What are the areas of assessment and intervention for traumatic brain injury?
Areas of Assessment & Intervention- a lot slower; slow processing
- Physical
- Visual
- Perceptual
- Cognitive
- Psychosocial
- ADL, IADL
- Community Reintegration
- Return to work, leisure, school
- Return to driving
Interventions:
- Rehabilitative
- Compensatory
- Adaptive
- Modifying
What are the similarities and differences between evaluation and intervention of the individual in the lower-level stages of brain injury and the individual in the intermediate to higher-levels of brain injury?
What evaluation and the tools used?
What intervention?
What is sensory stimulation intervention?
Evaluation of the Lower-Level Individual- Rancho 1-3
- Are they alert/ RAS/ coming out of coma
- Can they alert with eyes?
- Level of Arousal and Cognition
- Vision
- Sensation
- Joint ROM
- Motor Control
- Dysphagia
- Emotional and Behavioral Factors (levels 3-5)
Tools:
- Goniometer
- Muscle and tone testing (ROM/ gross motor testing)
- Neurological screening
- Glasgow Coma Scale- very general
- Rancho Los Amigos Levels of Cognitive Functioning Scale
Intervention of the Lower-Level Individual
- Score determines level of TBI
- 3-4 is severe
- Sensory Stimulation
- Wheelchair Positioning
- Bed Positioning
- Splinting and Casting- for tone and spasticity
- Dysphagia- want off tube
- Behavioral and Cognition
- Family and Caregiver Education
Sensory Stimulation: Intervention
- Goal: Increase level of awareness by trying to increase arousal with controlled sensory input
- Sensory Regulation: increases neurological signals to the reticular activating system
- Visual- pictures
- Auditory
- Olfactory
- Gustatory
- Tactile-
- Kinesthetic- ROM
- Theoretical aim of functional sensory stimulation:
- Reactivate highly processed neural pathways established prior to injury
- Favorite music, tap into whatever they like, things familiar, smells – anything familiar, family members voices
- During all activity, observe for any of the following changes: These are VERY simple- 5 sec. 30 sec
- Visual tracking
- Turning of head
- Physical responses
- Vocalizations
- Ability to follow verbal commands
Physical Status: Neuromuscular Impairments
- Decorticate Posturing
- Cerebrospinal tract
- Spastic hemiplegia (CVA)
- Decerebrate Posturing
- Upper brainstem
Lower- Level Stage: Identify areas of intervention for wheelchair positioning and discuss the clinical reasoning for the various interventions.
Wheelchair Positioning: Intervention
•Goal: Allow interaction with immediate environment (people and objects) in an upright, midline posture
- Facilitate head and trunk control- how long can they tolerate wheelchair
- Prevents skin breakdown and joint contractures
- Facilitate normal muscle tone- sitting will help break up high tone
- Inhibit primitive reflexes
- Increase sitting tolerance
- Enhance respiration and swallowing function
- Promote function
Effective seating and positioning:
- Stable base of support
- Maintenance of trunk in midline
- Facilitation of head in upright, midline position
- Frees UE for use
- Allows client to visually scan environment
- Handle secretions
- Safer swallowing trials
- Pelvis
- Pelvis- ALWAYS check for skin breakdown
- Sling seat vs. Solid Seat Insert
- Lumbar support
- Wedged seat
- Seatbelt
- Trunk
- Solid Back Insert or Firm Contoured Back
- Lateral Trunk Supports
- Chest Strap
- Lower Extremities
- Abductor Wedge- to prevent internal rotation & abduction
- Knees at 90 degrees
- Feet on Foot Plates
- •Upper Extremities
- Scapulae in neutral
- Shoulders slightly externally rotated and abducted
- Lap Tray- considered a restraint (if can’t get out)
- Full
- Half flip away
- Elbows in neutral position of slight flexion and forearm pronation
- Wrists and digits in a functional position
- Head
- Contoured Head Rest
- Forehead Strap
- Reclining wheelchair 10 to 15 degrees
- Reevaluate seating and positioning
- Modify Devices
- Schedule
Lower-Level Injury
Identify areas of intervention for bed positioning and discuss the clinical reasoning for the various interventions.
Bed Positioning: Intervention
- Critical due to increased time in bed
- Prevents pressure sores
- Facilitates normal muscle tone
Difficult to maintain optimal positioning due to:
- Spasticity and abnormal posturing
- Casts
- Splints
- IVs
- NG Tubes
- Fractures
- Medical precautions
Bed Positioning: Intervention- vail beds- used for behavioral problems- you must zip back up
Abnormal tone or posturing:
- Side-lying or semi-prone to normalize tone and provide sensory input
- Supine may facilitate tonic labyrinthine reflex extensor tone, and ATNR
- Pillows, foam wedges, and splints facilitates normal position and prevents abnormal postures
Lower-Level Injury
Identify areas of intervention for splinting and casting and discuss the clinical reasoning for the various interventions.
Indicated when:
- Spasticity interferes with functional movement and ADL Independence
- Joint ROM limitations present
- Soft-tissue contractures are possible
- Splints provide elongation and inhibition by positioning the joint in a static position with the muscles and the soft tissues on stretch
- Splinting of the elbows, wrists, and hands often implemented to maintain a functional position at rest and to reduce tone
Splinting and casting
- Reduce contractures
- Increase ROM
- Prevent skin breakdown- esp open hand
- Resting or functional position splint
- Cone splints See Photos
- Anti-spasticity splints
- Serial casting
- More aggressive
- Increases ROM in joints when contractures have formed or spasticity is present (or both)
- Serial Casting Program
- Moderate to severe spasticity that cannot be managed by splints
- Wearing schedule 5-7 days for each cast
- Most common are Elbow and Wrist-Hand
- Can be done in conjunction with motor point, nerve blocks or Botulinum toxin injections
- Indicators for completion of a casting program:
1) Obtaining functional ROM or plateauing
2) Improvement in ROM achieved and goal met
3) Bivalve (cut in half & velcro) cast to maintain functional position
4) Develop wearing schedule
Lower-Level Injury
What does dysphagia intervention consist of for the individual in the lower-level stages of brain injury?
Dysphagia: Intervention
- When emerging from coma, client is fed through NG tube or G-tube
- Once client is alert and oriented, the physician decides when the dysphagia evaluation is indicated
- Usually at intermediate- to advanced -level stages of rehab
Lower-Level Injury
What are the specific areas of behavioral and cognitive intervention for the individual in the lower-level stages of brain injury?
Document changes and progress in the following areas:
- Level of arousal and awareness
- Visual attention
- Visual tracking
- Ability to follow commands
- Attempts to establish communication
- Communicate wants and needs
Lower-Level Injury
What are some areas that can be addressed for family and caregiver education for the individual in the lower-level stages of brain injury?
- Sensory regulation program
- Items from home
- Positioning
- ROM
intermediate to higher-level brain injury
Identify areas for evaluation and intervention of the individual with an intermediate to higher-level brain injury.
Evaluation of the Intermediate- to Higher- Level Individual
- Physical Status
- Cognition
- Perception
- Vision
- Dysphagia
- Psychosocial and Behavioral Factors
- ADL, Work Re-entry, & Community Re-entry
Intermediate -higher level
What are the areas for evaluation, tools used for assessment, and interventions for the physical and neuromuscular status of individual with an intermediate to higher-level brain injury?
Intervention of Intermediate- to Higher-Level Individual:
- Physical Status:
- Joint ROM
- Muscular Strength
- Sensation
- Proprioception
- Kinesthesia
- Fine and Gross Motor Control
- Total Body Control
- Physical Status: Assessment
- Physical Status Limitations:
- Abnormal Tone
- Spasticity
- Muscle Weakness without abnormal tone
- Heterotopic Ossification
- Fractures
- Soft-tissue contractures
- Peripheral Nerve Compression
- Tools to Measure Physical Status:
- Goniometers
- Dynamometers
- Manual muscle testing
- Clinical Observation
- Standard Assessments:
- Jebsen Hand Function Test
- Minnesota Rate of Manipulation Test
- Minnesota Manal Dexterity Test
- Purdue Pegboard
Intermediate-higher level
What are the neuromuscular impairments? Interventions? Assessments?
Neuromuscular Impairments
- Spasticity
- Rigidity
- Soft-tissue contractures
- Primitive reflexes
- Diminished or lost postural reactions
- Muscular weakness
- Impaired sensation
Neuromuscular Intervention
- Facilitate control of muscle groups, progressing proximally to distally
- Encourage symmetrical posture
- Facilitate integration o f both sides of body into activities
- Encourage bilateral weight-bearing
- Introduce a normal sensory experience
Neuromuscular Intervention
Rehabilitation Techniques:
- Neurodevelopmental Treatment (NDT)
- Proprioceptive Neuromuscular Facilitation (PNF)
- Myofascial Release
- Rood techniques
- Physical Agent Modalities
- Facilitate trunk alignment
- Stimulate reciprocal trunk muscle activity
- Shift weight from a stable posture into all directions
- Move the lower trunk on a stable upper trunk; Move the upper trunk on a stable lower trunk
- Upper extremity intervention
What are the areas for intervention for ataxia for the individual with an intermediate to higher-level brain injury?
Ataxia: Intervention
- Motor dysfunction from damage to cerebellum
- Rehab methods ineffective
- Compensatory approach
What are the areas for evaluation, tools used for assessment, and interventions for the cognitive status of an individual with an intermediate to higher-level brain injury?
Cognition: Assessment
•Assessed within functional tasks
- Counting the number of errors and correct responses
- Assessing the amount of assistance or cueing required.
- Determining the percentage of the task that was completed correctly.
- Executive Function Performance Test (EFPT)
- Kitchen Task Assessment (KTA)
- Toglia’s Contextual Memory Test (CMT)
- Rancho Los Amigos Levels of Cognitive Function: http://www.rancho.org
- Rivermead Behavioral Memory Test
- Kohlman Evaluation of Living Skills
Other Factors that Affect Cognitive Performance:
- Language Barriers
- Aphasia
- Visual-perceptual Deficits
- Effects of Medication
- Educational and Cultural Background
- Previous experience with task
Cognition: Intervention
- Intervention implemented through ADL and IADL
- Attention and concentration
- Memory
- Initiation and termination of activities
- Safety awareness and judgement
- Processing of information
- Executive function and abstract thought
- Generalization
What are the areas for evaluation, tools used for assessment, and interventions for the perceptual status of an individual with an intermediate to higher-level brain injury?
Perceptual Function
- Right-Left Discrimination
- Form Constancy
- Position in Space
- Topographical Orientation
- Naming of Objects
Perceptual Motor Function
- Ideational Praxis
- Ideomotor Praxis
- Three-Dimensional Constructional Praxis
- Body Scheme Praxis
Perceptual Assessment
- Hooper Visual Organization Test
- Motor-Free Visual Perception Test-Revised
- Rivermead Perceptual Assessment Battery
- Loewenstein Occupational Therapy Cognitive Assessment
Perception: Intervention
- Rehabilitative and Compensatory
- Figure-ground – locating items on a similar background vs. facilitate identification
- Apraxia – hand-over-hand vs. Following sequential steps on picture cards
- Neglect syndrome – using neglected side vs. rearranging environment.
What are the areas for evaluation, tools used for assessment, and interventions for the visual status of an individual with an intermediate to higher-level brain injury?
Visual Screening
- Visual Attention
- Near and distant acuities
- Ocular movement (pursuits and saccades)
- Convergence
- Accomodation
- Ocular alignment
- Depth perception
- Visual field function
Vision: Intervention
- Use of corrective lenses
- Occlusion
- Prism lenses
- Vision Exercises
- Environmental Adaptations
- Corrective Surgery
- Temporary Compensatory Strategies
- Patching/Occlusion
- Prism glasses
- Use in conjunction with vision exercises
Vision Exercises: Rehabilitative and Compensatory
- Maximize residual vision
- Enhance impaired vision skills
- Increase awareness of vision deficits
- Learn compensatory strategies
- Compensatory Strategies
- Colored border along one side of page for reading
- Colored strip of tape along plate
- Contrasting colors
- Increasing lighting
- Use of large objects
- Corrective surgery
What are the areas for evaluation, tools used for assessment, and interventions for the dysphagia and self-feeding status of an individual with an intermediate to higher-level brain injury?
Dysphagia: Assessment
- Clinical beside assessment
- Videofluoroscopy
Dysphagia and Self-feeding: Interventions
- Environment
- Adaptive Devices
- Self-feeding and swallowing strategies
- Graded diet
What are the areas for evaluation, tools used for assessment, and interventions for the psychosocial and behavioral status of an individual with an intermediate to higher-level brain injury?
Psychosocial Skills: Evaluation
- Role Loss
- Social Conduct
- Interpersonal Skills
- Self-Expression
- Time Management
- Self-Control
- Social Support Systems
Psychosocial Assessments
- Assessment of Communication and Interaction Skills
- Occupational Role History
- Role Checklist
Psychosocial Skills: Intervention
- Rebuild desired social and occupational roles:
- Identify desired roles that were lost
- Identify activities that would support desired roles
- Identify rites of passage that were lost or never transitioned through
Psychosocial Skills: Intervention
- Interpersonal skills
- Self-expression
- Social appropriateness
- Time management
- Self-control
- Group Intervention
- Behavioral Management
- Environmental Interventions
- Interactive Interventions
- Behavioral Management Program
What are the areas for evaluation, tools used for assessment, and interventions for ADL, IADL, and transportation of an individual with an intermediate to higher-level brain injury?
ADL & IADL Assessment
ADL
- Self-Care
- Functional Mobility
- Emergency Response
IADL
- Meal Preparation
- Money Management
- Community Shopping
- Household Maintenance
- Medication Routine
- Assessment of Motor and Process Skills (AMPS)
- Functional Independence Measure (FIM)
- Functional Assessment Measure (FAM)
- http://www.tbims.org/combi/FAM/famform.pdf
- Independent Living Scales
- http://www.tbims.org/combi/ils/ils2012b.pdf
Home Management: Intervention
- Meal Preparation
- Laundry
- Cleaning
- Money Management
- Home repairs
- Community Shopping
- Functional Mobility: Intervention
- Bed Mobility
- Transfer Training
- Wheelchair Mobility
- Functional Ambulation in ADL
- Community Mobility
Transfers: Intervention
- Consistent transfer training
- Transfer to left and right sides
- -Bilateral UE & LE weight-bearing
- -Bilateral trunk muscles
- -Bilateral sensory input
- Family and caregiver training
What are the areas for discharge planning and assessment for the individual with an intermediate to higher-level brain injury?
Discharge Planning
- Home Safety
- Equipment Evaluation
- Family and Caregiver Education
- Driver’s Training
- Vocational Training and Work Skills
Driving: Assessment
- Clinical Assessment
- On-Road Assessment
Vocational Rehabilitation: Assessment
- Return to work for those with moderate to severe TBI tends to be unsuccessful.
- Assessment must be in the actual work setting.
- Community Reintegration
- Home
- Post-acute residential supportive-living arrangement
- Transitional living center
- Outpatient rehabilitation
- Day treatment programs
Community Reintegration: Assessment
- Community Integration Questionnaire (CIQ)
- http://www.tbims.org/combi/ciq/ciq.pdf
- Craig Handicap Assessment and Reporting Technique (CHART)
- http://www.tbims.org/combi/chart/CHART.pdf
- http://www.tbims.org/combi/chart/CHARTscore.pdf
- Disability Rating Scale (DRS)
- http://www.tbims.org/combi/drs/DRS%20Form.pdf
- Mayo-Portland Adaptability Inventory (MPAI)
- Perceived Controlled Scale for Brain Injury Rating Form (PCSBI)
- http://www.tbims.org/combi/pcsbi/PCS-BIforCOMBI.pdf
- Satisfaction With Life Scale (SWLS)
- http://www.tbims.org/combi/swls/swlsrat.html
- Supervision Rating Scale (SRS)
- http://www.tbims.org/combi/srs/srs.pdf
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Continuum of Care8
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CVA7
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Traditional Sensorimotor Approaches14
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Vision for the neuro client15
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Vestibular Rehabilitation8
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Cognition and Perception9
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Dysphagia11
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TBI20
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Positioning and Restraints8
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Pain3
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Cardiac and Pulmonary Rehabilitation10
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Neurodegenerative Diseases5
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Continence and Balance7
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Low Vision7
