Lecture slides for Session 2B

1. OT 537 ABI Part 3

2. The Glasgow Coma Scale (GCS)

3. Video series on coma: https://www.youtube.com/watch?v=aAvyVJ7SJZ8&feature=youtu.be

4. Rancho Los Amigos Scale
Level I No Response: Total Assistance
Level II Generalized Response: Total Assistance
Level III Localized Response: Total
Level IV Confused/Agitated: Maximal Assistance
Level V Confused, Inappropriate Non-Agitated: Maximal
Assistance
Level VI Confused, Appropriate: Moderate Assistance
Level VII Automatic, Appropriate: Minimal Assistance for
Daily Living Skills
Level VIII Purposeful, Appropriate: Stand-By Assistance
Level IX Purposeful, Appropriate: Stand-By Assistance on
Request
Level X Purposeful, Appropriate: Modified Independent

5. Justin’s Story
Video: https://youtu.be/lr8yMCAZKoI

6. Severe Disorders of Consciousness
As seen in the ICU:
• Trach
• ICP Monitor
• NG or G-tube
• Restraints
• Protocols for positioning
and stimulation
“The vast majority of individuals
who cross that one-year mark
without clear signs of
consciousness are not going to
recover consciousness after that.”

7. Hydrocephalus
Retrieved from http://familyshields.blogspot.com
Link to Prezi: http://prezi.com/gppghva3zkr9/?utm_campaign=share&utm_medium=copy&rc=ex0share

8. Transitioning from the Medical Treatment
Phase to the Rehab/Recovery Phase after TBI
Priorities:
 Medical stability
 Reduction of physical impairments
 Acquisition of basic self-care skills

10. Click here for
demo videos:
• Part 1
• Part 2

11. The Role of Occupational Therapy with Clients
with Severe Disorders of Consciousness
Restorative & Preventative Strategies
 ROM exercises
 Positioning protocols
 Tone alteration methods
 Reducing agitation by
normalizing/regulating the
environment
 Sensory stimulation (?)
 Family/caregiver education
and support
Intervention lays the foundation for later
focus on occupational engagement.

12. Ten Years Strong:
Nate’s Journey After TBI

13. The Role of Occupational Therapy with Clients
with Emerging Functional Statuses after TBIStrategies to Promote
Alertness/Participation and “Just Right
Challenges”
 Optimizing motor function with
a purposeful/functional
foundation
 Improving strength and
endurance
 Targeting balance and more
automatic skills
 Maximizing freedom of
movement and access to making
choices while maintaining safety
 Addressing social-emotional
and behavioral challenges
 Consulting with
family/caregivers and rehab
team
“One step
forward,
two steps
back”

14. The Role of Occupational Therapy in Facilitating
Community Reintegration in Clients after TBI
Centered on improving the acquisition and application
of skills in the following areas:
 Physical abilities including functional mobility
 Cognitive functioning
 Social integration
 Productivity
 Perception of self
 Interpersonal relationships
 Independent living skills (ADLs and iADLs)
OT intervention in this phase typically involves relearning (remediating) and
learning new ways to do things (compensatory strategies).

15. Tips for Providing Intervention
 Allow time for rest.
 Keep the environment
and instructions simple.
 Set reasonable goals.
 Give feedback and
redirect when necessary.
 Provide choices and vary
activities.
 Remember: Many times
patients do not remember
the facts, but they
remember how they felt!!
An OT Intervention Session
Recommended resource:
http://tbirecovery.org/LongTermPhase.html

17. Cerebrovascular Accident (CVA)
 Abnormality of brain function caused by disruption in
circulation leading to tissue damage
 4th Leading Cause of Death in US
 Affects approximately 795,000 people a year
 85% have upper limb impairments/15% regain hand
function
 Transient ischemic events (or Transient ischemic
accidents – TIAs) are similar to strokes; however the
tissue damage caused by a TIA is not permanent.

18. Ischemic infarction
The blood supply to the region is restricted due to
an occlusion of the blood vessel supplying the
area. These account for 87% of strokes.

19. Hemorrhagic Infarction
 A blood vessel to the brain ruptures.
 Accounts for 13% of strokes and are more fatal.
 Location and amount of tissue damage determines the
severity of symptoms and extent of disability.

20. Possible Presentation of Right
Hemisphere CVA
- Left hemiplegia
- Difficulty with special-perceptual tasks
- Learns better from verbal instruction vs. gestures
- Overestimates own abilities
- Impaired judgment and safety issues
- Disjointed thinking-patient may need more cues
- Increased distractibility
- Left side neglect

21. OT Session: Client with Left Neglect

22. Possible Presentation of Left Hemisphere CVA
 Right hemiplegia
 Verbal language deficits/Better with non-verbal
communication
 Difficulty with multi-step commands
 Impaired retention of information. Will need cues.
 Impaired right/left discrimination and recognition
 Disorganized approach to new problems- slow and cautious.
 Increased lability/May be behaviorally inappropriate.
 Easily angered/frustrated. Patient usually recognizes they
have deficits, especially in language and becomes frustrated

23. Terms
 Hemiplegia- full paralysis
 Hemiparesis- incomplete or partial paralysis
 Dysphagia
 Aphasia
 Dysarthria- motor speech disorder
 Somatosensory Deficits
 Incontinence
 Cognitive Deficits

24. Assessment
 Postural Control
 Sensation
 Endurance
 Functional performance
Upper Extremities:
 Voluntary Movement
 Coordination
 Strength- MMT/Functional Tasks
 ROM

25. Assessment
 ADLs
 FIM-The FIM is an 18-item, seven level ordinal
scale. Completed in approximately 20-30 minutes
in conference, by observation, or by telephone
interview.
 Barthel Index- 10 variables describing ADL and
mobility. A higher number is associated with a
greater likelihood of independence

26. Treatment
 Emergency Dept.  ICU: Breaking up clots, returning
oxygen to tissues, monitoring intracranial pressure
 Acute care: Early mobilization, return to self care, skin care,
fall prevention
 Rehabilitation: Promote return of motor function,
regaining occupational function; developing independence;
patient and family education
 Transition: Discharge planning, access to resources, return
to valued occupations, home and task modifications,
continued care and therapy as needed

27. Primary Goal: Prevent or Minimize Impairments
Hypotonicity in an upper extremity- increased risk for
subluxation and may benefit from a support sling.
Hypotonic in a lower extremity- support boot to prevent foot
drop and tightening of the heel cord may be indicated.
Treatment of patient with hypertonicity- Slow, prolonged
stretching, splinting and appropriate positioning to minimize
the chance of contractures. Out of bed and upright positioning
decreases chances of complications including bed sores,
pneumonia and de-conditioning.

28. Factors That Influence Recovery after CVA
Positive
1. Early return of muscle tone- 2 weeks
2. Early return of muscle function- 2 weeks
3. Intact sensation
4. Minimal spasticity
5. Intact cognition
6. Intact body scheme
7. Some spontaneous use of affected UE

29. Factors That Influence Recovery after CVA
 Negative Prognosis
-Prolonged muscle tone problems
-Apraxia- Difficulty with motor planning
-Poor sensation
-Receptive aphasia
-Unilateral Neglect
-Poor body scheme
-Poor spatial relations
-Poor selective motor control
-Continued incontinence

30. References
 Crepeau, E.B., Cohn, E.S., & Boyt-Schell, B.A. (2009).
Willard and Spackman’s Occupational Therapy (11th ed.),
Wolters Kluwer – Lippincott Williams & Wilkins.
 Davis, J. (2009). Treatment ideas and strategies in stroke
rehabilitation, OT Practice, December 14.
 Zachry, A.H. (2015). OT 537 Stroke Presentations.
 Randomski MV, Trombley-Latham CA, (2008)
Occupational Therapy for Physical Dysfunction (6th ed.),
Wolters Kluwer – Lippincott Williams & Wilkins