1. Conti, G. E. (2017). Acquired brain injury. In B. J. Atchison & D. P. Dirette (Eds.), Conditions in occupational therapy (pp. 363-386). Wolters Kluwer.
2. McMillan, I. R. (2011). The biomechanical frame of reference in occupational therapy. In E. A. S. Duncan (Ed.), Foundations for practice in occupational therapy (5th ed., pp. 179-194). Edinburgh: Churchill Livingstone.
3. Kielhofner, G., & Burke, J. P. (1980). A model of human occupation, part 1. Conceptual framework and content. American Journal of Occupational Therapy, 34, 572-581.
4. Schkade, J. K., & Schultz, S. (1992). Occupational adaptation: Toward a holistic approach for contemporary practice, Part 1. American Journal of Occupational Therapy, 46, 829-837.
5. Skalsky, A. J., & McDonald, C. M. (2012). Prevention and management of limb contractures in neuromuscular diseases. Physical medicine and rehabilitation clinics of North America, 23(3), 675–687. https://doi.org/10.1016/j.pmr.2012.06.009
6. Craig Hospital (2015). Low stimulation guidelines. Low Stimulation Guidelines. https://craighospital.org/resources/low-stimulation-guidelines
7. Bhattacharya, S., & Mishra, R. K. (2015). Pressure ulcers: Current understanding and newer modalities of treatment. Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 48(1), 4–16. https://doi.org/10.4103/0970-0358.155260
8. Persson, C. U., Holmegaard, L., Redfors, P., Jern, C., Blomstrand, C., & Jood, K. (2020). Increased muscle tone and contracture late after ischemic stroke. Brain and behavior, 10(2). https://doi.org/10.1002/brb3.1509
9. American Occupational Therapy Association (AOTA). (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48.
10. Models & Frames of Reference
10.1. Model of Human Occupation
10.1.1. This model guides the therapist in treatment by discovering internal and external motivators that affect performance. By discovering natural habits, roles, and routines, the therapist can create a client-centered evaluation, intervention, and discharge plan (Kielhofner & Burke, 1980)
10.2. Occupational Adaptation FOR
10.2.1. This FOR is appropriate for the client because it directly examines the relationship between the person and their environment. The therapist aims to discover environmental supports and barriers that affect occupational performance buy the person. The therapist will work with both the client and caregivers to modify or adapt parts of the environment to promote successful occupational performance (Schkade & Schultz, 1992)
10.3. Biomechanical FOR
10.3.1. This FOR is directly related to the client's care because the therapist will utilize techniques related to increasing ROM, endurance, and strength to enhance occupational performance across various environments of the client's life. The overarching goal is to prevent a greater decline of ROM by using proper positioning and moving the body part passively and actively (McMillan, 2011).
11. Giacino, J., & Kalmar, K. (2006). Coma recovery scale-revised. The Center for Outcome Measurement in Brain Injury. http://www.tbims.org/combi/crs
12. Centers for Disease Control and Prevention [CDC]. (2019). Basic Information: Symptoms of Traumatic Brain Injury (TBI). https://www.cdc.gov/traumaticbraininjury/symptoms.html
13. Facts and Statistics
13.1. Traumatic brain injury is defined as any traumatic blow to the brain resulting in loss of consciousness, amnesia, disorientation, or neurological signs. The top three leading causes of TBI in America include: falls, motor vehicle accidents, and violence. It is estimated that at least 1.7 billion Americans sustain a TBI each year. When compared to women, men between the age of 15 and 24 are twice as likely to sustain TBI (Conti, 2017).
14. Symptoms
14.1. Individuals with TBI experience a wide variety of symptoms depending on the location and severity of the injury. Symptoms can be related to motor, sensory, cognitive, and emotional deficits (CDC, 2019). Secondary deficits are common resulting in difficulty with mobility, executive functioning, and completing ADLs and IADLs (Conti, 2017).
15. References:
16. Prognosis
16.1. The response to TBI is highly individualistic in relation to the severity and wide range of symptoms. Following TBI, an individual may experience residual functional, emotional, psychological, and behavioral deficits for years after the initial injury. Intensive rehabilitation from occupational, physical, and speech therapies is crucial for enhancing occupational performance across various environments (Conti, 2017).
17. Client is a 56-year-old male diagnosed with a TBI after being struck by a car. He is classified as a Ranchos level II. He reacts to external stimuli inconsistently and non-purposefully with very limited response. He experiences difficulty remaining awake and alert. He scored a 1+ for UE and a 2 for LE tone while in the hospital as evidenced by the Modified Ashworth Scale. Client experiences no voluntary movement of extremities. He requires total assistance for all ADLs, IADLs, bed mobility, and transferring. Client lives with his wife and teenage daughter in a 1-story home. Client was just admitted to a skilled nursing facility one month after his hospital stay with very little change in response levels.
17.1. Problems & Deficits
17.1.1. Physical dysfunction
17.1.1.1. Increased tone in UEs and LEs - decreased ROM
17.1.1.2. No voluntary movement of extremities - contractures
17.1.2. Cognitive deficits
17.1.2.1. Decreased awareness/ alertness
17.1.2.2. Overall decline in executive functioning
17.1.3. Sensory deficits
17.1.3.1. Hypersensitive to visual and auditory stimuli
17.2. Evaluation & Assessment
17.2.1. Disability Rating Scale (DRS) (Conti, 2017)
17.2.1.1. This assessment tests a variety of disabilities for those with TBI. There are 8 domains tested and scored: eye opening, communication ability, motor response, feeding (cognitive ability only), toileting (cognitive ability only), grooming (cognitive ability only), level of functioning (physical, mental, emotional, social), and employability.
17.2.1.2. The DRS will be especially relevant for assessing this client's cognition in relation to alertness and responsiveness (i.e. eye opening, communication ability, motor response).
17.2.2. Coma Recovery Scale (CRS) (Giacino & Kalmar, 2006)
17.2.2.1. The CRS assesses disorders of consciousness among 6 domains: auditory, visual, motor, oromotor, communication, & arousal function. This assessment can be completed in addition to or instead of the DRS.
17.2.2.2. This assessment is beneficial for this client because it can be repeated multiple times by multiple disciplines to understand and track progression within the tested domains.
17.2.3. Modified Ashworth Scale (MAS) (Persson et al., 2020)
17.2.3.1. The MAS assesses spasticity in the extremities of individuals experiencing damage to the central nervous system. Spasticity is measured on a scale of 0-5.
17.2.3.2. This assessment will allow the therapist to track the amount of tone in the client's extremities through the progression of therapy. Understanding the love of tone in the client will help guide the therapist in creating appropriate interventions and goals.
17.3. Intervention Approaches (AOTA, 2014)
17.3.1. Restore
17.3.1.1. Range of motion: Restoring ROM is essential in preventing contractures, deep vein thrombosis, and muscle atrophy. The therapist can complete passive ROM exercises to the client's UEs and LEs while supine in bed during therapy sessions (Skalsky & McDonald, 2012).
17.3.2. Modify
17.3.2.1. Environment: Modifying the client's environment will prevent adverse responses to stimuli. Implementing dim lights, calm music, and limiting the number of visitors in the client's room will decrease visual and auditory sensation overload (Craig Hospital, 2015).
17.3.3. Prevent
17.3.3.1. Pressure ulcers: Individuals diagnosed as Rancho level II do not have voluntary movement of the extremities. This results in the inability to properly weight shift, ultimately leading to pressure ulcers. Pressure ulcers can be prevented by implementing an appropriate repositioning schedule into the individual's daily life (Bhattacharya & Mishra, 2015). The therapist can collaborate with caregivers and other members of the healthcare team to create an appropriate schedule of repositioning for the client.
17.3.4. Educate
17.3.4.1. Family & caregiver education: Educating caregivers and family members on the details of the client's health and rehabilitation is essential for overall quality of life and performance of the individual. The therapist can provide external resources, handouts, and training in relation to pressure ulcer and contracture prevention. They can also teach hands-on techniques related to PROM, and also educate on the importance of decreasing excess external stimuli.
17.4. Outcomes and Long Term Goals (AOTA, 2014)
17.4.1. Prevention of pressure ulcers and contractres to promote overall health and wellbeing
17.4.1.1. This outcome is reached through education and training of the caregiver to ensure competence with specific skills (i.e. positioning, PROM). Optimally, client will also show understanding of the importance of these skills and complete them independently.
17.4.1.1.1. LTG 1: Client will independently weight-shift in bed within 6 weeks to prevent pressure ulcers and contractures.
17.4.1.1.2. STG 1: Caregiver will independently position and complete PROM of the client within 1 week to prevent pressure ulcers and contractures.
17.4.2. Participation in daily occupations to promote overall independence
17.4.2.1. This outcome is reached by enhancing localized response to stimuli and addressing executive functioning related to task initiation, ability to follow instructions, and sustained attention.
17.4.2.1.1. LTG 2: Client will complete UBD with SPV and minimal verbal cues within 8 weeks to promote dressing independence.
17.4.2.1.2. STG 2: Client will respond to one step commands (close eyes, squeeze hand) with SPV and minimal verbal cues within 2 weeks to promote executive function for ADL participation.