TRAUMATIC BRAIN INJURY AND OCCUPATIONAL THERAPY

RANCHO LOS AMIGOS SCALE

AKA Level of Cognitive Functioning Scale (LOCFS)

LOCFS 1-3

Decreased response levels

Level I - No Response.

Level II - Generalized Response.

Level III - Localized Response.

OT Aims:
- Maintain ROM; Prevent contracture development
- Maintain skin integrity; Prevent decubitus ulcers
- Maintain respiratory status; Prevent complications

- Provide sensory stimulation; For arousal and to elicit movement

- Promote early return to functional mobility skills

OT Intervention
- Splinting; resting hand splint, antispasticity splint, AFO
- PROM
- Positioning; profer body alignment
- Sensory stimulation; auditory, visual, olfactory, gustatory and tactile

LOCFS 4-6

Mid-level recovery "Confused levels"

Level IV - Confused, Agitated Response.

Level V - Confused, Inappropriate, Non-agitated Response.

Level VI - Confused, Appropriate Response.

OT Aims:
- Prevent over-stimulation; confused and agitated pt
- Promote structured environment
- Increase memory ability and tolerance 

OT Intervention
- Behavioural modification 

- Education to pt and career; memory log, relaxation techniques, daily schedule

- Task simplication; break into small component, familiar activities, provide verbal and physical cues
- Reality orientation; time, place, person
- Safety education and management

LOCFS 7-10

High-level recovery "Appropriate levels"

Level VII - Automatic, Appropriate Response.

Level VIII - Purposeful, Appropriate Response (Alert and Orientated).

Level IX - Purposeful, Appropriate Response (Stand-by Assistance on Request).
Level X - Purposeful, Appropriate Response (Modified Independent).

OT Aims

- Promote independence in functional tasks
- Behavioural modification

- Improve postural control, symmetry and balance

- Provide emotional support

- Encourage socialization

OT Intervention

- Problem solving activities
- Functional skills retraining; mobility, ADL

- Behavioural, cognitive and emotional reintegration OT Aims

- Pt and family education

STROKE AND OCCUPATIONAL THERAPIST

What is Stroke?

Also known as CVA, cerebral vascular accident is a rapid loss of brain fx due to disturbance of blood supply to the brain.

Neuropathology

1. Atherosclerosis: plaque / fatty material in blood vessel and narrowing blood lumen >> reduction of blood flow.
2. Cause blood clot within vessel / by releasing small emboli through disintegration of atherosclerosis plaques.
3. Embolic infraction occurs somewhere in circulatory system.
4. Heart consequence as atrial fibrillation.
5. Enter cerebral circulation and occlude blood vessel at brain.
6. Causing brain low in energy.
7. Brain resort using anaerobic respiration within region of brain tissue affected by ischemia.
8. Result in stroke.

Causes

• Thrombus - blood clot within blood vessel
• Embolus - abnormal particles, air bubble / part of clot
• Anoxia - severe lack of oxygen in tissue / organ
• Hemorrhage - bleeding, blood flow from ruptured vessel
• Aneurysm - abnormal blood filled swelling, weakness of vessel wall
• Systemic Hypo perfusion - reduction of blood flow to all part of body cause by cardiac arrest / arrhythmias

Thrombus

Hemorrhage

Emboli

Neurological Deficit

Lt CVA (MCA)

• Loss of Voluntary Movement / Coordination.
• Impaired Sensation.
• Language Deficit.
• Problem in Articulate Speech.
• Blind Spot at Visual Field.
• Memory Deficit.
• Slow / Caution Personality.

Rt CVA (MCA)

• Weakness of Muscle.
• Impaired Sensation.
• Spatial & Perceptual Deficit.
• Unilateral Neglect.
• Dressing Apraxia.
• Impulsive Behaviour.

ACA Injured

• LL Paralysis.
• Loss of Sensation of LL.
• Loss of Bladder Control.
• Balance Problem.
• Lack of Spontan Emotion.
• Whispered Speech & Communication.
• Memory Impaired / Loss.

Vertebro Basilar Injured

• Visual Disturbance.
• Impaired Temperature Sensation.
• Impaired to Read / Name Objects.
• Vertigo / Dizziness.
• Balance Problem.
• Paralysis of Face.

Client Problem in Aspect of Domain of OT

Areas of Occupation 

1. Activities of Daily Living (BADL / ADL) 
2. Instrumental of ADL
3. Rest & Sleep
4. Education
5. Work
6. Leisure
7. Social Participation

Specific Assessment 

• Canadian Occupational Therapy Performance Measure / COPM - http://www.caot.ca/pdfs/57(2)82-87.pdf
• Stroke Impact Scale - http://www.northeastrehab.com/Forms/NRH_Forms/SIS_Handout.pdf
• Functional Independence Measure / FIm - http://www.va.gov/vdl/documents/Clinical/Func_Indep_Meas/fim_user_manual.pdf
• Kohlman Evaluation of Living Skill / KELS - http://www.health.utah.edu/ot/colleagues/evalreviews/kels.pdf
• Assessment of Motor and Process Skill / AMPS - 
• Role Check list - http://occupationaltherapyassistant.edublogs.org/files/2012/07/OTA-II-Lecture-6-handout-Role-Checklist-Instructions-2-15dc0y0.pdf
• Self-assessment of Leisure Interest - 
• Norbeck Social Support Questionnaire - http://nurseweb.ucsf.edu/www/NSSQ-Background.pdf
• Baltimore Therapeutic Equipment / BTE - 
• Nottingham Extended ADL Skill / NEADLS - http://www.nottingham.ac.uk/iwho/documents/neadl-notes.pdf
• Drivers Performance Testing - 
• Structured Observation of Activity Performance - 

Performance Skills

1. Motor and Praxis Skill

Specific Assessment

• Praxis
  - Goodglass Test of Apraxia
• Postural Control / Balance
  - Functional Reach Test -http://www.aic-learn.sg/uploadedFiles/Training_Grants/HDMP-ILTC/F.Functional%20Reach%20Test.pdf
  - Tinetti Balance Test - http://www.fysiovragenlijst.nl/docs/pdf/Tinetti%20Assessment%20Tool.pdf
  - Berg Balance Test - http://www.aadep.org/documents/filelibrary/presentations/pmd_evaluationmartin_and_pilley_aafp/BERG_B2_4FD2998A0AB77.PDF
  - Abreu's Quadraphonic Approach Postural Test -
  -Motor Assessment Scale / MAS (Balance Item)- http://www.rehabmeasures.org/PDF%20Library/Motor%20Assessment%20Scale%20Testing%20Form.pdf
• Functional Gross Mobility (in bed, during seated task performance, sit to stand, functional ambulation)
  - MAS
  - Timed Get Up and Go Test - http://www.unmc.edu/media/intmed/geriatrics/nebgec/pdf/frailelderlyjuly09/toolkits/timedupandgo_w_norms.pdf
• Skilled Arm and Hand Function
  - Fulg-Meyer Assessment - http://reseauconceptuel.umontreal.ca/rid=1K6ZN0YYW-1Z7JDJS-Z5/FuglMeyer.pdf
  - Wolf Motor Function Test - http://www.midss.ie/sites/www.midss.ie/files/wolf_motor_function_test_data_entry_form.pdf
  - MAS
  - Arm Motor Assessment Test -
  - Functional Test of Hemiplegic / Hemiparetic Upper Extremity -
  - Chedoke Arm & Hand Activity Inventory -
  - Motor Activity Log -
• Cognitive-Perceptual Skill (Judgement, Insight, Memory, Executive Fx)
  - LOTCA -
  - A-One -
  - Contextual Memory Test -
  - Rivermaid Behavioral Memory Test - 

Performance Pattern

• Habits, Routine, Ritual before and after onset
  - Activity Card Sort
  - Client and Family Interview
  - Time Configuration Assessment
  
• Context and Environments (Personal, Physical, Social, Temporal, and Virutal)- COPM- Norbeck Social Support Questionnaire- Accessibility Check list
  
• Activity Demands
  
  Physical, Spatial, Social and Temporal- Observation- Interview

• Sensory-Perceptual Skills (Spatial Relation, Visual Scanning & Perception)- Motor-Free Visual Perception Test- LOTCA- A-one- Cancellation Tests

Client Factors

1.     Primary Impairments

• Flaccid Paralysis (Paresis / Weakness)- Fugel-Meyer Assessment
• Spasticity - Modified Ashworth Scale
• Dysphagia- Video fluoroscopy- Modified Barium Swallow- Functional Feeding Assessment
• Somatosensory Deficits- Screen of Tactile & Proprioceptive Recognition- Screen of Tactile Discrimination- Stereognosis Screen
• Visual Field Deficit, Spatial Neglect, Topographic Disorientation, Attention Deficits- Confrontation Tests- Cancellation Tests- Functional Assessment / -Navigation- Test of Everyday Attention
• Impulsivity, Lability, Impaired Judgement, Impaired Insight- Functional Assessment

2.     Secondary Impairment

• Postural Malalignment- Visual and Manual Postural Assessment
• Limited Flexibility between Body Segment- Visual and Manual Assessment
• Limited Passive Range of Motion (ROM)- Goniometer
• Shoulder Subluxation- Visual and Manual Assessment
• Upper-Limb Distal Edema- Volumeter- Circumferential Measurement- Figure of Eight Measurement
• Complex Regional Pain Syndrome- Visual and Manual Assessment of Symptoms
• Learned Non-use- Motor Activity Log

Functional Limitation Commonly after Stroke

1. Inability to perform chosen occupation while seated
   Why? Loss of trunk and postural control.
   E.g. feeding, dressing, toileting, oral care, transfer and meal preparation
2. Inability to engage chosen occupation while standing
   Why? Impaired postural strategies
   E.g making a bed, stepping up on a curb, cleaning a wall mirror, and doffing slippers
3. Inability to communicate secondary to language dysfx
   Why? Damage to left (/right) hemisphere of brain
   E.g aphasia (global, wernicke's, broca's, anomic) and dysarthia
4. Inability to perform chosen occupation secondary to neurobehavioral / cognitive-perceptual impairment
   Why? Neurologic processing dysfx
   E.g Spatial relationship and spatial positioning, spatial neglect, body neglect, apraxia (motor / ideational), attention, figure-ground, initiation and perseverance, visual agnosia, problem solving
5. Inability to perform chosen tasks secondary to UL dysfx
   Why? Pain, contracture, deformity, weakness, loss of selective motor control and bio-mechanical alignment
   E.g reaching and manipulation

OT Intervention
Plan
- client’s goal within an OTPF
- planned intervention approaches
- recommendation / referral to others

Implementation

1.     Prevent Secondary Impairment

•  Prevention of postural deficits
  - slow, gentle, passive stretch to all muscle group
  - self exercise programmes in affected and non-affected limbs
  - bed and wheelchair positioning

• Preventive of pain (joint immobility and abnormal joint alignment)
  Shoulder Subluxation
  - provision of external support
  - external stimulation of rotator cuff muscles (TENS)
  - maintaining soft tissues length 
  - positioning programs- soft tissue elongations
  - splinting
  - client mx; weight bearing
  Hand Edema
  - Active movement of hand
  - Positioning of elevate the hand, compression and gentle massage techniques.
  
  Pressure Ulcers
  - Positioning and bed mobility
  - Sitting balance and weight shifting

•  Prevention of learned non-use
  - Teach client to be aware and use paretic limbs to the limits of current available motor fx.
• Prevention  of injury due to fall
  - Practice of unsupported sitting and functional standing
  - Home environment & structural adaptation
• Prevention of aspiration during feeding, eating and swallowing
  - Ax of oral motor skills and swallowing to determine whether client may proceed to solid and liquid diet.
  - Positioning intervention for safe and efficient swallowing
  - Improve sensation and muscle tone of oral structures
• Prevention of depression following stroke
  - Recognize sign&sx of depression for appropriate medical and psychological intervention

2. Restore Performance Skills

• Restore functional use of hemiparetic arm to maximum potential
  - Passive movement and exercise to improve scapulohumeral rhythm
  - Functional reaching tasks in all planes of motion
  - Practice performing functional tasks requiring highest level of grasp patterns from variety of trunk and arm position.
• Restore functional sitting balance skills to maximum potential
  - Functional tasks with graded challenges to shifting weight to all planes of motion while sitting, bending and reaching
• Restore functional skill in somatosensory processing to maximum potential
  - Improve tactile processing in hemiparetic limbs
  - Improve vestibular processing; graded tasks requiring maintain balance with different base of support (while standing / sitting)
• Restore functional skills in cognitive processing, planning and performance
  - Enhances client awareness of their neurobehavioural impairment
  - Graded practice opportunities to improve specific skill
  - Teach client to assess their own activity performance to make decision that will enhance their success in performing tasks
  - Teach client alternative strategies to maximize their performance in task situation that present cognitive or perceptual challenges
• Restore functional social interaction skills
  - Identify social challenges is currently experiencing, present role-playing situation
• Modify home environment
  - Modification of bedroom and bathroom
• Modify procedure of performing valued daily activities
  - Dressing or transfer techniques, using adaptive equipment
• Modify daily routine
  - Prepare daily schedule
• Maintain muscle length, joint ROM and postural alignment
  - Teach client and career for home programmes exercises
• Maintain improvement in balance
  - Ongoing appropriate challenges to current skills
• Promote Quality of Life and satisfaction
  - Provide structured, individual assignment for managing time
• Promote use of paretic limb
  - Use Motor Activity Log to set own goal of paretic limb use