Physical Therapy Following Traumatic Brain Injury (TBI)

Uploaded by MUSHPWeb1 on 22.03.2011

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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 Jeff Krug,
clinical instructor of physical therapy in the MU School
of Health Professions, to learn about physical therapy
after a Traumatic Brain Injury.
And Jeff, thanks a lot for being with us.
We appreciate it.
>> Jeff Krug: Glad to be here.
>> Interviewer: Jeff, at what point would a physical therapist
become involved with a patient following a TBI?
>> Jeff Krug: Right.
Physical therapy gets involved right away
in the acute care setting.
So they'll see people even when they're unstable medically.
Or, you know, kind of a scary environment
where patients are attached to a lot of tubes.
And we're still trying to make sure they're healthy.
And then we'll also see them once they're transferred
to rehabilitation centers.
So then we start to really focus on the things the person needs
to do to get back home.
And then we'll see them as out-patients, so they'll come
in for out-patient therapy as well.
Maybe come in once or twice a week, sometimes more.
We'll see them in home health and actually work with them
in their home environment.
So physical therapy covers a wide range
of environments in this population.
>> Interviewer: What can you do for a person in the early stages
when they're still in the acute care facility?
>> Jeff Krug: Right.
The main focus then is keeping people flexible and doing things
like range of motion and stretching them out,
keeping their muscles loose, monitoring their skin
to make sure that there's no skin breakdown or sores.
So we might help with the positioning program the
client has.
We'll do some basic exercise lying in bed
if the client is able to do that and able to kind
of tend to what we're doing.
We'll also make sure that as far as the positioning program goes,
not only maintaining skin integrity,
but keeping the flexibility aspect.
Not just stretching, but positioning plays a huge role.
Often after damage to the brain or an injury to the brain,
people develop some abnormal tightness,
something we call muscle tone.
And so we play a role in positioning,
sometimes even using things like casts and splints to try
to keep people as flexible as possible so when they can get up
and move around, their muscles haven't tightened up
and they're not limited.
>> Interviewer: What are the overall goals
of physical therapy?
>> Jeff Krug: Right.
Our main goals are mobility.
So it kind of is what it sounds like,
it's all about the physical functioning.
So we focus on the big things like getting in and out of bed,
getting on and off the toilet, In and out of a wheelchair,
in and out of the car.
And then the big one, of course, is walking,
which is a prime goal for a lot of people,
so we're fortunate in that regard.
It's very motivating.
So we focus mobility.
And then what we really do is we analyze the aspects
that affect mobility.
So are there problems with strength, with flexibility?
Is there abnormal muscle tone?
How could we decrease it if it's too high,
or increase it if it's too low?
Are there sensory problems, balance problems,
coordination problems?
So all of those basic impairments that result
in problems with what we call functional limitations
or functional activities like mobility.
>> Interviewer: So as a physical therapist, you really have
to do some analysis at the outset to figure
out what the patient needs before you actually engage
in the therapy obviously, right?
>> Jeff Krug: Right.
We do a very thorough assessment,
o covering all those aspects
that I mentioned we have some specific tests that we use.
And then there's even some specific outcome measures
for this population, where instead
of assessing just strength or sensation,
we'll actually assess some movement activities, some tests
and measures that have been studied and found
to be reliable and valid.
And so then we could take a baseline measurement
on a person, how they do with some basic mobility skills.
We could test them again later and see what kind
of a change we're getting, and also determine are they at risk
for falling, what's their mobility like?
>> Interviewer: What are some other things?
We talked about the early stages.
What are some other things that you could do for a person
with a TBI as they progress through their therapy?
>> Jeff Krug: Right.
As a person moves into rehab, the goals really become
about what does that person need to do to get back home?
And of course, everybody wants be a return to normal,
so they want to be able to move like they did before.
They want to be able to do all the activities
that they did before, and so we're going to try to make
that as possible, you know, as we can.
Sometimes that means compensating
and teaching the person different
compensatory strategies.
Maybe one side of their body moves well,
and the other side has some limitations.
Teaching them to use the side that's intact,
more specifically though, what we like to do
in rehab especially is focus on regaining function.
So we have some specific treatment approaches
that we have learned and gone to continuing education and studied
so that we can use those approaches
to regain the movement that has been lost.
>> Interviewer: I would think there would be some differences
in working with a child, an adult and an older person.
Is that right?
>> Jeff Krug: Yeah.
Some of it's just the interest
that people have at different ages.
When you're working with a child it becomes more
about play activities.
When you're working with someone who's middle-aged it becomes
about, you know, work and home activities.
And likewise, with an older adult,
it's some of the same homemaking or things that they do
around the house or being able to do social activities.
But maybe it's different in that, you know,
our bodies change as we get older, so how we move.
So with kids it becomes how can we engage those kids?
What can we do?
We not only have to come up with what we're actually trying
to treat, but we also have to come up with fun ways to do it.
So it becomes about incorporating play
into actually getting the movements that we want.
>> Interviewer: All right, Jeff.
Let's take a look at how you might work with a client.
>> Jeff Krug: Great.
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>> Interviewer: And joining us now is Evelyn who's going
to help us with our demonstration.
And Jeff, how would you help this client?
>> Jeff Krug: Right.
Well, with a Traumatic Brain Injury we could have a wide
variety of presentations.
Some clients are functioning at a lower level
where they may not be responding to a lot of cues,
following a lot of directions, have very limited movement.
Therefore, our treatment would be really focusing
on their positioning when they're lying in bed
or in a wheelchair, things to keep them flexible, splints
and positioning devices, range of motion.
But for our purposes, we're going to go ahead
and have Evelyn kind of simulate a common presentation
that we see with a brain injury, and that's where one side,
her left side, is going to be a very strong side with lots
of good movement, and on the right side we've got both legs,
both extremities are a little weaker.
Her arm is a little bit tighter.
She's holding it in a position like this.
And so that's a common presentation
with one-sided weakness and abnormal tightness.
And so we'll focus on that.
And so with Evelyn we will work on some bed mobility,
lying down, rolling, sitting back up.
But we're going to start with some more upright activities,
and these are critical to brain injury recovery,
especially with physical therapy.
We want the body to start to feel things like it did before.
Be lined up and symmetrical in sitting and in standing,
so it starts sending messages back
to the brain telling the brain where it is.
And hopefully that gets the movement
to start to happen again.
And so we would start with some sitting activities,
and that would involve some postural things.
So I may sit on the side of Evelyn, or I may actually get
up behind her and actually kneel behind her
and encourage her body to be upright and lined
up equal weight on left and ride side.
And so I may use my hands or even other parts of my body just
to kind to bring her upright, stretch her out,
make sure she's leaning to both sides.
I'll talk to my fellow team members,
especially the occupational therapist,
and discuss the best methods of maybe relaxing this arm
and getting it to loosen up, and putting it in a position
where she's putting weight through it.
That helps to kind of stretch it out and relax it as well.
And then I could focus on what's going on at the trunk.
We can strengthen the trunk muscles.
We can work on some balance things while we're here,
some reaching, some weight shifting,
and then once Evelyn demonstrates some improved
skills here, we would progress to where what we want
to do is go from a sitting position to a standing position.
And so again, with a Traumatic Brain Injury a variety
of abilities are there,
so the person's cognition may be impaired.
They may not be able to follow directions.
They may not understand what I want from them, a nd therefore,
I may have to demonstrate.
Or better yet, in physical therapy we use our hands
and we use our bodies,
especially in neurological rehab, to guide the movement.
And so that's what I'm going to do is I'm going to go ahead
and tell Evelyn what I want, maybe even demonstrate,
ut then also guide her through the movement.
And so the first thing we'll do is we'll say, "You know, Evelyn,
I want you to go ahead and stand on up."
And so we'll go to her legs and make sure they're on the floor,
we definitely want that so she's getting weight through her legs,
sending those sensory messages to the brain.
We're going to make sure it's symmetrical.
We may even take her weaker leg and move it back a little more
than the other leg so that we're forcing that leg
to do more of the work.
And so now what we'll do is kind of guide Evelyn forward
and when she gets far enough forward, I'll say to her,
"You know, if you feel like you're coming off the table,
go ahead and stand up."
Now, Evelyn may do like she just did and go
and activate those muscles and come to a full stand.
Or it may be that she's a little bit weak, and so her leg wants
to give way a little bit.
Her hip falls backward.
You see her trunk coming forward, so it's my job to kind
of support her and guide her back into an upright position.
I'm using my leg to block her knee so it doesn't give way,
I've got an elbow on her hip keeping her in place,
I've got a hand on her chest, so we're getting
that upright, good aligned posture.
And then from here what we can do is we can shift our weight a
little bit, and start
to actually put more weight on this right leg.
Typically, people like to rely on their strong side,
so they'll lean onto the strong side
and not give the weaker side a chance to do anything.
But I'm going to guide her and help her to come over here
so this leg gets the opportunity to feel this activity
like it did before and maybe start to resume functioning.
If her leg wants to give way a little bit,
what I can do is I can do a little bit of tapping
over the muscle, I can rub along the muscles.
A lot of times that will help to stimulate it
and get it to fire a little bit.
We can press downward a little a bit.
That'll activate some of the muscles in her trunk,
in her hip and her leg.
We can shift our weight side-to-side, but also forward
and back to start to get
that leg coming forward over the foot.
Maybe stretch that out if it's tight
down around the ankle area.
And then from here, once Evelyn's demonstrated
that she can hold this posture fairly well,
what we might do is ask her to go ahead
and shift all her weight over to this side
and step forward with the left leg.
And then shift and step back.
So now when she shifts and steps forward,
the entire body weight is going over this right leg.
Lots of sensory feedback to the brain, lots of stimulation
to get those muscles firing and working again, now standing,
shifting our weight, stepping and walking.
Those are things we've done throughout our entire life.
They're kind of automatic.
And so what we'd really like to do, at this point we've kind
of broken walking into pieces.
We're just doing the shifting and stepping here.
And we'll probably get a decent response,
but we might even get a better response from here
if we went ahead and just started,
if I provide some support and started her walking.
It's an automatic activity.
Our brain recognizes that it's something we've done
for a long time, so we'll try to tap into that as well.
Now, when it's time to rest or we finish the activity,
we'll go ahead and make sure she's nice and controlled.
Slow sitting, very symmetrical,
working the muscles not only coming up
but also going back down.
So those are some really good basic starting activities
for a person at this level just trying
to get the body moving like it did before.
>> Interviewer: All right, Evelyn and Jeff.
Thank you so much for that demonstration.
And we thank you for watching this interview
on Physical Therapy After TBI,
service of the Brain Injury Guide and Resources.
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