Occupational therapy for patients with acquired brain injury

Today, the occupational therapist Ángel Sánchez, after explaining in an earlier post the goals and functions of occupational therapy, addresses the role of occupational therapy in patients with acquired brain injury.

Occupational therapyis the use of purposeful activity or interventions designed to achieve functional outcomes which promote health, prevent injury or disability and which develop, improve or restore the highest possible level of independence of any individual who has an injury, illness, or other disorder or condition, in this case,of patients with acquired brain damage (ABI).

The primary goal of occupational therapy is to enable individuals to perform everyday life activities that are important and necessary to them. Occupational therapists assess motor, cognitive, perceptual, and interpersonal skills underlying activities of daily living, as well as occupations and life roles. Depending on the person’s potential for recovery, occupational therapy enhances performance in the activities by improving skills, teaching and developing compensatory and remedial or restorative strategies to maintain individual’s independence.

This intervention is characterized by some core features of occupational therapy practice, including the following among others:

• To enable patients with ABI to become independent in activities of daily living (hereafter, ADLs).
• To develop new roles and meaningful activities for patients.
• To teach strategies that will facilitate the generalization of learning, that is, what is learned in a clinical setting will transfer to everyday life.
• To use analysis, selection, and development of activities as therapeutic intervention processes that contribute to the patient achieving significant goals.

Patients with acquired brain injury share the common characteristic of having suffered a brain lesion that has interrupted their vital development. Within this heterogeneous group of patients, stroke and trauma are the most frequent causes, although other causes include brain tumors, assaults, encephalitis and cerebral anoxia (due to sleep apnea, carbon monoxide poisoning, myocardial infarction, etc.). Traffic, work and sports accidents, the increase in life expectancy and the improvement in acute care for these patients can contribute to increased morbidity.

Main deficits

It is difficult to establish a general pattern of impairment after an ABI, since the alterations found will depend on a number of factors, including the initial severity of the injury, the type and location of the injury, and the presence of complications in the acute phase, not to mention other relevant factors such as age, personality and pre-injury cognitive abilities.

Among the main deficits are sensory disorders and motor deficits (changes in muscle tone, problems with motor coordination and control, superficial and/or deep sensitivityabnormalities); language and communication difficulties (different types of aphasia, dysarthria, difficulty with verbal fluency and deficits in pragmatic communication skills); and neuropsychological disorders (cognitive and behavioral).

These changes should not be viewed in isolation; instead, special attention should be given to the difficulties they cause in patients’ daily functioning when performing their ADLs.

Activities of daily living

ADLs are those occupational tasks that individuals carry out on a daily basis according to their biological, emotional, cognitive, social and work roles, among which we can distinguish between:

• Basic activities of daily living (BADLs): activities involving the most basic and fundamental self-care skills such as eating, personal hygiene, dressing, bowel and bladder management, functional mobility and transfers.
• Instrumental activities of daily living (IADLs): activities thought to be more complex in nature that often require thinking skills and determine whether an individual can live independentlyin the community. IADLs include: shopping, financial management, meal preparation, community mobility, etc.

The primary goal of occupational therapy is to enable individuals to perform meaningful activities within a personal contextas independently as possible. Traditionally, intervention for patients with ABI has been divided into two models:

1. The recovery model, based on the restoration of physical, cognitive and perceptual abilities.
2. The adaptation model or functional model, focused on the use of those skills preserved by the individual to compensate for his or her deficits.

The treatment approach for the recovery model consists of tasks that require cortical information processing by focusing on the stimulation of the affected function to form new neural connections, especially by using tasks aiming at the analysis of the affected information processing abilities. Therefore, it implicitly assumes that the individual will be able to generalize this learning to any context and situation once the function is restored.

On the other hand, the adaptation modelor functional model is based on the idea that the brain has the ability to reorganize itself as well as to regain its ability to process information to a certain extent; in this way, the brain helps the person to learn to prioritize its residual potential and to use strategies to compensate for their deficits.

Evaluation and treatment are based on functional capacity (ADLs), that is, on what the patient can or cannot do. By doing so, individuals become aware of their situation regarding their physical, cognitive and perceptual limitations so to address their treatment (internal compensation). Similarly, individuals will improve if the focus is on adapting the environment and/or task to fit the person’s own characteristics (external compensation).

It is also important to consider a reflective model for treating brain injury in which decision-making is based on clinical reasoning together with the available scientific evidence to offer insights into patients’ treatment. Therefore, such decision-making should respond to the needs of the client by selecting the appropriate therapeutic strategies at each stage of the subject’s progress through the agreed development of the rehabilitation process.

Activity-based intervention

Occupational therapy makes learning and recovery possible through the modification of environmental stimuli, the presentation of occupational tasks and the modification of the context where occupations take place. Therefore, occupational therapyis an activity-based intervention for the following reasons:

• It maximizes the patient’s ability to improve the deficits resulting from brain injury, as well as to prevent possible disabilities resulting from them.
• It minimizes dependency as much as possible by enabling individuals to carry out relevant activities according to the roles that definethem.
• It promotes participation by facilitating the acquisition of new skills and having a holistic approach tothe rehabilitation process that focuses on client interests and preferences whenever possible.
• It stimulates and facilitates the generalization of learning by approaching rehabilitation from the most ecological perspective possible, that is, by carrying out activities of daily living independently and in a real-life context. This makes occupational therapy one of the most suitable fields for the treatment of patients with ABI, since it guarantees that learning and its implementation are carried out effectively.

Practice understood as the repetition of isolated movements or cognitive functions is giving way to the practice of functional activities in different contexts. Occupational therapy uses this knowledge to create the conditions for professional practice while trying to focus on the determination of the necessary conditions during the learning acquisition phase to try to optimize the retention and transfer of learning acquired by the patient.

Current research has shown that the skills required to perform“real” activities are acquired in real-life contexts and not through repetitive practice.

Occupational therapy practitioners modify the environment to stimulate the motor and cognitive behaviors and strategies that they seek to train for therapeutic purposes. It should be noted that latest results indicate thatusing occupation as a therapeutic medium is more effective than programs based on single, repetitive tasks.

A basic tool of an occupational therapy practice

Activity analysis is anessential component of occupational therapy. It identifies and selects those activities that will be used with a therapeutic purpose according to patients’ characteristics. Activity analys is has three general purposes:

1. ADL assessment
2. Skill assessment tool: motor, cognitive, behavioral, etc.
3. Treatment goal

In addition, these goals adhere to understanding the patient’s overall situation in relation to his or her personal interests, roles and existing skills after brain injury to developpurposeful activities that will be used as a treatment modality.

Individualized treatment

Regarding patients’ abilities, the occupational therapist assesses ADLs in the context in which they are to be performed to determine what components are needed to perform them and to compare them with the skills preserved by patients after sustaining a brain injury. This enables the creation of a personalized treatment plan that can be aimedat remediation and compensation ofimprovabledeficits, as well as the development of appropriate patient management guidelines.

From a sensorimotor perspective, this analysis includes the adequate postural set to perform an everyday activity, as well as the organization of the cognitive components of said activity, and the contextual factors that may influence its performance.

The use of activities in occupational therapy differs from the use of activities by other professionals:

• Occupational therapy has a two-fold objective. On the one hand, the appropriate design of an activity according to the patient’s perspective,age, gender, environment, and interests. On the other hand, the improvement of deficits exhibited by the subjectby stimulating their recovery.
• The occupational therapist is able to adapt the selected and contextual aspects of the activity. Thus, material adaptation, presentation format, size, weight, texture,order, guidelines and procedures to design the activity are basic features of occupational therapy intervention.
• The occupational therapist acts as a facilitator to carry out the task. This can be done in multiple ways: by properly positioning the patient before starting, stretching specific muscle groups required for active task performance, using relevant visual and verbal stimuli, directing movements, using orthoticor prosthetic devices, etc. These stimuli are adjusted in difficulty over time until the patient can successfully cope with task demandswithout assistance. Similarly, the occupational therapist plays a key role in the early stages of patient education to prevent the development of compensatory strategies that could lead to unintended secondary deficits
• The procedure of selectingactivities is unique for each patient, hence the occupational therapist treatsthe person with ABI as unique and different from any other patient with the same pathology.

Purposes of therapeutic occupation

Therapeutic occupation is used with two purposes:

1. Occupation-as-endis purposeful by definition. The purposeful nature of occupation-as-end is reflected by its ability to organize a person’s behavior, day, and life. Occupation-as-end is not only purposeful but also meaningful. The performance of activities or tasks carried out by a person is related to the importance that this person places on them.
2. Occupation-as-means refers to occupation acting as the therapeutic change agent to remediate the person’s impaired abilities or capacities. Occupation in this sense is synonymous with “purposeful activity. ”Purposeful activity demands particular, more circumscribed responses than occupation-as-end.

What makes occupation-as-means therapeutic?

1.  The activity must have a purpose or goal that makes a challenging demand and allows for success.
2. The activity must be meaningful and relevant to the person who is to change, thus motivating the will to learn and improve.

Therefore, the therapeutic aspects of occupation used as a means to change impairments are purposefulness and meaningfulness.

Occupation-as-means is based on the assumption that the activity itself has therapeutic properties that change organic or behavioral deficits. However, these inherent aspects cannot be easily identified in the activity analysis carried out by occupational therapists.

Whereas a meaningful occupation has purposefulness, strictly speaking, a purposeful activity may or may not be meaningful. The purpose of an activity is the goal, that is, the expected end result. The meaning is the value that accomplishment ofthat goal has for the person. Therefore, meaningfulness is individual and depends on the patient’s beliefs, preferences, context and culture, as well as their expectations in the recovery process.

In therapy, meaningfulness is developed through the personal exchange between the patient and the therapist to constructthe meaning of activities within the context of culture, life experiences and disability, by taking into account present needs.

Main goals of occupational therapy intervention in patients with acquired brain damage

Below is an overview of some of the main goals of occupational therapy intervention in patients with ABI:

Proper postural alignment

Weakness of certain muscle groups and loss of motor control over postural adjustments in trunk and limbs are the most commonly observed alterations following ABI. Therefore, prevention and treatment of musculoskeletal disorders secondary to brain injury is achieved through correct postural alignment in different positions used by the personwhile carrying out daily activities (lying, sitting, standing); it is also necessary to highlight the importance of properposture in the early stages of brain injury (patient-positioning system), as well as the necessary practice of different motor tasks.

Assessment andrestoration of postural alignment

Patients with brain injury often exhibit impaired ability to effectively associate certain muscle chains with specific actions (e.g., using a spoon at mealtime); this may be due to altered muscle tone of the structures involved, joint misalignment, or a loss of the motor engram needed to perform sequences of movements. The role of occupational therapy at this level basically consists of proper assessment of the affected components, restoration of postural alignment andrehabilitation of proper kinetic chains to successfully perform ADLs.

Stimulation of patient’s metacognition

Occupational therapy should stimulate patients’ metacognition, especially in the early stages of recovery of consciousness following brain injury, by highlighting the presence of deficits so that individuals can anticipate the difficulties they will encounter when dealing with a given activity, estimate the possible outcomes, and assesstheirtask performance.

Occupational therapists will then teach patients general strategies to be practiced in multiple contexts. For example, gathering relevant information to carry out a task such as making coffee before its execution can serve as a strategy to improve the monitoring and development of motor planning and the possible difficulties patients might encounter during the performance of this activity. OT practitioners will also facilitate the planning and execution of the activity.

Cognitive strategies

Just as kinetic chains and postural alignment serve as the basis for proper motor functioning, cognitive strategies provide the appropriate frame of reference to improvepatients’ abilities to interpret and manage complex information coming from different situations and contexts. These strategies aim to enable the person to select the relevant information from the environment and the activity—discarding the irrelevant, which could disrupt information processing—with the purpose of planning the most appropriate behavior (motor, sensory, etc.).

In a similar manner, it should not be forgotten—especially in the case of acquired brain injury—that the performance of ADLs always requires the participation and integration of a series of prerequisites or basic components at the sensorimotor, cognitive and behavioral levels, the alteration of which is directly related to the functional limitations that may occur and the impact of these limitations in the performance of ADLs.

Needs assessment

It is also the role of the occupational therapist to assess and recommend—in line with clients’ needs—assistive devices and technologiesto promote their independence, for example, long-handled shoehorns to put on shoes or adapted cutting boards for preparing food, among others. Occupational therapy practitioners have as well an important role in home and environmental modifications to increase patients’ accessibility [33]. Finally, occupational therapists also document professional practice, i.e., administrative documents pertaining to the dependency level in performing activities of daily living or the need for different assistive devices.

Patient characteristics following brain injury require a specific approach regarding their evaluation and treatment; the significance of their cognitive deficits as long-term predictors of poor functional outcomein relation to the need for assistance with ADLs should be highlighted.

Generalization

Occupational therapy’s goal for patients with ABI should focus on the generalization of new skills to various real-life contexts.

It is recommended the use of ADLs as a therapeutic medium and goal, rather than the repeated practice of single exercises, while taking into account patient characteristics following the injury.

In the last decade, occupational therapy as a discipline has acquired an increasingly important role both in hospital treatment and in the community context, showing its effectiveness, profitability and necessity to improve functional outcomes in patients with acquired brain injury.