Rehab Cell

Physical Medicine and Rehabilitation

Occupational Therapy after Traumatic Brain Injury

Occupational Therapy after Traumatic Brain Injury


[ Music ]>>Interviewer: The Brain Injury
Guide and Resources is a tool for professionals,
community members and family to understand Traumatic
Brain Injury, as well as how to promote better living for
those who live with a TBI. In this interview we will
talk with Giuli Krug, clinical assistant professor
of Occupational Therapy in the MU School of
Health Professions, to learn about occupational
therapy after a Traumatic Brain Injury. And Giuli, thanks a
lot for being with us. We appreciate it.>>Giuli Krug: It’s
good to be here. Thanks for having me.>>Interviewer: Giuli, when does
an occupational therapist become involved with a patient
following a TBI?>>Giuli Krug: Typically
occupational therapy will become involved as soon as somebody
is medically stable and able to tolerate intervention.>>Interviewer: And so what
would you do with a person at that very early stage?>>Giuli Krug: It depends on
their level of responsiveness. If an individual at
that point was still in what we would call a
minimally responsive state, we might work primarily on
positioning, range of motion and caregiver training. We may also work at that point
on fitting for a wheelchair so that family members, caregivers can move
the individual to different environments
for stimulation purposes. Another thing that we might work on with somebody who’s minimally
responsive is establishing a stimulation program
for that individual to provide regular stimulation
of all of the senses, vision, hearing, tactile senses, etc., to try to awaken
the sensory systems. If somebody is higher
functioning than that, we may begin right off the top
working on those automatic, over-learned kinds of activities
that we’ve all been doing since we were very young. So we might work on dressing
and hopefully tap in to some of those automatic
behaviors that were so familiar prior
to the accident. Often with those types of activities we can get more
engagement, both cognitively and physically, as a result.>>Interviewer: What are the
goals of occupational therapy?>>Giuli Krug: The
long-range goals of occupational therapy are to
help an individual to become as independent as possible in their meaningful
everyday activities. So for some people that may
be basic self-care activities: Bathing, dressing, grooming,
those kinds of things. For other people
it may go beyond that to home management
types of activities, work-related activities,
even leisure and play time activities.>>Interviewer: So Giuli,
what is the difference between physical therapy
and occupational therapy?>>Giuli Krug: Sure. Physical therapy is
primarily focused on mobility. And so anything that interferes
with somebody’s ability to get from point A to point
B, it typically falls under physical therapy’s realm. And occupational therapy,
where we certainly look at and consider mobility,
we look at that in terms of how does it impede one’s
ability to participate in their everyday
life activities? So we don’t solely
look at mobility. We look at overall
motor functions, cognition, visual perception. And any other type of
sensory disturbance that could potentially affect
somebody’s ability do their everyday tasks.>>Interviewer: And you talked about how you would help a
person at a very early stage. But how does occupational
therapy help a person with a TBI beyond that?>>Giuli Krug: TBI is
a very complex picture, especially in occupational
therapy because we do look at so many different aspects
of a person, so whereas early on we may be looking at more
physical maintenance types of things. As somebody progresses
and continues to improve through their recovery,
we will work on at varying degrees
those cognitive skills and motor skills in
task-specific ways. So we won’t just merely
do exercise, for example. We might work on
it strengthening, actually using a
functional activity. So for somebody who’s
perhaps independent with their daily living skills,
but still having difficulty with work-related tasks and
so on, we would just advance that treatment to really
focus in on the skills that are interfering with
return to work successfully.>>Interviewer: All
right, Giuli. Let’s take a look at how you
might work with a client.>>Giuli Krug: Okay. [ Music ]>>Interviewer: And
joining us now for our demonstration is Evelyn. And Giuli, tell us how you
would work with Evelyn.>>Giuli Krug: Okay. Well, we’re assuming at this
point that Evelyn is four, perhaps six months
after her brain injury. And I would assume up ’till this
point we probably would have spent considerable time
working on positioning, maintaining range of
motion, initially working on increasing responsiveness and
then perhaps moving into a phase to help her become more
independent using whatever she possibly can, whatever part
of her body she can to work on bathing and dressing
and grooming, and some of the basic
self-care tasks. Typically four to six
months post-injury, an individual may be living in
the community in their own home. And that’s often when we see that folks find they
have more difficulty than they anticipated
doing cooking activities, cleaning activities, return- to-
worktime types of activities, etc. So the first thing I notice
with Evelyn is her posture. I notice that her head is down and her shoulders
are a bit forward. And I notice that her arm looks to be fairly tight
against her body. Besides just looking at the
physical component of that, one thing, as an
occupational therapist, that I’m questioning
is her visual and cognitive abilities as well. Sometimes postural
abnormalities can be related to either cognitive and/or
visual deficits as well. So the first thing I’m
going to try to do is see if I can get Evelyn’s attention, and if she can correct
her own posture. So hello, Evelyn. How are you today? I’m wondering, can you sit
yourself up nice and tall? Good! Great job! Can you understand me, Evelyn? My name is Giuli. Okay. I want to make sure
that you can understand me. Can you go ahead and touch
your nose with your left hand? Very good. Thank you. And how about touching your
right knee with your left hand? Great. Thank you. Okay. By asking those
questions and having her move, I actually can look at a whole
grouping of different things. Not only is she understanding
me, does she have the motor
control to touch her nose with her finger to touch
her knee with her finger. and to discern right and left by touching her right
knee versus her left knee? So at this point, I’m
feeling relatively confident that she’s understanding
me pretty well, in spite of the fact
of being unable to verbalize back with me. Evelyn, I’m wondering if you
would be willing to take off that outer shirt for me
so I can see how you move. Okay. I’m going to ask you
to go ahead and get started and just do it the way
that you normally do. So typically, what we see
after a brain injury is that individuals
will automatically go to using the stronger
side of their body for their daily functional
tasks. Oftentimes in the rehabilitation
setting, acutely after injury, we have to go to a
compensatory type of strategy so that the person can become
as independent as possible as quickly as possible due to
short rehabilitation stays. After somebody has
completed that rehabilitation and has regained independence
in their daily activities, our goal is then to help them to
learn to use that nonfunctioning or lesser functioning extremity
during their functional daily activities. So here I’m just taking a look
at how Evelyn is moving normally for her at this point. [ Silence ] I’m encouraged that Evelyn
is actually attempting to use her right hand. It doesn’t appear that
she has good motor control in her right hand at this point. I will evaluate that further. But that she did stick her
sleeve in her hand shows me that she has recognition
of that side of her body. And she is aware that her arm is
there, which is very positive. I see she has some gross
movement of her arm here as she attempts to
pull her arm out, which is also very encouraging. That was perfect. Thank you very much! Okay. Can you guess what I’m
going to ask you to do next? I’m going to ask you to put
the shirt back on for me. Is that okay? Okay. I’ll have you go ahead and do it how you would
normally go about the task. [ Silence ] What we’re seeing here is
Evelyn is using a very classic compensatory strategy
for an individual who has lesser movement on one
side of the body than the other. She took her shirt off
of the strong side first, and she’s putting it on
the weaker side first. That’s the easiest way
to get a shirt on and off when you only have function
in one side of the body. Evelyn, do me a favor this time. When you’re pulling your
shirt up, will you try to straighten this
arm, your right arm, out as far as you can please? See if you can do it with
just your muscles and not by helping with this hand. Can you straighten your arm out? Good! That’s great! Go! Go! Go! Keep going! Keep going! Look at you, Evelyn! All right! And then pull that sleeve up. So this gives me the opportunity to see how much motor
control Evelyn has that she doesn’t typically use. [ Silence ] From here what I would do is
I would take a look overall at Evelyn’s movement of the
whole right side of her body in terms of how she engages
that side of her body, and the activities she’s
having difficulty with. And then we would proceed
to engage in treatment that incorporates the
right side of her body, working on motor
control, coordination, isolating movement
specifically for the task that she’s having the
most trouble with. Additionally, I would keep my
eye on her cognitive abilities. If she’s having difficulty
following directions, etc., we can modify the tasks that
we do in therapy accordingly. And if it is determined
eventually at some point that she has any other
issues with vision, sensation and so on, we can address
those in the context of functional activity as well. Can you button your shirt? [ Silence ] Can this hand help? [ Silence ] I can learn more from watching
somebody use their body and use their mind during
their everyday life activities, than I can from any
paper and pencil task. And it’s very helpful for us
as occupational therapists to use this type of
activity, both to assess and to treat individuals
after brain injury.>>Interviewer: All
right, Giuli and Evelyn. Thank you very much
for that demonstration. And we thank you for
watching this interview on Occupational Therapy
After TBI, a service of the Brain
Injury Guide and Resources. [ Music ]

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