Occupational Therapy after Traumatic Brain Injury

Uploaded by MUSHPWeb1 on 06.04.2011

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>> 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.
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