Midterm Flashcards
Resources for Stroke assessments and interventions:
- StrokeEngine
- Canadian Stroke Best Practice
- Evidence-Based Review of Stroke Rehabilitation
Stroke in Canada
-Leading neurological cause of death in Canada Prevalence
- There are between 40,000 to 50,000 strokes in Canada each year
- About 300,000 Canadians are living with the effects of stroke
- After age 55, the risk of stroke doubles every 10 years
- A stroke survivor has a 20% chance of having another stroke within 2 years
- For every 10,000 Canadian children under the age of 19, there are 6.7 strokes
Stroke in Canada
Cost
- Stroke costs the Canadian economy $2.7 billion a year
- The average acute care cost is about %27, 500 per stroke
- 58% of stroke patients return home after their stroke
- Many experience depression, as do up to 30% of caregivers
Learn the signs of Stroke
FAST
Face -look uneven
Arm-One arm hanging down
Speech-slurred
Time-Call 911 now
Types based on mechanism of damage (two types of strokes)
- Ischemic (most common)
- ->thrombosis (blood clot formed in the vessels of the brain)
- Embolism (blood clot formed somewhere else) - Hemorrhage (bleeding)
Ischemic Stroke
- Approx 80% of all strokes
- Blockage in artery with in brain because of blood clot or other substances
- Atherosclerosis = Narrowing of arteries caused plaque build up
Types of Ischemic Stroke
- Permanent Symptoms
2. Trainent Symptoms
Transient Ischemic Attack (TIA)
- Short-time (symptoms resolve in less than 24 hours)
- No permanent symptom
- Warning sign for impending major stroke (10-15% within 3 months)
Hemorrhagic Stroke
- Accounts for approximately 20% of cases
- Weakened blood vessel that ruptures and bleeds into surrounding brain
- Has greater mortality than ischemic stroke
- The blood accumulates and compresses the surrounding brain tissue
MRI of Ischemic and Hemorrhage
Ischemic (black in one area, acute)
Hemorrhage (white spots over more area)
How are the symptoms different?
Hemorrhagic: in addition to other stroke symptoms, will likely experience a sudden onset headache or head pain — a warning sign that might not occur during ischemic stroke.
Stroke symptoms: numbness or weakness on one side of the body or face, trouble speaking and difficulty with vision or balance.
Neurological impairments following stroke
- hemiplegia
- hemianopsia
- Aphasia
- Somatosensory deficits
- Incontinence
- Apraxia
- Depression
- Dysphagia
- Cognitive and perceptual deficits
Recovery
of every 100 people who have a stroke
- 10 recover completely (10%)
- *25 recover with a minor impairment or disability (25%)
- *40 are left with a moderate to severe impairment
- *10 are so severely disabled they require long-term care (10%)
- 15 die (15%)
*our patients
75% of 40,000 to 50,000 strokes in Canada each year = 33750 per year added to OT workload
Recover from stroke
- Brain recovery
- Neuroplasticity
- Improvement of performance components
- Adaption
Timeframe for recovery
- Golden time: first 1 to 3 months
- Gradual improvement for 1 year - up to 5 years
- Most independent in basic ADL
- Many are unable to return to work (depends on other factors)
Medical management
acute care
- Determining the cause and site
- Preventing progression
- Reducing cerebral edema
- Preventing secondary medical complications
- Treating acute symptoms
Medical management
-Acute ischemic stroke
- Restoration of blood flow
- Antithrombotics: aspirin and heparin
- Thrombolytics: dissolve the blood clots
- Thrombectomy: surgery
Interdisciplinary team approach
who are the members of the team
- Attending physician
- Resident
- Nurse
- Nutritionist
- Social worker
- Speech pathologist
- OT
When does OT start and when does it stop????
fill in later
-through the whole process?
Common lines and drains in ICU
1. Foley catheter:
to drain urine, avoid clamping the catheter, bag should be at a lower level than the patient’s bladder
Common lines and drains in ICU
2. External ventricular drain:
- to drain CSF
- you can change the head of the bed or mobilize the patient, only if clamped by the nurse.
Common lines and drains in ICU
3. Intracranial pressure monitoring catheter (ICP):
measures intracranial pressure for patients who had swelling and elevation of the intracranial pressure
-Passive therapy, positioning and splinting NO ADLs at this point
Common lines and drains in ICU
4. Spinal drain to drain CSF:
when the drain is open the patient should be flat in bed
-Can do ADL and move around only if the drain is clamped
Common lines and drains in ICU
5. Intravenous line (IV):
-they are superficial. Do not put pressure on them specially avoid splinting the area
Common lines and drains in ICU
6. Feeding tubes:
a) Nasogastric (NG)
b) Percutaneous endoscopic gastrostomy (PEG)
- While feeding make sure the head of the bed is raised 30 degrees to prevent aspiration
Initiating OT
- Check to make sure there is an order for OT. Check every session.***
- Ask the nurse if the information is current
- Review medical records: Is there a reason for holding the therapy: change in mental status, deep vein thrombosis, pulmonary embolism
- Check the facility standards
- Start with gross assessment of:
- vital signs: if there is great discrepancy, report to the nurse
- mental status
- movement/strength
How to work with a person in ICU
-Studies show that early OT and PT in ICU is safe
Monitor:
- Vital signs (document before, middle and after treatment)
- Changes in the neurological symptoms (posture, speech, pupils, …)
- Subjective complaints
-f any problems happen: terminate the treatment and inform medical team immediately
What can be done in acute phase (assessment and intervention)
-fill in later
Functional activities suggested in bed
1. Rolling to affected side
- To increase trunk rotation
- To increase awareness of affected side
Functional activities suggested in bed
2. Rolling to the unaffected side
- Passively guide the affected side
- Increase awareness of affected side
Functional activities suggested in bed
3. Maintaining side lying
- To avoid pressure on bony prominence in lower limbs
- Position scapula in protraction
- Use a roll towel under waist to give stretch to muscle
- Used rolled towel in mid-thoracic spine to hold the position
Functional activities suggested in bed
4. Bridging
- To strengthen the back and hip extensors
- To be used for transfers and dressing
Functional activities suggested in bed
5. Side lying on the affected side towards sitting
- Early weight bearing stage on affected side
- Patient needs help to start
- Side lying on the unaffected side towards sitting
Bed positioning
On back: pillow under affected arm and neck
Lying on affected side: leg straight pillow under unaffected leg, pillow between affected arm and unaffected arm, pillow supporting back
Lying on unaffected side: leg straight: pillows under affected leg, pillows under affected arm, pillows behind back for support
Weight Bearing activities:
-On upper limb
- in side lying
- while sitting (arm partially extended)
- infront of the sink
- Stabilizing objects
Weight Bearing activities:
-On lower limb
- Bridging
- Sitting at the edge of the bed, both feet on the floor
- Early transfer when medically stable
Graded sitting and standing activities:
1. Supported sitting in bed
- Raise the head of the bed gradually to 30 to 40 degrees and then to 80 degrees
- Start activities like
- ->grooming
- ->feeding
- ->leisure activities
- ->upper body dressing
Graded sitting and standing activities:
2. Supported sitting in a chair
- To increase out of bed sitting tolerance
- Use pillows
- Watch shoulder alignment
- Self-care, visual scanning, weight bearing
Graded sitting and standing activities:
3. Unsupported sitting in bed
- Can be in crossed leg position
- Head of bed is elevated but not touching the person’s back
- Pillows against the bed rail to protect the patient
Graded sitting and standing activities:
4. Unsupported sitting at the edge of the bed with feet dangling
- ***Safety first
- ensure equal weight bearing
- Postural control increases by touching the floor
Graded sitting and standing activities:
5. Sit to stand/Transfers
- Ensure lines and IVs have enough length
- Increase the bed height so the patient can get up easier
- Ensure appropriate alignment of the limbs
Graded sitting and standing activities:
6. Supported standing in from of a raised bed
- Early weight bearing
- Weight shifting
- Use arms
Splinting
Aims:
-Correct any biomechanical malalignment
-Protect join integrity
-Prevent muscle shortening
Maintain skin integrity
Develop wearing schedule - better at night than day time
Types of Splints:
- Resting hand splint
- Cone splint
- Adjustable inflatable splint (for patients with >1 stroke and increased muscle tone)
- Blanket/towel roll (roll around elbow to prevent elbow flexion)
Edema
cause and management
Cause: Blood clot or IV infiltrate Talk to nurse Edema management: -positional elevation -Extended limb above the heart level -Active and active assistive ROM -Note: Compression garments is not appropriate for IV related problems
Question: is raising foot rests of the wheelchair a good idea for managing edema in lower limbs: NO
-unless it is a tilt chair and then the legs can be higher than the heart
Shoulder Management
Aim and steps
- Educate the team to avoid pulling on the extremity
- Signage on the bed: (Please do not pull on patient’s arm. Please contact occupational therapy at 555-555-5555 with questions and concerns
- Supine: Suport shoulder in protraction and elbow and fingers in extension
- Edge of the bed: support on bed side table
- Out of bed in chair: support with pillows or an arm support
- Active and passive ROM : make sure scapula is moving with passive and active movement (glenohumeral rhythm)
Note 1: no use of slings in ICU as the person will not be moving
Note 2: if using IV on radial artery avoid wrist flex and ext
Raising spatial Awareness
- TV
- Phone
- Food
- Bed position to face the hallway
- Use bright coloured hand bands
- Family pictures
- More verbal cues
- Use less verbal cues as the person improves
Early cognitive management
ICU psychosis:
Contributing factors
ICU psychosis: -Fluctuating state of consciousness-fatigue, distraction, confusion, disorientation, restlessness, fear, anxiety, excitement, hallucination and delusion
Contributing factors: sleep problems, stress, sensory overload and underload, immobilization, not able to differentiate between day and night
Early cognitive Management
OT intervention:
- Gentle tactile and verbal stimulations
- involvement of patient in care
- Effective resting periods
- Decreasing monotony (same thing day in and day out)
- Mobilizing the patient
- Educating family in orienting patient to time of day and date
- Calendar and clock in view
- Music
- Massage
Dysphagia
-Patient might be NPO (nothing but mouth), if not, you can start dysphagia screening
Symptoms of Potential Dysphagia
- Facial weakness
- weak tongue movements
- poor lip closure
- Drooling
- Coughing on secretions
- Poor or wet voice quality
- Residual food accumulate in mouth
Oral motor Screening
Is there…
- Facial asymmetry
- Food pocket in the cheek
- Gag reflex … use tongue depressor
Can the patient….
- Close lips (symmetrical?)
- Blow air into his cheeks (symmetrical?)
- Stick out tongue (symmetrical?)
- Clear his/her voice
- Demonstrate volitional cough
- Manage secretions
Check the soft palate when the person says “AH”. Does the palate elevate?
Other Considerations:
Skin protection
Assessment (colour, temp, wet or dry)
Intervention: reduce pressure
Other Considerations:
Communication
- Use communication boards (pictures and not letters), yes/no signals, eye blinking, …
- Avoid shouting
- Speak slowly and directly to the patient’s face
- Reduce background noise
- One person to communicate at a time
- Be aware of signs of frustration
- Glasses/hearing aid?
ADL grading in ICU/Acute:
Simple
- Sitting with support
- Finger feeding
- Drinking from a cup
- Brushing teeth
- Washing face
- Donning pullover shirt
- Donning shorts in bed when bridging
ADL grading in ICU/Acute:
Complex:
- Sitting without back support
- Feeding with utensils
- Pouring liquid and drinking using a straw
- Brushing and cleaning dentures
- Washing face and upper body
- Donning a button-down shirt
- Donning pants with standing to pull up
Rehabilitation Phase
-Patients who have sustained an acute stroke should receive rehabilitation services if their post-stroke functional status is below their prestroke status and there is a potential for improvement
Acute –>Inpatient–>Outpatient
Criteria to quality for in-patient rehabilitation
- medically stable
- stamina to participate in the program demands/schedule
- Able to follow at minimum one-step commands, with communication support if required
- Sufficient attention, short term memory, and insight to progress through rehabilitation
- Potential to make functional gains
Timeframe for Recovery
- Golden time: first 1 to 3 months
- Gradual improvement for 1 year - up to 5 years
- most independent in basic ADL
- many are unable to return to work (depends on other factors)
Rehabilitation phase
which one goes first: compensatory treatment strategies Or Remedial treatment strategies????
When will you offer adaptive devices?
answer later
Assessment/intervention
Occupational Performance
- Self-care
- IADL
- Roles and responsibilities,
- Leisure
Assessment/intervention
-Component abilities and capacities
- Upper extremity function
- Postural adaptation
- Speech and language
- Cognition
- Psychological aspects
- Visual function
- Motor planning
- Dysphagia
Assessment/intervention
Upper extremity function
- somatosensory assessment
- shoulder subluxation
- shoulder-hand syndrome
- Voluntary movement
- Strength and endurance
- Functional performance
Occupational performance
what we are looking at and measures
- Roles
- Self-care
- IADL/Productivity
- Leisure
Measures:
- COPM
- FIM
- Barthel index
- Role checklist
Minimum requirements to be able to stay home alone:
- prepare or retrieve a simple meal
- use safety precautions and exhibit good judgement
- take medication
- get emergency aid
Somatosensory Problems
- Somatosensory problems usually accompany motor problems
- Test of sensation require attention, recognition and response to multiple stimuli
- If receptive aphasia –> the test results might not be valid
- If expressive aphasia –> use yes/no questions or written way of communication
- If mild stroke + dexterity problems –>might do two point discrimination test
Shoulder Subluxation
definition and types
-Subluxation of glenohumeral joint because of weakness or spasticity in the muscles around it
Types:
- Inferior subluxation
- Anterior subluxation
- Superior Subluxation
Shoulder-hand Syndrome
(complex regional pain syndrome/Reflex sympathetic dystrophy)
How it impacts each part
-Starts with pain and continues to stiffness in shoulder and hand
Shoulder: loss of ROM with abduction, flexion and external rotation
Elbow: usually no signs or symptoms
Wrist: intense pain during extension and dorsal edema tenderness during deep palpation
Hand: edema over metacarpals, no tenderness
Digits: moderate fusiform edema, intense. pain during flexion in MC and PIPs, loss of skin lines
Shoulder-hand syndrome
stages
Stage 1
*as the stages increase movement decreases
- Pain and increased sensitivity to touch
- Swelling and joint stiffness
- Increased warmth and redness
- Faster-than-normal nail and hair growth and excessive sweating
Shoulder-hand syndrome
stages
Stage 2
*as the stages increase movement decreases
- Swelling is more constant
- Skin wrinkles disappear
- Cooler skin
- Increases stiffness
Shoulder-hand syndrome
stages
Stage 3
-Rarely has pain or vasomotor changes but they have soft tissue dystrophy, contracture (frozen shoulder and claw hand), severe osteoporosis
Voluntary Movements
Test the followings:
- How are the movements: Reflexive or voluntary movement
- Can proximal segments stabilize to facilitate distal movements?
- Can movements happen unassisted?
- Can make movements in isolated joints?
- Are reciprocal movements in isolated joints?
- Are reciprocal movement present?
- Assessment tools?
Do we need to test AROM? do we need to test PROM?
Do We need to test muscle strength
-Answer later
Motor Recovery
- Rehab intensity
- Task specific practice
- Constraint induced movement therapy
- Mirror therapy
- Functional electrical stimulation
- Virtual reality
- Cognitive Orientation to occupation Performance
Postural control
Definition
-Individual ability to remain upright against gravity for stability and during. changes in body position
- Prerequisite to independence in ADLs
- Maintained by an interplay between sensory, motor and cognitive systems.
Postural Control
Problem in motor control
- uneven weight distribution and increased postural sway
- Unsteadiness and instability
- Frequent falls
Postural Control
Assessments
- Observe during: sitting, standing, transfers and self-care tasks
- Berg balance test
- Functional Reach Test
Body part Positioning that is abnormal sitting after stroke
Head, neck: Forward, flexed to weak side and rotate away. from the weak side
Shoulders:
- Uneven height
- involved side retracted
Spine and trunk:
- Curved from posterior
- Thoracic Kyphosis
- Shortened trunk muscles at one side
Arms:
- Use of strong arm
- Increased or decreased muscle tone on affected side
Pelvis:
- Asymmetrical weight bearing
- Posterior pelvic tilt
Legs:
- Hips in more extension, feet in front of the knees
- Feet not flat on floor unable to weight bear
Postural control problem -OT intervention
Goal: client will be able to complete lower body dressing independently
Intervention:
- Provide feedback on how the person is sitting by using mirror or by copying the therapist
- Use varying postures and transitional movement into activities
- Grade reaching activities
- Use bilateral upper extremity activities to improve balance (sitting and standing)
Speech and language
- Damage to left cerebral hemisphere
1. Aphasia - Fluent (Wernicke’s aphasia or receptive aphasia);
- can speak but have problem auditory comprehension and understanding of language, Might have difficulty with reading and writing
- Difficulty following instructions
Speech and language
- Damage to left cerebral hemisphere
1. Aphasia - non-fluent (broca’s aphasia or expressive aphasia):
- understands well but can not produce words
- Person can follow instructions
Speech and language
- Damage to left cerebral hemisphere
2. Dysarthria
-Slurred speech, drooling and decreased facial expression
Cognition (after stroke)
- Increased risk of cognitive impairments and dementia
- Risk of dementia predicted by size and location of CNS damage
- Risk is associated with increased age at the time of the stroke
- Even mild strokes can have an effect on
- ->learning and remembering new information
- ->Generalizing
- ->initiating actions
- ->confusion in familiar places
-Difficulties organizing thoughts and attention
Visual and Perceptual Deficits
Vision
- visual field cuts
- ->Hemianopsia
- Oculomotor control
Scanning
- Neglect
- Disorganized
Pattern recognition, visual memory, Visual cognition
Apraxia
Psychosocial changes
- Depression
1. Organic causes
2. reaction to the change - Anxiety
- Stress
- Anger
- Decreased insight vs Denial: Denial of need for rehab or unreasonable goals
More in rehab phase than acute phase
Importance of HOPE
Dysphagia signs and Symptoms
- Coughing, throat clearing, or choking during or after meals
- Shortness of breath
- Altered voice quality: wet, gurgling, or weak voice
- Difficulty moving food to start the swallow
- Spitting food out
- Poor lip closure, loss of food from mouth; Drooling
- Pocketing food in cheeks, under the tongue or the side of the mouth
- Slow, effortful chewing
- Rapid, uncontrolled eating
Consequences of dysphagia
Dehydration
->dry mouth, constipation, urinary tract infection, confusion, severe illness, or even death
Consequences of dysphagia
Malnutrition
–> weight loss, reduced energy, skin breakdown, impaired wound healing, and lower resistance tp infection
Consequences of dysphagia
Aspiration
-entry of saliva, food, liquid, or refluxed stomach contents) –>respiratory problems, and pneumonia
Consequences of dysphagia
Choking:
blockage of airway by piece of food, making it difficult or impossible to breathe
How to help with dysphagia
1. Proper positioning
- Sitting in chair or in bed (60 to 90 degrees)
- Head in middle and flexed slightly forward
- Encourage to stay upright about 30 min after meals
How to help with dysphagia
Reduced distractions
- Avoid clutter at the table
- Quiet environment
- no visitors at meal time
- Taking medication before or after meal rather than during
How to help with dysphagia
Adjust feeding rate, amount and texture
- Small, frequent meals
- Use teaspoon not a tablespoon
- encourage them to swallow twice
- Check for laryngeal elevation when swallowing which is the movement of the adam’s apple up and down
- Ensure the mouth is clear before introducing more food
- Use thickened liquids/ soft or pureed foods
How to help with dysphagia
Teach the person to:
- Eat slowly, and never rush
- Monitor slef-feeding with a mirror
- Remove pocketed food with their tongue
- Be aware of drooling and use a napkin if necessary
- Cough to clear the throat
- Wear loose-fitting clothes and avoid tight belts, to avoid reflux
oral hygiene
- Facilitate mouth care after meals
- remove dentures after each meal so food particles can’t collect and cause irritation
- Ask patients/caregivers to:
- ->At least once a day, check that the person’s mouth and tongue are pink and moist. If the mouth is dry with patchy white areas, or the tongue is white and coated, tell the team.
- Encourage the person to get regular dental check-ups
Transition to the community
- Discharge planning
- Resuming roles and tasks
- ->work
- ->Leisure
- ->sexuality
- ->Driving
- Community support and resources
- Fatigue
Driving rules in Ontario
_What the role of OT in regards to driving: Fill in later
Driving
1. what is the physician’s responsibility in regard to driving for people with had TIA ?
Fill in
After Stroke, for how long is the person not permitted to drive?
at least one month
You have a client who had a stroke and is allowed to drive but you notice that the person has unilateral neglect. What should you do? Can you report this? Would this be a breach of the confidentiality?
fill in
Who pays for the driving assessment
client
Top-down vs Bottom-up
- Self-care
- Productivity
- ->Meal preparation, home management, work, community mobility
- Leisure
Traumatic Brain Injury (TBI)
Definition
Alteration in brain function or any evidence of brian pathology caused by an external force
Traumatic Brain Injury (TBI)
Cause
External physical force; not congenital or degenerative diminished consciousness
Traumatic Brain Injury (TBI)
Types
There are different types of brain injuries; usually classified as mild, moderate, severe, and very severe
Traumatic Brain Injury (TBI)
Consequences
Emotional, cognitive, behavioural, and physica; impairment
TBI in Canada Stats
- Acquired brain injury is the leading cause of death and disability for canadians under the age of 35
- TBI occurs in 500 out of 100,000 individuals yearly in Canada
- 18,000 alone in ontario
- Over 5,000 children in canada will be seriously injured
- Every year in Canada, over 11,000 people die as a result of a traumatic brain injury
- Each year over 6,000 become permanently disabled after a traumatic brain injury
- Within the next hour, 6 Canadians will suffer a brain injury
TBI in Canada Cont
- About 3,000 (50%) of these individuals will be left with physical, cognitive/and or behavioural consequences severe enough to prevent them from returning to pre-injury lifestyles.
- The highest incidence of traumatic brain injury are men aged 16-24; men experience brain injury twice as often as women
- Occurs at a rate of 100 times more than spinal cord injury
Warning signs - Is there Brain Damage?
- Repeated vomiting
- Unusual behaviour
- Worsening headaches
- Memory problems
- Worsening Balance
- Double vision or other vision changes
- Decreased level of alertness
- Increased disorientation
- Seizures
External Forces Causing TBI
- Head struck by object or striking an object
- Brain undergoing acceleration/deceleration movement - NO direct external trauma (ie. Head strike)
- A foreign body penetrating the brain
- Forces generated from blasts or explosions
TBI Classifications
Open and closed
-A TBI can be classified as either an open or closed head injury
Open: Penetration into cranial cavity
Closed: No penetration into cranial cavity
TBI Classifications
location
Focal: Occurs in a specific area
Diffuse injury: occurs over a more widespread area
–>Traumatic axonal injury (TAI): a type of diffuse injury that results in damage to axons
Both(common in severe brain injury)
TBI Subtypes
Diffuse
- concussion
- Diffuse axonal injury
- Blast
- Abusive head trauma/shaken baby syndrome
TBI Subtypes
Focal
Contusion
Penetrating
Haemotoma
- Epidural
- Subarachnoid
- Subdural
- Intraventricular
- Intracerebral/intraparenchymal
Focal Brain Injury
If in anterior poles and inferior of frontal and temporal lobes
- Impairments in memory, emotional regulation, and drive
- Impulsivity
- Usually no motor impairments
- Usually no speech impairments
If frontal-lateral cortex damage
- ->hemiparesis
- Impulsivity
- Attentional impairment
Diffuse Brain Injury
- More common in motor vehicle accidents
- Cognitive impairments
- Diminished mental processing speed
- Decreased Divided attention
- Decreased higher level cognitive functions
- Behavioural changes: impulsivity, irritability, exaggerated pre-injury traits, apathy, poor initiative
Cerebrospinal Fluid (CSF) functions
- A cushion or buffer for the brain’s cortex
- A basic mechanical and immunological protection to the brain inside the skull
- Clearing waste
Common signs and Symptoms of TBI
Physical
- Nausea/vomiting
- Headache
- Sleep disturbance
- Dizziness
- Sensory motor problems
- Visual difficulties
- Balance problems
- Fatigue
- Sensitivity to light
Common signs and Symptoms of TBI
Cognitive
- Disorientation
- Concentration problems
- Memory difficulties
- Attention problems
- Slowed thinking
- Difficulty finding words
Common signs and Symptoms of TBI
Emotional
- Irritability
- Mood changes
- Anxiety
- Depression
Injury to Frontal Lobe consequences:
Sequencing Decision Making Attention Personality Problem Solving -Verbal Expression Spontaneity emotions Voluntary initiation of movements
Injury to temporal Lobe consequences:
- Spoken language
- Selective attention
- Sexuality
- Inhibitions
- Aggression
- Identification (identifying objects)
- Categorization
- Face Recognition
- Object finding
Injury to parietal Lobe consequences:
- Object classification
- Tactile Processing (what are their fingers telling them)
- Academic skills
- Cognitive ability
- Directional understanding
- Hand-Eye Coordination
- Spatial Orientation
Injury to Occipital Lobe consequences:
- Vision
- Visual Field
- Locating objects
- Colour Identification
- Hallucinations
- Word blindness
- Movement perception
- Reading/Writing
- Visual Processing
Injury to Cerebellum consequences:
-control of gross and fine motor skills
-Voluntary motor skills
-Balance
-Equilibrium (stand up and not fall over)
-coordination
Postural control
-Eye movement
Injury to brain stem consequences:
- Body Temperature
- Heart Rate
- Breathing
- Balance
- Movement
- Swallowing foods and liquids
- Vertigo
- Nausea
Secondary Injury/Conditions
- Disruption of autoregulation of cerebral blood flow, blood-brain barrier, vasomotor functions, increase in intracranial pressure, cerebral edema, intracranial hemorrhage, ischemic brain damage
- Fractures
- Cranial nerve damage
Damage to cranial Nerves can happen in TBI
Examples of Cranial Nerve Damage
-Olfactory nerve (cranial nerve I) damage
-Impairment include:
- Dysnomia -impaired sense of smell
- Ansomia-Complete loss of smell
- Prosmia- Sensation of smell without cause
- Cosmia-Smelling an offensive odor that does not exist
What OPIs can happen because of this damage
- Can impact taste
- Can impact safety (smelling smoke)
- Impact cooking
Seizures
Triggers
-Seizures might happen even if the person is taking medication
Triggers:
- Fever
- Drinking alcohol
- Sick with flu or cold
- Emotional upsets
- Fatigue
- Low blood sugar
- Poor nutrition
- Flashing lights such as in video games
- Loud noises
- Constipation
- Menstruation
Types of Seizures
Focal or partial
-Generalized Seizures
Phases of Life for a person with TBI
Pre-injury Phase
-Personality, education, skills and personal history
Phases of Life for a person with TBI
Post-injury
Acute phase (ICU)
-First few hours-diagnosis/triage
Medical treatment
Phases of Life for a person with TBI
Post-injury
-Intensive phase (ICU)
-Acute hospital care to discharge (occupational therapy starts)
Phases of Life for a person with TBI
Post-injury
Recovery Phase
-Education/training
Rehab
-occupational therapy
Phases of Life for a person with TBI
Post-injury
Survival phase
- Living a new phase
- rehab
- Occupational therapy
establishing and living a new life Duration: decades/lifetime
-Personal adjustment (abilities, deficits, personality, etc) -Social adjustment (family, friends, work, peers, etc) -Quality of life (productive, happy, engaged, etc)
Goal Setting and OT focus
Severe alteration in Consciousness (ICU)
-PROM/Positioning/tone management/splinting
-Sensory stimulation
-Reducing addiction
-Family support and education
`
Goal Setting and OT focus
Inpatient Rehabilitation
- Medical stability
- Reduction of physical impairments
- Basic self-care skills
Goal Setting and OT focus
Post-acute Rehab
- Medical needs
- Fundamental capacities
- Basic skill acquisition
- Community Integration
ICU Phase (medical Treatment)
-Very similar to stroke
-control of intracranial pressure (ICP)
monitor for pupil changes, decreased neurological responses; abnormal brainstem reflexes; flaccidity; behavioural changes; vomiting; and changes in pulse rate, blood pressure, and respiration rate
Recover Phase (rehabilitation)
- Similar to stroke:
- Highly correlated with:
- ->initial Glasgow Coma Score
- ->Length of coma
- ->Length of post traumatic amnesia (PTA)
Glasgow Coma Scale
looks and scores EVM
Best Eye response (E) (opening eyes) (1-4)
Best verbal response (V) (responding to questions) (1-5)
Best Motor Response (M) (move body somehow) (1-6)
GCS and TBI Severity (comparing scores to sevity)
GCS Score
13-15 –> mild injury
9-12 –> Moderate injury
8 or below –>severe injury
Don’t just focus on the total but also subcategories (if they are very low in one category)
7-9 make for people that need oxygen
Ongoing Monitoring - GCS
Frequency of observations
- Observations should be performed and recorded every 30 minutes until GCS equal to 15 achieved
- If GCS = 15 observe every 30 minutes for 2 hours, then 1x hourly for 4 hours, then every 2 hours thereafter;
- Should the individual with GCS equal to 15 deteriorate at any time after the initial 2-hour period, observations should revert to half-hourly
Ongoing Monitoring - GCS
Medical re-evaluation is warranted
- A sustained (30 min drop) of one point in GCS level (greater weight should be giver to a drop of one point in the motor score of the GSC);
- Any drop of 3 or more points in the eye-opening or verbal response score of the GCS 2 or more points in the motor response
Injury Severity Based on Length of Amnesia
severity compared to amnesia
smaller or equal to 1 hour mild
1-24 hours moderate
1-7 days severe
more than a week very severe
Medical Assessment of brain Injury Reported for Rehab
- Length of Amnesia
- Glasgow Coma Scale (GSC)
- Rancho Los Amigos Cognitive Functional Scale
Rancho Los Amigos Cognitive Function Scale -Revised
I - No response: total assistance
The brain injured patient looks as if they are in a very deep sleep and does not wake up even when
you talk to them or stimulate them. Your loved one may be in the Intensive Care Unit and may be
attached to a machine to help with breathing
II- Generalized response: total assitance
The patient seems to be asleep most of the time. They may wake up slowly to noises, movement
or touch. The patient may make a face or groan when touched, such as when a nurse gives a
needle, or takes blood pressure.
The patient may start to do simple things spontaneously or when you ask of them, such as “close
your eyes”, “stick out your tongue” or “squeeze my hand”. These are good signs, but you should
ask the nurse or therapists about better ways to judge if the patient is consistently following
commands
III - Localized response: total assistance
The patient is more awake for longer periods during the day. The ability to respond to stimuli and
to move the limbs and body are happening more often. For example, this might mean moving
an arm or leg in response to pain, following a command when asked, or reacting to a sound or
patient.
At this level, responses may not be the same every day, so the important thing to look for is
consistency.
IV - Confused/ agitated; maximal assistance
V - confused, inappropriate: non-agitated: maximal assistance
VI - Confused, appropriate: moderate assistance
VII. - Automatic appropriate: minimal assistance for daily life skills
VIII - Purposeful, appropriate: stand by assistance
IX - Purposeful, appropriate: stand by assistance on request
x - Purposeful, appropriate: modified independent
Rehabilitation Admission Criteria
- A traumatic brain injury diagnosis
- Medical stability
- The ability to improve through the rehab process
- The ability to learn and engage in rehab
OT Specialty Required for TBI Rehab
- Knowledge about managing TBI
- mental health
- +substance abuse
Comprehensive OT assessment Should include
- Awareness of impairments
- Attention
- Learning and memory
- Executive function
- Visual Spatial function
- Detection/expression of emotion
- Language, social communication
Examples of OT assessment Tools
- COPM
- Agitated Behavioural Scale
- The Mini Mental Status Exam (MMSE)
- Orientation Log (O-long)
- Test of Everyday Attention (TEA)
- Rivermead Behavioural Memory Test (RBMT)
- Behavioural Assessment of the Dysexcutive syndrom (BADS)
- The Multiple Errands Test
- AMPS
Factors to Consider During Cognitive Assessment
- Personal factors
- Pre-injury conditions
- Injury-related factors
Recommendations for Post Traumatic Amnesia
- A quiet and consistent environment and avoid overstimulation
- Low-stimulation rooms
- Evaluate the impact of visitors, assessment and therapy
- Minimize the use of restraints while facilitating the use of alternate measures in order to allow the person to move around freely
- Consistent healthcare professionals
- Establish the most reliable means of communication
- Provide frequent ressurance
- Present familiarizing information as tolerated by the person
- Help family members understand PTA and how to minimize triggering agitation
OT Interventions
- Acute rehabilitation (Intensive medical management)
- Inpatient rehabilitation
- Community rehabilitation (post-acute rehabilitation)
Interventions Based on Rancho Level
Rancho Levels I, II and III
Time of inactivity or underactivity
Goal: develop responses to sensory inputs and increase frequency, rate, variety and quality of responses
- Talk in calm, slow, normal voice, reassuring tone
- Do not expect the person to remember things you said
- Tell the person who you are (every time), date, time of day
- Explain what you are going to do
- Talk about familiar people
- Use radio and music (not all the time)
- Provide education to family member
Ask family:
- To keep a journal
- To take care of themselves (sleep well, eat well. etc.)
Can medication Help With Cognitive Problem
Attention:
- Methylphenidate
- Dextroamphetamine
- Amantadine
Memory
- Rivastigmine
- Donepezil
Interventions Based on Rancho Level
Rancho Level IV - Confused/Agitated
As the brain improves, it begins to “wake up” and may have difficulty controlling the level of response to the environment. This is called “agitation.” You will see the patient will have poor memory and be confused most of the day. At this level, the safety of the patient is the biggest priority. The team may suggest certain ways to decrease the risk of falls and pulling at medical tubes.The patient may cry, yell or scream, wave their arms around, or move about in bed as they react to their environment- even after the stimulus is removed. They may hit out at others or may try to remove tubes or try to climb out of bed. Either they are awake and active or asleep. This can be scary for you and the patient. At this time, the patient would benefit from a routine to help to manage the behaviour. The patient cannot focus on tasks for a long time. If there is too much happening, such as many visitors, the patient may become more confused or agitated. The only memories they have are for things that happened before the head injury. If the patient is able to speak, they may use the wrong words, mix up the order of words or tell stories that do not make sense. They are not able to find the right words as they are not yet able to think before they act.
Can be frightening for the family
Ask family
- Remind time , day and place
- Limit the number of visitors (NOT in a group)
- One thing at a time
- Use a way of communicate if the person cannot talk
- When agitated: do not walk out
- Reassurance
- Touch
- Soft music
Interventions Based on Rancho Level
Rancho Level V - Confused, Inappropriate
-Confused, inappropriate, needs time, speaks more
Rancho level VI-confused, Appropriate
LEVEL 5: CONFUSED – INAPPROPRIATE – NON-AGITATED
The patient may be more awake and can respond to simple commands. They are able to focus
longer, but will need to be told what to do several times. The patient is easily distracted so may
need to be asked several times to finish a task. They have memories of events in the past but they
will not have clear memories of events since the injury. For example, they may not recall what you
told them five minutes ago. They may be able to do simple tasks that they have done in the past,
like eating and dressing. They are not able to learn new information, and may seem to have lost
their manners. They may show inappropriate behaviour, such as sexual comments or actions, or
may eat their meals with poor manners.
LEVEL 6: CONFUSED - APPROPRIATE
The patient follows simple directions most times they are asked. Your loved one is able to recall
how to do things like feeding, dressing and bathing. Memory for events since their injury is still
poor, so learning new information is hard. The patient is more aware of time and place. Their
attention can sometimes be held for as long as 30 minutes. During that time they will talk and
behave more appropriately, although they may act like a machine and give the same answers
every time. They may still be confused at times. They are not safe to leave the unit alone as
they do not remember the way back to their room. They may seem selfish and care only about
themselves.
Teach family
- Person may laugh and cry easily
- Be patient, repeat information
- Help with activities
- Provide structure for basic tasks
- Use everyday situation as a learning experience
- Slowly increase independence
Interventions Based on Rancho Level
Rancho Level VII-Automatic, Appropriate
The person can now do daily routines with little or no confusion, but may not know what they have been doing. They usually have poor judgment, find it hard to find solutions to problems and make poor decisions about the future. They often do not realize they are having these problems (poor insight). They can now learn new information, but at a slower speed and with more difficulty than before the injury. They may need someone to be with them as they are not safe to be alone. They are able to take part in and enjoy more recreation and social activities.
- Can complete most tasks
- Limited insight and judgement
Teach the family
- ->to be patient
- Talk about safety issues
Interventions Based on Rancho Level
Rancho Level VIII-Purposeful, Appropriate (stand by Assistance)
Memory has improved but memory for recent events may still be a little impaired. Following severe
brain injury, a person may be slow to figure out situations and problems, deal with stress or use good
judgment in emergencies or unusual situations. Their behaviour is more appropriate and good enough
for the person to function in most social situations. Any problems remaining with thinking and behavour
might only be noticeable to close family and friends.
- Can complete most tasks day to day activities ADLs and IDLs
- Might remember past events but not recent events
- better stress tolerance
- can take care of medications
Teach family
-More in house activities
Interventions Based on Rancho Level
Rancho level IX - Purposeful, Appropriate (assistance on request)
- Can recall events and learn new tasks such as job training
- Can start a return to work processes
Interventions Based on Rancho Level
Rancho Level X - Purposeful, appropriate (modified independent)
-Can complete tasks but might need more time and assistance
-People might think they are all better but we need. to avocate for time
Family :
emotional support
-Let the person make their choices
Acute Rehabilitation
Severe alterations in consciousness
- ROM exercise
- positioning
- Tone management
- Splinting
- Sensory stimulation (on case to case basis)
- ->train families on how to provide stimulation
- Family support and education
Safety tips for acute Rehab
- Keep head in 30 degrees elevation
- Do not turn head to one side - ask nursing
- Gentle touching, quiet talking, stroking
- Supported sitting as soon as tolerated with doctor approval
- Watch person’s blood pressure
Acute Rehabilitation - Managing Agitation (i.e. Rancho IV)
Strategies to Normalize the Environment
-Familiar objects, photographs, quiet environment, orientation, information, normalize interactions
Acute Rehabilitation - Managing Agitation (i.e. Rancho IV)
-Strategies for Physical Management
- Devices that maximize freedom of movement
- Gross motor activities
- Change activity if needed
- Be calm, confident, and accepting
-mittens with no thumbs
be flexible
Inpatient Rehab
Goals of inpatient rehab
- Optimize motor functions
- Optimizing cognitive functions
- Optimizing visual and visual-perceptual function
- Restoring competence in self-care tasks
- Contributing to behavioural and emotional adaptation
- Supporting the family
Inpatient Rehab
Optimizing cognitive function
- Cognitive remediation activities and exercises
- memory strategy training
- group treatment
Recommendations for Improving Memory Impairments
- Clearly define intervention goals
- ->Selection of and training of goals that are relevant to the person with TBI (i.e., ecologically valid)
- Allow sufficient time and opportunity for practice
- Integrate methodologies that allow for breaking down tasks into smaller components such as task analysis when training multistep procedures
- Teach strategies using variations in the stimuli/information being presented (e.g., multiple exemplars, practical tasks).
- Promote strategies that allow for more effortful processing of information/stimuli (e.g., verbal elaboration, visual imagery)
- Use teaching strategies that constrain errors (e.g., errorless, spaced retrieval) when acquiring new or relearned information and procedures
- Consider group-based interventions
Mild Brain Injury
- population increasing
- Hidden symptoms
- Personality changes
- Disagreement about persistence of cognitive problems after mild TBI
- Little consensus about the best intervention
How to keep clients with ABI Actively Involved in rehab Program
-Contingent reward techniques were most effective at increasing adherence and compliance while interventions enabling clients’ active participation in rehabilitation appeared to increase engagement and motivation
A lot of ppl were not engaged in rehab and didn’t have great outcomes
Tried some behavioural approaches
Sent reminders - reduce need to remember the sessions
- Responded really well
Behavioural contract to sign
- Attendance
- Types of behaviours they would focus on in their participation
Most effective
- Using contingent rewards
- Rewarding positive behaviours instead of disciplining neg behavior
- Tokens
Interventions that enabled the client active participation increased engagement in rehab process
- Providing tailored info about their condition - better understanding
- Education and ability to direct their own goal setting
- Equipping them self management skills so they could have some
independence in the rehab process
Community Rehabilitation
-Goals of community rehabilitation
- optimizing cognitive function
- Optimizing visual and visual-perceptual function
- Restoring competence in self-maintenance roles
- Restoring competence in leisure and social participation
- Restoring competence in work
- contributing to behavioural and emotional adaption
- supporting the family
Community Rehabilitation
-Restoring competence in self-maintenance roles
- ADL training
- Community re-entry skills training
- Environmental adaptation
Access to interval care is needed even after discharge. The need for internal care is determined on the client’s needs, goals and the potential benefit of services
Community Integration Framework (CIF)
- Relationships
- Community Access
- Acceptance
- Occupation
- Being at home
- Picking up life again
- Heighten risks and vulnerability
To help design community integration programs for ppl with brain injury
Relationships
- Imp to foster both existing and new relationships
- Imp of relationships and social support as they return to the comm
Sense of belonging in the community and being able to return to meaning community activities
Feeling valued by others and having a personal sense of belonging with yo
- Often feel like they can’t offer as much to their family as they could
- Finding ways they can contribute
Need to engage in meaningful activity and choose how time was spent - Independence
Individuals wanted to do ordinary things at home Feel at home and comfortable in their home env
Resuming previous roles and having confidence to take one new roles What role imp before, what is imp going forward
-Thinking of big picture - goals and dreams
Acknowledging that there are additional risks
What are some safeguards we can put in place to reduce these risks
Components for a community Integration program for a person with Brain Injury
Assessment of Community Integration Programme Attributes (ACIPA)
-Person centred approaches and planning
-Relationships
-Working together
-Development of skill
-Service setting and atmosphere
-Support for service users
Service setting and atmosphere
Measure based on framework in the last slide
Evaluate community programs to support community integration for ppl injury
Scoring system:
Person centred approaches and planning
- Program understands needs of users
- Focuses on strengths and abilities rather than limitations - Individualized
Does this service support new and existing relationships?
Does it understand importance of relationships?
How it works with individuals themselves, with family, among teams
How it collabs with other agencies in the community
Do the services provide opportunities for development of skills
If it has links and strong network within the community Is it help in a typical community setting - appropriate
Are staff appropriately trained, able to offer specialty support e.g. couns return to work
Is the program welcoming, accessible, appropriate for users needs Needs more research about higher scores yielding better rehab outcome
Return to Work Programs
-Effective RTW interventions for patients with ABI are a combination of work-directed interventions,
coaching/education and/or skills training
longer they are away from work the harder it is for them to return
Gradual Return to Work
Indicate:
- A start date
- An indication of how to increase hours and days
- limitations and restrictions
- recommended accomodations
What they will need to success in the work env
Be explicit with employers from the start
That it is a proposed plan and that things may not go as expectations and modifications will need to be made along the way
Increased breaks
Built in breaks
More frequent breaks
shorter work days
modified hours, tasks
written list of work tasks
Less distractions if in a busy environment A quieter work area
Reduced workload
Quiet environment
education for other staff members, with permission from client Technology? Like computer screens
communication device
Permission from the client
Who among patients with acquired brain injury return to work after occupational rehabilitation? The rapid return-to-work-cohort study
who has shorter return to work time?
-Men or women??
40% were able to return to work within 2 years Those with mild returned sooner than moderate
RTW tends to be one of the most prominent rehab goals
But there is struggle and fear bc of their limitations
Find balanced approach - working toward RTW within overwhelming them Maslow hierarchy of needs
- Needs to focus on things like self care before jumping not work
Managerial roles took longer to get back to their roles
people with one impairment
Women return faster
Mild TBI/Concussion-examples from her clinic
- Practice setting: private practice; services funded through auto-insurance funding system
- Referral sources and referral time post-injury vary greatly
- Initial assessment (ideally in the home environment) takes holistic approach - consider self-care, productivity, and leisure activities - emphasis on understanding pre-accident life vs present status
Common Identified issues by her clients
- Chronic pain -headache and/or pain related to other sustained injuries
- Fatigue Physical, cognitive, psychosocial
- Depressive and anxiety symptoms
- > example of stressors
- ->change in abilities/coping with new limitations
- ->unable to work/financial stress
- ->Concerns related to accident circumstances
- Concerns related to long-term impact of impairments
- Change in family role
Cognitive symptoms - impaired memory and attention, “brain fog”
–>onset of headaches or worsening cognitive symptoms when completing cognitive activities
Sample Goals
#1 Occupation centered goal: Client will be able to complete daily self-care and engage in 4 hours of work each day. Process goal: Client will learn and regularly apply two pain management strategies (i.e., pacing, planning, prioritizing) to address energy conservation and pain management within three months to allow for appropriate balance between self-care, leisure and productivity (work) tasks.
#2 Occupation centered goal: Client will report sleeping for 7 hours 5 out of 7 nights within 3 months. Process goal: Client will learn and apply at least two sleep hygiene and positioning techniques to support improved sleep quality within three months.
Some of my Go To Approaches
Pacing -use of points system or colour coding system (i.e Parkwood Pacing Points System)
- Goal Setting Use of SMART goals
- Use of FitBIt for activity tracking/goal setting/monitoring heart rate
- Mindfulness/meditation - Use of apps (i.e, Insight Timer)
- Use of Brain Injury Workbook by Trevor Powell (along with functional cognitive activities)
- Worksheets from coping strategies to Promote Occupational Engagement and Recovery
- ->developing daily routines, goal setting, stress coping strategies, self-esteem builders, assertive communication
Interprofessional Approach
• Clients often working with rehabilitation team that can include: o Mental health provider (i.e., psychology, psychotherapy,
psychiatry)
o Physiotherapist / massage therapy (if appropriate)
o Kinesiology or personal trainer
o Family physician, various medical specialists (i.e., neurology)
o Speech-language pathology
o Case manager
o Other specialized treatments – i.e., vision therapy, aquatic therapy
• May need to complete referrals as required – important to understand roles of other professionals with respect to TBI rehabilitation
• Consider available community resources
Examples of Community Resources
Brain Injury Association of Ottawa Valley (BIAOV) http://biaov.org/ • Peer Support Group • Family Support Group • Peer Mentoring Program • Concussion Support Group • Step Up Work Centre Program •ArtisticExpressionsWorkshopProgram
Intrinsic recovery
refers to the remediation of neurological impairments, such as return of movement to a paralyzed limb.
Adaptive recovery
entails regaining the ability to perform meaningful activities, tasks, and roles without full restoration of neurological function, such as using the unaffected hand for dressing or walking with a cane or walker.
minimal IADL skills required to stay at home alone include
the ability to (1) prepare or retrieve a simple meal, (2) use safety precautions and exhibit good judgement, (3) take medication, and (4) get emergency aid,
Example goals:
The patient will gain competence in valued and nec- essary BADL and IADL in order to perform at the highest level of independence possible in the desired postdischarge setting.
● The patient will improve postural control in order to perform daily living tasks requiring balance and changes in body position.
● The patient will gain increased somatosensory percep- tion and/or will employ compensatory strategies in order to perform ADL safely.
● The patient and/or caregiver will demonstrate appro- priate management techniques for the hemiparetic upper extremity to prevent pain and other secondary mechanical or physiological movement restrictions.
● The patient will gain the necessary strength, endur- ance, and control of movement of the involved upper extremity in order to use the involved upper extremity spontaneously during the performance of ADL.
● The patient will gain visual function or will employ compensatory strategies in order to safely resume pre- viously performed ADL.
● The patient will improve motor planning ability in order to relearn old methods or learn new methods of performing ADL.
● The patient and/or caregiver will demonstrate appro- priate strategies for improving or compensating for cognitive deficits during the performance of ADL.
● The patient and/or caregiver will be able to verbalize the reality and impact of emotional reactions to stroke and identify coping strategies or resources to help ad- just to living with a stroke.
● The caregiver will demonstrate appropriate methods and problem-solving strategies for assisting the patient with ADL and with home activities to improve/preserve performance skills.
● The patient will gain competence in tasks and activities necessary to resume valued roles or to assume new meaningful roles in the community
Intervention will vary with
the patient’s stage of recovery, intervention setting, living environment, extent of impairment, and personal goals and preferences
*Safety of the patient, during and after treatment, is a concern during all phases
Hemiplegia, hemiparesis
- Impaired postural adaptation, bilateral integration
- Impaired mobility
- Decreased independence in any or all basic activities of daily living (BADL) and instrumental activities of daily living (IADL)
Hemianopsia, other visual deficits
- Decreased awareness of environment, decreased ability to adapt to environment
- Impaired ability to read, write, navigate during mobility, recognize people and places, drive; can affect all BADL and IADL
Aphasia
- Impaired speech and comprehension of verbal or written language; inability to communicate, read, or comprehend signs or directions
- Decreased social, community involvement; isolation
Dysarthria
Slurred speech, difficulty with oral motor functions such as eating, altered facial expressions
Somatosensory deficits
Increased risk of injury to insensitive areas Impairment of coordinated, dexterous movement
Incontinence
- Loss of independence in toileting
- Increased risk of skin breakdown Decreased social, community involvement
Dysphagia
- At risk for aspiration
- Impaired ability to eat or drink by mouth
Apraxia
Decreased independence in any motor activity (ADL, speech, mobility), decreased ability to learn new tasks or skills
Cognitive deficits
Decreased independence in BADL and IADL, decreased ability to learn new techniques, decreased social interactions
Depression
Decreased motivation, participation in activity; decreased social interaction
The National Institutes of Health Stroke Scale
consciousness, vision, extraocular movements, facial palsy, limb strength, ataxia, sensation, speech, and language
Stroke Impact Scale
- developed to be a more comprehensive measure of outcomes for stroke survivors
- The scale is a self-report interviewer-administered measure with questions pertaining to higher level functions of affected limbs, memory and thinking, mood and emotions, communication skills, home and community mobility, typical daily activities, and participation in meaningful life roles.
IADL Scale
is an observed measure that ranks quality of per- formance of activities such as using a telephone, managing medications, and handling finances.
Assessment of Performance Skills and Client Factors
Postural Adaptation
though: seated and standing and during self-care tasks such as dressing, transfers, and bathing
BUT can also use tests like Berg Balance Test, The functional Reach Test
Poor Trunk Control can impact:
increased risk of falls, contracture and deformity, diminished sitting and standing endurance, decreased visual feedback and swallowing effectiveness secondary to head and neck misalignment, and impaired ability to interact with the environment
A person with hemiplegia typically has decreased motor control, poor bilateral and sensory integration, and impaired automatic postural responses
As a result, the patient must devote increased effort to remaining upright, with decreased ability to focus on purposeful tasks. When engaging in a challenging activity, the hemiplegic patient often resorts to compensatory strategies to help maintain stability, such as using upper extremities for support
Upper extremity function: what to look at
- somatosensory (these types of tests on its own require attention, recognition, and response to many stimuli) –>observe reactions
- ->tests that could be used two point discrimination, and Moberg Pick-up Test
- Mechanical and physiological components
- ->muscle tone, pain
- ->ask if this was pervious or new
- ->Shoulder Subluxation
- Voluntary Movement
- -> reflexive movement
- ->DO proximal stabilize to provide support
- ->can you perform isolated actions
Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) -describe upper extremity motor impairment
- Strength and Endurance
- Methods used to quantify muscle strength after stroke include assessments of motor performance (e.g., Fugl-Meyer), manual muscle testing, dynamometry to measure grip strength, and measurements of active range of motion
- Functional Performance
- One difficulty in measuring function after stroke results from the normal differences in performance ability between dominant and nondominant arms. Eating with utensils, combing hair, and writing, for example, are normally performed by the dominant arm; testing the abil- ity of a hemiparetic nondominant arm to perform these tasks is not relevant or useful to a patient.
- The Functional Test for the Hemiplegic/Paretic Upper Extremity
The Functional Test for the Hemiplegic/Paretic Upper Extremity
- standardized test developed by occupational therapists specifically to evaluate patients’ ability to use the hemiplegic upper extremity for purposeful tasks.
- 17 tasks divided into seven functional levels that range from absence of voluntary movement to selective and coordinated movement
Overall Categories for Assessment of Performance skills
- Postural Adaptation
- Upper extremity function
- Motor Learning ability
Motor learning ability
Visual function
- homonymous hemianopsia
- hemi-neglect or unilateral neglect.
- ->most challenging IADL were driving, shopping, financial management, and meal preparation, all requiring one or more of the performance skills of mobility, reading, or writing
Speech and Language
- Aphasia
- Dysarthria
Motor Planning
- Failure to orient the head or body correctly to a task, –> also hand
- ->difficult initiating
- ->hesitation and preservation
- -> does not follow command unless similar object
Cognition
- decreased safety awareness and difficulty learning new techniques for performing tasks.
- performance-based assessments: focusing on the adaptive abilities of planning, initiation, organization, sequencing, judgment, and problem solving are more predictive of real-world ability
Psychosocial Aspects
- denial, frustration, anger, impatience, irritability, overdependence, apathy, aggression, insensitivity to others, and rigid thinking
- decreased social participation, and eventual isolation
Acute Treatment Stroke:
Early Mobilization and Return to Self-Care
Lowering Risk for Secondary Complications
- Skin care
- ->proper transfers, bed and seating positions, seating selection (appropriate wheelchair), watching for signs
- maintaining soft tissue length
- -> Proper positioning and soft tissue and joint mobilization.
- fall prevention
- ->detecting and removing environmental hazards, scheduled routine toileting, optimizing motor control, recommending appropriate adaptive devices, and teaching safety measures to the patient and family.
- patient And Family education
- ->realistic understanding of the causes and consequences of stroke and the process, goals, and prognosis of rehabilitation
Rehabilitation Phase:
Treatment to improve performance of Occupational Tasks
- ADLs and IADLs
- -> IADL tasks such as homemaking, home management, and community mobility involve greater interaction with the physical and social environment and require higher level problem- solving and social skills than BADL tasks
Treatment to Improve Performance Skills and Client Factors
- Postural adaptation
- Upper extremity function
- Motor learning abilities
Putting on a front-buttoning shirt, for example, besides helping a patient gain independence in the task of dressing, addresses the following component abilities, capacities, and conditions:
- Joint and soft-tissue integrity
- Voluntary movement and function of involved upper extremity
- Somatosensory perception
- Visual-Perceptual skills
- Cognitive skills
-Postural Adaptation intervention:
–>providing feedback, using various postures standing rather than sitting (grading the activity), reaching, bimanual activities so they have to sit or stand unsupported
-Upper extremity function
somatosensory
- safety concerns, impaired grasp and manipulation skills in the affected hand, reduced ability to regain skilled movements necessary for ADL, and impaired spontaneous use of the affected hand, frequently leading to learned nonuse
- The patient is encouraged to use the involved hand in ADL as soon as possible and use different textures (e.g., foam, terry cloth, and Velcro®) on weight-bearing surfaces or on the holding surfaces of commonly used utensils, such as cups, forks, and pens.
Mechanical and Physiological Components of Movement.
-Alternative positioning methods and devices for shoulder support include taping of the shoulder and scapula (Ridgway & Byrne, 1999), wheelchair lapboards
and armrest troughs, use of a table while seated or standing, putting the hand in a pocket or under a belt, and using an over-the-shoulder bag while standing
reaching
-frequent changes of position to prevent contractures and pain and recognize that if a patient is only moving his affected arm during therapy sessions, then therapy alone may not provide sufficient soft-tissue lengthening to maintain full ROM
-self-managed ROM include bilateral activities such as having the patient clasp his or her hands while leaning forward to reach for the floor or pushing both hands forward with arms supported on a towel on a table
Voluntary Movement and Function:
-Treatment should progress from unilateral activities, in which the patient can concentrate fully on control of the hemiparetic arm, to bilateral simultaneous activities, in which both arms perform the same movement together (such as lifting and carrying a box and catching and throwing a large ball), to bilateral alternating activities, in which the two arms perform different movements at the same time (such as sorting and assembling nuts and bolts)
Task-Specific and Task oriented Intervention
–>target a meaningful occupation
Constraint-Induced Movement Therapy
Emerging Techniques and Technologies.
Motor Learning ability
Visual Dysfunction
- (1) establish or restore the person’s performance skills or (2) modify the context of the activity and/ or environment
- visual scanning ability using functional activities to increase the speed and accuracy of visual search to the area of the VFD or by training in the compensatory skill of turning the head to the left
- simplifying activity demands, such as locating all items needed for grooming in one drawer; simplifying task sequence, such as installing a speed dial feature on a phone; or altering the built environment to eliminate clutter and obstacles
Speech and Language Disorders
- promote proper posture to aid respiration and eye contact important to speech.
- (counting repetitions of an activity or naming objects used) or addressing functional reading and writing tasks (reading signs and recipes or writing checks).
Motor Planning Deficits.
Cognitive Deficits
- retraining of specific component skills, teaching compensation techniques or substitution of intact abilities, and adaptation of the environment
- prompts or cues to shape desired behavior; providing feedback on performance with suggestions and strategies for improvement; providing visual aids, such as memory logs, checklists, maps, or diagrams for deficits of memory, sequencing, or organization; and simplifying the environment and grading tasks for patients with attention deficits.
Psychological adjustments
-reinforce the efforts of the rehabilitation team and encourage patients and families to talk about their reactions to stroke and their comprehension of its progression and prognosis.
-recognize the signs and symptoms of depression and inform appropriate team members if treatment has not been initiated
develop coping strategies, including problem-solving strategies, social support, information seeking, and engagement in activities, helps decrease the impact of psychological distress
Tips to help with aphasia:
-Avoid unnecessary noise:
-Do not speak to the patient or request speech when he or she is engaged in a physical activity
-Allow enough time for the patient to respond;
-Never assume that the person with aphasia cannot understand what is being said;
-Speak slowly and clearly using simple, concise language;
Use demonstration, visual cues, and gestures as needed to help with comprehension.
Transition to the community:
Discharge planning
- discharge setting; training the patient, family, and caregiver in essential skills; and arranging for continuity of care with community services
Patient, Family and Caregiver Education
- techniques and problem-solving strategies for use after rehabilitation
- demonstration, experiential sessions, and written instructions
Resuming valued roles
- work: appropriate work-readiness training should be encouraged
- interventions to address return to work must focus on the individual (e.g., adjustment to disability), work (physical and psychological demands of a client’s job), and community (e.g., access to transportation)—emphasizing the person-environment-occupation fit rather than impairments after stroke.
- Leisure: many report decreased energy, motivation, or time for leisure pursuits because of fatigue, depression, and/or the increased demands of self-care
- may give up golf rather than play at a reduced level of performance
-Sexuality: reassure their clients that these problems are common and that sexual activity after stroke is not contraindicated
- Driving
- -> (1) a pre-driving evaluation battery to test for visual scanning, visual attention, higher level visual-cognitive skills, distractibility, mental slowness, problem solving, and ability to follow directions; (2) a driving simulator evaluation; and (3) a road test, both on a protected course and in traffic
- Community support and resources
- ->facilities maintain current inventories of community resources, provide this information to stroke survivors and their caregivers, and offer assistance in obtaining needed services
-Post-discharge continuity of Care
Rancho Los Amigos Levels of Cognitive Functioning Scale.
It helps clinicians to communicate about a patient’s level of cognitive function among themselves and with families and to develop appropriate rehabilitation strategies
Behavior-Based Assessment Instruments.
Agitated behavior Scale:
–> Measure of agitation that can be used to measure changes in agitation level over time (Center for Outcome Measurement in Brain Injury [COMBI], 2011). Consists of 14 items. Total score reflects overall agitation, with subscales specific to disinhibition, aggression, and lability.
Disability Rating Scale
–> Provides quantitative information on recovery from severe traumatic brain injury (TBI) from coma to community (COMBI, 2011). Consists of eight items in four categories: arousal and awareness; cognitive ability to handle self- care functions; physical dependence on others; and psychosocial adaptability for work, housework, or school.
JFK Coma Recovery Scale-Revised
–>Detects subtle changes in neurobehavioral status to differentiate between vegetative and minimally conscious states and identifies emergence from minimally conscious state (COMBI, 2011). Twenty-three items in six areas: auditory, visual, motor, oromotor-verbal, communication, and arousal. Specific stimuli are administered to elicit specific responses with responses criterion referenced.
Western NeuroSensory Stimulation Profile (Ansell & Keenan, 1989)
–>Assesses cognitive function in severely impaired adults (Rancho levels II–IV) and monitors change in noncomatose patients who are slow to recover. Battery consists of 32 items related to arousal, attention, response to stimuli, and expressive communication and results in a profile of six subscales that summarize individual patterns of responses.
Single-Subject Experimental Methodology (severe)
brain injury was able to follow a verbal command to squeeze her hand. The protocol began with the therapist performing passive range of motion (PROM) to the patient’s right hand, placing the patient’s hand in hers, and then waiting 1 minute. There were three conditions: (1) correct command (“Squeeze my hand”), (2) incorrect command (“Tie your shoes”), and (3) observation period (equal duration, but no command given).
Interventions (Severe)
- include both preventative and restorative strategies
- minimize or avoid pulmonary and urinary tract infections; skin breakdowns; and muscle, tendon, and soft-tissue contractures
- fostering alertness and goal-directed behavioral responsiveness and may include pharmacotherapy with centrally activating medications, thalamic deep brain stimulation, and sensory stimulation procedures
- Positioning
- Side-lying or semiprone in bed, if permitted, with good body alignment is preferable to supine if the patient has abnormal posture
- small pillow, should be in neutral alignment with the trunk; the bottom upper extremity should be in moderate scapular protraction and humeral external rotation; the top upper extremity should be in scapular protraction, slight shoulder flexion, and resting on a pillow to avoid horizontal adduction; the bottom elbow should be flexed; the top elbow should be extended; wrists should be in extension; and cones should be placed in the hands to decrease spasticity and maintain thumb web spaces.
- Passive Range of Motion
- Splinting and Casting
- Sensory Stimulation
- ->promote arousal from coma, appropriate patterns of movement, and interaction with the environment
- ->response to tactile, vestibular, olfactory, kinesthetic, proprioceptive, auditory, and visual stimuli
- Management of agitation (see below)
- Family Support and Education
Safety Precautions for Treating Patients with Disorders of Consciousness
for pupil changes; decreased neurological responses; abnormal brainstem reflexes; flaccidity; behavioral changes; vomiting; and changes in pulse rate, blood pressure, and respiration rate. Fluids may be restricted, or the patient’s head may be positioned in neutral at 30° of elevation in an attempt to regulate ICP.
Management of agitation (severe)
Determine what factors are contributing to the problem. Clinicians examine the following variables:
- Client: Extent and location of brain damage; state of bodily dysfunction, including pain; and pre-morbid factors such as intellect, personality traits, and coping style
- Social: Persons present during maladaptive behavior; reinforcers
- Physical Environment:
The primary aim of behavior management at this phase is to avoid inadvertent reinforcement of undesirable behaviors while ensuring the continuation of medically necessary treatment and doing as little as possible to impede the natural course of recovery
Managing Agitation: Rancho Level IV:
Strategies to Normalize the Environment
- Ask family members to bring in familiar objects
-quiet environment with minimal distracters
-Provide orientation information and maintain a predictable daily structure and routine.
Introduce yourself at each session, telling the patient where he or she is and what you are going to do
Managing Agitation: Rancho Level IV:
Physical Management
- maximize freedom of move- ment along with safety. Mittens without separations for the thumb may keep patients from pulling out tubes
- Engage the patient in gross motor activities such as face washing, catching a ball, hitting a balloon, and putting on simple clothing, if he or she is able. Physical activity, walking, or even being wheeled in the wheelchair may help decrease agitation
- Be prepared to change activity or take a break at the first sign that the patient is becoming restless or agitated.
- Exude calm, confidence, and acceptance.
Inpatient acute Rehab
Assessment
- screening vision, visual perception, and cognition
- Clinicians must determine the extent to which patients can scan, attend, follow, and retain instructions to interpret performance on other traditional assessments, including upper extremity strength and function and activities of daily living (ADL)
Inpatient acute Rehab Treatment
Optimizing Motor Function.
- optimizing motor, visual-perceptual, and cognitive functions; restoring competence in fundamental self-maintenance task
- 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
Optimizing Visual and Visual-Perceptual Function.
-identify possible visual impairments as early as possible
Optimizing Cognitive Function
- Card or board games, puzzles, and paper-and-pencil tasks such as word recognition or letter or number cancellation drills, and computer programs
- Occupational therapists also strategically place familiar pictures and objects, calendars, and clocks in the patient’s room to optimize orientation.
Restoring Competence in Self Maintenance Tasks.
- Bathing, dressing, hygiene, and eating.
- Graded activities
Contributing to Behavioral and Emotional Adaptation.
-avoid placing patients in situations that are fraught with frustration and failure and instead structure experiences that reinforce patients’ confidence that they still have the potential to accomplish things
Supporting patient family
1) the full spectrum of possible TBI outcomes to enhance realistic expectations;
(2) the effects of TBI on family systems and possible alterations in family dynamics post discharge;
(3) the benefits, challenges, and responsibilities of care- taking and supervision post discharge; and
(4) resources available for postacute rehabilitation
Mayo-Portland Adaptability Inventory
Designed for interdisciplinary postacute rehabilitation; covers broad range of observable attributes, such as physical function, cognitive capacity, emotional status, social behavior, self-care, work, and driving (Center for Outcome Measurement in Brain Injury [COMBI], 2011). Patient’s status on 30 items is rated on a four- category scale: no impairment, impairment on clinical examination but does not interfere with everyday function, impairment does interfere with everyday function, or complete or nearly complete loss of function.
Moss Attention Rating Scale
Twenty-two–item observational scale of attention-related behavior following TBI (COMBI, 2011). Items, which include behaviors indicative of good as well as impaired attention, are rated on a 5-point Likert-type scale.
Neurobehavioral Rating Scale
Twenty-seven–item clinical rating scale measures common cognitive, behavioral, and emotional disturbances associated with TBI; used to track neurobehavioral recovery and measure behavioral change in response to intervention.
Patient Competency Rating Scale
Thirty-item self-report measure to evaluate self-awareness following TBI (COMBI, 2011). The patient’s responses are compared to the ratings of a relative or therapist to identify discrepancies indicating overestimation of abilities. Domains include activities of daily living, behavioral and emotional function, cognitive abilities, and physical function.
Participation Objective, Participation Subjective
Twenty-six–item measure of participation in five categories:
(1) domestic life;
(2) major life activities;
(3) transportation;
(4) interpersonal interactions and relationships; and
(5) community, recreational, and civic life (COMBI, 2011). For each item, the person is asked about level of participation (objective), satisfaction with that level of participation (subjective), and how important that particular activity is to satisfaction with life (subjective). Objective and subjective responses contribute to total score.
Occupational Therapy Assessment: Post-acute Rehabilitation.
-COPM
Treatment: Postacute Rehabilitation.
Optimizing Cognitive Function (usually in Rancho level VII or VIII)
- impairments in short- and long-term memory, reasoning, conceptualization, comprehension, abstract thinking, information-processing speed, organization of information, simplification of problems, judgment, and problem solving
- environment to optimize occupational functioning
- compensatory cognitive strategies, such as paper or electronic calendars/organizers, cueing devices, smart phones, and problem-solving schemata, in the context of personally relevant real-world tasks
Optimizing Visual and Visual-Perceptual Function
-ENVIRONMENTAL CHANGES: changes in lighting for reading and writing, oculomotor exercises, and strategy training,
Restoring Competence in Self-maintenance Roles
-homemaking tasks, such as cleaning, meal preparation, and laundry, occupational therapy addresses community reentry skills (IADLS)
Restoring Competence in Leisure and Social Participation.
-Social skills retaining: instruction and modeling of the social skill, practicing the skill with feedback, and shaping the skill until it is used correctly
Restoring Competence in Work.
-prevocational programs that focus on work behaviors and habits, such as punctuality, thoroughness, response to feedback, and ability to take and use notes.
Supporting the Client’s Family.
(1) the protracted nature of TBI recovery,
(2) the experience of recovery from the patient’s perspective,
(3) adjustment to and possible management of behavioral and personality changes
(4) sexuality issues,
(5) community resources, and
(6) home adaptation.
Survivorship
- Recommend that a life care plan be prepared for survivors of moderate to severe TBI
- Promote to possible referral sources what you are able to do to enhance community integration and quality of life for persons with TBI.
- Establish the kind of therapeutic relationship with clients and family members that will make them want to return to you for help
- Make sure that the discharge from outpatient occupational therapy incorporates plans for follow-up and clear information regarding possible circumstances in the future when further occupational therapy services may be helpful.
