Occupational Therapy Management

In Traumatic Brain Injury

S.Mahalakshmi
BOT final year
 Definition

Traumatic brain injury (TBI) results from a penetrating (open)

or non-penetrating (closed) injury to the brain. TBI is a life-altering
experience that causes physical, cognitive, behavioral, and emotional
changes affecting the person’s ability to engage in occupations,
participation, and health. Survivors of TBI may show a variety of
problems because the range of disability after a TBI is more varied
than in other central nervous system dysfunction.
 Clinical Picture of Persons with
Traumatic Brain Injury

The neuromusculoskeletal and movement-related disorders

experienced by clients after TBI can vary from severe motor
involvement (of the trunk or of one to all four extremities) to minimally
impaired coordination and muscle strength and full isolated voluntary
control. Most clients who require OT will exhibit deficits in one or more
of the following areas:

Primitive reflexes, Muscle tone, Motor control, Postural

stability, Endurance, ROM, Strength, Sensation
 Abnormal Reflexes

Common reflexes exhibited in severely brain-injured adults

are the asymmetrical tonic neck reflex and the symmetrical tonic
neck reflex. Treatment focuses on inhibiting these brainstem
reflexes and facilitating normal movement patterns. Demonstrated
patterning of the right side (flexion of the upper extremity [UE] and
extension of the lower extremity [LE]) and did not recover
functional movement of his right UE. The occupational therapist
would facilitate normal movement patterns involving the entire
body (head, neck, trunk, and extremities).
 Abnormal Muscle Tone

When muscle tone is affected by the TBI, it varies from

hypotonicity (flaccidity) to hypertonicity (spasticity) and can affect
all skeletal muscles of the head, neck, trunk, and extremities. When
muscles are flaccid, the resistance to passive movement is
diminished and the stretch reflex is dampened. The affected body
part may appear floppy and will require support to prevent
subluxation.
 Muscle Weakness

After a TBI, muscle weakness or below-average muscle

strength can be mild to severe. When muscle weakness is
present in the head, neck, and trunk, the client may have difficulty
with head control or posture while sitting. If weakness is present
in both UEs, deficits in gross and fine motor control or
coordination will be present. Has weakness of his right side
(hemiparesis), suggesting that he will demonstrate problems with
motor control.
 Postural Dysfunction

Postural deficits result from imbalanced muscle tone;

delayed or absent righting reactions; impaired motor control; and
deficits in vision, cognition, and perception. Abnormal postures
frequently exhibited in adults with moderate to severe TBI.
 Ataxia

Ataxia is abnormal movement and disordered muscle tone

seen in clients with TBI due to damage to the cerebellum and/ or to
the sensory pathways. Ataxia can affect movements of the head,
neck, and trunk but usually affects the extremities. The client with
ataxia has lost the ability to make small, minute adjustments that
allow for smooth coordination of movements Shakiness and
incoordination cause problems in fine motor tasks such as writing,
fastening, typing on a keyboard, using the keys on a cell phone, and
eating.
 Limitations of Joint Motion

Loss of active and passive ROM is a common problem.

Interventions for loss of ROM vary depending on the cause; the
occupational therapist should determine the cause of the loss of ROM
before the OT begins treatment. Has lost active and passive
ROM of his non-functional right UE, which did not respond either to
daily ROM exercises or to medication to reduce spasticity.
 Sensory Changes

Personswith TBI may experience dulling or a loss of the

following: light touch sensation, sharp or dull discrimination,
proprioception, kinesthesia, or stereognosis of the extremities. Cranial
nerve involvement may cause loss of pain and light touch sensation in
the face and impaired senses of taste and smell. Demonstrated reduced
tactile sensation, or hyposensitivity, of the right side. Treatment focuses
on increasing his awareness of the lack of protective sensation.
 Dysphagia

The majority of clients with severe TBI will have dysphagia

(problems swallowing). Many may have difficulty controlling oral
secretions, handling thin liquids, chewing, or managing food with
mixed textures. They may aspirate food or liquid into their lungs and
choke easily. The presence of cognitive, behavioral, and linguistic
problems as the result of brain injury further complicates the ability to
eat and drink normally.
 Perceptual Function

The ability to accurately perceive sensory information and respond to

people and objects within the environment is necessary for successful,
independent function. Damage in TBI, impairment may involve visual, tactile,
body scheme, language, and motor functions. Impairments in the following
areas: visual agnosia (inability or slowness in recognizing objects by sight),
impaired left/right discrimination, impaired figure-ground, reduced
topographical orientation (spatial orientation), impaired depth perception,
tactile agnosia (astereognosis or inability), impaired body scheme (reduced
ability to identify body parts), left unilateral neglect (reduced perception of
left space), apraxia (impaired motor planning).
 Cognitive Function

Varying degrees of cognitive deficits may result from TBI and

include disorientation, decreased levels of attention, reduced
concentration, impaired memory, impaired initiation, diminished safety
awareness, decreased ability to process information accurately, and
difficulty with executive functions and abstract reasoning
 Behavioral Function

Behavioral impairments often occur during recovery from a

TBI and can challenge both the treatment staff and the families.
Behavioral management is a key element of rehabilitation after a TBI.
Common behaviors seen in persons after a TBI include lowered
frustration tolerance, agitation, combativeness, disinhibition,
emotional lability, and refusal to cooperate.
 Occupational Therapy Evaluation

 Rancho Los Amigos Levels of Cognitive Functioning Scale

Acute Stages of Recovery
 Glasgow Coma Scale (GCS):
Not administered by occupational therapists but important for
quantifying level of consciousness and predicting recovery with early
treatment and prognostic indicators.
 Western Neuro Sensory Stimulation Profile (WNSSP)
 Coma Recovery Scale
Inpatient Rehabilitation

 Functional Independence Measure (FIM)

 Functional Assessment Measure (FAM)

 Assessment of Motor and Process Skills (AMPS)

 Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)

 Kitchen Task Assessment (KTA)

Postacute Rehabilitation

 Canadian Occupational Performance Measure (COPM)

 Safety Assessment of Function and the Environment for

Rehabilitation (SAFER)

 Interest Checklist
 Occupational Therapy Intervention

Acute Stages of Recovery

 Positioning

 AROM, AAROM, PROM exercises

 Sensory stimulation

 Splinting and casting

 Patient and family education and support

Inpatient Rehabilitation

 Optimize gross and fine motor functioning and abilities through meaningful
tasks and activities

 Optimize visual-perceptual functioning and abilities through environmental

adaptations, compensatory techniques, and assistive devices such as low-
vision aids

 Maximize cognitive functioning and abilities with compensatory or

remedial strategies that optimize the areas of orientation, attention, and
memory

 Increase independence in ADL and IADL

Postacute Rehabilitation

 Community reintegration

 Maximize cognitive abilities in natural environments by teaching

compensatory and adaptive cognitive strategies

 Environmental modifications and adaptive equipment

 Restore competence in ADL and IADL

 Participation in previous or new leisure activities

 Patient and family education and support

 Positioning

Occupational therapists collaborate with other members of the

rehabilitation team to optimize positioning to normalize muscle tone
and minimize the development of contractures and atypical postures
associated with more severe injuries that can ultimately affect motor
performance (Rinehart, 1990).
 Passive Range of Motion

PROM programs are used in conjunction with positioning to

minimize the development of contractures from abnormal tone and
static postures. Holding the stretch until muscles relax stretch and
inappropriate stimulation and handling should be avoided. PROM
within the limits of pain and positioning helps to minimize contractures
from heterotopic ossification.
 Splinting and Casting

The goals of splinting and casting are to decrease abnormal tone

and increase the patient’s functional movement. Although it appears
that serial casting may be more effective in treating range of motion
limitations in the lower extremity (Golisz, 2009).
 Sensory Stimulation

The goals of a sensory stimulation program are to promote

arousal from coma, appropriate patterns of movement, and interaction
with the environment (Rinehart, 1990). Sensory stimulation programs
are individualized to the patient’s physical and cognitive functioning.
 Family Support and Education

To truly collaborate with family members and provide right-

timed education, clinicians try to learn about patient and family
background. Clinicians are advised to employ interpersonal
communication skills such as the use of reframing statements or
clarifying questions to inquire about such matters as family structure,
family routines and activities, and experiences with service providers
(Sohlberg et al., 2001).
Optimizing Motor Function

Therapists initially help patients with

more severe cognitive impairments optimize
their motor function by engaging them in gross
motor activities that they can perform almost
automatically, such as playing catch or hitting a
punching bag Such activities minimize the
demands on weakened cognitive functions, such
as attention, concentration, and memory.
Intervention increasingly focuses on refining
motor functions as the patient’s motor and
cognitive recovery progress.
 Optimizing Cognitive Function

Inpatients with TBI are typically in a period of relatively rapid

improvement, so therapists provide cognitive remediation activities and
exercises to challenge and stimulate primary cognitive domains
(attention, memory, and executive function) in the hope that natural
recovery will be enhanced and accelerated.

Card or board games, puzzles, and paper-and-pencil tasks such

as word recognition or letter or number cancellation drills, and
computer programs may be used.
 Self-Maintenance Tasks

As previously mentioned, inpatient rehabilitation usually focuses

on helping patients reacquire basic self-care skills, such as bathing,
dressing, hygiene, and eating. In general, a given self-care task is
simplified until the patient is consistently successful in performing it,
and then the complexity is gradually increased while the externally
provided structure is gradually decreased.
 Community Reintegration

Occupational therapy practitioners are key rehabilitation

professionals in assisting individuals with brain injury to reintegrate
back into the community. Their education and training make them
experts at evaluation and analysis of an individual’s performance
abilities relative to the demands of the activity.
 Assist in developing effective schedules and routines
 Teach the use of memory compensation techniques such as daily
planners
 Facilitate the identification and development of healthy, fulfilling
hobbies or other leisure activities
 Leisure and Social Participation

Occupational therapy plays an important role on the post acute

rehabilitation team by helping the client resume previous leisure
activities or determine new leisure outlets that are more in line with
current abilities.

Leisure activities post-TBI tend to be sedentary, home-based,

and socially isolated (Wise et al., 2010). Few friendships withstand the
cognitive, behavioral, and emotional upheaval that comes with TBI.
 Vocational Rehabilitation

After clients reestablish their competence in self-maintenance

roles, they are ready to explore return to work. Postacute occupational
therapy facilitates that process with prevocational programs that focus
on work behaviors and habits, such as punctuality, thoroughness,
response to feedback, and ability to take and use notes.

Occupational therapists may also link clients with appropriate

volunteer jobs where they can employ newly learned compensatory
cognitive strategies and build their endurance and work tolerance.
 Dysphagia and Self-feeding

Intervention strategies for dysphagia follow the same guidelines

as for other neurological impairments; intervention, however, may be
more complex in this population as a result of bilateral neurological
involvement, cognitive and behavioral issues, and severe neuromuscular
impairments.

Common pieces of adaptive equipment, such as a rocker knife,

plate guard, and nonspill mug, may be used if the client demonstrates
diminished strength, coordination, or perceptual deficits.
 Functional Mobility

Mobility training can be subdivided into bed mobility, transfer

training, wheelchair mobility, functional ambulation in ADL, and
community mobility. The NDT principles of bilateral extremity use,
equal weight bearing, and tone normalization are used in intervention
strategies that address functional mobility.

The rehabilitation model, based on the principles of NDT and

PNF, should be used with the intermediate-level client with TBI in acute
and subacute stages of rehabilitation.
 Home safety

The client is to be discharged home, the therapist should the home

(or transitional living setting) to recommend modification for increased
safety for example, client with balance difficulties should have grab burs in
the shower stall. Increased lighting should be provided as necessary for
client with vision deficits because low lighting has been linked to falls.

If a wheelchair is indicated, the therapist should recommend

modification to doorways and bathroom spaces and should suggest the
replacement of high-pile carpeting with tiles, wood, or other surfaces that
can be easily traversed by a wheelchair.
 Family and Caregiver Education

Family members and caregiver should be involved in the client’s

rehabilitation from the beginning of treatment and should be considered
members of the intervention team.

Education of the caregivers in such activities as transfers,

wheelchair, mobility, ADLs, bed positioning, splint schedules,
equipment usage, ROM exercises, and self-feeding techniques will
facilitate follow-through with the skills that have been learned in
rehabilitation hospital.
 Perception

Treatment of perceptual deficits involves both rehabilitative and

compensatory intervention. For example, impairment of figure-ground
perception might be treated using a rehabilitative approach through the
repeated practice of locating object against a similar background.

Aphasia (a perceptual-speech disorder) can also be treated using

both rehabilitative and compensatory approaches. An expressive aphasia
may be treated rehabilitatively through repeated conversation exercises
in which client are give feedback regarding their incorrect spoken words
and challenged to express the words that they meant to verbalize
 Adaptive Equipment

Hygiene

Brush Holder Wash Mitt

Using only one hand, a scrub
brush with suction cups can be
adhered to a sink surface to clean
fingernails or to enable cleaning
of dentures.
Universal Cuff (palmar view)
A wash mitt fastens with Velcro
around the wrist. It can be used
when hand strength is inadequate
for grasp of a washcloth.
Universal Cuff (back of hand)
 The universal cuff is used The device generally needs
to hold utensils or devices in a to be set up for the user, however
hand that has little to no grip after the utensil is in place and the
ability. It is called "universal" cuff device is strapped into the individual
for the reason that it can be used the device can be used
with almost any object that can be independently.
slid into the palmar piece of the
device.
 Dressing

Sock Aid Dressing Stick

The sock aid assists the The dressing stick is

donning of socks or stockings
without requiring either bending
over to reach the feet or lifting the
legs to the hands
primarily used in putting on pants.
It is an extended reach of the hand
that will hook onto the pant or
underwear (as shown in the
leftmost illustration ) .
 Long Handle Reacher
The long handle reacher
can be used in any instance that an
extended reach is required (as
shown in these pictures).
Long Handle Shoe Horn
The long handle shoe horn
is little different from its
predecessor the regular shoe horn,
as illustrated. The only difference is
that this device has a longer handle
so that one can use it while
maintaining an upright or near
upright position when donning their
shoes.
 Zipper Pull Button Hook

The button hook is a firm

The zipper pull is used wire loop which is fastened to a
with individuals with poor finger wooden handle. It is used for
grasp and have great difficulty fastening buttons by individuals who
zipping up clothing. have either poor manipulation ability
with both hands, or by those who
have the use of only one hand.
 Bathing
Adapted Shower
A tub seat minimizes risk
of falls in the tub when balance is
compromised. A hand-held
shower allows control of the
shower stream while seated
Tub Seat and Hand Brush with
built-up grip
Grab bars are not
necessary with use of a tub seat,
but if standing in a tub is
appropriate, such a bar will
provide steadying assist. It it
imperative for safety that grab bars
be bolted into wall studs/supports.
 Reference

 Pedretti’s Occupational Therapy Practice Skills For Physical

Dysfunction-sixth Edition

 Physical Dysfunction Practice Skills For The Occupational Therapy

Assistant-third Edition

 Occupational Therapy For Physical Dysfunction A. Trombly Latham.-

Seventh Edition.

 Willard & Spackman’s Occupational Therapy-11th Edition

 Adaptive Equipment: An Illustrated Guide. Northeast Rehabilitation

Hospital