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Toni Talks about PT Today

The Walking Wounded

Published September 28, 2010 10:31 AM by Toni Patt

The hospital where I work is a level-one trauma facility. That means we get anything and everything resulting from MVAs. Naturally this includes many brain injuries. I enjoy TBI patients because they usually have good potential and are fun to work with. It's a nice break from my stroke patients. For the past few days I've been working with a man who jumped out of a moving car. From a PT standpoint he's done great. It's too bad he won't be able to go home.

I discharged him from my caseload today. He was walking independently on the nursing floor without any deviations or assist. As far as his OT and I can tell, he has no physical impairments. His cognition is another story. He had an emergent hemicraniectomy immediately following admission. As a result, he is lacking a bone flap on the left side of his head and must wear a helmet. He is impulsive and distractible, emotionally labile and lacks insight into his deficits as well as his functional ability. He refuses to wear his helmet, preferring a pillowcase wrapped around his head.

In other words, he is a "walking wounded." The walking wounded are individuals who survive a TBI with good motor recovery. They are able to walk around and perform most basic functional activities with minimal or no cueing but require 24/7 supervision. They can never be left alone. They lack the ability to care for themselves. They are their own source of danger.

Sometimes the cognitive impairment is minimal. Sometimes, as in the case of my patient, it is more severe. His family will not be able to adequately supervise or care for him. Families who try are usually overwhelmed in a short period of time. One parent told me it was like talking care of a two-year-old again except this two-year-old outweighed her by 50 pounds and became violent when frustrated. She had the bruises to prove it.

PTs don't have a lot to offer these people. Sometimes our goal of mobility makes things worse instead of better. They have minimal options if their families can't care for them. Taking a TBI patient home means a huge lifestyle adjustment. Placing one in a facility means a huge financial burden. There is very little respite care for caregivers and few options for anything else. Sometimes over time they progress beyond some of the behavioral issues. Most will never return to their old selves.

This is an underserved population. One problem is the lack of understanding of what is really involved with caring for such a person. We tend to think the worst is over if someone survives the accident. More often, survival is actually the beginning of the worst that is yet to come. It can take a family up to 12 months to begin to adjust to the new individual. It can take another three or four years to complete the adjustment process.

I don't know what's going to happen to my patient. So far no family has come forward and he is unfunded. His pillowcase helmet won't protect him if anything happens and he lacks the ability to make decisions about his care. We can't put him out on the street and he has nowhere to go. Social work is trying to locate his brother, so at least there is hope.


Your article reminds us that physical therapists do not and should not practice in a vacuum.  It is our responsibility to have knowledge of our community's support services.  Especially out-patient PTs need to have a resource base of community services that we can refer our patients and patient's families to.  I have spoken with so many families that are exhausted by the grind of caring for a family member with a chronic neurologic injury.  We should be able to refer these people to resources that will help the long term outcomes of our patients.  

Megan December 4, 2010 8:03 PM

I worked in a group home for mentally and physically handicapped adults.  One resident comes to mind, he was 18 or 19 when he entered the system and according to his notes his family "functionally abandoned" him.  I met him when he was 20. He was similar in that his mobility was good but his mental capacity to judge was poor and he had a lot of seizure activity without knowing or understanding it.  

Another patient in a hospital had a TBI from a night on the town and her family refused to take her back.  She was 18 and the frustration level from S.S. was high because placement at that age can be difficult.   I often wonder what ever became of those two.

On a good note another TBI had the aspiration of becoming a PTA and shadowed us after his treatment at our hospital. Unfortunately his ability to reason and comprehend probably limited his progression in school.  The really good news is that his family was extremely supportive and did adapt to his change and were very successful with it.  They also had the resources and connections to make those changes.

Jason Marketti September 28, 2010 11:20 PM

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