Occupational Therapy Intervention in Medical and Neurological Conditions PDF

OCCUPATIONAL THERAPY INTERVENTION IN MEDICAL AND NEUROLOGICAL CONDITIONS OCT464 Interventions for Traumatic Brain Injury: An Occupational Therapy Approach  Page 2 Topics...

OCCUPATIONAL THERAPY INTERVENTION IN MEDICAL AND NEUROLOGICAL CONDITIONS OCT464 Interventions for Traumatic Brain Injury: An Occupational Therapy Approach  Page 2 Topics Definitions, Incidence and Clinical Features Disorders of Consciousness Clinical Picture Traumatic Brain Injury Intervention (Lower level to Intermediate) Intervention (Intermediate to Higher Level) Support for the Caregiver unlimited  Page 3 TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external mechanical force. Alteration in brain function is determined by: any loss of or decrease in the level of consciousness; Definition any loss of memory for events immediately before or after the injury (post- traumatic amnesia); a neurological deficit such as weakness, paralysis, loss of balance, change in vision, sensory loss, or aphasia; any change in mental state at the time of the injury such as confusion, disorientation, or slowed thinking; and/or visual, neuro radiologic, or laboratory evidence of damage to the brain (Menon et al., 2010). unlimited  Focal versus Diffuse Injuries Focal and diffuse brain injury are ways to classify brain injury. Focal injury occurs in a specific location, while diffuse injury occurs over a more widespread area. It is common for both focal and diffuse damage to occur as the result of the same event. Many traumatic brain injuries have aspects of both focal and diffuse injury. Focal injuries are commonly associated with an injury in which the head strikes or is struck by an object while diffuse injuries are more often found in acceleration/deceleration injuries, in which the head does not necessarily contact anything, but brain tissue is damaged because tissue types with varying densities accelerate at different rates.  Coma & Level of Consciousness Consciousness is a state of environmental awareness and self-awareness. Coma involves the absence of awareness of self and the environment despite maximal external stimuli. No periods of wakefulness occur in the coma state. When coma resolves, the person becomes either partially aware of self and the environment (“minimally conscious”) or, if no awareness is present, “vegetative”.  Page 6 Definitions of Severe Disorders of Consciousness Vegetative state Wakefulness without awareness. Characteristics: No awareness of self or the environment and an inability to interact with others. No sustained, reproducible or voluntary behavioural responses to sensory stimuli No language comprehension or expression Sleep wake cycle of variable length Ability to regulate temperature, breathing, and circulation to permit survival with routine medical and nursing care. Incontinence (Bowel & Bladder) Persistent vegetative state refers to a condition of past and continuing disability with an uncertain future (1 month). The condition may improve or when the client does not improve, then the term permanent vegetative state is appropriate, signifying that the chance of regaining consciousness before death is exceedingly small. unlimited  The Glasgow Coma Scale (GCS) Traditional method used by healthcare professionals to assess level of consciousness after TBI. GCS has been used to quantify the severity of brain injury and predict outcome. Three behavioural areas assessed: Motor Responses (When reached 5 or 6, no longer in a coma or vegetative state) Verbal Responses Eye Opening  Page 9 Ranchos Los Amigos Scale unlimited  Clinical Picture An individual with TBI may exhibits a variety of symptoms, depending on the type, severity, and location of the injury. Individual may have limitations in most of the following areas. Physical Status Cognitive Status Visual Status Perceptual Skills Psychosocial Factors Behavioural Status  Physical Status Decorticate, Decerebrate, & Motor Rigidity Abnormal Muscle Tone & Spasticity Muscle Weakness Decreased Functional Endurance Ataxia Postural Deficits Limitation of Joint Motion Sensation Integration of Total Body Movements  Cognitive Status Attention & Concentration Memory Initiation & Termination of Activities Safety Awareness & Judgement Processing of Information Executive Functions & Abstract Thought Generalization  Psychosocial Factors Self-Concept Social Roles Independent Living Status Dealing with Loss Affective Changes  Evaluation of the Lower Level Individual Clients emerging from coma and at the beginning stages of injury (Level I to III) may exhibit minimal arousal and limited purposeful movements. Necessary to evaluate in short sessions and at different times of the day. A quiet and minimal distractions environment will enhance the client’s ability to attend to and follow commands.  Evaluation of the Lower Level Individual Level of arousal & cognition (can the client visually attend to the speaker and follow commands?; communicate through verbalization, gestures, eye movements) Vision (Is the client able to visually scan or attend to a person, object, or activity; maintain eye contact) Sensation (Respond to external stimulation such as pain, temperature, movement of the joints) Joint ROM (Has the client lost ROM in certain joints, contractures) Motor Control (Increased or decreased tone, any primitive reflex, spontaneous motor movements) Emotional & Behavioural Factors (Flat or expressive, response such as crying or laughing observed in response to interactions)  OT Intervention Intervention of the Lower Level Individual General aim (Rancho Level I through III) is to increase the individual’s level of response and overall awareness of self and environment. All stimulation should be well structured and broken down into simple steps and commands. Sufficient time is necessary for an individual’s response because cognitive processing is often significantly delayed during this phase of recovery.  Intervention of the Lower Level Individual Sensory Stimulation Bed Positioning Splinting Wheelchair Positioning Emotional & Behavioural Management Family & Caregiver Education  Sensory Stimulation Intervention should start as soon as they are medically stable. At this stage, they are lack responsiveness to pain, touch, sound, or sight. The goal of intervention is to increase the client’s level of awareness by trying to increase arousal with controlled sensory input. Sensory stimulation can be introduced in variety ways and methods. Introducing isolated visual, auditory, tactile, olfactory, and gustatory stimulants to the individual may heighten arousal. (e.g. flashlight for eye opening and visual tracking, playing familiar music, variety of scents, presentation of taste to the clients’ lips and tongue) Any response from the client is noted. Kinaesthetic input also should be incorporated in early intervention (rolling from side to side, simple functional activities e.g. wiping mouth, combing hair, applying lotion to the skin, sitting the individual up at the edge of the bed, stand by using tilt table or hydraulic standing frame)  Bed Positioning Proper bed positioning is critical in the early stages of TBI. The client tend to spend a lot of time in bed, proper positioning is crucial to prevent pressure sores and facilitate normal muscle tone.  Page 20 When resting in bed, it is important to be properly positioned in order to protect the skin, muscles and joints. Proper padding and positioning can promote range of motion, comfort and rest, as well as keep the skin from developing sores. Resting on the Back: Support the head with a pillow. Put a foam pad under the heels so they do not touch the bed surface. Position the arms at side Keep the feet from leaning on the bed's footboard. unlimited  Page 21 Resting on the Side: Support the head with a pillow. Place a pillow behind the back for support. Place a pillow lengthwise between the legs. Do not let the knees or ankles touch each other while on the side. Place a foam pad between the ankles and between the bed and the ankle. Keep the feet from leaning on the footboard. Support the top arm with a pillow (let the arm rest on top of the pillow). Do not pull or jerk the arm out from the side. Support the top arm with a pillow (let the arm rest on the pillow). unlimited  Wheelchair Positioning Seating and positioning are important components of treatment for lower level patients. 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 the client 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 reflex, increase sitting tolerance, enhance respiration, and swallowing function & promote function. Effective seating and positioning requires a stable base of support at the pelvis, maintenance of the trunk in midline, and facilitation of the head in an upright, midline position. Therapy sessions can be more effective and beneficial  Splinting May be indicated when: Spasticity interferes with functional movement and ADL independence Joint ROM limitations are present Soft-tissue contractures 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. Resting or Functional Position Splint Cone Splint Anti Spasticity Splint  Behavioural & Cognition As clients emerge from coma and become more alert and aware of their surroundings, it is important to track their improvement and attempts to establish a form of communication. Establishing a way for the client to communicate wants and needs is the utmost importance because it helps guide intervention. Also to accurately asses cognitive level. A reliable yes/no system should typically be implemented. E.g. eye blinks, eye gaze, head nods, and motor movements such as thumb up and down. Once a system is established, communication is possible.  Family & Caregiver Education Starts immediately because they are integral part of the intervention team. Family members often play an essential role in eliciting the clients’ response and in implementing the sensory regulation program, positioning the client in bed, and contributing to the ROM program. Later, when the individual is more alert and mobile, family members can be involved in transfers, wheelchair positioning, feeding programs and ADL retraining. Participation in in-patient rehabilitation sessions can help family members learn about the patient’s strengths and weaknesses, techniques for helping him or her optimize performance, and help minimize expectations of an abrupt recovery to the “same person” the patient was before the injury (Phipps et al., 1997).  Page 26 In Patient Rehabilitation Aimed at optimizing motor, visual-perceptual, and cognitive functions; restoring competence in fundamental self-maintenance tasks; contributing to the patient’s continuing behavioral and emotional adaptation. Motor Vision and Cognitive Self Behavioral Functions Visual Functions Maintenance and Emotional Perception Task Adaptation unlimited  Page 27 Optimizing Visual and Visual-Perceptual Function TBI frequently results in foundational visual and/or visual-perceptual disturbances that impair 5 occupational function (Bouska & Gallaway, 1991). 0 Category 1 Category 2 Category 3 Category 4 Visual field loss is often in the superior fields, and the oculomotor system is frequently impaired, with poor fixation, deviation of the eyes resulting in diplopia, and difficulty in visual scanning (Scott & Dow, 1995). unlimited ** Accounting, Business & Finance  Page 28 Visual Scanning Techniques 90 % 75 % 70 % 50 % Visual scanning is the Teaching a Cancellation Tasks Visual Search Tasks ability to locate a systematic target using an method of organized visual scanning can search pattern assist an individual in moving through their environment safely and independently. unlimited  Page 29 Cancellation Tasks A set of printed stimuli (usually letters, numbers, or symbols) is presented to the person, who is then asked to find and cross out, or cancel, a specific stimulus wherever it appears on the page. If the patient is encouraged to scan line by line, from left to right and top to bottom, this can help to improving reading skills as well. Frequency: 40 h during 8 weeks Grading: The difficulty can be adjusted by varying the type of stimuli (letters vs. symbols), the visual similarity of the target to the distractors (stars among letters vs. letters among letters), the size of the set (number of rows and columns), and configuration of the set (random vs. organized in lines) EBP: fnhum-07-00358.pdf unlimited  Page 30 unlimited  Page 31 Visual Search Tasks Place common objects strategically in front of the person and then ask them to find specific items, including those you’ve placed on the affected side (if patient has hemiplegia from the TBI). Frequency: 40 h during 8 weeks Grading: The difficulty can be adjusted by varying the type of stimuli, the visual similarity of the target to the distractors and the size of the set. EBP: fnhum-07-00358.pdf unlimited  Page 32 unlimited  Page 33 Self Maintenance Skills Inpatient rehabilitation usually Methods: In general, a given The therapist structures focuses on helping patients self-care task is simplified until the task, gathers the reacquire basic self-care skills, the patient is consistently items to be used, and such as bathing, dressing, successful in performing it, and sequences the task by hygiene, and eating. then the complexity is gradually providing the patient increased while the externally with the appropriate provided structure is gradually item and instructions, decreased. one step at a time. unlimited Intervention of the Intermediate to Higher Level Individual Involves two primary approaches Rehabilitative model Supported by the theory of neuroplasticity (the brain can repair itself or reorganized its neural pathway to allow the relearning of functions that has been lost) Compensatory model The repair of damaged brain tissue either has occurred to its full extent or cannot occur, leaving the individual unable to perform lost functions without external assistance. (Adaptive equipment, environmental modifications, and compensatory strategies that allow the client to perform ADLs. Intervention of the Intermediate to Higher Level Individual Neuromuscular Impairments Spasticity, rigidity, contractures, lost of postural reactions, muscular weakness, impaired sensation affect the ability to perform activities independently and with control. Common principles: To facilitate control of muscle groups, symmetrical postures, integration of both sides of the body, bilateral weight bearing, introduce a normal sensory experience. (NDT, PNF, Rood, PAM, followed by meaningful functional activities) Intervention of the Intermediate to Higher Level Individual Cognition Intervention designed to enhance cognitive skills should be implemented through functional ADLs & IADLs. Clients always difficulties in concrete thinking (abstract concepts)., generalization of skills from one task to another. Best to engage clients in activities that they need to participate in everyday life. (Use of public transport, bus schedule (problem solving, planning, organization, concentration, frustration tolerance, sequencing, money management, and categorization) Use of computer programs. Intervention of the Intermediate to Higher Level Individual Perception Involves both rehabilitative and compensatory intervention. (Refer to Previous Lecture) Behavioural Management Environmental Alter objects or environment features to facilitate appropriate behaviour, inhibit unwanted behaviour, maintain individual safety. (Agitated clients – quiet, isolated room without roommate, remove extraneous stimuli. Require one to one care (safety precautions for therapist) Interactive Approach used to interact with client and should be consistent for entire team. (Speaking in calm, concise manner, refraining from detailed explanation that will increase confusion & frustration.  Page 38 Behavioural and Emotional Adaptation Brain damage itself may cause psychosocial changes, such as irritability, aggressiveness, or apathy As the patient Patients who becomes more alert, lack awareness his or her awareness of deficits may of the situation may also become increase irritability, frustrated with uncooperative-ness, staff and family or mood fluctuations. who limit their activities. Furthermore, patients who repeatedly fail on a variety of tasks may become depressed or anxious unlimited  Page 39 Examples of strategies that contribute to patients’ ability to learn effective behaviors during inpatient rehabilitation and beyond: Redesign the environment (Ylvisaker, Jacobs, & Feeney, 2003). For example, if noise and distractions seem to contribute to a patient’s irritability and aggressiveness, provide treatment and care in areas that are calm and quiet. Identify positive competing behavior and, as a team, consistently and frequently reward all instances of adaptive behavior (Eames, Haffey, & Cope, 1990). Help the patient to learn new skills and to experience success to reduce frustration-induced maladaptive behavior. unlimited Intervention of the Intermediate to Higher Level Individual Functional Mobility Bed Mobility Scooting up and down, rolling, bridging, moving from supine to and from sitting and standing positions. Transfer Training Wheelchair Mobility Ability to manage wheelchair parts, propelling indoor and outdoor on variety of surfaces Functional Ambulation in ADLs Use of UE & LE to carry and manipulate objects Community Mobility Ability to negotiate their environment (side walk, curbs, traffic signs). Ability to initiate actions quickly (crossing the street on green light before turning to red), perceived depth and spatial relations. Compensatory strategies should only be used only in the later stages of recovery when the client has not been able to demonstrate significant improvement in functional mobility skills and must learn the strategies to enhance the ability to live independently in community. Intervention of the Intermediate to Higher Level Individual Home Management Meal preparation Laundry Cleaning Money Management Home Repairs Community Shopping As in all other area of intervention, home management are graded to accommodate the client’s functional level. Role of the client (Spouse / parent). Sensory overload and its resultant agitation in the parent with TBI are commonly reported problem for families. Intervention of the Intermediate to Higher Level Individual Community Reintegration Upon discharged, they should received training to facilitate the transition from hospital to community. Psychosocial Skills Deep sense of isolation and loneliness Loss of roles Therapist should help the client to enhance or regain interpersonal skills, self expression, social appropriateness, time management, self control. Group intervention.  Page 43 Restoring Competence in Leisure and Social Participation Social skills retraining following severe head injury develops skill in social behaviors and facilitates Leisure activities post-TBI tend to be sedentary, successful social home-based, and socially isolated interactions. Dahlberg et al (2007) Helping the client resume previous Focus on helping the client initiate leisure activities or determine new new social contacts, participate in leisure outlets that are more in line support groups, and reestablish the with current abilities. social skills necessary for maintaining and building a social unlimited network  Page 44 Supporting the Patient’s Family Holland and Shigaki (1998) recommended that the rehabilitation team provide the family with information about (1) the full spectrum of possible TBI outcomes to enhance realistic expectations; (2) the effects of TBI on family systems and possible alterations in family dynamics post discharge; (3) the benefits, challenges, and responsibilities of care-taking and supervision post discharge; and (4) resources available for post acute rehabilitation. unlimited  Page 45 THANK YOU… unlimited