Final Project: Abnormal Posturing

             For my final course project, I have chosen to present a case and do further research on what is known as abnormal posturing. Many of you who are further along in your educational programs may be fairly familiar with this concept, but it was something that I had never heard of when I came across a patient with such posturing on a home visit here in Trivandrum, which is what sparked my interest in the subject.
            The patient was a 47 year old man that had been hit by a car while riding a bicycle 6 months earlier, which resulted in a traumatic head injury that had caused a midline shift and an epidural hemorrhage which required a craniotomy to stop the bleeding and relieve the pressure that the leaking blood was exerting on the brain. When we arrived, the family gathered in the room and the neighbors came to observe through the open window, and you could tell that everyone cared deeply for the patient. Dr. Annama began examining the patient and noticed that he appeared at first to be “awake” but indeed was unresponsive, and that his pupils did not respond to light stimulus. We also saw that he had a nasogastric tube due to the fact that he was unresponsive and therefore unable to swallow, as well as a urinary catheter. His breathing was labored, and was accompanied by a painful moan at times. Abbey explained to me that the man was in a decorticate posture, which is indicative of severe damage to the central nervous system. It was heartbreaking to see such a relatively young man in such a vegetative state, which had one day been imposed on him so incredibly suddenly. That being said, I was fascinated from a medical standpoint in regard to what the physiological reasoning was behind this phenomenon.
            When a muscle contracts in an uninjured person, the antagonistic muscles on the opposite side of the joint resist the contraction to some degree. The damage to the central nervous system results in a total or partial absence of this opposing force, which causes the abnormal posturing. Posturing can occur on just one or both sides of the body, and patients can alternate between different postures as their condition improves or worsens. The causes of these conditions include intracranial hemorrhaging, brain tumors, strokes, encephalopathies, head injuries, and intracranial hypertension. The less severe type of posturing (in relative terms) is decorticate position, which was the position, which was displayed in our patient. Decorticate posture is indicative of damage to the nerve pathway that connects the brain and the spinal cord. A person in this position will have their arms fixed in a flexed position, or bent inward on the chest, their hands clenched into fists, their legs extended and their feet turned inward, as seen in the bottom diagram of the photo below. The more severe type of posturing is decerebrate position. Decerebrate posture is usually indicative of severe damage to the brain itself, and is characterized by extension of the arms and legs, plantar flexion, and backwards arching of the head and neck, as seen in the top figure in the photo below.

            Aside from the physiological understanding, there is also a prognostic component to these postures that may or may not be conveyed accurately to the family of the patient by the medical professionals. Abbey and I were concerned, from what we understood during our home visit, that the family of the patient was under the impression that he could essentially make a full recovery. They seemed relatively free of grief, and were reporting that they believed he was making significant progress because the patient would occasionally move one of his limbs, or appear to perk up in response to an auditory stimulus. That being said, the accident had occurred more than 6 months prior to our visit, and the patient was still almost entirely unresponsive, could very likely be in excruciating pain, and had been existing under conditions which severely compromised his quality of life ever since. It was Dr. Annama’s belief that another doctor had previously instilled this unrealistic sense of hope in the family, who didn’t know better. On one hand this is believeable because nobody likes to be the bearer of bad news, but on the other hand, it is utterly unacceptable from a person that has vowed to ensure the beneficience of the patient, in that it has subjected both the patient and his family to a long road of waiting and suffering as the inevitable slowly encroaches. The principle that I will take away from this specific experience will be, in Dr. Raj’s words, to always be sure to restore a realistic hope in the family members and loved ones of individuals who have fallen victim to one of the etiological conditions of these abnormal postures. I will also be sure to educate the family about what causes their loved ones to take on this unnatural and unsettling form and what it means for their prognosis and the life left ahead of them. I am fortunate to have been given this incredible opportunity at this time in my educational career, and will undoubtedly be a more well-rounded nurse in my future because of it.