIOUSNESS
a fte r W. B ryan Jennet, M .D ., F.R .C.S. and J. M cG uire, M.C.S.P.

F I S I O T E R A P I E

T erm s often 
used M o to r R esponse V erbal R esponse

C / 3

Z
O
oz
p

C / 3
□
o
o
C / 3zo
o

C O M A

S T U P O R

Confused

A utom atic 
in “P .T .A .”

D row sy

N one
N o  response to stim ulus 
Flaccid
O utlook is grave 

D ecerebrate
On stim ulus accentuates this posture. 
O u tlo o k serious.

*1. W ithdraw al from  pain 
D ecorticate. N on-p u rp o sefu l 
m o vem en t in response to stim ulus.

*2. Localises pain
A s  above, m ore definite response.

O beys sim ple com m ands 
On stim ulus —  p urp o sefu l response 
to pain
C o-ordinated spontaneous m ovem ent 

N o rm al M o to r A ctivity 

N orm al M o to r A ctivity

N orm al M o to r A ctivity 
Easily roused

N one

N one

N one

G runts only

In con sequ en tial talk

C onfused but relevant replies

M ild disorientation only on 
testing.
D isorientated but can tell 
name, address, etc.

O rientated but sleepy 
Can give a good account o f 
name, place, time, etc.

“P T A .” =  P ost T rau m a tic A m nesia . .
* f  “W ithdraw al” m eans that he indicates his displeasure by accentuating his position 
♦2. “L ocalises” m eans that h e tends to kn ow  where the pain fu l stim ulus is being applied.

We m ust talk  norm ally, definitely, clearly and simply. 
I believe th at tone o f voice is a m ost im p o rta n t factor, 
particularly if th e p a tie n t is slow to un d erstan d  o u r

Jords. We do h av e a tendency to shout w hen w e feel at our message is n o t getting across, b u t it is im p o r­tant not to do this as w e risk  in ju rin g  th e p atien t s 
self-esteem. H e m ay well resent being spoken to as if 
he is an im becile. One p atien t asked w hy she was 
being scolded w hen those talking to h e r h ad  sim ply 
assumed th a t she w as not sufficiently conscious to 
understand w h at she was being asked to do, and had 
therefore been talking ra th e r loudly.

Assessment
We know, fro m  th e  injuries received an d  th e a rea of 

damage, th a t we m ay expect certain m anifestations; 
nevertheless, assessm ent requires acute an d  continuous 
observation. .

We a re  constantly trying to find b etter ways o f 
assessing o u r patients and o f recording th e observa­
tions but, w hether we use a ch art o r an o th e r m ethod, 
the essential facto r is th a t w e should be system atic.

A m ongst th e  facto rs fo r consideration are:
(i) th e state o f the chest;

(ii) associated in ju ries o r diseases (also unassociated 
diseases) a n d  any rem edial m easures p ertain in g  
to these;

(iii) th e p o sitio n  assum ed by th e  patient, w hich m ay 
prove to  be h a b itu a l;

(iv) the level o f consciousness;
(v) th e response o f any p a rt o f th e body to  passive 

m ovem ent, including
(vi) changes in  p o stu ral tone.

As tim e goes o n  we m ust;
(i) m ake observations on th e  p atien t s m ental and 

em otional status an d  estim ate his degree of 
attention, understanding an d  insight;

(ii) be alert to perceptual problem s affecting his 
aw areness of bod y  im age an d  q uality o f balance;

(iii) test fo r sensory disturbances, including visual 
an d  au d ito ry  abilities;

(iv) becom e aw are o f speech, com m unication and 
sw allowing problem s.

T h e  question is: W here does the p h y sio th erap ist’s 
resp o n sib ility  end? H ow  m uch o f this m ay  be passed 
over to the psychiatrists, speech, an d  occu p atio n al 
therapists? I t w ould seem th a t if the ph y sio th erap ist 
does n ot receive satisfactory answ ers to h e r specific 
problem , she has to resort to doing a p p ro p ria te  tests 
herself.

T h e  next th ree concepts are p a rt o f a w hole, an d  are 
only separated fo r purposes o f convenience.

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8 P H Y S I O T H E R A P Y D E C E M B E R  19^

P ositioning

O f course, the chest condition and associated injuries 
w ill dictate, to a large extent, w hat we a re  able to do 
b u t we m ust rem em ber th a t noise fro m  an unconscious 
p a tie n t is a call fo r help. N oise indicates th at the 
p a tie n t’s airw ay  is p artially  blocked due to the fact 
th at he is no longer in a su itab le position. D e te rio ra ­
tio n  of his p osition is less likely to h appen if pillow s 
are  placed u n d er the m attress, w here possible, rath er 
than u n d er the patient.

O th er purposes o f po sitio n in g  are:
(i) to prevent increased m uscle tone in undesired 

p attern s;
(ii) to keep the a p p ro p ria te  m uscle groups u n d er the 

influence o f sustained stretch;
(iii) allow  the p a tie n t to experience n orm al patterns;
(iv) to prevent the fo rm a tio n  o f bed sores.
T hus, p ositioning is an ad ju n ct to passive m ovem ents 

o r m ay, in itself, act as a passive movem ent. M a in ta in ­
ing the positioning p a tte rn  is n o t easy an d  in the tim e 
period between turning, the p a tie n t’s position m ay 
d eterio rate, th erefore p erio d ic repositioning m ay be 
required. T his is most im p o rtan t because, as well as 
experiencing m ore norm al patterns, the p atien t must 
be prevented from  experiencing undesirable patterns 
since d eform ities m ay occur if abnorm al p attern s b e ­
come h ab itu al. F o r  exam ple, the flexion, adduction, 
in tern al ro ta tio n  p attern  o f the hem iplegic arm  be­
comes intensified if the scapula is strongly retracted, 
th erefo re we should aim  at p ositioning the p atien t in 
such a w ay th a t the scapula is p ro tracted  and the 
arm  sup p o rted  in  som e degree o f abduction.

T h e  longer a h a b it has been established the m ore 
difficult it is to break and replace w ith an  acceptable 
h ab it.

C are m ust be taken to prev en t stim ulating the re­
leased p rim itiv e reflexes, unless there is a specific 
reason fo r  doing so.

Passive M ovements

W e know  th at passive m ovem ents are aim ed at:
(i) increasing the circu latory ra te  an d  thereby 

facilitatin g  coughing and keeping the chest clear, 
and preventing circulatory com plications and 
oedem a;

(ii) preventing loss of range in joints and muscles;
(iii) helping the p atien t to experience m ore norm al 

m ovem ent patterns.
As w e know, there is a strong tendency fo r m obility 

to be lost in the trunk, h ip  and shoulder, tendo achilles, 
an d  m etacarpo-phalangeal joints o f the hand. W hen 
m obilising, the ro ta to ry  elem ent is o f p rim e im portance, 
as are  rhythm  and rep etitio n , as these are m ost effective 
elem ents in helping to reduce spasticity. F u ll p attern ed  
m ovem ents are  m ost useful, w ith specific atten tio n  being 
given to one jo in t w hen necessary.

T h ere is danger in thinking  th a t reflex inhibiting 
p attern s can be substituted fo r m obilising passive m ove­
m ents and o th er m ovem ents. W e m ust rem em ber th at 
a n orm al body requires “w arm ing u p ” before fu rth e r 
m ovem ent takes place, in o rd er to m obilise joints and 
m uscles and facilitate m ovem ent. M any of Professor 
R o o d ’s techniques m ay be used successfully h ere: e.g. 
in o rd er to stim ulate th e p a tie n t’s response by m eans 
of th e n o rm al postural reflex m echanism , P rofessor 
R ood m ay swing a p a tie n t fo re to aft, w hile he is in 
a p ro n e position.

Restraint

H ow  does one prevent th e  p a tie n t pulling out dr' 
and tubes o r injuring him self? T ying th e  patient? 
limbs offers a n  afferent stim ulus. H ow  desirable • 
th a t stim ulus, o r the response to th a t stim ulus, •— n 18 
to m ention the p a tie n t’s increasing fru stra tio n ?  The0* 
are occasions w hen p atien ts a re  “ coming u p ” o r seda* 
tion is n o t a su itab le procedure, and in these cases 
the m ethod of re stra in t needs to be carefully chosen 
Splints an d  o th er aids should only be used if the 
have a positive and d esirable effect. O f course accent 
able aids do exist, fo r exam ple boxing gloves, coJ 
sides and fishnets. C onfining the h an d  in a gl0J  
prevents the p atien t grasping the d rain , b u t does not 
resist the m ovem ent entirely. Presum ably the patient 
will n o t feel th a t his effort to rem ove an irritatio n  is 
being d eliberately thw arted. C ot sides and fishnets 
sim ply ensure that the p a tie n t will n o t fall o u t of bed 
w hile he attem pts to kneel o r stand. One does not wish 
to restrain  his activities, one is concerned about his 
safety.

Period o f Neglect.

T his indicates the period during w hich visible im- 
provem ent is lacking —  b u t fo r the physiotherapist it 
can be a positive and exciting period. T h is period does 
n o t occur during the first sh o rt w hile of recovery, and 
when it does occur the p a tie n t m ay be a t any level 
o f consciousness.

T his causes me to th in k  a b o u t the neuro-development 
of norm al infants. T h ey  all follow  a general pattern, 
but w ithin th at fram ew o rk  they ex h ib it specific personal 
variations. A n in fan t m ay show spurts o f development 
in one field w hile exhibiting slowing dow n or pause in 
another. H e  m ay develop m o re slowly or m ore quickly 
in a p a rtic u la r field. W h y  is this so? W h at is going on? 
I feel th at we can ap p ly  th e sam e questions to our 
recovering p a tie n t during the p erio d  o f pause. Is he 
consolidating his previous im provem ent? Is he harness­
ing his energy fo r the next sp u rt o f im provem ent? Is he 
re-establishing h is p ersonality?

Of course, in the brain-dam aged adult, such periods 
m ay last fo r a considerable length o f tim e, during 
w hich period iced w ater baths m ay be resorted to in 
ord er to try  and b rin g  a b o u t a change in th e  situation.

R em em bering th at during illness th ere is a regressicl 
in beh av io u r, we m ust ask: W h at shall we do? W e mi^ 
n o t neglect th e ap ath e tic p atien t, n o r fight th e  rebellious 
one, because fu tu re  im provem ent depends on present 
treatm ent. T hus we m ay have to use a new approach 
and d istract and inveigle the p a tie n t to respond.

Conclusion

N o outcom e is certain, though w e do have some 
idea of w hat to expect and the in d iv id u al’s pre- 
m orbid p erso n ality  is of great im portance. E arly  treat­
m ent prepares the p a tie n t fo r the later stages o f treat­
m ent, thus it is im p o rtan t th a t it is adequate, effective 
and satisfactory. A “b alan c ed ” person is o u r aim , and 
we shall only achieve this if we give h im  a balanced 
treatm ent.

Reference

Jennet, W. B ryan. An i n t r o d u c t i o n  t o  N e u r o s u r g e r y ,  
3rd Ed., W illiam  H ein em a n n  M edical Books, L o n d o n , 
1973.

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