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Occupational Therapy Practice Guidelines for Adults with Traumatic Brain Injury

Kathleen Gosliz, OTR, OTD, National Guideline Clearinghouse

Occupational Therapy Practice Guidelines for Adults with Traumatic Brain Injury
Multimedia

For professionals, this guide is a thorough overview of the occupational therapy process for people with traumatic brain injury.

Disease/Condition(s)

Traumatic brain injury, including:

  • Traumatic acquired brain injury
  • Nontraumatic acquired brain injury

Guideline Category

  • Counseling
  • Evaluation
  • Management
  • Prevention
  • Rehabilitation
  • Risk Assessment
  • Screening
  • Treatment

Clinical Specialty

  • Family Practice
  • Internal Medicine
  • Neurology
  • Physical Medicine and Rehabilitation
  • Preventive Medicine

Intended Users

  • Advanced Practice Nurses
  • Allied Health Personnel
  • Health Care Providers
  • Health Plans
  • Hospitals
  • Managed Care Organizations
  • Nurses
  • Occupational Therapists
  • Physical Therapists
  • Physician Assistants
  • Physicians
  • Psychologists/Non-physician Behavioral Health Clinicians
  • Social Workers
  • Speech-Language Pathologists
  • Utilization Management

Guideline Objective(s)

  • To provide an overview of the occupational therapy process for individuals with traumatic brain injury (TBI)
  • To define the occupational therapy domain and process and interventions that occur within the boundaries of acceptable practice
  • To help occupational therapists and occupational therapy assistants, as well as the individuals who manage, reimburse, or set policy regarding occupational therapy services, understand the contribution of occupational therapy in treating adults with TBI
  • To serve as a reference for health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations

Target Population

Adults with traumatically-acquired and nontraumatically-acquired brain injury

Interventions and Practices Considered

  1. Referral for occupational services
  2. Evaluation
    • Developing the occupational profile
    • Analysis of occupational performance through observation and assessment
  3. Developing an intervention plan
  4. Interventions during the coma recovery phase
    • Sensory stimulation programs
    • Neuromuscular recovery programs
    • Management of heterotopic ossifications
  5. Interventions during the acute rehabilitation recovery phase
    • Intervention addressing the needs of patients with agitation
    • Intervention addressing motor recovery
    • Intervention addressing cognitive impairment
    • Intervention addressing areas of occupational performance
  6. Interventions during the community recovery phase
    • Intervention addressing social and coping skills
    • Intervention addressing occupational performance
    • Intervention addressing education and work activities in context
    • Intervention addressing community mobility
  7. Intervention review
  8. Outcomes monitoring
  9. Discontinuation, discharge planning, and follow-up
  10. Occupational therapy services to organizations and populations

Major Outcomes Considered

  • Validity and reliability of assessment tools
  • Performance of activities of daily living
  • Sensory perceptual skills
  • Motor and praxis skills
  • Emotional regulation skills
  • Cognitive skills
  • Communication and social skills
  • Occupational performance
  • Long-term disability

Methodology

Methods Used to Collect/Select the Evidence

  • Hand-searches of Published Literature (Primary Sources)
  • Hand-searches of Published Literature (Secondary Sources)
  • Searches of Electronic Databases
  • Description of Methods Used to Collect/Select the Evidence

Evidence-based Literature Review

Four focused questions and one subquestion were developed for the evidence-based literature review on rehabilitation of adults after traumatic brain injury (TBI). The questions were generated to provide needed information to update the previously published guidelines for the practice of occupational therapy with persons after TBI. The questions reviewed were:

  1. What is the evidence that challenging demands to the brain, such as therapy, activity, or sensory stimulation, reorganizes brain function beyond spontaneous recovery after traumatic brain injury?
    1. What is the evidence for the effect of sensory stimulation on the arousal level of persons in coma or persistent vegetative state after traumatic brain injury?
  2. What is the evidence for the effect of interventions (published between 2000 and 2006) to enable persons with TBI to participate in areas of occupation (activities of daily living, instrumental activities of daily living, work, leisure, social participation, and education)?
  3. What is the evidence for the effect of interventions to address psychosocial, behavioral, and social functions on the occupational performance of persons with TBI?
  4. What is the evidence for the effect of interventions to address cognitive/perceptual functions (attention, memory, executive functions) on the occupational performance of persons with TBI?

Literature Review Methodology

Search items for the review were developed by the reviewer. Search terms used for all questions included the following: brain injury AND rehabilitation, brain injury AND rehabilitation AND community, brain injury AND rehabilitation AND critical reviews, brain injury AND rehabilitation AND meta-analysis, brain injury AND effects AND social AND therapy, brain injury AND effects AND behavioral, brain injury AND effects AND memory therapy, brain injury AND effects AND attention therapy, brain injury AND effects AND problem solving, brain injury AND RCT AND rehabilitation, brain injury AND effects AND cognitive therapy, brain injury AND task-specific training, brain injury AND school NOT children, brain injury AND participation, brain injury AND motor tasks, brain injury AND activities of daily living AND effects, brain injury AND sensory stimulation, brain injury AND enriched environment, brain injury AND use-dependent plasticity, brain injury AND leisure, brain injury AND plasticity (1985–2006), brain injury AND occupational therapy, brain injury AND education NOT children, brain injury AND return to work, Prigitano, Ben-Yishay.

The search consisted of peer-reviewed literature published between 1990 and April 2006, with the following exceptions. For question 1, the plasticity literature was searched from 1985, when studies of human brain plasticity first appeared. For question 3, the search consisted of peer-reviewed literature published from 2000 to April 2006, because the previous guidelines included literature through 1999. The databases searched included PubMed (Medline of the National Library of Medicine; nlm.gov); PsycINFO; Web of Science, which includes the Science Citation Index and the Social Science Citation Index; and CINAHL. Consolidated information sources searched included OTSeeker.com; OTCATS.com; DARE (Database of Abstracts of Reviews of Effectiveness) at http://www.crd.york.ac.uk/crdweb/; and the Cochrane Collaboration (www.cochrane.org), which maintains a database of systematic reviews. These databases provide peer-reviewed summaries of research journal articles with commentary on the overall strength of the evidence. Reference lists of retrieved articles were examined for potential additional articles.

The inclusion criteria for primary research included:

  1. Participants were diagnosed with acquired brain injury, but not stroke.
  2. Participants were adults (≥18 years of age).
  3. The research studied the effects of occupational therapy intervention or interventions claimed and researched by other disciplines but also used by occupational therapists. The intervention had to represent current occupational therapy practice or theoretically could be occupational therapy practice. Studies of the effects of multidisciplinary rehabilitation that included occupational therapy were included.
  4. Outcome was measured in terms of occupational performance. In cases in which outcome was reported via multiple assessments, only those pertaining to occupational performance were examined for this review.
  5. Research was written in English.
  6. Meta-analyses or critical reviews, which are judged to be strong Level I evidence, were included if available.

The following types of studies were excluded:

  1. Prediction studies
  2. Correlational studies
  3. Measurement studies
  4. Multidisciplinary intervention without occupational therapy mentioned
  5. Observational studies of the course of outcome post–traumatic brain injury

A total of 2,297 titles were retrieved. After duplicates were discarded, 1,832 abstracts were reviewed. A total of 278 articles were retrieved from Boston University's Mugar Library, the Boston University Library of Science and Engineering, the Boston University Medical Library, the Boston University e-journal subscription, and the Wilma L. West Library of the American Occupational Therapy Foundation.

In May 2008, a review was completed to update the information from the initial review. The search included evidence-based information published between May 2006 and May 2008 and some earlier seminal articles and followed the original search terms, inclusion and exclusion criteria, and databases. Articles selected from this review were included in the appropriate evidence tables.

Number of Source Documents

A total of 99 articles were included as evidence.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence:

Level I
Definition - Systematic reviews, meta-analyses, and randomized, controlled trials

Level II
Definition - Two groups, nonrandomized studies (e.g., cohort, case control)

Level III
Definition - One group, nonrandomized (e.g., before-after, pretest and posttest)

Level IV
Definition - Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)

Level V
Definition - Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The review author reviewed the articles that met criteria for their quality (i.e., scientific rigor, lack of bias) and levels of evidence. Guidelines for reviewing quantitative studies were based on those developed by Law and colleagues* to ensure that the evidence is ranked according to uniform definitions of research design elements.

All studies included in the review, as well as those not specifically described in the evidence-based literature review section of the practice guideline, are summarized, critically appraised, and cited in full in the evidence tables in Appendix D of the original guideline document.

Law M, editor. Evidence-based rehabilitation: a guide to practice. Thorofare (NJ): Slack; 2002.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The developers used an evidence-based perspective and key concepts from the second edition of the Occupational Therapy Practice Framework: Domain and Process (see "Availability of Companion Documents" field) to provide an overview of the occupational therapy process for individuals with traumatic brain injury. The recommendations are based upon the strength of the evidence for a given topic in combination with the expert opinion of review authors and the advisory group reviewing this practice guideline.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendation

A - Strongly recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B - Recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.

C - No recommendation is made for or against routine provision of the intervention by occupational therapy practitioners. At least fair evidence was found that the intervention can improve outcomes, but concludes that the balance of the benefits and harm is too close to justify a general recommendation.

D - Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

I - Insufficient evidence to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harm cannot be determined.

Note: Recommendation criteria are based on standard language from the Agency for Healthcare Research and Quality (2009).

Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Referral

Occupational Profile

The purpose of the occupational profile is to determine who the client or clients are, identify their needs or concerns, and ascertain how these concerns affect engagement in occupational performance. Information for the occupational profile is gathered through formal and informal interviews with the client and significant others. Conversations with the client help the occupational therapist gain perspective of how the client spent his or her time; what activities the client wants or needs to do; and how the environment in which the client lives, works, and plays supports or hinders occupational engagement. During the initial phases of recovery from traumatic brain injury (TBI), when the client may experience disorders of consciousness or significant confusion and impaired awareness, the occupational therapist may need to take a broad perspective of the client that includes the family, friends, and colleagues and seek information from these people about the occupations and activities in which the client engaged prior to the injury, in addition to his or her typical patterns of performance. Family videotapes of the client engaging in typical occupations and activities can provide the therapist with insight into the client's mannerisms and personality. Once the client is cognitively capable of contributing personal information, the occupational therapist can informally and formally gather information for the occupational profile during one or more sessions and verify the accuracy of information previously gathered from family and close friends.

Developing the occupational profile involves the following steps:

  • Identify the client or clients
  • Determine why the client is seeking services
  • Identify the areas of occupation that are successful and the areas that are causing problems or risks
  • Discuss significant aspects of the client's occupational history
  • Determine the client's priorities and desired outcomes

Analysis of Occupational Performance

Information from the occupational profile is used by the occupational therapist to focus on the specific areas of occupation and the context and environment in which the client will live and function. During the early phases of recovery, an occupational therapist may not be able to focus on occupational performance because the client's ability to engage in purposeful and goal-directed behavior is limited by coma or confusional states. During this period of rehabilitation, the occupational therapist may address underlying impairments that have the potential to interfere with occupational performance upon the return of mental alertness and purposeful behavior. When the occupational therapist is able to analyze occupational performance, the following steps are generally included:

  • Observe the client as he or she performs the occupations in the natural or least-restrictive environment (when possible), and note the effectiveness of the client's performance skills (e.g., motor and praxis, sensory–perceptual, cognitive, emotional regulation, communication and social) and performance patterns (e.g., habits, routines, rituals, roles).
  • Select specific assessments and evaluation methods that will identify and measure the factors related to the specific aspects of the domain that may be influencing the client’s performance. These assessments may focus on the client's body structures and functions, activity performance, or community participation. See Table 2 in the original guideline document for examples of selected assessments.
  • Interpret the assessment data to identify what supports or hinders performance.
  • Develop or refine a hypothesis regarding the client's performance (i.e., identify underlying impairments or performance skill limitations that may be influencing occupational performance in multiple areas, such as memory impairments affecting morning hygiene, home management tasks, work tasks, and social interaction).
  • Develop goals in collaboration with the client and possibly the family that address the client's desired outcomes.
  • Identify potential intervention approaches, guided by best practice and the evidence, and discuss them with the client and/or family.
  • Document the evaluation process and communicate the results to the appropriate team members and community agencies.

Areas of Occupation

Evaluation of various areas of occupation relevant to the client's age and previous lifestyle are performed as the client emerges from coma and is able to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Because individuals often experience TBI at a young age and can live for many years after the injury, clients may need periodic reevaluation of their rehabilitative needs throughout life as developmental changes occur and they assume new roles involving new areas of occupation.

Occupational therapists may elect to use an evaluation approach that focuses on possible impairments affecting performance of functional tasks (labeled a bottom-up evaluation by some occupational therapists) or an evaluation approach that begins by analyzing the roles of the individual with TBI and the areas of occupation that encompass the client's typical day (labeled a top-down evaluation by some occupational therapists).

Performance Skills

The evaluation of individuals with TBI includes overt and subtle factors that may affect performance. Performance skills, the observable elements of action of an occupation, can be subdivided into motor and praxis, sensory–perceptual, cognitive processing, emotional regulatory, and communication and social skills. Individuals who sustain a TBI may present with deficits in any or all of these performance skills. Motor and praxis deficits such as spasticity, ataxia, apraxia, balance and vestibular disorders, and weakness and deconditioning are common in clients with TBI and interfere with the performance of many desired occupations, including self-care, work, and leisure.

Client Factors

Client factors are the underlying abilities, values, beliefs, and spirituality; body functions; and body structures that affect the individual's occupational performance. Clients with TBI may experience both primary and secondary impairments as a result of the injury. Due to the traumatic nature of the event leading to the brain injury, they also may experience impairments in multiple body structures and body functions. Common primary impairments are motor paralysis, sensory loss, and cognitive impairments. Early in the rehabilitation process with clients in coma or emerging from coma, the occupational therapist must adopt a bottom-up evaluation approach and assess body structures and functions to determine current potential for improvement and the risk for secondary impairments if these factors are not addressed. Secondary impairments, such as joint contractures or heterotopic ossifications, can present future obstacles to the client's abilities, skills, and performance of valued activities. Most of these assessment procedures require specialized training, which is a core component in occupational therapy education.

Performance Patterns

Performance patterns are "behaviors related to daily life activities that are habitual or routine"; they include habits, routines, rituals, and roles. In the acute rehabilitation phase of recovery, when confusion and memory impairments are most evident, individuals with TBI may have difficulty recalling habits, organizing and sequencing routines, and fulfilling their previous life roles.

Contexts

Occupational therapists acknowledge the influence of cultural, personal, temporal, virtual, physical, and social–contextual factors on occupations and activities. Environmental factors that support or inhibit occupational performance of individuals with TBI should be identified throughout the evaluation and intervention process. Refer to the original guideline document for a detailed discussion of these contextual factors.

Activity Demands

Determining whether a client may be able to complete an activity depends not only on the performance skills, performance patterns, and client factors of an individual but also on the demands the activity itself places on the person. The demands of an activity are aspects of the activity that include the tools needed to carry out the activity, the space and social demands required by the activity, and the required actions and performance skills needed to take part in the given activity.

During the early phases of recovery when the client is emerging from coma and inconsistently responds to verbal commands and environmental stimuli, the occupational therapist will identify the parameters of the activity demands in which the client is able to best perform.

As the client enters the agitated phase of recovery, the therapist again will analyze various activities to identify those demands or components of the activities that either increase or decrease the client's agitation and self-stimulatory behavior. Selecting intervention activities that meet the client's current level of functioning and do not overly challenge areas of impairment may assist the client in maintaining a calm behavioral state.

Clients with cognitive impairments from TBI may demonstrate varied performance skills on the basis of the demands of the environment and activity. Clients able to perform structured and predictable functional activities within the rehabilitation setting may experience significant difficulty when attempting similar activities in more complex, unstructured, and unpredictable natural settings of the home and community. Occupational therapists, through their use of activity analysis, can identify the type of activity and environment in which the client can perform at his or her best. During the course of occupational therapy intervention, occupational therapy practitioners grade and vary the activity demands of the selected intervention task, and the environment in which it is performed, to provide the client with a "just-right challenge" to be therapeutic without exceeding his or her current level of skills. As the client improves, the therapist gradually modifies the activities to provide more challenge to the client. Therapists assist the clients in their ability to perform under the current environment and activity demands and also consider how future changes in the environment and activity may challenge the client's skill level.

Clients with motor impairments from TBI may need adaptive equipment and environmental modifications to engage in the selected activities (e.g., changes to the tools or utensils used in the activity, reorganization of equipment and supplies in the environment). The occupational therapist carefully analyzes the client's need for adaptive equipment and balances the selected equipment and environmental modifications to the client's cognitive ability to learn new ways of approaching and completing activities.

Considerations in Assessments

It is critical that therapists use their knowledge of assessments and clinical judgment to decide which assessments should be selected for each client at a particular time. This careful selection of assessments provides the most valuable data and eliminates the tendency to bombard the client with excessive assessment demands.

Knowledge of the typical recovery pattern seen after TBI (see Table 1 in the original guideline document) can help the occupational therapist determine when it is most appropriate to focus on various components of the client’s occupational performance and the types of assessments to administer.

Occupational therapists vary their approach to evaluating the individual with TBI, shifting their focus among the broad components of health and functioning defined by the World Health Organization (WHO) International Classification of Functioning (ICF) classification of impairments, activity limitations, or participation restrictions (see Table 3 in the original guideline document for a comparison of the ICF language to the Occupational Therapy Practice Framework language).

Assessment Instruments

In selecting the most appropriate type of assessment, an occupational therapist first decides the focus of the assessment, given the client's stage of recovery, and what questions need to be answered. If the therapist needs to determine the presence and severity of impairments, a standardized assessment that compares the client's scores with expected performance within the person's age group may be selected. If the therapist needs to understand the effect of impairments on occupational performance, a top-down approach using direct observation of function may provide information on how the cognitive or motor impairments affect functional activity performance or community participation. Occupational therapists may select dynamic assessments that emphasize the processes involved in learning and change to gather information to guide treatment planning and intervention (e.g., conditions that increase or decrease display of impairments). Performing evaluations that include all three components of functioning as defined by the ICF (i.e., body structures and functions, activities, and participation) enables occupational therapists to compile a comprehensive view on the person's functioning.

Because individuals with TBI may have impairments (e.g., motor, praxis, cognitive) similar to other clients with neurological diagnoses (e.g., multiple sclerosis, stroke), occupational therapists may consider using assessments developed for these populations when evaluating the status of clients with TBI. Some of these assessments may be generic enough in their design to provide valid information regarding the recovery of skills in the individual with TBI; however, the therapist should be cautious, as the validity of these assessments with the TBI population may not have been established. It is preferable that occupational therapists select assessments that have proven efficacy in detecting and quantifying the typical pattern of impairments seen in clients with TBI (see Table 2 in the original guideline document). Keeping current with the published literature on evaluations of persons with TBI provides important information to guide therapists in selecting specific assessments for individual clients.

Intervention

Occupational therapy intervention with individuals who have sustained a TBI may occur at any point along the continuum of recovery. The intervention, guided by information about the client gathered during the evaluation, incorporates a variety of approaches using preparatory methods (i.e., therapist-selected methods and techniques that prepare the client for occupational performance, such as serial casting or sensory stimulation), purposeful interventions (i.e., specifically selected activities that allow the client to develop skills that enhance occupational engagement, such as role-playing of social situations or practicing grocery shopping in a simulated environment), and occupation-based interventions (i.e., client-directed occupations within context that match identified goals, such as interviewing for a job or preparing a meal for one's family). The focus of intervention may shift among establishing, restoring, or maintaining occupational performance; modifying the environment and/or contexts and activity demands or patterns; promoting health; or preventing further disability and occupational performance problems.

During occupational therapy intervention, therapists make demands on persons with brain injury to learn new strategies and relearn old activities and tasks under new environmental, social, and temporal conditions. Many occupational therapists believe that challenging demands to the brain reorganize brain function beyond spontaneous recovery, yet evidence supporting the efficacy of common rehabilitation intervention for clients with TBI remains limited and tends to support interventions associated with a compensatory rather than restorative approach, at least in the area of cognitive rehabilitation.

Intervention Plan

As a part of the occupational therapy process, the occupational therapist develops an intervention plan that considers the client's goals, values, and beliefs; the client's health and well-being; the client's performance skills and performance patterns; collective influence of the context, environment, activity demands, and client factors on the client's performance; and the context of service delivery in which the intervention is provided (e.g., caregiver expectations, organization's purpose, payer's requirements, or applicable regulations). The intervention plan outlines and guides the therapist's actions and is based on the best available evidence to meet the identified outcomes.

Once the occupational therapist has identified targeted goals in collaboration with the client or family, the therapist determines the intervention approach that is best suited to address the goals. Some approaches may be more appropriate at various points in the recovery from TBI (see the table below) than others. The intervention approaches used by occupational therapy practitioners include:

  • Prevent, an intervention approach designed to address clients with or without disability who are at risk for occupational performance problems; for example, intervention to prevent development of secondary impairments such as joint contractures during the coma phase of recovery.
  • Establish and restore, an intervention approach designed to change client variables to establish a skill or ability that has not yet developed or to restore a skill or ability that has been impaired; for example, restoring hand coordination to engage in functional activities such as cooking.
  • Modify activity demands and the contexts in which activities are performed to support safe, independent performance of valued activities within the constraints of motor, cognitive, or perceptual limitations.
  • Create or promote a healthy and satisfying lifestyle that includes adherence to medication routine, appropriate diet, appropriate levels of physical activity, and satisfying levels of engagement in social relationships and activities by providing enriched contextual and activity experiences that will enhance performance for all persons in the natural contexts of life.
  • Maintain performance and health that the individual with TBI has previously regained or that neuropathology has spared

Occupational therapy practitioners also consider the types of interventions when determining the most effective treatment plan for a given client. The types of interventions include therapeutic use of self; therapeutic use of occupations and activities, which includes preparatory methods, purposeful activity, and occupation-based activity; consultation; and education. Although all types of occupational therapy interventions are used for all approaches, the therapeutic use of self (i.e., therapist's use of his or her personality, perception, and judgment) is an overarching concept that should be considered in each therapeutic interaction. Therapeutic use of self is a vital responsibility of the occupational therapist and occupational therapy assistant, as well as all members of the health care team.

Table: Occupational Therapy Intervention Approaches and Examples of Their Use with Clients at Various Levels of Recovery from Traumatic Brain Injury

Intervention Approaches Commonly Used During the Coma Phase of Recovery (Rancho Los Amigos Levels I–III)

Interventions typically focus on state of consciousness and WHO ICF areas of impairments.

Intervention Approach

Prevent
Sample Occupational Therapy Treatment Activities:

  • Prevent loss of muscle length and joint mobility by performing range of motion (ROM), serial casting, tone-inhibiting techniques, and positioning of patient in the bed and wheelchair.
  • Prevent skin breakdown and postural deformities by providing the client with proper body alignment in tilt-in-space wheelchair with head rest, lap tray, gel seat cushion, and trunk inserts and providing nursing staff with a splint-wearing schedule.

Establish/Restore
Sample Occupational Therapy Treatment Activities:

  • Restore the client's connection to the external environment by positively reinforcing appropriate behavioral responses to sensory stimulation.
  • Restore the client's ability to follow one-step demands for a motor response in relation to sensory stimulation within 15 seconds of request or stimulus.

Establish/Restore
Sample Occupational Therapy Treatment Activities:

  • Modify environment to vary levels of stimulation and prevent accommodation and attenuation to environmental stimuli (e.g., vary lighting, noise level, visual stimulation, temperature).

Maintain
Sample Occupational Therapy Treatment Activities:

  • Maintain muscle length and joint mobility by instructing caregivers in routine stretching exercises.

Intervention Approaches Commonly Used During the Acute Rehab Phase of Recovery (Rancho Los Amigos Levels IV–VI)

Interventions typically focus on motor and cognitive skills and WHO ICF areas of impairments and activity limitations.

Prevent
Sample Occupational Therapy Treatment Activities:

  • Prevent aspiration during feeding by modifying the food texture and head positioning if the client displays signs of dysphagia.

Establish/Restore
Sample Occupational Therapy Treatment Activities:

  • Establish the client's ability to release energy constructively during agitated periods by providing structured and familiar activities with minimal challenges to areas of impairments.
  • Restore ability to perform self-care by engaging the client in a daily self-care program of showering, dressing, and grooming, providing verbal and physical cues as needed.
  • Restore normal patterns of movement by engaging the client in various functional motor tasks (e.g., grooming, self-feeding, object manipulation) with gradual increases in the unpredictability and complexity of the contextual and activity demands, providing tactile input to guide and normalize movement patterns.
  • Establish skills to safely and efficiently transfer from wheelchair to various surfaces (e.g., toilet, bed, chair, car).
  • Establish and restore cognitive skills by teaching cognitive strategies to improve performance; engage in a variety of activities related to roles, responsibilities, and interests (e.g., financial management, cooking, parenting, leisure pursuits).
  • Establish strategies and new routines to accurately use external memory aids to recall scheduled appointments and events and to take medications.
  • Establish habits to ensure accuracy of work (e.g., self-monitoring of work for errors, timely completion, match with instructions).

Modify
Sample Occupational Therapy Treatment Activities:

  • Modify the client's hospital room to provide environmental cues to minimize confusion and to provide orientation to person, time, and place.
  • Modify tasks and environments to enable independence (e.g., provide adaptive equipment to increase independence in ADLs and IADLs, such as checklists for activity sequences and external memory aids).

Maintain
Sample Occupational Therapy Treatment Activities:

  • Maintain the client's postural alignment while sitting by providing structural wheelchair supports.
  • Maintain the client's maximum ROM obtained with serial casting by providing resting cast/splint for night wear.

Intervention Approaches Commonly Used During the Community Phase of Recovery (Rancho Los Amigos Levels VII–X)

Interventions typically focus on higher cognitive skills and WHO ICF areas of activity limitations and participation restrictions.

Prevent
Sample Occupational Therapy Treatment Activities:

  • Prevent development of substance abuse and depression by educating the client about the risks and developing healthy alternative coping strategies.
  • Prevent client injury by modifying the home environment to decrease safety risks (e.g., installing grab bars and raised toilet seats, removing throw rugs and potential obstacles, installing automatic turn-off switches for stove burners and safety locks on cabinets).

Establish/Restore
Sample Occupational Therapy Treatment Activities:

  • Restore cognitive and social communication skills by having the client plan and complete a community outing with family and friends; practice social pragmatics in group activities and role-playing.
  • Establish daily routines to enable the client to complete desired morning rituals in a timely manner and prevent late arrival at work or school.
  • Restore joint mobility and motor function after surgical excision of heterotopic ossification or botulism toxin injections for muscle spasticity.
  • Work with local brain injury support group to establish leisure skill program to increase social networks for community-dwelling individuals with TBI.

Modify
Sample Occupational Therapy Treatment Activities:

  • Modify home and community environments to support independent performance of activities.
  • Modify daily routines to plan physically and cognitively challenging activities when well rested (e.g., pay bills in the morning when well rested; perform activities requiring fine motor demands when muscles are not fatigued).
  • Modify community mobility to accommodate for nondriving status.

Create/Promote
Sample Occupational Therapy Treatment Activities:

  • Promote a healthy lifestyle that includes engagement in occupations that support physical and mental health (e.g., develop exercise program, create list of healthy food and meal selections, identify healthy social activities to foster social relationships).
  • Advocate for development of an accessible, community-based center that promotes healthy leisure occupations for all citizens, including those community-dwelling individuals with TBI.

Maintain
Sample Occupational Therapy Treatment Activities:

  • Maintain gains made in ROM achieved by serial casting by wearing resting elbow splint for several hours per day.
  • Maintain social support systems in the community by engaging in leisure activities with friends from the local brain injury family group.

Note: Rancho Los Amigos levels taken from Hagen, C. (1998). The Rancho Los Amigos Levels of Cognitive Functioning: The revised levels (3rd ed.). Downey, CA: Los Amigos Research and Educational Institute.

Intervention During the Coma Recovery Phase

During the early period of recovery from a TBI, the occupational therapist working with the client in coma typically focuses the intervention on establishing or restoring the client factors or impairments that resulted from the injury. Intervention also focuses on preventing the development of secondary impairments that occur in the period of unconsciousness. Global mental functions, such as level of consciousness and alertness, often are addressed through a program of coma arousal or sensory stimulation.

Sensory Stimulation Programs

Some persons who sustained a TBI continue in a coma or a vegetative state for a prolonged period of time or permanently. Because the senses are the gateways to consciousness, controlled application of sensory stimuli in an organized way is an adjunctive treatment often provided to these patients by occupational therapists.

Neuromusculoskeletal Recovery Programs

Occupational therapy intervention for neuromusculoskeletal and movement-related functions after brain injury is focused on either impairments that are a primary consequence of that injury (e.g., impairments in voluntary movement, abnormal tone, balance) or secondary impairments resulting from the immobility or excessive muscle tone, such as contractures of the muscles or joints and diffuse weakness and deconditioning. At the coma phase of recovery, intervention for neuromuscular motor impairments is generally passive in nature, using more preparatory methods such as passive range of motion (PROM), splinting and serial casting, and positioning in the bed and wheelchair to either establish and restore motor control or prevent the development of secondary joint and muscle contractures. Joint contractures can result in significant limitations in self-care, particularly dressing and hygiene.

Management of Heterotopic Ossifications (HO)

Monitoring clients for the development of HO (e.g., observation for an inflammatory reaction, palpable mass, or limited ROM in joints of the limbs) in clients with abnormal tone is important. During the acute inflammatory stage, the occupational therapist should position the patient's involved limb in a functional position and initiate gentle PROM, monitoring the patient for signs of pain (e.g., facial grimace, change in vital signs). Once acute inflammatory signs have subsided, continued mobilization is indicated to maintain range. Resting the joint appears more likely to lead to decreased joint range, whereas continued mobilization may lead to formation of a pseudarthrosis. Positioning the client in coma in a wheelchair with adequate supports for the head and trunk also can decrease muscle tone, foster increased upright motor control in a functional posture, and improve awareness of stimuli within the environment.

Intervention During the Acute Rehabilitation Recovery Phase

The acute rehabilitation phase of recovery begins as the client is medically stable and emerging from the coma. Occupational therapists, as part of the rehabilitation team working with clients who have TBI, must address the client's physical, cognitive, communicative, emotional, and spiritual needs while planning for the client's transition to the next setting, whether it is subacute rehabilitation, an outpatient program, or home in the community. Reduced lengths of stay and a reimbursement system focused more on motor recovery than cognitive and neurobehavioral recovery can make justification for the client's need for occupational therapy intervention challenging.

Addressing the Needs of the Patient with Agitation

Clients with TBI often are admitted to an acute rehabilitation hospital when they begin to display signs of entering the phase of agitation (i.e., Rancho Los Amigos Level IV). Agitation has been defined as a state of aggression during posttraumatic amnesia in the absence of physical, medical, or psychiatric causes that may involve a component of akathisia (i.e., a constant sensation of inner restlessness), impulsivity, decreased frustration tolerance, disinhibition, and inappropriate social behavior. This phase of recovery from TBI encompasses a spectrum of behaviors that fluctuate with changes in situational factors such as environmental stimulation, task demands, and time of day.

Agitated behavior may limit the client's engagement and progress in rehabilitative therapy; however, occupational therapists may engage clients in structured self-care activities, simple games and activities requiring use of cognitive skills, and simple gross motor activities to expend excess energy and deal with the restlessness or akathisia. Frequent breaks may be needed and treatment sessions may need to be shortened or varied to maintain the client's attention and lessen frustration and potential display of agitated behavior. Although it is difficult to focus on restoring underlying impairments because the client's capacity for new learning is significantly limited by the posttraumatic amnesia that typically accompanies the period of agitation, the occupational therapist can structure tasks and the environment to regulate overstimulation, confusion, and frustration. The therapist also may provide environmental cues to help orient the client during periods of confusion (e.g., wall calendars, clocks, labeled photos of rehabilitative staff, signs indicating the client's room). As the agitation lessens, the cognitive and motor challenges presented to the client gradually can be increased to address underlying impairments.

Addressing Motor Recovery

As the client with TBI emerges from coma and performs more voluntary movement, the occupational therapist begins to address impairments seen within the sensory (i.e., peripheral and cranial nerve function, vision) and neuromusculoskeletal and movement-related systems (i.e., joint and bone integrity, muscle tone, movement functions).

Clients with persistent spasticity resulting in joint contractures interfering with performance of functional activities, who have not been successfully managed with more conservative rehabilitation techniques, may be candidates for botulinum toxin A injections, motor point or neural blocks, surgical release of the contracted tissue, or intrathecal baclofen pump placement. Occupational therapy intervention following these procedures can be helpful to increase functional integration of the limb into daily activities.

Occupational therapists apply the principles of practice and feedback, task-specificity, and training intensity when providing intervention focused on motor skill recovery. Two commonly used approaches to address movement related impairments after TBI are motor learning and constraint-induced movement therapy (CIMT).

Motor learning is a process of learning to produce skilled movement that involves practice and experience. Occupational therapists using a motor learning approach set up the therapeutic learning environment, typically the occupational therapy clinic, to promote skill acquisition by varying the tasks and environment to meet the patient's current learning abilities.

CIMT, a motor skill intervention approach based on the learning principles of shaping and preventing learned nonuse, was initially designed to increase the use of the impaired arm in chronic stroke patients. CIMT involves three main components: (1) intensive training of the affected arm, (2) practice to promote transfer of therapeutic gains from the clinical environment to real-world situations, and (3) constraint of the less-affected arm during the entire period of intervention. CIMT programs typically involve several consecutive days (e.g., 10–14) of intervention, during which the less-affected arm is constrained by a splint or sling during waking hours, and functional movements are performed with the hemiparetic arm for up to 6 hours each day. Variations of the program (e.g., modified constraint-induced therapy [mCIT], which involves lessened hours of constraint and guided functional movement sessions or elimination of the constraint element entirely) have been developed to address institutional, therapist, client, and family reservations regarding patient safety and compliance and also practicality and resource utilization during inpatient hospitalizations.

Intervention Addressing Cognitive Impairments

Interdisciplinary and comprehensive cognitive rehabilitation is an integral component of intervention with individuals who have sustained TBI. Even in those clients with good physical and medical recoveries, cognitive impairments in the area of attention, memory, and executive functions can limit the person's ability to engage in functional, social, and vocational activities. As the client emerges from the agitated phase of recovery and can more actively engage in the rehabilitative process, the occupational therapist begins to address cognitive impairments and the resulting limitations to functional activity performance and social participation more formally. Although the area of cognitive rehabilitation is discussed here under the acute rehabilitation phase, this intervention focus continues long after the client is discharged from inpatient services into the community.

Cognitive Rehabilitation Approaches

Occupational therapists select cognitive rehabilitation intervention approaches that focus on the individual, the task, or the environment, on the basis of an understanding of the client's ability to learn and generalize information. When there is potential for change in the client's underlying cognitive impairments, the occupational therapist uses a remedial approach focused on improving and restoring the client's attention, memory, or executive function skills. Using activities that challenge the client's inherent cognitive processes and abilities, the therapist provides opportunities for the client to practice using the skills in controlled therapeutic settings and graded tasks.

Functional approaches, which capitalize on the client's strengths and abilities, shift the focus of intervention from restoring underlying impairments to minimizing their limitations on engagement in activities and participation within the community. Occupational therapists' training in analyzing and adapting activities and environments enables them to consider the cognitive strengths of the person and match compensatory strategies to those abilities. Therapists may modify the client's environment (e.g., placing cue cards or signs in key locations, labeling closets or drawers to identify their contents) or modify the activity (e.g., pre-selecting and pre-arranging items needed for completion of the task or presenting items for only one step of a task at a time). For clients with limited ability to learn and generalize information, a functional skill training program incorporating vanishing cues and errorless learning in the natural environment may be used.

Capitalizing on procedural memory, occupational therapists may teach the client to perform specific activities (e.g., completing morning hygiene, preparing simple snacks, following a medication schedule) that would decrease caregiver burden and provide some level of independence. Clients are trained on the same activity that they are expected to perform in the same environment in which it would be performed.

Awareness and Metacognition

Metacognition refers to the use of clients' knowledge and experiences of their own cognitive processes to guide their engagement in tasks. A lack of awareness (i.e., diminished metacognition) of the functionally relevant effects of cognitive or physical impairments resulting from the TBI can be a barrier to the patient’s active engagement in the rehabilitation program.

Occupational therapists attempt to foster clients' awareness of their abilities and limitations in a supportive yet constructive manner. They may have clients estimate performance prior to engaging in quantifiable tasks, then compare actual performance to the estimate, rate achievement of specific goals (i.e., goal attainment scales), analyze videotapes of themselves performing tasks, use self-monitoring checklists, engage in self-questioning (e.g., "Did I check my work for errors?"), or engage in structured journaling at the end of each treatment session to help clients reflect on their activity experiences, identify challenges, and anticipate what they might do differently the next time. A trial of awareness training can help distinguish those clients who may be able to generalize compensatory strategies to a variety of situations and those clients who might benefit more from a task-specific functional training approach.

Attention

Multidimensional attentional impairments are common after a TBI and include difficulty sustaining attention, shifting the focus of attention, and processing information rapidly. Occupational therapists grade intervention activities and control environmental stimuli to provide a "just-right challenge" to the client's attentional capacity by slowly introducing additional stimuli to the task and environment to build the client's ability to work with competing stimuli. The occupational therapist helps the client understand the conditions that can support or break down attentional skills and apply strategies to control the task and environment to support optimal performance.

Memory

Memory deficits are the most common cognitive impairment seen by occupational therapists and other rehabilitation professionals who care for patients with TBI. Rehabilitation itself is a learning process requiring memory; thus, clients with TBI and memory impairments may be limited in their ability to adapt to residual impairments without specific interventions aimed at their memory. Early in the recovery from TBI, clients may display posttraumatic amnesia for several days or weeks. During this time they are not encoding or retaining new information, although they may be actively engaged in rehabilitation programs. Clients may display confabulations (i.e., filling in memory gaps with imagined stories) or delusions. Although these early memory impairments typically resolve over time, occupational therapists can provide environmental cues to orient the client to personal information and a history of the events leading to the TBI. Therapists also may provide training in the application of specific strategies to enhance encoding of information (e.g., chunking information, rehearsal, creating rhymes and stories with the information, visual imagery) or the retrieval of information (e.g., alphabetical searching, retracing steps, association).

Technology has great potential to help clients with memory impairments be more functionally independent with use of cognitive orthotics or external memory aids. Devices such as alarm watches, PDAs, portable recording devices, and pill boxes with programmable alarms can provide the client with cues to complete time-dependent tasks with more self-sufficiency. Occupational therapists train clients in identifying daily situations where use of external memory aids is appropriate, how to program the devices, and how to retrieve information from the devices. Errorless-learning techniques, which capitalize on procedural memory, can be used to train clients with severe memory impairments to consistently use external memory aids. Using role-play situations and homework memory assignments, practitioners provide practice in consistent use of external memory aids. Occupational therapists collaborate with other members of the rehabilitation team to ensure their efforts to address the memory impairments are coordinated and consistent. Independent living requires prospective memory skills (e.g., remembering to pay utility bills by particular dates) and cognitive reminders in PDAs, daily planners, and wall calendars are used by people without brain injury to assist recall, thus making them socially acceptable.

Executive Function

Executive functions include higher-level cognitive skills of planning, judgment, decision making, organization, problem solving, self-monitoring, and cognitive flexibility that enable individuals to engage in self-directed behavior. Impairments in executive functions significantly influence functional and vocational outcomes and social participation. The relative structure of daily routines during inpatient rehabilitation may not reveal the limiting nature of executive impairments. Discharge home to the community with unstructured time and unpredictable events may unmask the true extent of executive dysfunction. Occupational therapy intervention addressing executive functions may occur in both individual and group sessions using a variety of unstructured tasks that required planning, organization, and flexibility.

Intervention Addressing Areas of Occupation

As the client emerges from the period of agitation, occupational therapy intervention can begin to focus on the client's performance of more client-centered areas of occupation, including ADLs (e.g., feeding, dressing, grooming, toileting, bathing, transfers) and instrumental activities of daily living (IADLs) (e.g., meal preparation, shopping, financial and home management, child rearing, caring for pets). The occupational therapist may delay focusing on some areas of occupation (e.g., work, education, leisure) until the client is transitioning back to his or her community.

Occupational therapists use information obtained from the occupational profile and an analysis of the client's roles (e.g., student, parent, worker, friend, volunteer) to engage in client-centered identification of priority areas of occupation to address within therapy sessions. Limitations in many performance skills (e.g., motor, cognitive, sensory and perceptual, emotional and behavioral, communication skills) can contribute to observed difficulty in ADLs and IADLs. The therapist combines knowledge of the person's assets and limitations in performance skills with an in-depth understanding of the activity demands of the occupations and supports or barriers contributed by the environment and context in which the client engages in the occupations to design an intervention plan that enables the client to engage in meaningful occupations that he or she wants or needs to do.

The occupational therapist determines where to focus intervention (i.e., the client, the activity, or the environment) based upon consideration of several questions: "Are the client's impairments expected to change?" "What activity demands or environmental conditions match the client's current capabilities?" "Can the client learn and generalize information?" "Is the client responsive to cues?" and "Is the client aware of his or her limitations?" If the client with TBI has severely limited awareness of his or her difficulties, or displays significantly limited ability to benefit from cues and potential for change, the therapist uses an approach that changes the environment or activity rather than a treatment approach that targets change in strategy use within the person. Occupational therapists using an approach focused on modification of the activity complete an in-depth analysis of the task for points of breakdown in performance, then identify adaptations that support the client's performance of the task (e.g., placing an entire outfit for the next day in the top drawer of the bureau with a checklist outlining the sequence for donning so the client can dress independently in the morning). Similarly, the occupational therapist may analyze the environment for supports or barriers to independent performance of areas of occupation and structure the environment to enable more independence (e.g., placing cue signs in visible key locations to remind the individual to perform a task and minimize executive function skills).

Intervention approaches using adaptations to the task or environment require repetitive practice of the task and caregiver support and education on how to structure tasks and the environment for optimal performance. Although some adaptations to the environment may be fixed (e.g., a door alarm to prevent wandering or color-coded labels on the inside or outside of drawers and closets to reduce memory demands), other modifications depend upon the consistency and reliability of another person (e.g., filling and programming an alarmed pill box to aid the client in following a medication schedule). Throughout intervention focused on modifying and adapting tasks and the environment, the occupational therapist is acutely aware that acceptance of these interventions requires the client to accept a new vision of himself or herself and a willingness to accept change to the pattern or conditions of how he or she performs activities.

If the individual with TBI demonstrates potential for improvement in underlying cognitive and motor impairments, shows awareness of current limitations, and shows the ability to alter performance when provided cues and feedback, the occupational therapist may choose to focus intervention on restoring underlying cognitive and motor impairments that contribute to difficulties in the performance of functional tasks. Addressing executive-planning skills such as organization by developing cognitive strategies (e.g., checklists, self-monitoring strategies), occupational therapists may focus intervention on addressing underlying impairments to restore ability to enable more consistent, independent occupational performance. Application of cognitive strategies will be practiced in performance of a variety of ADLs and IADLs and individual and group intervention sessions to encourage generalization of the strategy to multiple areas of occupation. Occupational therapists working with clients during both the acute rehabilitation and community phases of recovery should incorporate functional, occupation-based activities into the intervention plan that require flexible adaptation of behavior in "What if?" situations and planning and organizing activities in time (e.g., organizing a day's activities or errands; planning a menu, lunch, picnic, vacation, or social gathering; role-playing phone calls to schedule several appointments; charting dates to pay bills on a wall calendar).

A comprehensive occupational therapy intervention program addressing ADLs and IADLs considers multiple parameters that contribute to successful performance, including familiarity of the environment and the items used; the client's typical performance patterns (i.e., habits and routines); safety risks resulting from motor and cognitive–behavioral impairments; possible adaptive devices and compensatory techniques to improve performance; team and family support for implementation of the selected approaches; and the client's ability to monitor and correct performance. Occupational therapists working in acute rehabilitation settings engage the client in tasks such as showering, grooming his or her hair and nails, folding laundry, making a bed, vacuuming, planning and cooking a meal, sending an e-mail, dialing a cell phone, and so on. It is common to see occupational therapists modifying the clinical environment to simulate the client's home or using real-world environments like the hospital gift shop, cafeteria, or library as settings to practice performance skills. Community outings to grocery stores, banks, restaurants, and shopping centers all provide opportunities for clients with TBI to practice areas of occupational performance prior to transitioning back into their communities.

Intervention During the Community Recovery Phase

Intervention Addressing Social and Coping Skills

Shortened lengths of inpatient hospitalizations have resulted in less time for clients and family members to prepare for the transition home to the community. Adjustment to the variety of physical, cognitive, and neurobehavioral impairments resulting from TBI require functional coping skills from both the client and family.

Brain injury support groups, such as those run by the state affiliates of the Brain Injury Association of America (BIAA), are vital links to education, life planning, and emotional support for clients and families. These community groups offer information on life planning and real-world problem solving. They also may offer leisure and social networking opportunities in groups where the client's neurobehavioral problems are more easily understood and accepted. Occupational therapists encourage clients and their families to connect to local brain injury support groups and may work with the groups to provide educational information sessions or develop programming to address leisure and social needs of the members.

The ability to maintain existing friendships and develop new friendships is challenged when a person experiences a TBI. Impairments in cognitive and social skills, as well as limitations in the ability to engage in shared occupations, can result in the distancing of friends from the individual who sustained the injury. One group of researchers has suggested that friends be included in educational programs and treatment sessions offered throughout inpatient rehabilitation to support and strengthen existing community-based friendships. Occupational therapy practitioners may educate friends in practical skills, such as moving a wheelchair or transferring the client into and out of a car, or more complex issues, such as managing disinhibited behaviors. Clients with TBI may engage in therapeutic activities that involve friends, such as communicating via e-mail, using photos and videos to reminisce, or sharing previous leisure activities such as TV or computer-based video gaming programs.

Occupational therapy practitioners begin addressing social skills during inpatient rehabilitation, but often these impairments in social skills become more evident when the individual with TBI is discharged home to the community and reassumes social roles. In the community setting, the occupational therapy practitioners may conduct social skills training groups to address cognitive components of social interaction, the pragmatics of social conversation, and tasks involved in developing and maintaining friendships and relationships. Techniques such as goal setting, individualized written contracts, role playing and rehearsal, peer mentoring and role modeling, and videotaping social interactions with self-reflection and supportive feedback may be used in individual and group sessions.

Individuals with TBI and impaired coping skills can show signs of depression and poorer outcomes. When impaired coping skills are coupled with neurobehavioral symptoms such as impulsivity, the person with TBI may be at greater risk for alcohol and drug abuse. Depression is, however, often amenable to treatment with a combination of psychological and pharmacological therapies.

Family-focused intervention may help the family unit manage the cognitive and neurobehavioral symptoms of their member with TBI upon return home to the community.

Intervention Addressing Occupational Performance

Although acute inpatient rehabilitation typically focuses on the performance of ADLs, individuals more than 10 years after their brain injury can show clinically significant improvements in functional skills when engaged in rehabilitation programs focused on retraining specific skills or training of new skills previously not part of the client's roles. Using elements of procedural learning in a natural environment with no expectations for generalization or improvement in cognitive functioning, an occupational therapist may develop a program that incorporates errorless learning, practice of a specific task with fading cues, positive prompts, and praise and encouragement. Intervention may focus on meaningful tasks such as teaching a client who was injured as a preadolescent but is now a young adult to shave his face or her legs, assisting a client to learn the public transit system to commute to new job in supported employment, training a client to prepare hot snacks, or training a client to consistently perform a morning hygiene program.

Occupational therapists also may need to assist the client and family in adapting strategies taught during acute inpatient hospitalization to sustain the same level of independence within the home environment. The natural cues offered by the familiar home and community environments may support greater independence, but these environments also challenge cognitive and physical skills due to their unpredictable nature.

Intervention Addressing Education and Work Activities in Context

Returning to community living often brings the desire to return to life roles of student or worker, yet residual cognitive, motor, and behavioral impairments may require continued rehabilitation to make these goals possible. School reintegration and vocational rehabilitation are important aspects of community recovery for clients with TBI.

Clients who wish to return to academic studies need to practice strategies that will support success in the student role. Occupational therapists may create simulated classroom instructional sessions for the client to practice taking notes and processing complex information, and review study habits and test-taking strategies. Cognitive orthotics such as personal digital assistants (PDAs), portable tape recorders, alarm watches, and laptop computers with scheduling software may be explored for their ability to compensate for residual cognitive impairments.

The occupational therapist may perform a campus visit to a community college with the client or use maps and resources from the college's Web site to help the client map out the location of classes and key student services. The therapist and client may role-play situations in which the client needs to advocate for services with the office for students with disabilities. If the client plans on residing in a dormitory on campus, the occupational therapist may perform an environmental assessment and make recommendations to accommodate the space for physical or cognitive impairments using photos and videos of the environment, or refer the client to an occupational therapist residing in the region for a more in-depth environmental assessment.

Case-coordinated early intervention focused on vocational skills can reduce unemployment among clients with TBI. Occupational therapists' unique ability to analyze task demands and environmental conditions and match these to the client's capabilities makes them well qualified to address vocational issues in individuals with TBI. Occupational therapists working in community-based return-to-work programs provide job coaching, instruction, and education in safe work practices. They also may recommend modifications to job tasks, work hours, or work positions or may recommend specialized equipment or cognitive orthoses that enable efficient and accurate job performance.

Those clients with TBI who are able to return to work activities may need additional coordinated interventions and support to sustain their work status.

Intervention Addressing Community Mobility

When the client is discharged from acute inpatient rehabilitation to his or her home, issues of community mobility, and driving specifically, should be addressed with the client and family. Most states have laws requiring physicians to report a loss of consciousness, cognitive disturbance, visual–perceptual deficit, or a seizure disorder due to a TBI to the state's department of motor vehicles. Some occupational therapists specialize in driver rehabilitation and can assist the client and family in determining if and when a return to driving for community mobility is possible.

Driving assessments should investigate the client's driving skills using Michon's hierarchically interconnected levels (operational, tactical, and strategic), considering performance in clinic-based assessments, on-road evaluations, and subsequent car accident or traffic rules violation rates to determine fitness to drive.

Holistic, intensive, and multidisciplinary neurorehabilitation can help individuals with TBI return to safe driving. Occupational therapists may use driving simulators both to evaluate the client's judgment, problem solving, and reaction times and to practice responding to simulated driving events in a safe although virtual environment. Clients who perform well in clinic-based and behind-the-wheel or on-road driving assessments typically participate in a trial of driver's training to practice and reinforce safe driving behaviors in gradually more challenging situations. Periodic follow-up on driving skills may be warranted.

For clients unable to resume independent driving, occupational therapists can provide intervention in use of alternatives for community mobility, including pedestrian routes, community-based transportation services for people with disabilities, taxi services, and public transportation systems.

Intervention Review

Intervention review is a continuous process of reevaluating and reviewing the intervention plan, the effectiveness of its delivery, progress toward targeted outcomes, and the need for future occupational therapy and referrals to other agencies or professionals. Reevaluation may involve re-administering assessments used at the time of initial evaluation, a satisfaction questionnaire completed by the client, or questions that evaluate each goal. Reevaluation normally substantiates progress toward goal attainment, indicates any change in functional status, and directs modification of the intervention plan, if necessary. Because recovery from TBI involves multiple stages of client functioning and lengthy intervention, it is important for occupational therapists to periodically review the intervention plan to determine whether it reflects the client or family's current priorities, incorporates intervention approaches that meet those needs, and integrates current available evidence.

Outcome Monitoring

Occupational therapy practitioners and occupational therapy assistants document outcomes in discharge evaluations or discontinuation notes within the time frames, formats, and standards established by practice settings, agencies, external accreditation programs, and payers. A focus on outcomes is interwoven throughout the process of occupational therapy, and occupational therapists may contribute their patient data and perspective to comprehensive team-based outcome assessments.

Discontinuation, Discharge Planning, and Follow-Up

The existing health care reimbursement system in the United States bases eligibility for medical rehabilitation, length of stay, and discharge from services on motor impairments limiting function more than the cognitive behavioral impairments limiting resumption of life roles and independent living. When clients with TBI are discharged from structured inpatient rehabilitation programs to their homes and communities, the true extent of their limitations may be revealed, often at a time when their financial and supportive resources are depleted. Occupational therapists' strength in analyzing and adapting functional tasks can be of great assistance in helping clients with TBI living in the community in resuming meaningful roles and occupations.

Occupational Therapy Services to Organizations and Populations

Occupational therapists who provide services to organizations rather than individuals with TBI enter the therapeutic relationship with respect for the values and beliefs of the organization. They seek to understand the collective abilities and needs of the members of the organization and how the features and structure of the organization support or inhibit the overall performance of individuals within the organization. The skills of an occupational therapist with experience in community-based programming, program development, and management and reimbursement can assist community organizations and agencies in dealing with the issues and needs of the TBI population. Therapists work to affect the organization's design and ability to more effectively and efficiently meet the needs of individuals with TBI and other stakeholders while empowering the members with TBI to seek satisfying lives.

Table: Recommendations for Occupational Therapy Interventions for Clients With Traumatic Brain Injury* (see definitions for recommendation grades [A, B, C, D, I] at the end of the "Major Recommendations" field)

Recommendation for Inclusion of Intervention in Occupational Therapy Services

Intervention:

  • Recommended - supported by strong or moderate evidence
  • No Recommendation - existing evidence is limited, insufficient, or inconclusive)
  • Recommended Against - supported by strong or moderate evidence)

Overall recovery

Recommended:

  • Early and aggressive rehabilitative intervention to reduce length of stay and improve short-term functional outcomes (B)
  • Post-acute functionally based rehabilitation (B)

No Recommendation:

  • Continued outpatient therapy sustains early gains (C)
  • Challenging therapeutic interventions requiring mental manipulation to reorganize brain function (I)
  • Family intervention (I)
  • Short-term intervention for individuals with mild traumatic brain injury (MTBI) (I)

Interventions focused on client factors/impairments

Recommended:

  • Constraint-induced movement therapy (CIMT) (A)
  • Serial casting of ankle plantar contractures (A)
  • Serial casting of upper-extremity contractures (B)
  • Purposeful activities for fine motor recovery (B)

No Recommendation:

  • Sensory stimulation or coma arousal programs (I)
  • Cognitive–behavioral therapy for insomnia (I)
  • Continuous passive motion (CPM) for heterotopic ossifications (HO) in lower extremity (I)
  •  Calendars for temporal reorientation (I)
  • Telerehabilitation for cognitive impairments (I)

Recommended against:

  • Nocturnal hand splinting to improve range of motion (ROM), pain, or function (D) is not effective

Interventions focused on performance skills

Recommended:

  • Errorless learning (A)
  • Compensatory approaches to cognitive rehabilitation (A)
  • Memory rehabilitation utilizing restorative (visualization, mnemonics); compensatory (internal mnemonics and external aids); and external change/adapt environment strategies for clients with mild-to-moderate impairments (A)
  • Computerized memory orthoses for prospective memory (A)
  • Awareness training embedded in functional task performance (A)
  • Group-based cognitive rehabilitation (A)
  • Social skills training (B)
  • Establishment of goals valued by the client, combined with compensatory training and environmental adaptation (B)
  • Pager systems for memory and planning problems (B)
  • PDA to remind client about therapy goals (B)
  • Mobile phones as compensatory memory aids (B)
  • Environmental cues for performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (B)
  •  Attention remediation programs for clients in the chronic phase of recovery (B)

No Recommendation:

  • Goal management training (GMT) (C)
  • Behavioral approach using positive reinforcement (C)
  • Attention processing therapy (C)
  • Prospective memory training (I)
  • Treating the client within environments that are graded to reduce structure and to increase distractions equal to real-life situations (I)
  • Positive talk training (I)
  • Organizational supports to reduce everyday memory problems (I)
  • Multidisciplinary cognitive rehabilitation (I)
  • TEACH–M approach for using a simple e-mail interface (I)
  • Self-determination model to address integrated self-awareness (I)
  • Intervention focused on perception of emotion on psychosocial functioning (I)
  • Gross motor activities for attention (I)
  • Sustained attention training for hemiattention disorder (I)
  • Web-based interactive assistance for performance of targeted functional activity (I)
  • Modified memory diary with a pair of pages for each day of the week (i.e., timetable and to-do list) (I)
  • Use of an alphanumeric pager system to increase memory notebook use (I)
  • Computer-related activities designed to enhance participation in desired social roles (I)
  • Game format to teach information about TBI (I)
  • Role-playing to achieve friendships and intimate relationships (I)
  • Cognitive groups to achieve return to employment (I)

Recommended Against:

  • Drills and computerized practice training is not effective for improving attention or memory (D)

Interventions focused on occupational performance areas and/or participation

Recommended:

  • Functional–experiential treatment for older clients with TBI and independent living goals (B)
  • Written contracts to achieve short-term goals (B)
  • Life skills training to increase community participation (B)
  • Intensive cognitive rehabilitation (ICRP) to return to work for military personnel (B)

No Recommendation:

  • Electronic aids for daily living (EADLs) (I)
  • Wrist-worn electronic device for community navigation (I)

*Suggested recommendations are based on the available evidence and content experts' opinions. See Appendix E in the original guideline document for a list of supporting evidence used to develop these recommendations.

The acute rehabilitation phase of recovery begins as the client is medically stable and emerging from the coma. Occupational therapists, as part of the rehabilitation team working with clients who have TBI, must address the client's physical, cognitive, communicative, emotional, and spiritual needs while planning for the client's transition to the next setting, whether it is subacute rehabilitation, an outpatient program, or home in the community. Reduced lengths of stay and a reimbursement system focused more on motor recovery than cognitive and neurobehavioral recovery can make justification for the client’s need for occupational therapy intervention challenging.

Definitions:

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence:

Level I
Definition - Systematic reviews, meta-analyses, and randomized, controlled trials

Level II
Definition - Two groups, nonrandomized studies (e.g., cohort, case control)

Level III
Definition - One group, nonrandomized (e.g., before-after, pretest and posttest)

Level IV
Definition - Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)

Level V
Definition - Case reports and expert opinions, which include narrative literature reviews and consensus statements

Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.

Strength of Recommendation

A - Strongly recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B - Recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.

C - No recommendation is made for or against routine provision of the intervention by occupational therapy practitioners. At least fair evidence was found that the intervention can improve outcomes, but concludes that the balance of the benefits and harm is too close to justify a general recommendation.

D - Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

I - Insufficient evidence to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harm cannot be determined.

Note: Recommendation criteria are based on standard language from the Agency for Healthcare Research and Quality (2009).

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

A total of 99 articles were included as evidence: Level I (32 articles); Level II (10 articles); Level III (16 articles); Level IV (20 articles); Level V (20 articles); uncategorized (1 article). In addition, the decision was made to incorporate evidence from the systematic review on constraint-induced movement therapy (CIMT) completed for the Occupational Therapy Practice Guideline for Adults With Stroke*.

See Appendix E in the original guideline document for a list of supporting evidence used to develop specific recommendations for occupational therapy interventions.

*Sabari, J. Occupational therapy practice guidelines for adults with stroke. Bethesda (MD): American Occupational Therapy Association Press; 2008.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

This guideline may be used to improve quality of care, enhance consumer satisfaction, promote appropriate use of services, and reduce cost by assisting:

  • Occupational therapists and occupational therapy assistants in communicating about their services to external audiences
  • Other health care practitioners, case managers, families and caregivers, and health care facility managers in determining whether referral for occupational therapy services would be appropriate
  • Third-party payers in determining the medical necessity for occupational therapy
  • Health and education planning teams in determining the need for occupational therapy
  • Legislators, third-party payers, and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants
  • Program developers, administrators, legislators, and third-party payers in understanding the scope of occupational therapy services
  • Program evaluators and policy analysts in this practice area in determining outcome measures for analyzing the effectiveness of occupational therapy intervention
  • Policy, education, and health care benefit analysts in understanding the appropriateness of occupational therapy services for traumatic brain injury (TBI)
  • Policymakers, legislators, and organizations in understanding the contribution occupational therapy can make in program development and health care reform for persons with TBI
  • Occupational therapy educators in designing appropriate curricula that incorporate the role of occupational therapy with TBI

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

  • This guideline does not discuss all possible methods of care, and although it does recommend some specific methods of care, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given intervention in light of a specific person's circumstances, needs, and available evidence to support the intervention.
  • This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Staff Training/Competency Material

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

Golisz K. Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda (MD): American Occupational Therapy Association (AOTA); 2009. 258 p. [282 references]

 Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2009

Guideline Developer(s)

American Occupational Therapy Association, Inc. - Professional Association

Source(s) of Funding

American Occupational Therapy Association, Inc.

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Author: Kathleen Gosliz, OTR, OTD, Associate Professor, Occupational Therapy Graduate Program, Mercy College, Dobbs Ferry, NY

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone:1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online from the AOTA website.

Availability of Companion Documents

The following is available:

  • Occupational therapy practice framework: domain and process (2nd ed.) 2008. American Journal of Occupational Therapy (AOTA), 62, 625–688. Electronic copies: Available to subscribers from the AOTA website.

In addition, two case studies, Coma Stage of Recovery and Acute Rehabilitation Stage of Recovery, are available in the original guideline document.

Patient Resources

None provided

NGC Status

This NGC summary was completed by ECRI Institute on October 27, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

National Guideline Clearinghouse (NGC). Guideline summary: Occupational therapy practice guidelines for adults with traumatic brain injury. In: National Guideline Clearinghouse. Excerpted from the original by the American Occupational Therapy Association, 2009. Available at: www.guideline.gov. Used with permission.

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