Occupational Therapy Approaches to Traumatic Brain Injury

Laura H Krefting, Jerry A Johnson

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781560240648
• eBook ISBN: 9781136580277
• Topic: Medizin
• Subtopic: Gesundheitsversorgung

This sensitive book provides a much-needed compilation and description of OT programs for the care of individuals disabled by traumatic brain injury (TBI). Focusing on the disabled individual, the family, and the societal responses to the injured, this comprehensive book covers the spectrum of available services from intensive care to transitional and community living. Both theoretical approaches to the problems of brain injury as well as practical treatment techniques are explored in Occupational Therapy Approaches to Traumatic Brain Injury. The processes of assessment and intervention are vital to the recovery of brain-injured patients and this thorough book devotes two chapters specifically to assessment and several chapters on intervention and family involvement. This useful volume contains information about rehabilitation from 'coma to community,'as well as numerous other approaches.The findings and treatment suggestions presented here are applicable to many helping professionals working with TBI patients. Health care practitioners working with brain injured persons and their families in both institutional and community contexts, physical therapists, physicians, nurses, and psychologists and social workers involved with assessment will find this an invaluable addition to their professional references.

Measuring Clinical Change in Cognitive Rehabilitation of Patients with Brain Damage: Two Cases, Traumatic Brain Injury and Cerebral Vascular Accident

Noomi Katz, PhD, OTR
Dorit Hefner, OTR
Rachel Reuben, OTR

SUMMARY. The purpose of this article is to demonstrate the use of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) as a measure of clinical change in the cognitive rehabilitation of brain damaged patients. Two cases are presented, one a traumatic brain injured (TBI) young male patient and the second an elderly male patient suffering from cerebral vascular accident (CVA). Evaluation and treatment combined sensory motor stimulation, cognitive remediation and functional approaches. Profiles of cognitive performance to follow-up progress during the process of recovery are presented. Recommendations are made to utilize occupational therapy ongoing assessments for documenting clinical change.

INTRODUCTION

Measuring recovery of function is one of the most difficult issues in the rehabilitation of brain damaged persons. According to Almli and Finger (1988) “Recovery is a theoretical construct that implies a complete regaining of identical functions that were lost or impaired after brain damage” (p.8). This definition of recovery, even though ideal, is very hard to measure because in most cases we have no objective measures of previous functional level of the brain damaged patient. Within cognitive rehabilitation it is assumed that most normal adults achieve a basic cognitive task performance. We, therefore, start by assessing the patients' current cognitive task performance. This assessment serves as a base line for measuring progress, and together with premorbid information, sensory motor evaluation and functional status evaluation in daily activities, is the basis for treatment planning.

The cognitive rehabilitation evaluation and intervention approach of occupational therapy at Loewenstein Rehabilitation Hospital (LRH) combines sensory motor, functional and cognitive retraining approaches (Siev, Freishtat & Zoltan, 1986; Zoltan & Ryckman, 1985), with differential emphasis depending on the individual patient's deficits and stage of illness. Treatment focuses generally on direct remediation of the specific cognitive impairments at the acute stage—phase one. While in phase two, when the patient is stabilized, work centers on compensation techniques in functional tasks. In both phases major emphasis is given to cognitive rehabilitation therapy in restoring function with direct retraining and/or compensating for impaired functions (Ylvisaker & Gobble, 1987). As Ylvisaker and Gobble state, cognitive rehabilitation has become the keystone of many rehabilitation programs.

Numerous treatment approaches are identified in the occupational therapy literature as separate entities, such as: sensory integration, transfer of training, functional and neurodevelopmental treatment (Siev et al., 1986); adaptive functional treatment approach or remedial treatment (Neistadt, 1988); behavioral approach (Fussey & Giles, 1988; Giles & Clark-Wilson, 1988); or deficit-specific approach versus information processing approach which defines treatment in a multicontext approach (Toglia, 1989). This appears to be theoretically sound, but clinically these approaches are not practiced in isolation. This is suggested also by the multiframe of reference approach in cognitive rehabilitation (Abreu, 1987; Abreu & Toglia, 1987).

In practice, a combination of approaches is used depending on the patient's impairments and phase of illness, premorbid capabilities and experiences, motivational and affective reactions, and environmental conditions. Cognitive rehabilitation may include only remedial table-top or computer training, or may be used in combination with direct activities of daily living (ADL) functional training, including also behavioral methods at certain phases of treatment. Work on sensory motor deficits using such neurodevelopmental concepts as body alignment, positioning and active movement patterns are used also to facilitate higher cortical function (Abreu & Toglia, 1987). Thus, Toglia's (1989) recent description of a multicontext approach which, as she states, shares some similarities with both remedial and functional treatment approaches, appears to be more fruitful clinically.

A vast research literature exists already about the efficacy of remedial and/or functional approaches but neither has unequivocally shown either functional carryover or generalization, and many researchers failed to examine essential variables significant to the outcomes studied (Neistadt, 1988). Nevertheless, the relationships between cognitive abilities and functional performance in activities of daily living and the effectiveness of cognitive rehabilitation has been demonstrated in various studies (Ben-Yishay & Diller, 1983; Bernspang, Viitanen & Eriksson, 1989; Carter, Howard & O'Neil, 1983; Carter, Oliveira, Duponte & Lynch, 1988; Soderback, 1988).

Based on the premise that cognitive abilities are significantly related to functional outcomes, the purpose of this article is to demonstrate the use of a cognitive assessment battery as one measure of clinical change in the treatment of brain damaged patients. Two cases are presented: one, a traumatic brain injured (TBI) patient, and the second, a patient suffering from cerebral vascular accident (CVA). Patients were treated by an interdisciplinary rehabilitative team and no claim of a specific occupational therapy treatment effectiveness is made here. Only the treatment process in occupational therapy is described, and changes in cognitive performance in conjunction with sensory motor and ADL tasks are followed.

INSTRUMENT

The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) was developed at Loewenstein Rehabilitation Hospital (LRH) in Israel, to assess basic cognitive abilities of brain injured patients (Katz, Itzkovich, Averbuch & Elazar, 1989; Najenson, Rahmani, Elazar & Averbuch, 1984). Basic cognitive abilities are defined as those “intellectual functions thought to be prerequisite for managing everyday encounters with the environment” (Najenson et al., 1984, p. 315). Cognition is conceived as a general term including attention, perception, thinking and memory.

The LOTCA battery was derived from clinical experience as well as from Luria's (neuropsychological) and Piaget's (developmental) theories and evaluation procedures (Golden, 1984; Inhelder & Piaget, 1964). The battery provides an initial profile of the cognitive abilities of the brain injured patient as a starting point for occupational therapy intervention, and a screening test for further assessment. It consists of 20 sub-tests and is divided into four areas: orientation; visual and spatial perception; visuomotor organization; and thinking operations. It takes 30 to 45 minutes to administer, and can be divided into shorter sessions if necessary. Procedures for evaluating patients with expressive language deficits are included.

The battery's measurement properties were established in various ways. Inter-rater reliability coefficients of .82 to .97 for the various sub-tests was determined, and an alpha coefficient of .85 and above for internal consistency of the 3 areas of perception, visuomotor organization and thinking operations were established using two patients groups and a normal control group (Katz et al., 1989). Validity in differentiating between known groups was determined with the Wilcoxon two sample test showing that all sub-tests differentiated at the .0001 level of significance between controls and each of the patient groups (TBI and CVA). Initial construct validity was examined using an exploratory factor analysis, which showed a three factor solution and a total amount of variance explained above 60% which is a substantial percentage supporting the assumed structure of the LOTCA (Katz et al., 1989). Criterion validity was examined within the CCI group for the visuomotor organization area using the Block Design sub-test of the WAIS (Wechsler, 1981). A Pearson correlation coefficient of r = .68 was found between the score on the Block Design and the mean score of the visuomotor organization sub-tests of the LOTCA, and a r = .77 when time was not measured on the Block Design. Almost identical results were found for a group of chronic schizophrenic adult inpatients (r = .69 and r = .78).

In addition, age level standards were determined testing 240 normal primary school children, 40 subjects in each age group between six to twelve years. Children's performance on the LOTCA were assessed to determine age norms of the various sub-tests, as well as to verify the hierarchical order of acquiring the various cognitive competencies included in the battery. Results show a clear developmental sequence in performance along the LOTCA sub-tests. Level of performance increased steadily with age, while the speed to perform the visuomotor tasks decreased concomitant with the increase towards maximal performance (Averbuch & Katz, 1989). These findings support the battery's assumed hierarchical order and the intended basic level of cognitive abilities measured with the LOTCA.

Thus, the measurement properties of the LOTCA were found to be reliable both in agreement between raters and in the internal consistency of its 3 component areas: perception, visuomotor organization, and thinking. The LOTCA was also found to be valid in differentiating between healthy adult persons and brain damaged patients. This finding, along with the results of a previous study where the performance profile of psychiatric patients was shown to differ from CCI patients (Averbuch & Katz, 1988), suggests that the LOTCA differentiates level of performance as well as enables differentiation between patterns of cognitive deficits related to the site of the brain lesions.

On the individual level the LOTCA is used at LRH as a measure of the patient's status over time, that is, as a measure for clinical change. In those cases in which deficits were present at initial assessment, the LOTCA is employed as a measure for follow-up on patients' progress. It is recommended that the assessment be repeated after an interval of at least two months to avoid simple memory carry over. However, learning as a possible explanation for higher scores must always be considered since many similar tasks are practiced during treatment. But it is precisely this learning, if generalized, that is the purpose of treatment, so that it should not be regarded as a threat to validity as defined in measurement theory.

TBI CASE STUDY

Jacob is a 24-year-old man with right hand dominance. He is Israeli born, unmarried, and finished tenth grade, spending the last two years in a technical junior high school focusing on carpentry. After three years of mandatory army service Jacob began studying for the matriculations exams as part of an adult education project. He was a truck driver when he was injured in a car accident.

Diagnosis

Cranio Cerebral Injury: Prolonged unawareness state; brain contusion; status/post left temporo-parietal acute subdural hematoma; status/post left temporo-parietal craniotomy.

Course of the disease: Jacob was injured on February 23, 1989, and hospitalized in coma. Brain catscan (CT) showed left subdural hematoma with slight deviation of the midline. A craniotomy was performed in the temporo-parietal area. After the surgery, while Jacob was still in a coma, a severe right hemiparesis was noted. Twenty days after injury Jacob opened his eyes for the first time and could perform simple tracking. Later, active movements on the left side began to return with an increase in spasticity on the right side.

Jacob was transferred to LRH one month after his injury. He was still restless, aware of his surroundings but had not yet vocalized. He was incontinent and was tube fed. Jacob was referred to the occupational therapy department immediately after his ar...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• CONTENTS
• ABOUT THE EDITORS
• Preface
• Introduction
• Development of the ADL Profile: An Evaluation for Adults with Severe Head Injury
• Measuring Clinical Change in Cognitive Rehabilitation of Patients with Brain Damage: Two Cases, Traumatic Brain Injury and Cerebral Vascular Accident
• Goal Attainment Scaling in Post-Acute Outpatient Brain Injury Rehabilitation
• The TBIIM: An Intervention Model for the Treatment of Individuals with Traumatic Brain Injury
• Family Intervention with the Traumatically Brain Injured Patient
• A Descriptive Study of Family Directed Therapy for Traumatically Brain Injured Persons
• Executive Function and Cognitive Remediation: A Study of Activity Preference
• Stroke Clients' Perceptions of Disability and Treatment
• SOMETHING NEW AND DIFFERENT
• BOOK REVIEW