Traumatic Brain Injury

Focal Brain Injury

Focal brain injury is caused by a direct blow to the head after collision with an external object or fall, a penetrating injury resulting from a weapon, and collision of the brain with the inner tables of the skull. The bones of the face or skull may or may not be fractured. Common findings in individuals with focal injury resulting from falls include intracerebral and brain surface contusions, particularly in the inferior and dorsal-lateral frontal lobes, anterior and medial temporal lobes, and less commonly, the inferior cerebellum. Assaults and missile wounds can occur anywhere in the brain depending on the direction of force. Other surface areas of the brain, including those not directly below the blow to the head, can also suffer contusions as a result of collision of the brain with the inner tables of the skull. The directly injured area is referred as the coup, and the site of the indirect injury is known as the contrecoup.^29,30

If there are injuries to the coverings of the brain, especially the dura, pia, and arachnoid, other focal hemorrhages occur. Epidural hematomas (EDHs) are associated with skull fractures in adults with disruption of the integrity of the meningeal arteries; children may have arterial disruption with or without a skull fracture. Individuals with an EDH may initially be alert after the blow to the skull; as the hematoma develops between the skull and the dura, it can cause pressure on underlying brain tissue (secondary injury) with rapid deterioration in mental and physical status. Prompt recognition and neurosurgical treatment can save lives and limit morbidity.³⁶

Subdural hematomas (SDHs) occur between the dura and the brain surface through tearing of bridging veins. The rate of hemorrhage is often slower than that of an EDH because venous bleeding is more gradual than arterial. An SDH may occur just as frequently on the side of the head opposite the direct blow; therefore, an EDH can occur on one side of the brain adjacent to the trauma and an SDH on the other. SDHs tend to spread around the entire surface of one hemisphere or less commonly in the posterior fossa. Acute SDH is diagnosed within 48 hours of injury, subacute SDH within 2 to 14 days after injury, and chronic SDH after 2 weeks. The fall or blow to the head in individuals with subacute or chronic SDH may have occurred days before the person arrives at the hospital, with symptoms being typical of changes in mental status. The urgency of treating SDH depends on the clinical condition of the individual and the extent of adjacent brain tissue affected as observed on radiology.⁶⁷

Multifocal and Diffuse Brain Injury

With multifocal and diffuse brain injuries, there may be sudden deceleration of the body and head with variable forces transmitted to the surface and deeper portions of the brain. Motor vehicle, bicycle, and skateboard crashes are typical etiologic factors, but falls from a high surface or off a horse or bull can also result in multifocal and diffuse injuries.

Intracerebral hemorrhage (ICH) is nearly always present as a focal injury with missile wounds and is common after falls and assaults. Within the first week after TBI, particularly in clients with blood-clotting abnormalities, ICH may appear on follow-up computed tomography (CT) scans. With high-speed deceleration injury, multiple small, deep ICHs occur throughout the neuraxis; on high-resolution CT or magnetic resonance imaging (MRI), they are typically visible at the junction between gray and white matter and in the basal ganglia, corpus callosum, midbrain, and/or cerebellum.

Subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH) occur when the pia or arachnoid is torn. SAH caused by trauma is less frequently associated with vasospasms than is SAH caused by rupture of an aneurysm. A large IVH can block the flow of cerebrospinal fluid (CSF) and result in acute hydrocephalus. Thus, clinical evaluation of the possibility of a ruptured aneurysm causing brain dysfunction, which may result from a fall or motor vehicle crash, is important with either of these entities.

Diffuse axonal injuries (DAIs) are prototypic lesions caused by rapid deceleration. The degree of injury may vary from primary axonotomy, with complete disruption of the nerve, to axonal dysfunction, wherein the structural integrity of the nerve remains intact but there is loss of ability to transmit normally along neuronal pathways. The clinical severity of DAI is measured by the depth and length of coma (i.e., the time from onset of the injury until the individual performs purposeful activity) and associated signs such as pupillary abnormalities.⁴⁷

Prevention of Secondary Brain Injuries

The brain, like any body tissue, reacts to injury with swelling or edema, neurochemical injury cascades, changes in blood flow, and inflammation. Unlike other tissues, the brain is confined in a closed container, the skull, which protects it from outside injury but also confines the amount of swelling or blood accumulation that can occur. The brain is also the organ least able to tolerate loss of blood flow or oxygen. Secondary injury occurs as a result of the effects of brain swelling in a closed space, loss of perfusion, and decreased delivery of oxygen to healthy and damaged tissue. Recovery is related to the extent of the initial pathology and secondary injury.²⁵

Guidelines for the management of severe TBI to minimize the impact of secondary injury have been developed over the last 10 years by the American Association of Neurological Surgeons (AANS) and the Brain Trauma Foundation. Some of these areas include resuscitation of blood pressure and oxygenation, management of elevated intracranial pressure (ICP) or hypertension, nutrition after acute trauma, and seizure prophylaxis. These care recommendations are based on a critical review of the available literature on the management of individuals with TBI and are categorized into the following groups: standards, which represent a high degree of clinical certainty; guidelines, which represent a moderate degree of clinical certainty; and options, which represent a low degree of clinical certainty.¹¹ Each of these terms—standards, guidelines, and options—are used as labels for forms of intervention in individuals who have sustained a TBI.

Areas of intervention that are considered standards are relatively few and relate to interventions that may be more harmful than helpful. They include the following:

Guidelines, which have a moderate degree of certainty regarding efficacy, include the following for individuals with severe TBI: (1) all regions should have an organized trauma care system; (2) hypotension (systolic blood pressure <90 mm Hg) or hypoxia (apnea, cyanosis, oxygen saturation <90% in the field, or a Pao₂ of 60 mm Hg) must be monitored and corrected immediately; (3) ICP monitoring is appropriate for injuries in individuals younger than 40 years with a systolic blood pressure lower than 90 mm Hg, with Glasgow Coma Scale (GCS) scores between 3 and 8, or when CT scans show hematomas, contusions, edema, or compressed basal cisterns; (4) intervention should be initiated to lower ICP if it exceeds 20 to 25 mm Hg; (5) effective ICP treatments include mannitol, high-dose barbiturate therapy, ventriculostomy for drainage of CSF, and craniectomy (i.e., removal of portions of the skull to allow external brain swelling [bone flap]); and (6) enteral or parenteral nutritional support at 140% of the basal rate in nonparalyzed and 100% in paralyzed individuals, with 15% of calories provided as protein within 7 days of TBI.

PTSs are classified as immediate when they occur during the first 24 hours after injury, early when they occur during the first 7 days, and late after the first 7 days. Prophylactic treatment with phenytoin or carbamazepine during the first week after TBI is an intervention option recognized by both the AANS and the American Academy of Physical Medicine and Rehabilitation. Both organizations recognize that the efficacy of prophylactic treatment diminishes greatly after the first week and thus recommend discontinuation of anticonvulsant medication as standard treatment after the first week.^10,11 If late PTSs develop, treatment is warranted because the reoccurrence rate is greater than 80%.³³ All patients and caregivers should learn recognition of and first aid for seizures, as well as risk modification. Avoidance of alcohol, street drugs, and prescribed medications that lower the seizure threshold is important for clients recovering from TBI. The groups at highest risk are those with penetration of metal and bone into the brain substance, biparietal contusions, multiple intracranial operations, and any injury that causes more than a 5-mm lateral shift on CT.²⁰

Implementation of the aforementioned standards and guidelines more typically takes place in designated trauma centers, where physicians, nurses, and allied health providers are accustomed to treating large numbers of individuals with TBI. Studies in both academic and community hospital settings have shown that morbidity and mortality can be reduced appreciably by following the AANS guidelines.⁵⁹

After survival from the initial injury, ongoing optimal medical and health management can facilitate an individual’s recovery and ability to participate in his or her own rehabilitation. Early detection and prompt management of sleep and mood disorders, pain, hydrocephalus, heterotopic ossification, and endocrinopathies, which are all common sequelae of TBI, must be addressed. Medical therapeutic interventions should be based on behavioral, cognitive, and functional performance factors that are observable and measurable by members of a rehabilitation team.

Physical Status

An individual with TBI may exhibit a variety of symptoms, depending on the type, severity, and location of the injury. Individuals may have limitations in most of the areas listed in the following sections, or they may have subtle deficits evident only during more complex activities. Table 34-3 shows some of the most common clinically diagnosed physical signs and symptoms of a client who has suffered a TBI.

Cognitive Status

Cognitive deficits are always evident to varying degrees and can affect many aspects of the individual’s quality of life, as mentioned in previous sections. The most common include decreased attention and concentration, impaired memory, impaired initiation and termination of activities, decreased safety awareness and poor judgment, impulsivity, and difficulty with executive functions and abstract thinking (e.g., problem solving, planning, integration of new learning, and generalization).

Visual Status

Visual skills involve the ability to accurately see stimuli from the external environment (see Chapter 24). Visual skills do not involve the identification of objects, which is a function of perception. Among the many deficits in visual skills that may result from TBI are accommodative dysfunction (causing blurred vision), convergence insufficiency (the inability to maintain a single vision while fixating on an object), lateral or medial strabismus, nystagmus, hemianopia, and impairment of scanning and pursuits. Saccades (fast, jerky movements of the eyes as they change from one position of gaze to another, as needed to read a book) may also be compromised by TBI. Reduced blink rate, ptosis (drooping of the eyelid), and lagophthalmos (incomplete eyelid closure) are also common visual deficits resulting from damage to the oculomotor nerve.⁷

Dysfunction in any of these visual elements can profoundly affect daily life function. Individuals rely on vision indirectly in social and interpersonal interactions. Vision is used as a cueing and feedback system for motor skills such as ambulation and for eye-hand coordination activities. Deficits in vision can affect all daily life activities, including the areas of hygiene and grooming, meal preparation and eating, wheelchair mobility, reading and writing, and driving.

Perceptual Skills

Perception is the ability to interpret stimuli from the external environment (see Chapter 25). Perception is a function of the secondary cortical areas of the right hemisphere, including the secondary visual area, the secondary somatosensory area, the secondary auditory area, and the multimodal parietal-occipital-temporal area. Perceptual deficits are more often a result of right hemisphere damage but may also occur with lesions in the left hemisphere. Perception can be grouped into the following categories: visual perception, body schema perception, motor perception, and speech and language perception. An individual with impairments in visual perceptual may exhibit difficulty in right-left discrimination, figure-ground discrimination, form constancy, position in space, and topographic orientation. Visual perceptual deficits also include visual agnosia, in which the individual displays difficulty recognizing familiar objects and people. For example, prosopagnosia is the inability to connect faces with names. Prosopagnosia results from damage to the multimodal association area.⁷

Body schema perception is awareness of the spatial characteristics of a person’s own body. This awareness is derived from the neural synthesis of tactile, proprioceptive, and pressure sensory associations about the body and its individual parts. A common problem in persons with TBI is anosognosia, a failure to recognize deficits or limitations. This may lead to the body schema perceptual dysfunction of unilateral neglect syndrome, in which the individual has lost the ability to integrate perceptions from one side of the body or environment (usually the left). Unilateral neglect is commonly caused by a lesion in the right parietal lobe but can also occur as a result of frontal and occipital lobe damage. Patients with left unilateral neglect may disown their left extremities and treat them as though they belong to someone else. For example, these individuals may shave only the right side of their face or dress only the right side of their body.⁷

Aphasia is a disturbance in comprehension or formulation of language (or both) caused by dysfunction in specific brain regions, typically the left hemisphere.¹⁹ A few left-handed individuals have language dominance in the right hemisphere. Establishing reliable communication is crucial in treating anyone with aphasia. If auditory comprehension is compromised, gestural demonstration of instructions or activities will be more reliable. Common types of aphasia involving disorders of comprehension include the Wernicke and transcortical sensory types. Affected individuals will have longer periods of PTA because they do not understand orientation questions, and although their spoken language is fluent, it includes verbal paraphasias, or word substitutions. Clients with aphasia may also misinterpret speech and become suspicious and agitated. Insight into their communication deficit may be limited.

The nonfluent aphasias (Broca’s aphasia and transcortical motor aphasia) are characterized by relatively preserved comprehension but effortful or explosive speech with phonemic paraphasias (e.g., “bork” for “fork”). Conduction aphasia (i.e., intact comprehension, fluent speech, impaired repetition) and anomic aphasia are characterized by circumlocution and frequently paraphasias. Individuals with these types of aphasia are typically aware of their problems and are often frustrated by their limitations. They should be encouraged to use gestures to express their immediate desires and needs.

Dyslexia (disturbance in reading), agraphia (disorder of writing), and dyscalculia (disturbance in calculation) frequently accompany the aphasias. However, with traumatic aphasias, these capabilities may be better preserved than with stroke; treating therapists should always attempt alternative modes of communication.

Dysprosody or aprosody is impaired production or comprehension of the tonal inflections or emotional tone of speech. Executive dysprosody is an inability to inflect one’s voice to convey emotion. It can occur with cerebellar, basal ganglia, or right frontal lobe injury. Receptive dysprosody is an inability to perceive the emotional content of other people’s spoken language. It occurs with right temporal or parietal injury and less often with left hemisphere injury. Individuals with this disorder may miss the point of a joke or story because they cannot comprehend the subtle innuendoes and implicit meanings conveyed through tonal qualities and inflections.⁷⁵ Even more disabling is the inability to interpret anger, humor, or sarcasm during communication with others.¹⁸ Perceptual-motor dysfunction is impairment in motor planning, or an apraxia. It is a disorder of learned movement that cannot be explained by weakness, lack of sensation, inattention, or comprehension of the requested task.¹⁸ The apraxias are usually a result of impairment of the premotor cortex, corpus callosum, or connections between the temporal/parietal lobes and frontal motor cortex.³⁷ It is in these cortical areas that established motor patterns for specific activities are stored and accessed for the execution of common movement patterns. Ideational apraxia is an inability to understand the demands of a task or use of the wrong motor plan for a specific task. For example, individuals suffering from ideational apraxia may not understand that a shirt is an item of clothing to be placed on the torso and UEs. Not understanding the demands of the task, they may be unable to activate the motor plan for UE dressing or may activate the wrong plan and attempt to place their legs through the sleeve holes. This deficit is sometimes referred to as a dressing apraxia. Ideomotor apraxia is loss of the kinetic memory of a movement pattern for a specific activity. Individuals with this disorder may understand that a shirt is an item of clothing to be placed on the torso and UEs but be unable to execute the appropriate movement plan because it is no longer accessible. Constructional apraxia is an inability to accurately assemble pieces of an object to form a three-dimensional whole. For example, a former carpenter who suffers from constructional apraxia may be unable to put together the wooden pieces of a basic birdhouse kit.

Psychosocial Factors

Researchers have found that the greatest concerns of clients 1 or more years after TBI are the psychosocial deficits that prevent them from rebuilding a satisfactory quality of life. As the time after injury increases, clients and family members view such psychosocial factors as being more detrimental than both the physical and cognitive sequelae of TBI.

For example, in Marisol’s case, it was initially difficult to assess her psychosocial status because she was nonvocal. The team was able to assess her mood on the basis of her level of participation and affect during therapy. Marisol would laugh appropriately and become visibly more interactive, with brighter affect, when her boyfriend arrived to visit.

Marisol continued to engage in positive interactions throughout her 4-month inpatient and day treatment stay. Her discharge plan involved moving to Georgia with her mother. When the move was discussed with Marisol, it was evident that she was quite saddened by the knowledge that she would no longer be able to see her boyfriend. The team observed her closely to assess whether her sadness would eventually culminate in depressive symptoms.

Behavioral Status

Behavioral impairments are a natural part of the recovery process. The Rancho Los Amigos cognitive level IV is typically described by the rehabilitation team as the “agitated, confused” level.⁶³ During this stage of recovery, affected individuals can be described as restless and combative. They may be responding to internal body experiences, or some external environmental stimuli may be provoking the agitation. Commonly observed behavior includes yelling, swearing, grabbing, and biting. Behavioral problems can be disturbing to both the individual’s family and the intervention team; therefore, behavioral management is an essential component in TBI rehabilitation.

A comprehensive behavior management program should be established for anyone who exhibits behavior that interferes with active participation in therapy and achievement of goals. The goals and objectives of a comprehensive program include maintaining a safe environment for individuals and staff at all times, developing and consistently implementing behavior management techniques, minimizing the use of all restrictive modalities, and providing an environment that facilitates participation and appropriate behavior in the hospital setting and after discharge.⁶⁵

Interventions used in an effective behavior management program include one-on-one coaching, intervention with psychotropic medications, and individually designed behavior management guidelines and interventions. One-on-one coaching, usually performed by a trained nursing assistant or rehabilitation technician, is especially necessary for clients who are at risk of harming themselves or others. In many cases, implementation of a behavior management program is necessary 24 hours a day, 7 days a week. A coach will help reinforce the client’s behavior plan and redirect inappropriate or maladaptive behavior. Medications are required to regulate sleep and minimize agitation and combative behavior until clients can control the behavior on their own. Because pain may often provoke agitation, assessing patients’ level of pain and providing appropriate medication may resolve the restlessness, agitation, and/or inability to sleep. Medications must be chosen carefully to prevent side effects such as clouding of awareness and psychomotor slowing. Clients should have specific behavioral end points, such as establishing adequate sleep at night, facilitating attention during functional activities, and decreasing the frequency of verbal or physical outbursts.

Environmental modifications are a proactive approach to prevent and minimize undesirable behavior. Such modifications may include use of a cubicle or net bed, an alarm system, a helmet, and walkie-talkies. A drug and alcohol policy is frequently necessary; it is well documented that many individuals with TBI have pre-existing alcohol or drug problems (or both).⁶⁶

The first step in becoming more comfortable when working with clients who have behavior problems is to understand why they occur and how they manifest themselves.

Clients who are exhibiting agitation, combativeness, disinhibition, and refusal to cooperate and participate in activities typically have difficulty filtering distractions and can become agitated in noisy environments. Providing a quiet room during interventions and use of a cubicle bed may help minimize noise and reduce outbursts.

A disinhibited individual may lack awareness of the external environment and may make indiscriminate sexual remarks or gestures to others. Ignoring comments, redirecting inappropriate behavior, and modeling acceptable behavior are typical therapeutic interventions.

Clients who refuse to cooperate and participate in intervention can be the most challenging because this attitude may affect their ability to remain in an acute rehabilitation program. The lack of participation is typically organically based and due to cognitive deficits such as impaired initiation and lack of insight into their disability. It is important to document such behavior throughout the course of care; however, when clients refuse to participate, documenting progress can be challenging.

Interventions include providing consistent structure through daily schedules and goal sheets that provide visual cues for expectations, as well as visual and physical guidance through activities until clients are capable of completing tasks without assistance.

1. Level of arousal and cognition—Can the client visually attend to the speaker and follow commands such as “open your mouth” and “squeeze your eyes closed”? Can he or she communicate through verbalizations, gestures, or eye movements? Does he or she demonstrate purposeful movements such as pulling at vital tubes? How easy/difficult is it to wake the client, and how long can the client stay awake?

2. Vision—Is the client able to visually scan or attend to a person, object, or activity? Can the client maintain eye contact?

3. Sensation—Does the client respond to external stimulation such as pain, temperature, and movement of the joints?

4. Joint ROM—Has the client lost ROM in certain joints as a result of decorticate or decerebrate posturing, increased tone or spasticity, contractures, or heterotopic ossification?

5. Motor control—Does the client exhibit decorticate or decerebrate posturing? Is there an increase in tone and spasticity? Is there decreased tone and hypotonicity? Are deep tendon responses present, diminished, or absent? Does the client exhibit the presence of primitive reflexes? Does the client engage in spontaneous motor movements, such as scratching the face?

6. Dysphagia—Does the client handle his or her own secretions, drool, or swallow spontaneously? Does the client demonstrate poor oral-motor control? Answers to these questions provide valuable information on whether a swallowing evaluation is indicated.

7. Emotional and behavioral factors—Is the client’s affect flat or expressive? Are responses such as crying or laughing observed in response to interactions with the rehabilitation team or family members?

Sensory Stimulation

Intervention for clients emerging from coma should start as soon as they are medically stable. Intervention generally begins in the intensive care unit. At this stage, clients frequently lack responsiveness to pain, touch, sound, or sight. They may exhibit a generalized response to pain that appears reflexive (e.g., attempting to pull away from painful stimuli). The goal of intervention is to increase the client’s level of awareness by trying to increase arousal with controlled sensory input. Sensory regulation increases neurologic signals to the reticular activation system, the structure of the brainstem that alerts the brain to important sensory input from the external environment.

Sensory stimulation can be introduced in a variety of ways and methods. Introducing isolated visual, auditory, tactile, olfactory, and gustatory stimulants to the individual may heighten arousal. For example, a flashlight may be used to elicit eye opening and visual tracking. Playing familiar music may facilitate autonomic responses, such as a change in the respiratory rate or changes in blood pressure. Introducing olfactory stimulation through a variety of scents may elicit eye opening or head turning. Gustatory stimulation involves the controlled presentation of taste to the client’s lips and tongue through use of a cotton swab. Such stimulants may include salty, sweet, bitter, and sour tastes. Any response from the client is noted.

Kinesthetic input is incorporated early in the intervention. One of the most effective ways to facilitate volitional movement is by actively guiding movements in a normalized fashion while performing functional activities. The therapist actively helps the client perform simple movements, such as rolling from side to side, and perform simple functional activities such as wiping the mouth with a washcloth, combing hair, and applying lotion to the skin. The theoretic aim of functional sensory stimulation is to reactivate highly processed neural pathways that had been established before the injury. Other activities related to functional sensory stimulation include sitting the individual up at the edge of the bed and having the client stand by using a tilt table or a hydraulic standing frame. During all these activities, the therapist observes the client for any changes such as visual tracking, turning of the head, physical responses, vocalizations, and ability to follow verbal commands.

Wheelchair Positioning

Seating and positioning are important components of treatment in lower-level patients. Being properly positioned in a wheelchair allows these patients to interact with their immediate environment in an upright, midline posture. Proper positioning aims to facilitate head and trunk control so that clients can see and interact with people and objects in the environment. A proper wheelchair seating position helps prevent skin breakdown and joint contractures, facilitate normal muscle tone, inhibit primitive reflexes, increase sitting tolerance, enhance respiration and swallowing function, and promote function (Figure 34-1).

Effective seating and positioning require a stable base of support at the pelvis, maintenance of the trunk in the midline, and facilitation of the head in an upright, midline position. This position frees the UEs for use and allows the client to visually scan the environment. Once the client has a seating system that encourages and promotes function, therapy sessions can be more effective and beneficial. For example, clients generally find it easier to handle their secretions in this position, so swallowing trials may be safer and more effective.

Marisol required a wheelchair and specific positioning devices when she entered the acute rehabilitation program. Given her motor abilities and deficits, what type of wheelchair set-up would you prescribe?

Bed Positioning

Proper bed positioning is critical in the early stages of TBI. Because the client tends to spend a lot of time in bed, proper bed positioning is crucial to prevent pressure sores, facilitate normal muscle tone, and prevent loss of pelvis and trunk ROM and mobility. It is often difficult to maintain optimal positioning because of spasticity and abnormal posturing. Other complications that may interfere with proper positioning are casts or splints, intravenous tubes, nasogastric tubes, fractures, or any other medical precautions that must be maintained while in bed.

If the client exhibits abnormal tone or posturing, a side-lying or semiprone position is preferable. This position assists in normalizing tone and providing sensory input. A supine position may elicit a tonic labyrinthine reflex and extensor tone. A supine position with the head in a lateral position could elicit an asymmetric tonic neck reflex. Clients with TBI generally have bilateral involvement requiring a program for side-lying on both sides. The traditional bed-positioning techniques used for patients who have suffered a cerebrovascular accident may require modification depending on the extent of bilateral involvement. Pillows, foam wedges, and splints may be incorporated into the bed-positioning program to facilitate normal positions and prevent abnormal postures such as extreme elbow flexion, head and neck extension, and footdrop deformity.

Splinting and Casting

Splinting or casting may be indicated when (1) spasticity interferes with functional movement and independence in ADLs, (2) joint ROM limitations are present, and (3) soft tissue contractures are possible. Splints have been thought to provide elongation and inhibition by positioning the joint in a static position with the muscles and soft tissues on stretch. Splinting of the elbows, wrists, and hands is often implemented to maintain a functional position at rest and to reduce tone. Serial casting is a more aggressive intervention to increase ROM in the joints when contractures have formed or spasticity is present (or both). Splinting and casting not only reduce contractures and increase ROM but also prevent skin breakdown. Because clients with TBI often have limited active ROM, the UE joints often assume a position of flexion (particularly when severe finger flexor spasticity has caused the fingers and nails to embed in the palmar surface of the hand), and this may cause moisture, redness, and breakdown of the skin.

A resting or functional position splint (Figure 34-3) is one that is worn when the client is not involved in active movements or functional tasks. Once the splint has been fitted, a wearing schedule must be established for the rehabilitation team and caregivers to follow. A typical splint schedule during the day requires the client to wear the splint for repeated, alternating 2-hour periods (2 hours on, followed by 2 hours off). The client must be monitored frequently for any skin breakdown or tonal changes that may change the initial fit of the splint. The team and caregivers should be trained in proper application and removal of each splint.

Other common splints worn at this stage of recovery are cone splints, used in the palm of the hand to keep the fingers from digging into the palmar surface. Frequently, rolled cloths are put into the clenched hand; however, because this may facilitate increased spasticity, a hard cone splint is more appropriate. An antispasticity splint (Figure 34-4) not only positions the hand and wrist in a functional position but also abducts the fingers to further decrease spasticity. Splints are modified as needed and may eventually be discontinued if the individual’s motor control and tone improve.

A serial casting program is indicated when moderate to severe spasticity cannot be managed by splints. The goal of casting is to increase ROM and decrease tone gradually by using a progressive succession of separately fabricated casts, each worn continuously for a period of weeks. Casts are often left on for 5 to 7 days, which places the muscle and tendons on prolonged stretch and reduces tone. Successive casts are designed to increase ROM further until a functional joint range is achieved and maintained. A common difficulty that prevents serial casting from being successful is skin breakdown. If skin breakdown occurs because of a cast that is worn for several days, the cast must be removed until the skin has healed. While wound healing is occurring, spasticity again increases and any gain in joint ROM is often lost.

The most common UE casts are the elbow cast, which is used for loss of passive range of motion (PROM) in the elbow flexors, and the wrist-hand cast, which is used for loss of PROM in the wrist and finger flexors. Other variations of these casts include elbow dropout, wrist, thumb, hand, and individual finger casts. However, casting of more than one joint at a time often leads to skin breakdown as a result of multiple pressure points. It is thus recommended that casting be applied to one joint at a time.²⁸

Casting is frequently used in conjunction with motor point, nerve blocks or botulinum toxin injections. Blocks involve the injection of a chemical substance (e.g., lidocaine, bupivacaine, phenol) into the nerve or motor point to inhibit the innervation of spastic muscles temporarily. Botulinum toxin is injected directly into the target muscle and works by causing presynaptic blockade of acetylcholine release.

Indications for termination of a casting program include achieving functional ROM or plateauing (e.g., the individual has not gained significant improvement in ROM after two consecutive casts). When improvement in ROM has been made and the goal has been achieved, the final cast is cut in half lengthwise, the edges are finished, and the cast is used as a bivalve splint to maintain the functional position. Velcro straps or elastic wrap bandages are used to secure them in place (Figure 34-5). A wearing schedule is then established.

Casting is an advanced intervention technique that carries some risk. Competent use of the technique requires knowledge and advanced clinical training. Marisol had increased spasticity and reduced function in her UEs. What splint or cast (or both) would best suit her needs initially?

Dysphagia

Patients emerging from coma are fed through a nasogastric or gastrointestinal tube. Once the patient is alert and more oriented, the physician decides when evaluation for dysphagia is indicated. Dysphagia programs usually begin in the intermediate- to advanced-level stages of rehabilitation (see Chapter 27).

Behavioral and Cognition

As clients emerge from coma and become more alert and aware of their surroundings, it is important to track their improvement and attempt to establish a form of communication. In acute rehabilitation, tracking the level of arousal and awareness is important because it demonstrates progress. Several scales and assessments are available, including the WHIM, JFK, and Orientation Log. These measurement tools will document improvements in visual attention, visual tracking, and ability to follow commands.

Establishing a way for the client to communicate wants and needs is of the utmost importance because it helps guide intervention. It also allows the team to more accurately assess the client’s cognitive level. A reliable yes/no system should typically be implemented. Examples include eye blinks, eye gaze, head nods, and motor movements such as thumb up and down. Once a system is established, communication is possible. In the case of Marisol, she gained some active movement of her right UE and with guiding was able to use large colored buttons to answer yes and no to questions. The yes/no buttons were positioned on the lap tray of her wheelchair and provided a buzz sound when touched. She was effectively able to answer simple questions such as do you need to use the bathroom or are you in pain when asked.

Family and Caregiver Education

Education of family members and caregivers starts immediately because they are an integral part of the intervention team. Family members often play an essential role in eliciting the client’s responses and implementing the sensory regulation program, positioning the client in bed, and contributing to the ROM program. At the earliest stage after the injury, therapy may be limited; therefore, setting up a simple intervention plan for the family to implement is important in fostering the client’s recovery and maintaining passive joint motion. Family members often feel helpless, and allowing them to be actively involved helps alleviate their feelings of helplessness and focus their array of emotions. Later, when the individual is more alert and mobile, family members can be involved in transfers, wheelchair positioning, feeding programs, and ADL retraining. Providing several education materials is helpful for family members. Brain injury patient education booklets and Internet Websites are effective tools in educating patients and family members.

Physical Status

The physical status evaluation includes an assessment of joint ROM, muscular strength, sensation, proprioception, kinesthesia, fine and gross motor control, and total body control (i.e., dynamic sitting or standing balance). Limitations in physical status are usually the result of abnormal tone, spasticity, and muscle weakness without abnormal tone, heterotopic ossification, fractures, soft tissue contractures, and peripheral nerve compression. Tools to assess physical status include goniometers, dynamometers, manual muscle testing, and clinical observation. Standard assessments may include the Jebsen Hand Function Test,⁴⁰ the Minnesota Rate of Manipulation Tests,⁵⁴ the Minnesota Manual Dexterity test,⁵⁴ and the Purdue Pegboard.⁷⁰

Dysphagia

Dysphagia assessment may include both clinical (bedside) evaluation and videofluoroscopy. The bedside examination provides the therapist with a variety of information. For example, aspiration can be caused by impulsivity because the client may gulp large portions of food quickly. Pocketing food and drooling may be apparent and are a result of impaired oral motor control. The dysphagia examination can also provide the therapist with information regarding cognitive status. Does the client appear to understand what to do with the utensils and food items? Is neglect present and causing the client to leave one side of the plate untouched? Does the client know the names of the utensils and food items, or is aphasia suspected?

Performed by a speech pathologist or a trained occupational therapist, videofluoroscopy provides information regarding the anatomy and physiology of the oral, pharyngeal, and esophageal stages of swallowing. Videofluoroscopy is the only dysphagia assessment tool that can provide information on the individual’s ability to manage liquids and solid foods. This information will be used to design a feeding program that may require a diet of thick liquids and puréed foods. Swallowing status should be re-evaluated as the individual improves in rehabilitation and can progress to thin liquids and solid foods. (See Chapter 27 for more information on dysphagia.)

Improper positioning, behavioral disorders, and cognitive-perceptual impairment have all been implicated as factors contributing to swallowing disorders. Dysphagia intervention must address seating and positioning and cognitive-perceptual distortions. Formal assessments to evaluate dysphagia include the Dysphagia Evaluation Protocol 4 and the Evaluation of Oral Function in Feeding.⁶⁹

Cognition

Cognitive skills are assessed within functional tasks (e.g., ADLs, meal preparation, money management, and community skills). Tasks that involve paper and pencil can also provide valuable information, although they are only part of the equation. Assessment of a client’s cognition during preparation of a cold meal may include the following skills: (1) following two- to three-step written or spoken directions, (2) correctly sequencing the order of steps, (3) attending to the task with minimal distraction, and (4) displaying good safety and judgment. The therapist may evaluate the client’s cognitive status by measuring any of the following: (1) counting the number of errors and correct responses, (2) assessing the amount of assistance or cueing required (minimal, moderate, or maximal), and (3) determining the percentage of the task that was completed correctly. Assessment of the complexity of the activity (simple versus multistep or basic to complex) and the conditions of the environment (isolated versus multistimulus or quiet to distracting) is also important.

When assessing an individual’s cognitive skills, the therapist must consider and document other factors that may affect performance. Such factors include language barriers (e.g., the presence of aphasia, a primary language other than English), visual-perceptual deficits, the effects of medication on cognitive level, educational and cultural background, and previous experience with the task. Formal cognitive assessments that may be used with a TBI population include the Allen Cognitive Level Test,² the Loewenstein Occupational Therapy Cognitive Assessment,⁵⁰ the Rivermead Behavioral Memory Test,⁷⁷ Kohlman Evaluation of Living Skills,⁴³ and the Cognitive Assessment of Minnesota.⁶⁴

Vision

Clients with TBI should undergo vision screening. The vision screening should be completed as early as possible in the rehabilitation process because early detection of visual deficits will allow the intervention team to obtain more reliable information regarding the client’s overall health status. For example, diplopia (double vision) or accommodative dysfunction (inability to adjust focus for changes in distance) will probably influence the results of the neuropsychology or speech-language pathology assessments.

Vision screening is a tool that allows therapists to identify potential deficits in vision. Although therapists cannot diagnose conditions of vision dysfunction, they can determine whether an individual passes or fails a visual screening based on standard criteria. The screening is a means of determining which clients require a referral to an optometrist or ophthalmologist for a complete evaluation and intervention. A comprehensive vision intervention program is designed by an optometrist and implemented by an occupational therapist or vision therapist. A visual history questionnaire should be completed as well. The questionnaire should contain an ophthalmologic history, questions regarding the use of glasses and contact lenses, and questions about the presence of blurred vision, dizziness, headaches, eyestrain, diplopia, and visual field loss.

Common areas evaluated in a vision screening include visual attention, near and distant acuity, ocular movement (e.g., pursuits and saccades), convergence, accommodation, ocular alignment, depth perception (stereopsis), and visual field function. Visual dysfunction can also be identified during clinical observation of the individual’s performance in functional activities. Tilting the head as a result of a field deficit, closing or covering one eye to decrease blurred vision, and bumping into walls or objects in the environment because of a field deficit or unilateral neglect are all easily observed behavior indicative of visual dysfunction.

Perceptual Function

Perceptual evaluation should be performed when the therapist has obtained a clear understanding of the individual’s cognitive, sensory, motor, and language status because deficits in these areas may skew the client’s performance on a perceptual evaluation. Evaluation of visual perception should include right-left discrimination, form constancy, position in space, topographic orientation, and naming of objects. Evaluation of perceptual-speech and language function should assess for aphasia, and anomia. Evaluation of perceptual motor function should include the functions of ideational praxis, ideomotor praxis, three-dimensional constructional praxis, and body schema perception (including identification of unilateral neglect). Formal perceptual assessments that can be used for a population of adults with TBI include the Hooper Visual Organization Test,³⁸ Motor-Free Visual Perception Test—Revised,¹⁶ Rivermead Perceptual Assessment Battery,⁷⁶ and Loewenstein Occupational Therapy Cognitive Assessment.⁵⁰

Activities of Daily Living

Intermediate-level clients should be assessed in all basic ADLs (e.g., grooming, oral hygiene, bathing, toileting, dressing, functional mobility, and emergency response). Advanced-level clients should also be assessed with regard to instrumental activities of daily living (IADLs), such as hot and cold meal preparation, money management, community shopping (Figure 34-6), household maintenance, cleaning and clothing care, safety procedures, medication routine, and work readiness. The therapist will have ample opportunity during assessment to observe cognitive skills, perceptual skills, and behavioral appropriateness.³¹ Formal assessments that can be used for a population with TBI to assess ADL skills include the Arnadottir OT-ADL Neurobehavioral Evaluation,⁴ Assessment of Motor and Process Skills,²³ Functional Independence Measure,³⁵ and the Klein-Bell Activities of Daily Living Scale.⁴²

Clients with a history of alcohol abuse require assessment of leisure patterns. An interest history and interest checklist may reveal healthful leisure interests that can replace alcohol use. The combination of leisure skills development and substance abuse rehabilitation will help clients manage time more effectively and thereby refrain from using alcohol after discharge.

Vocational Rehabilitation

Advanced-level clients may be evaluated to determine whether they are ready to return to work. It has been well documented that return to work after moderate to severe TBI is generally unsuccessful. High unemployment rates have been attributed to the adverse emotional, behavioral, and neuropsychologic changes arising from TBI. Substance abuse in the TBI population is also a major factor inhibiting the ability to return to and maintain employment.²⁶

Vocational assessment for advanced-level clients must involve assessment in the actual work setting because psychometric tests and job simulations in themselves do not accurately determine work potential. The client is often able to compensate in a familiar work setting for deficits that may appear to be significant impairments on a psychometric test. The therapist’s vocational evaluation should summarize the individual’s interests, strengths, and areas of deficit. The report should conclude with recommendations stating the modifications required, realistic job goals, and a plan for achieving these goals with professional assistance as needed.

Psychosocial Skills

Advanced-level clients who will be discharged to the home setting or a community-supported living residence should also undergo a psychosocial skill evaluation. Such an evaluation should assess role loss, social conduct, interpersonal skills, self-expression, time management, and self-control. The therapist should also assess the client’s social support system, ability to form and maintain friendships, and resources to decrease feelings of isolation (such as TBI support groups). The ability to form and maintain intimate and sexual relationships after TBI will be of paramount concern to single clients who sustained their TBI between the ages of 18 and 30. Child rearing and care of family members will be of concern for clients who are responsible for children and other family members.

Assessment of psychosocial skills in clients with TBI is critical. For 1 or more years after injury, clients with TBI report that their psychosocial deficits significantly diminish life satisfaction and are a greater problem than the physical and cognitive deficits combined. Psychosocial impairment is often neglected in the rehabilitation setting, which prioritizes intervention for acute physical, cognitive, and perceptual deficits. Psychosocial difficulties are more apparent after discharge, when the individual has left the structured and safe setting of the rehabilitation hospital to re-enter the community. It is important to address psychosocial difficulties before the individual is discharged. Psychosocial assessment tools that can be used for this population include the Assessment of Communication and Interaction Skills,⁶⁵ the Occupational Role History,²⁴ and the Role Checklist.⁵⁶

Marisol received skilled occupational therapy intervention throughout a 3-month inpatient rehabilitation stay, followed by 6 weeks in a day treatment program. Marisol participated in a multifaceted spasticity reduction program and neuromuscular re-education, which improved ROM and functional use of her right UE. As her ROM and selective movement improved, Marisol learned how to feed, dress, and bathe herself with minimal assistance. As Marisol’s head and trunk control improved, she was able to participate in all aspects of bed mobility and transfers. Daily guided self-care tasks were a critical part of her morning schedule. Performing meaningful, routine tasks allowed Marisol to work on her basic cognitive abilities. Spontaneous neurologic recovery, cognitive re-education, and memory strategies improved Marisol’s ability to plan, organize, and sequence her ADLs and recall her daily therapy schedule with occasional verbal cues. Marisol was referred to an outpatient occupational therapy program after discharge from the day treatment program.

Neuromuscular Impairments

As in beginning-level individuals with TBI, numerous types of neuromuscular impairment can be present in intermediate- to advanced-level individuals. Spasticity, rigidity, soft tissue contractures, the presence of primitive reflexes, diminished or lost postural reactions, muscular weakness, and impaired sensation affect the ability to perform activities independently and with normal control (see Table 34-3). The prerequisites for normal movement include normal postural tone, balanced integration of flexor control (reciprocal innervation), normal proximal stability, and the ability to implement selective movement patterns.

The common principles of intervention for neuromuscular impairment are to facilitate control of muscle groups, progressing proximally to distally; encourage symmetric posture; facilitate integration of both sides of the body into activities; encourage bilateral weight bearing; and introduce a normal sensory experience. Effective rehabilitation techniques for such individuals include neurodevelopmental treatment (NDT), proprioceptive neuromuscular facilitation (PNF), myofascial release, Rood techniques, and some physical agent modalities (see Chapters 29 and 31). These clinical interventions require education beyond the entry level and must be either incorporated into or followed by a meaningful functional activity that requires the same movement. The following brief overview of principles is merely an introduction and cannot substitute for training in the specific techniques.

Intervention for impaired neuromuscular control should begin at the pelvis because positioning of the pelvis affects the motor control of all other body parts. A variety of approaches may be used to normalize pelvic positioning. For example, clients with TBI commonly have a posterior pelvic tilt. To move the client to a more functional erect pelvic position, a therapist trained in NDT might use anterior pelvic tilt mobilization. A therapist with a different approach might use a bedsheet behind the pelvis to lift and rotate the pelvis forward over the heads of the femurs. In either case, individuals would be directed to raise their head and sit up tall.

The trunk is positioned after the pelvis. Proper positioning of the trunk frees the UEs for functional activities. Major principles include the following: (1) facilitating trunk alignment, (2) stimulating reciprocal trunk muscle activity, (3) encouraging the individual to shift weight out of a stable posture into all directions (bending forward, bending backward, reaching to each side while laterally flexing the trunk), and (4) helping the individual move the lower part of the trunk on a stable upper trunk or move the upper trunk on a stable lower trunk. Once trunk control improves, intervention should progress to the UEs.

Competent practitioners may apply rehabilitative techniques in a variety of ways. A client with soft tissue contractures or spasticity in a particular muscle group may benefit from NDT mobilization and inhibitory techniques for the agonistic muscle group. A client with low tone or weak muscles (without the presence of spasticity) may benefit from NDT, PNF, Rood, and physical agent modalities. Kinesio-taping can assist in providing stability to weak muscle groups. Neuromuscular electrical stimulation can effectively stimulate UE muscle groups, including the triceps, pronators, supinators, and wrist and finger extensors, to enhance muscle strength, increase sensory awareness, and assist in motor learning and coordination.¹³

Many advanced-level clients have fairly intact motor control and are able to ambulate independently and use both UEs in functional activities. However, close observation reveals subtle trunk and extremity deficits related to coordination and speed of movement. The intervention for trunk control focuses on developing full isolated movements of the trunk and extremities, good dynamic standing balance for all activities (including reaching and bending to high and low surfaces), and the ability to shift weight naturally from one LE to the other during activities. UE intervention programs are designed to increase scapular stability and improve fine motor control. A goal of intervention is to improve the client’s speed while maintaining good coordination and minimizing compensatory strategies (Figure 34-7).

Ataxia

Ataxia is a common motor dysfunction that occurs primarily as a result of damage to the cerebellum or to the neural pathways leading to and from the cerebellum. Ataxia develops early in the acute stage of recovery and may remain permanently. It is a clinical problem for which rehabilitation methods are generally ineffective. More often, therapists train the client in use of compensatory strategies to control the effects of ataxia. For example, weighting of body parts and the use of resistive activities often improve control during the performance of tasks but show inconsistent carryover of muscular control when the resistance is removed. When applying weights to clients, the therapist must identify at which joint (or joints) the tremor originates. Applying weights to clients’ wrists when the tremor emerges from the trunk and shoulders is ineffective. Weighted eating utensils and cups are also used as compensatory aids to reduce the effects of ataxia on the UEs; however, these assistive devices are limited in their effectiveness.

Cognition

Intervention designed to enhance cognitive skills should be implemented through functional ADLs and IADLs. A common impairment in cognition is concrete thinking, in which the individual is likely to have difficulty with abstract concepts. Activities that require generalization of skills from one task to another will be difficult for clients with TBI. It is best to engage these clients in activities that they need to participate in everyday life. For example, if the client will return to a community environment in which it is necessary to use public transportation, interpreting bus schedules is a meaningful and relevant activity that addresses many critical cognitive skills, including problem solving, planning, organization, concentration, tolerance of frustration, sequencing, money management, and categorization. Another way to address the aforementioned cognitive skills is by planning a trip to the hardware store to purchase supplies necessary to install a hand-held showerhead.

Clients at an advanced level of recovery who demonstrate high-level cognitive skills often display subtle cognitive deficits in the areas of organization, planning, sequencing, and short-term memory.

Generally, neuropsychologists and cognitive educators have implemented the use of computers in cognitive retraining. However, use of computer programs has not been shown to generalize to the cognitive skills needed to improve performance in IADLs.⁵⁵ Computers can be used in therapy if they are meaningful in the client’s daily life; the therapist should address the client’s specific computer needs. For example, by simplifying tool bars and menus and programming step-by-step written directions that appear on screen, therapists may reprogram a client’s home computer to make it less complicated to use. Software programs that do not represent functional activities should be avoided. Since 36% of Americans with a disability use a computer at home (U.S. Census, 2008) and 60% of working-age adults are likely to benefit from the use of accessible technology because of disabilities, it is important to introduce computers into treatment as a therapeutic modality. The occupational therapist can not only set up a computer by using the built-in accessibility options and utilities but also provide specialty assistive technology products such as voice recognition, alternative keyboards, and trackballs to allow patients successful access and use.³² Computer access not only facilitates cognitive retraining opportunities but can also be a source of communication and address visual, perceptual, and motor deficits.

Vision

Intervention alternatives for clients with TBI and visual dysfunction include the use of corrective lenses, occlusion (e.g., patching one eye), prism lenses, vision exercises, environmental adaptations, and corrective surgery. An optometrist or ophthalmologist can evaluate the client’s vision and prescribe glasses to address any accommodative dysfunction caused by brain injury. However, the glasses should not be prescribed until the client has passed the subacute phase of rehabilitation because an accommodative dysfunction that appears in the acute stage of brain injury may improve during the recovery process.

A common technique to eliminate double vision (diplopia) is patching, or occlusion. The client wears a patch over one eye to block the image seen by that eye and eliminate diplopia. Patching is a temporary compensatory strategy. An optometrist may prescribe prism glasses or binasal occluders for clients with consistent diplopia resulting from permanent oculomotor nerve damage. The prisms assist the eyes in fusing images. Prism glasses are not effective for those with significant lateral strabismus or exotropia (outward eye turn). Binasal occluders encourage the malaligned eye to fixate centrally. Prism glasses and binasal occluders are used conjointly with vision exercises. The goal of this intervention is to decrease the diplopia and eventually eliminate the need for prisms or occluders.

Vision exercises consist of a series of activities that (1) maximize residual vision, (2) enhance impaired vision skills (the rehabilitative approach), (3) increase the client’s awareness of his or her visual deficits, and (4) help the client learn compensatory strategies. Intervention progresses from monocular to binocular vision and follows a developmental progression (supine to sitting to standing). Exercises initially address basic skills such as visual attention, pursuits, and saccades and may progress to more difficult skills such as fusion and stereopsis. These vision exercises are based on the rehabilitative model, which holds that impaired visual skills can improve with training.

Environmental adaptations for visual deficits are based on the compensatory model. Compensatory strategies for visual deficits include using a colored border along one side of a page to facilitate reading. A colored strip of tape along one side of a plate or meal tray to promote self-feeding is one option. Use of large objects, such as a clock with bold numbers or a telephone with enlarged buttons, is another compensatory technique. Contrasting colors to highlight controls and knobs (e.g., marking TV/VCR remote control buttons with fluorescent paint) may be helpful. Increasing lighting in an environment and using textures as cues (e.g., placing textured tape on a banister by the bottom step to alert the individual that the bottom step is coming and thereby reduce falls) may be used for clients with low vision. The latter compensatory strategy is also valuable for clients with vertical gaze paralysis who can look neither up nor down. Those who have lost pupil constriction should wear sunglasses whenever they are in bright light.

Corrective surgery performed by an ophthalmologist may be indicated to align the eyes and eliminate double vision; however, the individual must wait at least a year after the injury to allow any improvement that may occur naturally in the course of recovery.

Perception

Treatment of perceptual deficits involves both rehabilitative and compensatory intervention. For example, impairment of figure-ground perception might be treated via a rehabilitative approach through the repeated practice of locating objects against a similar background (e.g., finding a white shirt on a bed with white sheets or finding a spoon in a drawer of similar stainless steel utensils). Using a compensatory approach, the therapist would help the client arrange the kitchen drawers so that utensils are categorized (perhaps color-coded) and distinctly divided to facilitate identification.

Aphasia (a perceptual-speech disorder) can also be treated by both rehabilitative and compensatory approaches. Expressive aphasia may be treated rehabilitatively through repeated conversation exercises in which clients are given feedback regarding their incorrect spoken words and challenged to express the words that they meant to verbalize. If the client has not made significant gains in expressive speech through use of the rehabilitative approach, the compensatory approach should be used to help the client articulate his or her needs to caregivers. For example, a chart with letters, words, or pictures (or a combination of the three) of important items in the client’s environment can be used to help the client identify needs such as eating, toileting, and medications. Such a chart may be used concomitantly with rehabilitative approaches.

Through a rehabilitative approach, apraxia can be treated by helping the client perform specific tasks (e.g., hair combing) hand over hand (i.e., the therapist’s hands guide the client’s hands during hair combing). The rehabilitative approach holds that through repeated hand-over-hand exercise, the client’s brain can repair the neural pathways that mediate specific motor patterns, such as those needed for hair combing, or can reorganize pathways so that different, undamaged areas of the brain can establish new pathways for specific motor patterns. Using a compensatory approach, the client may comb his or her hair by following steps through the visual interpretation of pictures sequentially depicted (pictures) or listed (words) on a poster or note card.

Neglect syndrome (a disorder of body schema) can also be addressed by using rehabilitation and compensatory strategies. Severe neglect syndromes tend to decrease as a natural part of the recovery process. However, some neglect syndromes may continue into the postacute rehabilitation stage. With a rehabilitative approach, the client is encouraged to use the neglected extremity for all ADLs. The client’s room may be rearranged to encourage interaction with the neglected part of the environment (e.g., placing the television or standing bed tray in the left side of the room if the client has left-sided neglect). A compensatory model is used when the client has not demonstrated significant improvement in attending to the neglected side of the body or environment. The meal tray may be placed within the client’s field of vision to maximize success. A colored border may be placed on the left side of book pages to cue the individual to scan the entire line while reading.

Behavioral Management

The types of intervention strategies used to decrease and eliminate problem behavior may be divided into two categories: environmental and interactive. Environmental interventions alter objects or other environmental features to facilitate appropriate behavior, inhibit unwanted behavior, and maintain individual safety. Agitated clients should be placed in a quiet, isolated room without a roommate. All extraneous stimuli (e.g., radios and televisions) should be removed. Similarly, therapy is provided in a private, quiet room away from other people and extraneous stimuli.

An agitated client who demonstrates severe behavioral problems may require one-to-one care. The client is assigned a rehabilitation aide who remains with the client throughout the day (including during therapy) to monitor and regulate his or her behavior. The rehabilitation aide may wear an alarm bracelet that signals staff when the client attempts to wander away from the appropriate floor or out of the building. Walkie-talkies and pagers may be used with those who are at risk of eloping. One walkie-talkie or pager remains in the nursing station; the other is held by the therapist or staff member who is providing one-to-one care to the client. If the client begins to act aggressively or attempts to elope, the rehabilitation aide can alert the staff that assistance is needed.

Interactive interventions are the approaches that staff and caregivers use to interact with the client. The entire team should implement these interventions in a consistent way. Consistent implementation includes speaking in a calm and concise manner and deliberately refraining from detailed explanations that will only increase the client’s confusion and frustration. For safety’s sake, therapists should also keep the door open when working with the client at the bedside and should always maintain awareness of the individual in relation to self.

A client who is in the postacute stages of rehabilitation and who continues to exhibit behavioral problems should be placed in a behavioral management program. Such a program should allow the client to experience the natural consequences of inappropriate behavior (e.g., losing community recreational privileges) in an effort to encourage more appropriate responses. Drug therapy may be used for those who do not make significant improvements in their behavior and who present a safety risk to themselves and others.

Dysphagia and Self-Feeding

Intervention strategies for dysphagia follow the same guidelines as for other neurologic impairments; intervention, however, may be more complex in this population as a result of bilateral neurologic involvement, cognitive and behavioral issues, and severe neuromuscular impairments.^5,6 A self-feeding program may begin in a quiet area, such as the client’s room. Eating is then advanced to more social situations, such as the hospital dining room. 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. If the client displays decreased attention, introducing one piece of adaptive equipment at a time may help. Clients with heightened impulsivity may benefit from the strategy of placing the fork down after each bite to ensure that they completely chew and swallow before initiating the next bite. Depending on the client’s level of dysphagia (i.e., pre-oral, oral, pharyngeal, and esophageal), a diet of thick liquids or puréed foods may be indicated until the client makes progress toward recovery.

Functional Mobility

Mobility training can be subdivided into bed mobility, transfer training, wheelchair mobility, functional ambulation during performance of ADLs, 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 for intermediate-level clients with TBI in the acute and subacute stages of rehabilitation. Allowing a client with loss of function to use compensatory strategies, such as grabbing a bed rail with one hand and rolling or standing on one leg to transfer, may appear to enable the client to function more independently earlier. However, use of such strategies diminishes the client’s ability to perform activities with a bilateral UE pattern at a later point. In time, unilateral performance of activities results in hemiplegic postures, contractures, and abnormal gait deviations. Compensatory strategies should be used only in the later stages of recovery and when the client has not been able to demonstrate significant improvement in functional mobility skills and thus must learn compensatory strategies to enhance the ability to live independently in the community.

Transfers

Because individuals with TBI commonly have memory deficits and limited carryover of information, transfer training should be consistent (in technique and sequence) among all staff members treating the client. It is preferable that transfers for intermediate- and advanced-level clients be practiced while moving to both the right and the left sides. Without such practice, clients who become proficient in a transfer toward the uninvolved side (in the hospital) may be dismayed to find that the home setting or public restroom requires transfers toward the opposite side. Additionally, teaching them to transfer to both sides provides weight bearing on both LEs, the use of bilateral trunk muscles, and bilateral sensory input.

Family members and caregivers should be trained in proper transferring techniques (including proper body mechanics) and cleared by a therapist before transferring the individual alone. The decision about when to begin caregiver training depends on the client’s functional level and ability to cooperate, the discharge date, and the caregiver’s physical and cognitive abilities.

Home Management

As the client’s skills and independence in self-care, dressing, self-feeding, and functional mobility increase, intervention is expanded to include home management skills in preparation for discharge to the community. Home management skills include meal preparation, laundry, cleaning, money management (e.g., balancing a checkbook, paying bills, and budgeting), home repairs (e.g., changing a washer in a leaking faucet), and community shopping (which includes making a shopping list, locating the correct items in the store, and paying the correct amount of money at the cash register). Examples of high-level activities include planning a monthly budget, organizing a file cabinet, ordering from a catalog or the Internet, and filing income taxes. These are skills that adults need to live independently in the community and are thus relevant for most clients with TBI.

The degree to which clients participate in home management activities varies. For example, some prepare only simple meals using a microwave oven. For those who must prepare meals to live independently in the community but who are not interested in cooking, the goal is to help them safely prepare simple hot and cold meals at home. Some clients perform no household cleaning activities other than making their bed and doing the laundry. Common sense dictates that therapeutic interventions first address the activities that the client performed before the injury.

As in all other areas of intervention, home management skills are graded to accommodate the client’s functional level. Beginning meal preparation tasks may involve making a cold sandwich, whereas beginning money management skills may involve learning to perform basic cash transactions. As clients progress in home management skills, the meal preparation task may be graded to preparing a two-item hot meal using a stovetop, oven, or microwave oven. Money management skills may be graded to writing checks and balancing a checkbook. As the client continues to gain skills, activities requiring higher-level demands are performed until the client reaches the desired goals.

Child care, if appropriate, must not be overlooked as an area of intervention. Family involvement is critical if a mother or father is to return effectively to his or her role as a spouse and parent. Sensory overload and its resultant agitation in a parent with TBI are a commonly reported problem for families. Occupational therapy sessions should gradually reintroduce parents to their role of caring for their children. Some hospitals have a family suite in which family members can practice ADLs and interpersonal skills with the client on weekends in preparation for discharge. This allows family members to gain a greater awareness of their loved one’s impairments and need for assistance. It also makes the transition from hospital to home less stressful for both clients and family members.

The occupational therapist can also assist parents with TBI in the adaptation of strollers, cribs, and child care equipment to make handling of such items easier. Safely bathing or carrying a baby, preparing a meal while simultaneously caring for children, and one-handed diapering and dressing techniques are all examples of areas that could be addressed by occupational therapy services.

Community Reintegration

Clients who will be discharged from the acute rehabilitation hospital to home or to a postacute, residential supportive living arrangement should receive training to facilitate the transition from the hospital to the community. Clients who achieve a maximal level of independence in the protected and structured environment of the rehabilitation hospital may find that community reintegration holds even greater challenges. Community trips—in which an advanced-level client with TBI is accompanied in the community by the occupational therapist (and perhaps a family member) to practice IADLs in the natural environment—should be implemented to provide the client with the opportunity to rebuild daily life skills. Depositing or withdrawing money from the bank or ATM, using the public transportation system, planning a shopping list, and purchasing items at the grocery or hardware store are activities that will facilitate initiation of the client’s re-entry into the community. Having the client perform ADLs within the community setting will also allow the therapist to observe the client’s ability to interact successfully or otherwise with the environment. The client will be provided a chance to receive valuable feedback from others in the community regarding his or her behavior.

Some clients are discharged from the acute rehabilitation center to a transitional living center. Transitional living centers are designed to develop daily life skills by providing the client an opportunity to temporarily live in a community group setting with 24-hour staff supervision and assistance. The goal of transitional living centers is to facilitate progression from supervised living to greater independence in community living. The client is usually discharged from the transitional living center to a relative’s home or to a residential supportive living facility that provides various levels of living arrangements (e.g., community apartments and shared community group homes). Because long-term residential community facilities for people with TBI are expensive and not covered by most insurance companies, many are discharged home, where they receive continued intervention in outpatient rehabilitation or in day treatment programs that provide community, work, and school re-entry training.

Psychosocial Skills

Individuals with TBI commonly report 1 or more years after the injury that psychosocial impairment is the greatest obstacle to rebuilding a meaningful lifestyle. Many report feeling a deep sense of isolation and loneliness. Loss of roles such as partner or spouse, worker or student, independent home maintainer, friend, and community member often leaves individuals feeling as though they have lost their identity. The goal of the occupational therapist, particularly in postacute TBI centers (e.g., day treatment programs, outpatient rehabilitation, transitional living sites, and long-term community supportive living arrangements), is to help rebuild desired occupational and social roles. This involves a three-step process: (1) identifying the desired roles that were lost secondary to TBI, (2) identifying activities that would support the desired roles, and (3) identifying rites of passage that were either lost or never transitioned through as a result of TBI. Rites of passage are socially recognized events that mark the transition from one life stage to another. Common rites of passage in Western society include obtaining a driver’s license, graduating from secondary school or obtaining a higher education degree, securing full-time employment, living independently in the community, dating, marrying, and parenting.

Once the desired occupational and social roles, activities, and rites of passage have been identified, the therapist facilitates the client’s use of adaptation, compensatory strategies, and integration of new learning. The therapist will also help the client enhance or regain interpersonal skills, self-expression, social appropriateness, time management, and self-control. Such psychosocial skills will be critical if the client is to re-enter the community—to live in a neighborhood setting, hold a job, perform volunteer work in the community, and participate in desired recreational opportunities along with other adult community members.

Group intervention is beneficial because it enables the client to meet others experiencing the same life concerns (thereby decreasing feelings of isolation). Groups can offer exposure to peer reactions, which is particularly helpful if the client exhibits socially inappropriate behavior. Groups may also facilitate problem solving by providing the opportunity to speak with others who have successfully dealt with the same or similar problems. Participants who have been in the group longer can become peer mentors to new group members. The opportunity to help others—to share one’s experience of having a brain injury with others who can benefit from that knowledge—has been shown to enhance an individual’s life satisfaction, feelings of competence, and sense of usefulness. Many states have support groups for individuals with TBI that are run by state associations for brain injury.

Substance Use

If the client’s preinjury history includes substance use, the client should receive drug and rehabilitation services specifically designed for individuals with TBI. Clients with a history of substance use may not display any signs of a desire to return to substance use while in the structured and protective environment of the subacute rehabilitation facility. Substance use may become a problem only after the client is discharged to home, a community-supported living arrangement, or any residential situation in which long periods may be spent alone and unsupervised. Drug rehabilitation services are critical for clients with a substance abuse history because return to substance use after brain injury has been closely implicated in the occurrence of a second TBI.

Discharge Planning

Planning for discharge from occupational therapy services begins at the initial evaluation and continues until the last day of intervention. Components of discharge planning include a home safety evaluation (if the client will be discharged home), equipment evaluation and ordering, family and caregiver education, recommendations for a driver’s training program (if indicated), and recommendations for successful return to school or vocational retraining and work skills.

Review Questions

1. AAA Foundation for Traffic Safety. Available at http://www.aaafoundation.org-Roadwise Review.

2. Allen, CK. Occupational therapy for psychiatric diseases: measurement and management of cognition disabilities. Boston, Mass: Little, Brown; 1985.

3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, ed 4. Washington, DC: American Psychiatric Association; 1994.

4. Arnadottir, G. The brain and behavior. Philadelphia, Pa: Mosby; 1990.

5. Avery-Smith, W, Dellarosa, DM. Approaches to treating dysphagia in individuals with brain injury. Am J Occup Ther. 1994;48(3):235.

6. Avery-Smith, W, Dellarosa, DM, Brod Rosen, A. Dysphagia evaluation protocol. San Antonio, Tex: Therapy Skill Builders; 1996.

7. Bennett, SE, Karnes, JL. Neurological disabilities. Philadelphia, Pa: JB Lippincott; 1998.

8. Bombardier, CH, Temkin, NR, Machamer, J, Dikmen, SS. The natural history of drinking and alcohol-related problems after traumatic brain injury. Arch Phys Med Rehabil. 2003;84(2):185.

9. Brain Injury Association. Fact sheets. Washington, DC: Brain Injury Association; 2006.

10. Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation. Practice parameter: antiepileptic drug treatment of posttraumatic seizures. Arch Phys Med Rehabil. 1998;79(5):594.

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