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Occupational Therapy Interventions for Brain Injury

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John Dudzik

on 2 December 2012

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Transcript of Occupational Therapy Interventions for Brain Injury

Incidence, Prevalence, and Risk Factors Secondary Brain Injury Occupational Therapy
Interventions Brain Herniation Cortical Contusions Primary Brain Injury Learning Objectives

1) Identify performance areas for brain injury addressed by occupational therapy
2) Describe interventions used by occupational therapy to address impairments following brain injury
3) Identify clinical challenges associated with low level brain injury and agitation
4) Discuss strategies to incorporate the family in the therapy process Background and
Pathology Learning Objectives

1) Understand the demographics of brain injury including age, gender, and mechanisms of injury.

2) Understand changes in brain function that follow primary and secondary forms of brain injury.

3) Describe the pathology related to the different types of brain injury and the sequelae of each. Learning Objectives

1) Differentiate the lobes and the specific functions of the brain
2) Relate the functional changes following brain injury to the areas that are damaged Management of Social and Behavioral Issues Facilitating recovery
of motor function and control Cognitive rehabilitation Incorporating the family
into the therapy process Brain Structure
and Function Parietal Lobe Temporal Lobe Occipital Lobe Limbic System Brain Stem Occupational Therapy Interventions for Brain Injury Hydrocephalus following brain trauma Cerebral Edema John M. Dudzik, MHS, OTR/L Hematomas Hemorrhages due to trauma Penetrating injuries Every 21 seconds a person sustains a brain injury in the United States.

1.4 million Americans sustain traumatic brain injuries each year.

50,000 people die every year as a result of a traumatic brain injury.

235,000 people are hospitalized each year with a traumatic brain injury. Age
greatest risk 15 - 19 years (highest mortality)

second peak 0-4 years

increased mortality in ages younger than 5 and older than 65 Gender
Males are about 1.5 times as likely as females to sustain a TBI

Motor vehicle collisions are the leading cause of TBI related deaths for women ages 15-74.

Falls are the leading cause of death from TBI for women over 75 years and for men over 85 years of age. Occupational Therapy Interventions
are influenced by a variety of of factors including:

1)The extent and location of brain injury;

2) Age, premorbid status, and social supports;

3)The progression recovery of an individual's
performance skills in motor function, cognition,
perceptual-motor abilities, and behavior.

Incorporating the individual's family and support system is an essential element of the therapy process and is critical for a transition to life following therapy services. Addressing Changes in
Perceptual-Motor Abilities Occurs immediately at the time of injury
Due to the initial external forces on the brain (acceleration-deceleration or rotational)
- Can be focal or diffuse
- Skull fractures
- Intracranial hemorrhages
subarachnoid hemorrhage
intracerebral hemorrhage
- Hematomas
epidural hematoma
subdural hematoma
- Cortical contusions
- Diffuse Axonal Injuries
- Penetrating brain injuries Begins immediately after trauma and continues for hours or days
- Biochemical and physiological sequelae of the primary injury
- Neurochemical and cellular events
- Intracranial pressure
- Cerebral edema
- Hydrocephalus
- Brain Herniation Syndrome Primary Causes of Brain Injury Motor control
Language production (left)
Executive functions
Inhibition Spatial orientation
Constructional abilities
Reading, writing, calculations (left)
Recognition of familiar faces
Memory Language comprehension (left)
Sensory prosody (right)
Emotion Vision
Visual perception Regulates emotion and memory
Forms a direct connection between upper and lower brain functions Controls:
respiration,blood pressure, GI function and
arousal/alertness level Positioning is directed at influencing flexor or extensor tone to maintain joint integrity and alignment, providing support to facilitate a patients’ level of alertness, and maximizing a patient’s opportunity for interaction with the environment. Seating systems and orthotic devices such as casts or splints can utilized to improve positioning and a patient’s functional abilities through:
Decreasing the occurrence of contractures and maintaining ROM;
Decreasing the development of spasticity;
Improving positioning in bed or wheelchair for better alignment of an individual's head, trunk and extremities
Seating systems are directed toward maintaining an upright posture to allow greater interaction with the environment and mobility by the patient. Facilitating Recovery of Motor Function Handling techniques often continue to be based on neuro-rehabilitative principles such as NDT and PNF while also drawing on principles of musculo-skeletal management. Recent findings regarding motor control and motor learning are leading to shifts in thinking about approaches that best promote motor recovery.

Incorporating functional activities into treatment has gained greater emphasis in these treatment approaches as a means of fostering recovery of motor function. Changes in visual and sensory processing can influence patients’ abilities to perceive their environment and carry out effective action. Occupational therapy interventions in this area of performance are directed to remediate deficits in:
- Occulomotor function

- Visual field deficits

- Visual integration and spatial awareness

- Body awareness including balance and
movement through the environment

- Interpretation of tactile information Case Study 1
Patient: 34 year old female
TBI with less than 1 hour loss of consciousness,
C.N. VII injury, right side weakness.
Additional information: Admitted to inpatient rehabilitation 8 days post-injury. Case Study 2
Patient: 18 year old female, injured in MVA
TBI, diffuse axonal injury (DAI) including basal ganglia and cerebellar pathways, focal damage to frontal lobe.
Additional information: Comatose for 7 days, 5 weeks post injury at time of admission to day rehab program. Case Study Presentations and Discussion Perceptual-Motor Abilities Cognitive abilities and deficits impact functional tasks that may be addressed in treatment.
A patient's functional abilities may be affected in:

- Attention abilities including sustained,
alternating and divided attention

- Orientation

- Memory including short and long term,
retrospective and prospective memory

- Initiation and sequencing

- Executive function skills such as
problem-solving and planning Cognitive Function Addressing behavioral issues that arise is another significant clinical challenge in therapy. Managing changes in behavior and occurrences of agitation during treatment is essential for maximizing patient safety and ensuring optimal participation in therapy.

Factors influencing changes in behavior:
- Type, location and extent of brain injury
- Age
- Pre-morbid patient characteristics (education level, personality and intellectual abilities)
- Cognitive impairments
- Family involvement and support Addressing Behavioral Change and Agitation following brain injury Managing Changes in Behavior and Agitation Treatment considerations Establish task parameters to aid you in focusing on the specific skills or deficit areas you want to address in therapy.
- Environmental factors (treatment area, time of day, duration of treatment session).

- Amount and type of stimuli (tactile, visual, motor and cognitive).

- Presentation mode (demonstration, verbal, manual/tactile).

- Sequence/rules of task. Coma Stimulation and Sensory Regulation Throughout this process, it is vital to monitor the type and intensity of stimulation presented in order to assure optimal responses from the patient.
Factors to consider include:
- length of treatment sessions.
- modalities of stimulation presented (tactile, olfactory, visual, familiar, novel).
- allowing rest periods.
- allowing for patient responses as these may be slowed/delayed. Coma Stimulation and Sensory Regulation Coma stimulation is directed at providing and regulating environmental and multisensory stimulation to elicit and increase patient arousal and responses. Low Level Brain Injury Definitions of severe alterations of consciousness (adapted from American Congress of Rehabilitation Medicine, 1995b). Coma – denotes that the patient is unarousable, an absence of sleep-wake cycles and the loss of capacity for environmental interaction. Persistent vegetative state (PVS) – indicates a complete loss of ability to interact with the environment even though the patient has some capacity for spontaneous or stimulus-induced arousal. Minimally conscious state (MCS) – patients have ability to interact with the environment although responses are inconsistent and require external stimulation. Low level brain injured patients can represent significant clinical challenges for therapists, especially in the realm of managing a patient's physical capabilities. Functional Activity Incorporating functional tasks into the therapy process Clinicians can assess which activities the patient is capable of participating in and what factors need to be taken into consideration to enhance the patient’s response.
- Length of task
- Time of day
- Patient’s physical state (for example, fatigue, length of time patient has been up)
- Positioning Basic ADL tasks can form the base of treatment activities.

Treatment can be directed toward assisting the patient in developing more complex planning and organizational skills for basic self care including safety awareness, completing related tasks that form a sequence (such as full AM ADL) as well as addressing residual motor and perceptual deficits that may be present. Incorporating functional tasks Define component skills that are essential for the patient to carry out more complex behaviors.
- Orientation/awareness of deficits

- Emotional control and the ability to participate in therapeutic activities without being disruptive

- Ability to follow commands and sequence tasks

- Attention and initiation

- Perceptual-Motor ability

- Motor function Skull Fractures Vault - the outer surface of the skull
Closed fractures due not have communication with the outside environment
Compound fractures are open to the environment due to trauma to the cranial vault
Linear - a break in a single line over the skull
Stellate - starlike fracture
Depressed - skull fragments are pushed inward toward the brain Basal - occurring at the base of the skull
Coincides with trauma over a large area
Frequently occurs in the cribiform plate of the ethmoid bone
Can lead to blood in the sinuses or CSF leaking from the nose or eyes Intracranial hemorrhages intracerebral hemorrhages subarachnoid hemorrhages Pooling of blood which displaces brain tissue Epidural hematomas Subdural hematomas Produced by gunshot wounds, non-missile objects

Can transmit shockwaves that create a cylinder of damage up to 30 times greater than the penetrating object Caused by movement of the brain within the skull, leading to bruising of the cortical surface

- can occur bilaterally in the skull

- contre-coup injury resulting from brain's movement in the skull being suddenly stopped and trauma to the side away from the initial trauma Diffuse Axonal Injury - Occurs as nerve cells are damaged as the brain moves rapidly within the skull

- Results in extensive damage as white matter is sheared

- leads to extensive disruption of axons and myelin sheaths throughout the brain Intracranial Pressure Increases in intracranial pressure often associated with poorer outcomes
- Contributes to cerebral ischemia and hypoxia within the brain
- Associated with cerebral edema, hydrocephalus and herniation syndromes - Can be diffuse or local
- Caused by disruption of blood-brain barrier
- Can lead to impaired vaso-motor regulation
- Occurs in conjunction with dilation of cerebral blood vessels Two types of hydrocephalus
- Communicating
- Non-communicating
Occurs as a result of dilation of the ventricular system and accumulation of fluid within the brain
Compromises cerebral perfusion in the frontal and periventricular areas Results from mechanical compression or intracranial hypertension
- Increased rate of mortality is associated with this syndrome
Three main patterns
- subfalcine
- transtentorial
- cerebellar Key points The frontal lobe is vulnerable to injury as a result of its location in the front of the skull and proximity to rough bony surfaces within the skull
Deficits following injury can include:
- Impaired movement of the contralateral side
- Non-fluent aphasia
- Changes in behavior, especailly social behavior
- Problems with initiation, attention and motivation Key Points Primary functions include:
- Integrating sensory and perceptual information to form a unified perception of this information.
- Construction of a spatial construct of the world around us. Key Points Deficits can result in:
- Expressive and/or receptive aphasia
- memory problems Key Points Injury to this areas will result in:
Problems with vision and interpretation of visual information Key Points Damage to the limbic system can result in:
- Behavioral changes, especially agitation.
- Memory loss
- Changes in or loss of sense of smell. Key Points Each of the sections of the brain stem have vital roles in brain function in part due to the cranial nerves located in this part of the brain
- Midbrain - Involved in functions such as vision, oculomotor control, hearing and body movement.
- Pons - Forms the main connection with the cerebellum. Reticular activating system within this area plays a critical role in sleep and a person's level of consciousness.
- Medulla - Contains structures that maintain body functions such as respiration and heart rate. Acknowledgements Introductory sections on brain injury background, pathology, and neurology adapted from Sylvia A. Duraski, MS, APRN, BC, CRRN-A,CBIT Nurse Practitioner and
Kara C. Kozub, MA CCC-SLP, BIS Allied Health Manager Brain Injury Medicine and Rehabilitation,
Rehabilitation Institute of Chicago Principles of positioning Facilitating Recovery of Motor Function Treatment using this frame of reference focuses on facilitation of normal movement through sensory input – especially proprioceptive- and using reflexes as building blocks. This approach endeavors to elicit motor responses are providing sensory input and feedback during functional activities such as ADL as well as clinic treatment. Facilitating Recovery of Motor Function - Teaching patients to accomplish goals for functional tasks rather than specific muscle or movement patterns.

- Assisting patients in developing and learning alternative movement strategies to aid in generalizing skills and adaptive responses for daily activities.

- Integrating familiar elements of the patient’s environment into the treatment process.

Structure tasks to allow for repetition, gradually decreasing/modifying assistance and cues to gain a better understanding of a patient’s level of learning and carryover of training. Ways to incorporate a motor control and motor learning frame of reference in treatment include: Advancing functional activity For individuals at a higher level of functional ability, IADL tasks can be introduced to provide more complex challenges as well as address activities the patient may need or want to accomplish at home or in the community.

Examples could include: meal preparation, family/home management, community re-entry activities, return to work or school and leisure/avocational activities. Family involvement Seeking ways to involve the patient’s family in the rehabilitation process is a vital aspect of the treatment process.

Encouraging family’s participation in treatment sessions needs to be done in a way that aids in increasing their understanding of the patient’s recovery without overwhelming either the patient or family members. Assisting family in developing an understanding of activities they can be part of during therapy as well as during periods outside treatment sessions such as weekends can enhance the recovery process.
A patient’s family can provide insights into how a patient is responding during times a therapist is not present as well as carry over treatment activities such as , positioning, ROM, use of memory aids, and other cognitive retraining tasks Family Involvement in the therapy process Managing Agitation Behaviors indicative of agitation can present in both verbal and non-verbal forms.
Verbal Non-verbal
depression impulsivity
verbal aggression physical aggression
disinhibition akathesia (excess repetitive movement)
lack of cooperation
perseveration restlessness
social withdrawal
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