Jacobs Journal of Physical Rehabilitation Medicine

Comprehensive Treatment of Complex Postural Needs (CPN) in Spastic-dystonic Tetraplegia Secondary to Traumatic Brain Injury (TBI): A Pilot Case Study

Published on: 2018-07-21


Aim of this interventional evaluation study was to assess the modification and amelioration of complex postural attitudes in a patient with functional disorders, related to a spastic-dystonic muscle pattern of trunk and limbs secondary of traumatic brain injury (TBI), by using a comprehensive treatment approach.
Methods and Main outcomes:
A male, 37 years old, affected by TBI with a complex spastic-dystonic muscle pattern of trunk and limbs implicating a whole of disfuctional postural attitudes never treated before and conditioning the quality of life and care-giver approach, was recovered in our Section from April to June 2013.
Step 1.
Baseline evaluation. After recovery in our Section of Neurological Rehabilitation, patient underwent to a clinical and functional evaluation in a resting bed position and in a noiseless milieu.
Step 2.
Rehabilitative approach. Our patient underwent physiotherapy during the recovery and observational period, 6 days a week, in 2-hour session, in line with the GCS National Consensus Coference about the treatment protocol of patients affected by severe brain injury.
Step 3.
Botulinum neurotoxin treatment. In line with our internal treatment protocol, BoNTX-A (Xeomin®) was injected after 15 days and 49 days of hospitalization to reduce muscle overactivity and the pathological schema observed. Ultrasound guide to optimize the treatment tecnique was used for the multisegmental botulinum toxin treatment of the neck, of the right shoulder and of the right lower limb.
Step 4.
Functional orthopaedic approach. To realize a surgical correction of the unstable left ankle, completely intrarotated and in varus dislocated, a comprehensive bone and joint stabilization was made 35 days after hospitalization.
Step 5.
Assistive postural device approach. To optimize patient’s postural attitude and to increase his ergonomic sitting and standing outbed positioning, an innovative disability-assistive postural chair and an orthostatic aid device were used at the end of this mutlidisciplinary approach.
Main outcomes and results:
Evaluation was made at time T0 (at the beginning of hospitalization), T1 (15 days after hospitalization), time T2 (30 days after hospitalization), time T3 (45 days after hospitalization) and time T4 (60 days after hospitalization) using: a. outcome measures (MAS of upper and lower limb; TCT), b. objective behavioural and cognitive aspects; c. objective postural attitudes in different conditions considered. After our comprehensive treatment approach we observed:
? a significant change of all complex postural limb and trunk attitudes and a significant change of multisegmental muscle hypertonous
? an amelioration of the individual grade of space and environment exploration
? a progressive vertical positioning using an innovative static aid
? with the introduction of an innovative postural chair, the maintaining of an optimal and ergonomic sitting position
This interventional case study suggests that a comprehensive clinical-functional and surgical (multidisciplinary) approach is needed for an appropriate and incisive change and amelioration of CPN secondary to TBI


Spasticity; Severe brain injury; Outcome assessment; Wheelchair design; Seating systems