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Copy of Traumatic Brain Injury

by Vari-OT

M Rafidah

on 28 October 2013

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Transcript of Copy of Traumatic Brain Injury

Introduction to Traumatic Brain Injury (TBI)
Acute Phase
Inpatient Phase
The Road Ahead
Traumatic Brain Injury
An injury to the head or brain caused by externally inflicted trauma
Any period of loss of or decreased consciousness
Any loss of memory for events immediately before or after the injury
Neurological deficits (weakness, loss of balance, change in vision)
Who it Affects
Highest rate is in children 0-4 years, followed by adolescents and young adults and then people over the age of 75 years
Older adults have the highest rate of TBI hospitalization and death
Men have more TBIs than women
Common Causes of TBI
Motor vehicle accidents
Interpersonal violence
Types of TBI
Physical Mechanisms of Injury
Impact loading

Inertial loading

Focal vs. Diffuse
Focal injury – occurs at a specific location, which affects the grey matter of the brain
Diffuse injury – widespread damage, causing degeneration of white matter

Penetrating Vs. Closed
Penetrating injuries – involve the object entering or lodging within the cranial cavity
Closed injuries – result from rapid rotation or shaking of the brain within the skull or impact to the skull
Consequences of TBI
Disruptions to everyday life, and work
Changes in family and social functioning
Burdensome financial costs
Impairments are often:
Method and timing are unique depending on the individual
Treatment focus changes as patient progresses from acute phase to long term phase of recovery
Some Statistics
Within the next hour 6 Canadian will suffer a brain injury.
More than 18,000 Ontarions suffer a brain injury this year.
1 in 26 or 1.3 million Canadians are estimated to be living with an Acquired Brain Injury (ABI).
Brain injuries are the number one killer and disabler of those under the age of 44 years.
Brain injury can be a non-visible disability.
One in five sports-related injuries are head injuries.
The Brian Injury Association of Canada
Ontario Brain Injury Association
Providence Care: Regional Community Brain Injury Services, Kingston
Phases of TBI Rehabilitation
Acute Phase Goals:
Medical Stability
Preventing secondary effects of TBI
Physical Rehabilitation
Emergency medical management
Ensuring adequate airway
Stabilizing blood pressure
Immobilizing patient on rigid backboard
Monitoring vital signs
Optimizing cerebral perfusion and brain tissue oxygenation
Minimizing brain swelling
Acute Stage Rehabilitation includes:
Multidisciplinary team
Rate of Recovery
Client Characteristics
Family Support
The Role of OT Focuses on:
Motor impairments
Aphasia and dysarthria
Sensory impairments
Visual impairments
Cognitive impairments
Emotional, psychological and neurobehavioural problems
This includes:
Range of motion exercises
Positioning protocols
Tone alteration methods
Sensory Stimulation
Reducing agitation
Supporting and educating family members
Glasgow Coma Scale
Computed Tomography (CT) scan
Coma/Near Coma Scale
Behavioral Rehabilitation
Coma Recovery Scale

Cognitive Rehabilitation
Rancho Los Amigos Levels of Cognitive Function Scale
Western Neuro Sensory Stimulation Profile
Glasgow Outcome Scale
Current Practice
Best Practice
Neuroplasticity and Brain Injury
Early Mobilization
Survivor (Outpatient) Phase
When can clients fully participate in intensive inpatient rehabilitation?
When they are capable of demonstrating stimulus specific responses
When post- traumatic confusion or agitation resolves
Length of Stay
Average is 2-3 months
What are the goals of OT in inpatient rehabilitation?
Improve independence in:
Improve cognitive-perceptual function:
Visual processing
Executive Function
Role of OT on the Neuro-Rehabilitation Team
Evaluation and treatment
Focus = holistic approach
Physical, cognitive and behavioral impairments affecting various ADL’s
Activity analysis
Initial Evaluation
Initiated by a thorough clinical interview
Individual's level of insight
Standardized assessments (testing motor, perceptual, attention and executive function)
Upper Extremity Function
Comprehensive examination
Standardized testing
Treatment of Upper Extremity Function
ROM: Treatment involves use of modalities
Strength: Rood, Neurodevelopmental Treatment (NDT), Proprioceptive Neuromuscular Facilitation approach (PNF)
Tone: Splinting, functional tasks
The ability of muscle groups to complete a timely, smooth pattern and sequence of motion
Assessment: naturalistic observation and standardized testing
Functional assessments: ROM, fine motor coordination
Treatment: therapeutic exercises, compensatory strategies
Important for safety in ADL’s
Touch, taste, smell and vision are evaluated by the OT
Treatment: sensory re-education techniques and/or teaching adaptive techniques
Often work collaboratively with the neuro-optometrists
Vision = sensorimotor process
Perception = cognitive process
Role of right hemisphere
Evaluation of perception begins with an assessment of visual foundation skills: visual acuity, visual fields, and oculomotor function
Functional Mobility:
Assessment: bed, toilet and shower/tub transfers, postural and trunk control, sitting and standing balance
Wheelchair management: transfer training

Assessment: ADL activity, Berg Balance Test, Functional Reach Test
Intervention: compensatory strategies in natural environment
Ability to scan, attend, follow, and retain instructions
Optimizing Cognitive Capacities and Abilities
Remediate the deficit
Acquire behavioural routines
Change the physical and social context
Learn compensative cognitive strategies
Cognitive remediation and exercises
Examples of Interventions
Card games
Board games
Paper and pencil tasks
Computer programs
Group support
Intervention for Impaired Memory
Develop functional goals
Day planner or pill organizer
Written instructions
Memory aids
Internal memory strategies for mild memory impairment
Memory notebook
Computer programs or pagers for moderate to severe memory impairments
Attention Remediation
Attention process training (APT)
Time-pressure management training
Metacognitive training
Functional activities can be used to improve attention
A client can begin dressing in a quiet room, with only one article of clothing
Dressing can be gradually complicated by naturally occurring distractions (an open door)
As the client improves, the OT my begin verbally discussing plans while he the client dresses
Executive Functioning Skills include:
Executive Functioning Compensatory Strategies
Task segmentation
Rehabilitation to Executive Functioning
Problem solving training techniques
Metacognitive skills
Restoring Competence in Basic Self-Maintenance Tasks
Simplify self-care tasks
Decrease external structure gradually
Minimize environmental distractions
Decrease cueing
Utilize checklists or graded cues
Dynamic investigative approach
Behavioural and Emotional Adaptation
Work in an interdisciplinary rehabilitation team to plan to minimize and inhibit unacceptable behaviour
Find out antecedent of unacceptable behaviour
Use procedural memory
Reward adaptive behaviour
Schedule pleasurable activities
Redesign and normalize the environment
Use time-outs
Withhold rewards that maintain maladaptive behaviour
Help client learn new skills
Help client experience success
Address cognitive impairments
"I have been living with multiple effects of a severe TBI for 23 years…Many of these years were spent in lonely isolation, wondering when the nightmare would end…Now, I am focusing my energy on reaching out as well as within to live this life.”
Survivor (Outpatient) Phase Rehabilitation:
The phase that begins upon discharge from health care facility and lasts for years following the injury.
Rehabilitative Frame of Reference:
Top Down Approach
Cognitive rehabilitation will result in improved functional behaviour
Cognitive interventions have been preferred to functional interventions for people after TBI

Bottom-Up Approach
If foundational skills are developed, task performance will be improved
Example, practice self-care tasks as they improve with repetition and self-esteem will improve as a result
Relating Theory to Practice in Survivor (Outpatient) Phase

Person – Environment – Occupation
Client factors
Environmental factors
Rehabilitation Goals of Survivor Phase:
Optimize occupational function at home
ADL’s, IADLs, community reintegration, vocational re-entry, driving assessment
Retraining and preparation for personal, domestic and occupational activities
Management of behaviours
Enable and sustain optimal community participation
Role of Occupational Therapy in Survivor Phase
Education (for client and caregivers)
Support group
Understand integration of factors impacting function
Recommend that life care management plan
Follow –up plans
Enable and sustain optimal community participation
Pain management strategies
Ensuring sufficient support after discharge
Rehabilitation Methods
Compensatory and restorative rehabilitation
Skill (re)training
Skill and complex behaviour training (basic cognitive processes must be intact)
Focus of Rehabilitation in Survivor Phase:
Injuries secondary to the trauma
Vision problems
Two types of fatigue: mental and physical
Mental fatigue may plague the TBI patient far longer than physical fatigue
Visuoperceptual disruptions
Cognitive Deficits in:
Short-term memory loss
Lack of initiation
Unable to recall words - anomia
Cognitive Rehabilitation
Setting: home and community
Addresses attention, memory, executive function
compensatory strategy training
Internal and external aids
Neuropsychological scaffolding
Complex skill and small components
Use of games and computers in rehabilitation process
The center of the brain which allows us to keep our emotions in check and respond in a socially appropriate manner, is frequently injured by a TBI
Behavioural issues
Personality changes
Mood disorders
Difficulty achieving independence in community living
Difficulties returning to a productive life
Aggressive verbal statements and physical actions towards others
Psychosocial skills affect social integration
Easily angered
Exhibit other emotions more freely
Difficulty communicating
Social skills retraining
Reduced self-esteem
Family/caregiver strain as a result of emotional and behavioural changes in client
Decreased satisfaction and quality of life
Neurobehavioural and emotional consequences of TBI had significant effects on both the quality of life of survivors and level of strain felt by family caregivers
Aggressive behaviour, PTSD, depression, and loss of self-esteem
Behavioural/Emotional Rehabilitation
Address behaviours and moods that interferes with client function ex. impulsivity, anger
Reassure and object to behaviours accordingly to avoid social isolation or rejection in community
Behaviour Modification
Cognitive Training
Rehabilitation Plan
Self –care skills training: dressing, washing, automatic routines, ensure assistance where required
1. What are key ways in which this stage of rehabilitation differs from the previous two stages?
2. What cognitive deficit does it address and what is another example of a compensatory strategy for cognition?
3. Why does the interaction of cognitive deficits matter to us as OT’s?
4. How does mental fatigue affect function?
5. What are some of the emotional/mood affects of traumatic brain injury?
Community Integration:
Despite ADL skills, independence in community living is difficult for many people after TBI
Includes reintegration into family
As many of 30% of moderate to severe head injury patients are able to return to work, although not necessarily their original job
Financial, employment, transportation, and socializing challenges may arise
Community Rehabilitation may address:
Vocational and Return to Work
Safety judgment
Community Integration Questionnaire (CIQ)
Functional Independence Measure (FIM)
The Patient Competency Rating Scale (PCRS)
Perceived Control Scale for Brain Injury(PCS-BI)
The Mayo-Portland Adaptability Inventory (MPAI)
Behavioural Assessment
Life Challenges
Learning Objectives:
After this seminar, the audience will be able to do the following:

1. Describe the similarities and differences in the typical course of
recovery for persons with traumatic brain injury.
2. Select appropriate assessment tools and strategies for persons with
traumatic brain injury during the course of their rehabilitation.
3. Apply information from this seminar to the treatment of motor,
cognitive, behavioural, and emotional aspects of traumatic brain
4. Analyze how needs of family members change during recovery and
adaptation and determine how to meet their needs in occupational
5. Anticipate possible roles for occupational therapists in addressing
long-term needs of survivors of traumatic brain injury.
Injuries of the left side of the brain can cause:
Difficulties in understanding language (receptive language)
Difficulties in speaking or verbal output (expressive language)
Catastrophic reactions (depression, anxiety)
Verbal memory deficits
Impaired logic
Sequencing difficulties
Decreased control over right-sided body movements
Injuries of the right side of the brain can cause:
Visual-spatial impairment
Visual memory deficits
Left neglect (inattention to the left side of the body)
Decreased awareness of deficits
Altered creativity and music perception
Loss of “the big picture” type of thinking
Decreased control over left-sided body movements
Frame of Reference
Bottom-Up Approach

Relating Theory to Practice
The Brain Game
The Brain Game
Measurement of visual perception: Motor Free Visual Perception Test (MVPT)
Observation during naturalistic activities (e.g. dressing and grooming) is essential component of OT assessment of visual perception
Compensatory strategies
Retraining treatment activities
DISCUSSION (for candy)
If you were the OT working with Josh who had just sustained a TBI, what information would be important to gather from his family, and educate them on in the acute phase?
The Brain Game
The Brain Game
Back to the Case Study of Josh:

Josh could not return to his previous work as a landscaper, and through a local vocational rehabilitation program was able to find work at the General Hospital in his town. He now works in a hospital central unit where he is responsible for stocking carts with the necessary nursing supplies. He would restock the hospital carts daily and occasionally transports them to the appropriate floors. He is also responsible for replacing stock as needed with the stock that is on the lower shelves and within his reach. He was initially responsible for stock 7 units daily. He was able to do this when working along side the job coach, but since the absence of his coach Josh’s production rate has slowed and he has increasingly made errors.
What must an OT consider before/when using PROM?
How can these items be used in rehabilitation? Why is that important?
How would you position (or ensure positioning) of a client with TBI?
What is the difference between a coma and vegetative state? What does vegetative state mean to the rehabilitation process?
Return to Work:
Contribution to quality of life
Many survivors experience change in employment following TBI
Cognitive deficits will affect reentry
Assessment of skills
Prevocational training
Workplace modifications
Who is most likely to acquire a TBI?
Define a focal head injury and explain how you may acquire one.
After watching Josh’s story and hearing about the cognitive and physical impairments he experienced after his accident, what interventions do you think were done at this time to improve his functioning?
1.You are an OT working in an inpatient setting, and you are working with a client who has acquired a traumatic brain injury. You want to find out more about the family home environment before the client is discharged. The family brings you pictures of the home that look very similar to the picture above. How might this kitchen be adapted to better facilitate functioning of a client with a brain injury?
What is the most common test used for visual-perception?
Bonus: How has it been adapted for use in adults living with a brain injury?
Other factors affecting job performance:
errors made due to distraction
behavioural issues interfering with his work
defensive, resentful of needing a job coach
difficulty accepting working for a new (female) supervisor

As Josh’s OT facilitating his vocational rehabilitation what are some compensatory strategies that you could implement to help Josh with the following issues to ensure success in the workplace?

1. Frequent confusion as to the sequences of tasks and performing tasks that were not part of job description.

2. Continual difficulty meeting an adequate production rate.

3. Wasting a lot of time constantly looking for rubber bands to use when stocking carts and while doing inventory.

4. Excessive “fooling around” with co-workers subsequently not completing all of his tasks.

5. Rude and inappropriate remarks to female employees.
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