When working with acquired or traumatic brain injuries for the first time, it can be challenging, exciting, and even stressful as a student or new grad. This is especially true if you have not been exposed to such a patient or any cognitive interventions for traumatic brain injury.

The purpose of this post is to cover basic information and helpful intervention ideas so that you can be prepared and equipped to provide the best care for your patient. OT programs usually spend about one day lecturing on this and unfortunately don’t have much to provide you as a new OT.

What is a Traumatic Brain Injury (TBI)?

AOTA’s definition really sums it up pretty clearly and concisely, defining traumatic brain injury as…

“…an occurrence that happens when the person’s head is severely hit or shaken, or when an object goes into the brain, and can range from mild to severe.”

The most common causes of TBI are car and motorcycle accidents, falls, and other accidents that result in a blow to the head.

AOTA explains that…

“…individuals with TBI may have changes to their personality, trouble with memory, confusion, or poor judgment. They may be tired, depressed, or anxious. The changes to the brain after TBI can affect people’s ability to do daily activities (occupations). It may also affect their roles, such as employee, spouse, parent, and friend.”

This is where we as occupational therapists come in to help our patients with traumatic or acquired brain injuries live their most productive lives as independently and safely as possible.

Be Prepared for Agitated Patients

As a therapist, you want to be aware that your patient could be agitated and combative, depending on their Ranchos Los Amigos level. It also depends on much stimuli they are receiving, which can be a lot in the hospital – especially with staff that may not be educated in this area.

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If your is patient agitated, first look at the surrounding environment. Is the TV on loudly? Are all of the fluorescent lights on brightly? Are several family members talking to the patient at once? Do you notice nurses talking loudly at/in front of the patient?

Note: This means no offense to nursing, but when I was a CNA for four years I saw more often than not nurses lacking the in depth training on sensory processing which can contribute to over-stimulation.

Whether your patient is or is not agitated, they all will benefit from low stimulation environments while their brain is healing. Be sure to keep this in mind before you bring your patient to a crowded gym. This can be just as detrimental as the above reasons.

Team Up With Speech Therapy

Another tremendous benefit will be to collaborate with your patient’s speech therapist to make sure you two are on the same page with interventions. It’s also very important to make sure you aren’t doing the same things!

Occupational therapy can get muddy with speech therapy since they are also working on attention, memory, problem-solving, etc.

6 Functional Inpatient Rehab Treatment Ideas

These treatment ideas tie into ADLs/I-ADLs (these may differ from what works in your setting):

1. Meal Prep

Hopefully you have a training kitchen in your setting because you can work on so much cognitively with this activity. Following a recipe, listing ingredients, following prep instructions, planning a meal and safety in the kitchen are great ways to not only work cognition but help prepare your patient for going home.

2. Medication Management

If your hospital has a pre-made medication management kit, then you’re all set to help your patient practice setting up daily medications using the pill box organizer and fake medications.

If not, here is a link to make your own medication management kit.

3. Money Management

You can use fake money that your hospital may have already. If they do not, you can get an inexpensive play money kit with coins and bills on Amazon and use it again and again with future patients with cognitive deficits to work on paying for purchases, ordering from a catalog, simple adding and subtracting, and budgeting. This is an affiliate link which monetarily supports My OT Spot.
You can create these yourself by using a day planner, calendar, or creating a memory book to assist the patient in writing down what they have done that day. You can add pictures of family members with their names written down, important phone numbers, addresses and dates.

5. Leisure Activities

This might include things like puzzles, card games and word finding sheets which all work on attention, concentration and focus, which can be affected after brain injury or stroke.

For more detail on specific games to play based on your patient’s cognitive and physical deficits, check out this helpful article, “Playing Around With Recovery” from the Stroke Association.

6. ADLs!

Basic ADLs, that is. If you have a patient that is at a Ranchos stage that they cannot cognitively work on IADLs yet and is showing difficulty with motor planning, sequencing, initiation, or attention, I will do repetitive basic ADL retraining.

This includes mainly the basics such as dressing, bathing, toileting and self-feeding, if they are not on swallow precautions/NPO.

You’ll want to really focus on the environment to make sure it’s not too cluttered. Turn off the TV and focus on one task at a time as well as your cuing.

Cognitive interventions for traumatic brain injury.

You want to ensure you are providing simple cues like “What is this,” “Brush your hair,” “This is a shirt,” if your patient is at this level. Remember the KISS acronym of Keep It Simple, Sweetie!

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Remember to Educate Others

Don’t forget to educate their caregivers on these cuing tactics as well, since family can sometimes be way too overstimulating without realizing it.

Caregivers (including hospital staff) will also benefit from education on the injury and the nature of your patient’s cognitive impairment.

You should also make post-discharge recommendations like 24 hour supervision when home. Don’t forget to add ongoing education about safety recommendations like grab bars, swallow precautions, impulsivity, etc. This will help your patient reduce the risk of any further accident or injury.

Always Tailor Your Treatment Plans

I also want to point out (which is probably obvious) that these cognitive interventions are not one-size-fits-all, and each patient will be different and respond differently.

Be sure to grade these up or down and make sure each treatment fits into the “just-right challenge.” Treatments that are too difficult or too easy can lead to the patient being frustrated.

Your patient may also demonstrate physical limitations, so remember to keep that in mind and incorporate interventions targeting those limitations as well. You want to help the patient both physically and cognitively.

Other Important Things to Know

  • If a patient is showing signs of agitation or frustration, do not stand right in front of them; give them space and try to remind yourself not to overstimulate them as you’re providing the intervention.
  • Cognitive rest breaks are very important. Think of it as taking physical breathers during the interventions, as your patient is working really hard cognitively to perform the task you’ve given them. It’s okay to take breathers!

What Happens After Rehab?

If you are working in acute rehab with patients with brain injury, you will learn quickly that the patient’s brain will very likely not be “healed” to it’s full potential. Hospital stays are usually one to three weeks and the brain can heal for up to 12 months or more. This of course varies for each person.

If you are in the acute setting, you can recommend outpatient or community-based rehab for your patient to continue to work to regain the skills needed to thrive post-hospital discharge.

For a great source on community reintegration, check out this easy to follow (not dense!) Community Reintegration Fact Sheet from AOTA. I highly, highly recommend checking this sheet out so you can fully understand the continuum of care post-DC.

For another useful tip sheet on working with TBI’s, check out this fact sheet on AOTA’s TBI page.

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I hope this post helped you form some beginning ideas of what you can incorporate during brain injury rehab. I feel like this post barely skimmed the surface, as there is just so much involved in neuro-rehabilitation. If I’m missing anything major, please add it in the comments below.

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