Migraines are debilitating headaches that affect millions of people worldwide. While they are commonly known for their intense pain, migraines can also be influenced by sensory sensitivity and overload. In this blog post, we will explore the relationship between sensory sensitivity and migraines, addressing important questions and providing strategies to promote relief.

Post concussion, migraine can be an issue that has a huge impact on your patients ability to fully re-integrate into the world. Whether you are a physical therapist (PT), occupational therapist (OT), or speech therapist (SLP), these strategies can be integrated into your practice to assist individuals dealing with migraines.

Let’s examine the link between sensory processing and migraine, to see how a therapist is best placed to address the issue!

Teach your patients to monitor their migraine symptoms with this concussion log!

Are Migraines a Sensory Processing Disorder?

While migraines are not classified as a sensory processing disorder, individuals who experience migraines often exhibit heightened sensitivity to various sensory stimuli. Sensory processing disorders, on the other hand, involve difficulties in processing and responding to sensory information. However, sensory sensitivity can contribute to migraine symptoms and exacerbate their intensity.

Can Sensory Overload Trigger Migraines?

Yes, sensory overload can indeed trigger migraines. When the brain is overwhelmed by excessive or conflicting sensory input, it can lead to a migraine episode. Common sensory triggers include bright lights, loud noises, strong smells, and certain textures. For individuals prone to migraines, managing sensory overload becomes crucial to prevent or reduce the frequency and severity of migraine attacks.

How can a PT, OT and SLP be instrumental in treating migraines?

Effective Relaxation Techniques for Treating Migraines

Relaxation techniques can play a significant role in managing migraines and promoting relief. Here are some effective techniques that can be recommended to individuals experiencing migraines:

1. Deep Breathing: 

Encourage slow, deep breathing exercises to promote relaxation and reduce stress levels. Inhaling deeply through the nose and exhaling slowly through the mouth can help calm the nervous system and alleviate migraine symptoms.

2.  Progressive Muscle Relaxation: 

This technique involves systematically tensing and relaxing different muscle groups in the body. Guiding individuals through the process can help release muscle tension, ease physical discomfort, and reduce the impact of migraines.

3.  Guided Imagery: 

Using visualization techniques, individuals can imagine themselves in peaceful and calming environments. Guided imagery can help distract from migraine symptoms, reduce stress, and induce a sense of relaxation.

4.  Mindfulness Meditation: 

Practicing mindfulness involves focusing on the present moment without judgment. Mindfulness meditation can help individuals manage stress, enhance self-awareness, and reduce the impact of migraines by redirecting attention away from pain.

Read more about mindfulness/meditation with concussion in rehab right here!

 Strategies for PTs, OTs, and Speech Therapists 

As PTs, OTs, and Speech Therapists, you have a unique opportunity to support individuals experiencing migraines. Here are some strategies you can incorporate into your practice to help:

1.  Education: 

Educate your patients about the connection between sensory sensitivity and migraines. By increasing their awareness, they can better understand their triggers and make informed decisions about managing their condition.

2.  Environmental Modifications: 

Collaborate with your patients to identify and minimize sensory triggers in their environment. This may involve adjusting lighting conditions, reducing noise levels, providing access to quiet spaces, and recommending ergonomic modifications.

3.  Sensory Integration Therapy: 

For individuals with sensory processing difficulties, sensory integration therapy can be beneficial. Work with an OT to develop personalized interventions that address sensory sensitivities and help regulate sensory input.

4.  Stress Management Techniques:

Teach stress management techniques such as relaxation exercises, breathing techniques, and mindfulness practices. By helping patients manage stress effectively, you can contribute to reducing the occurrence and intensity of migraines.

5.  Posture and Body Mechanics: 

Assist patients in improving their posture and body mechanics to reduce muscle tension and minimize physical strain. This can include ergonomic assessments, postural exercises, and guidance on proper body mechanics to prevent exacerbation of migraine symptoms.

6.  Physical Exercise and Activity: 

Encourage patients to engage in regular physical exercise and activity, as it can help reduce stress, promote overall well-being, and potentially decrease the frequency and severity of migraines. However, it is important to consider individual limitations and tailor exercise recommendations accordingly.

7.  Relaxation Equipment and Tools: 

Introduce patients to relaxation equipment and tools that can aid in managing sensory sensitivity and promoting relaxation. This may include weighted blankets, eye masks, noise-canceling headphones, and aromatherapy diffusers with calming scents.

8.  Collaboration with Other Healthcare Professionals: 

Foster a collaborative approach by working closely with other healthcare professionals involved in the care of individuals with migraines. This may include neurologists, psychologists, and pain management specialists. By coordinating efforts, you can ensure a comprehensive and holistic approach to migraine management.

9.  Patient Empowerment and Self-Management: 

Empower patients to take an active role in managing their migraines. Educate them about self-care strategies, including lifestyle modifications, stress management, and the importance of maintaining a migraine diary to track triggers and symptoms. By encouraging self-management, patients can gain a sense of control over their condition.

Sensory sensitivity can significantly impact the experience of migraines. By understanding the relationship between sensory overload and migraines, and implementing effective strategies, physical therapists, occupational therapists, and speech therapists can play a vital role in promoting relief and improving the quality of life for individuals with migraines. By incorporating relaxation techniques, environmental modifications, and collaborating with other healthcare professionals, you can provide comprehensive care and support to those dealing with migraines.

Remember, it is crucial to tailor interventions to each individual’s specific needs and collaborate closely with other healthcare professionals to ensure the best possible outcomes. By utilizing these strategies, you can make a positive difference in the lives of your patients who are seeking relief from the burdensome impact of migraines.

*Note: This blog post provides general information and strategies. It is essential to consult with healthcare professionals and specialists for personalized advice and treatment options.*

Want to learn more about specific interventions that you can use to promote health and independence with your patients who have had concussion? Check out our course: Practical Approaches to Concussion Management here for more essential strategies!

Emily Cahalan

Emily Cahalan OTR/L, CLT, CBIS: Emily is an OT with almost fifteen years experience in the field, having graduated from National University of Ireland, Galway in 2010.  Emily is passionate about inpatient rehabilitation and specifically lymphedema therapy in this space.  In her (limited) spare time, Emily has started accepting OTD Capstone students to do her part in further promoting the advancement of OT in the rehab world.

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750,000 people have a cerebrovascular accident (CVA) per year in the United States, which comes out to over 2,000 per day. 

Returning home after having a CVA can be a difficult transition for both the clients and their families. Maintaining or re-establishing roles can be an important component of the rehabilitation process and returning to the things that are important to these clients. Due to the prevalence of CVA in the U.S., it is important for practitioners to know how to address the transition home for our patients after a stroke which includes returning to roles such as a partner in marriage and parenting.

Parenting

Whether it is the parent of someone who has sustained a stroke or the client is a parent, there are some things as therapists that we can do to support this dynamic.  

1. Awareness to Behavior/Temperament Changes & De-escalation Strategies 

There may be times when the client becomes easily agitated and demonstrates “challenging” behaviors. It is important for the family of the client to understand that the area of the brain that was injured during the stroke, could alter behavior within the role as a parent (or in a marriage). There are strategies that can be used to de-escalate the situation during these instances. 

• Ask less general questions and more specific “how can I help” questions to decrease overwhelming feelings and develop a positive-collaborative communication style.

• Deep breathing in stressful situations and using this prior to responding in these situations. Breathing in through the nose and out through the mouth 3-5 times.

• Allow the client to express their emotions but encourage respectful vocabulary and remember the importance of staying calm and not responding negatively.

• Allow time for emotions to settle and return to subjects later using “I” statements to resolve the conflict. REMEMBER if safety is the concern it is important that this is prioritized and there is not any immediate danger to the caregiver or the client.

2. Supervision & Knowing Current Functional Limitations 

The motor, cognitive, and sensory changes that exist post stroke are not consistent for every client. Conversations about level of function and independence can be difficult for parents and families and typically relate back to safety. Understanding what the client is capable of doing at their current level of function is instrumental to maintaining safety within the home.

3. Support

Including a son/daughter in the rehabilitation is up to the discretion of the family, however there are some benefits to this inclusion. Fostering an understanding of the parent’s injury to the son/daughter can be done through including them in home programs/homework, attending therapy sessions to better understand what to work on within the home, and family education about the nature of the injury and the current limitations the client is experiencing.

Marriage

The challenges associated with returning to parenting and marriage after a stroke might involve some of the same strategies and techniques that we can teach to our clients and their loved ones to ease the transition back into the home.

1. Strategies for Maintaining Relationship & Managing Stressful Situations

• De-escalation strategies 

• Counseling appointments together and/or separate

• “Family meetings” with therapy or medical team for conflict resolution

•  Support groups

• Attending therapy (and other medical appointments together)

• Developing healthy communication patterns that can help achieve safe ADL collaboration and practicing this with your rehab team

2. Sex & Intimacy 

There is often a disconnect when considering sex and intimacy after being discharged from an acute or post-acute facility. Opening communication to topics such as:

• Discussing level of comfortability and the needs of both people in the partnership

• Exploring appropriate assistive devices that can promote independence during sexual activity 

• Using body positioning and current level of function to meet their goals as they relate to sex and intimacy. 

Read our article about sex and intimacy after stroke here!

Other Considerations

1. Return to Work

In addition to marriage and parenting after a stroke, the client might be preparing to transition back into the workplace. If the client identifies returning to work as an important goal for themselves, it is important we know how to support them such as targeting functional movements, strengthening, ROM, etc. necessary for work tasks in therapy sessions to promote return after a stroke. There are other recommendations we can make to assist these clients return to work such as:

• Encouraging open communication about current functional limitations with workplace boss/supervisor

• Education on body awareness and the importance of taking rest breaks during physically or cognitively demanding tasks

• Educating the client about proper ergonomics and strategies to set up the environment for success
  • Items are within reach of unaffected side
  • Supporting affected side to prevent shoulder subluxation
  • Seated position when appropriate

2. Friends/socialization 

Recognizing that rejoining friends and attending social events after a stroke may be an emotional experience for the client. Oftentimes it involves working through discomfort associated with friends noticing physical or other limitations. Recommendations for navigating these situations can include: 

• Starting with a comfortable environment that is set up for the client to be successful with a smaller crowd and progressing from there

• A plan for instances of incontinence that involve discrete management

• Implementing a space specifically for the client to go to such as a car or bedroom in times of frustration or feeling overwhelmed

Returning home and to the roles within a marriage or as a parent after a stroke can be a difficult transition for our clients and in order to holistically approach this transition, practitioners MUST address marriage, parenting, and the other roles important to each client. Being prepared to navigate these challenges as they arise will leave clients and their families better equipped for this transition.

Interested in learning more about inpatient rehab and strategies to get your client home? Check out our Inpatient Stroke Rehabilitation: 14 Strategies to Get your Patient Home. 

Terrell Kane

Terrell is a doctoral capstone student working with ARC Seminars to complete a qualitative research study tailored towards benefiting the profession of occupational therapy. He is earning his OTD degree from Gannon University located in Ruskin, FL.

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Each year 1.5 million people sustain a Traumatic Brain Injury (TBI) and despite this staggering prevalence, TBI is often referred to as a ‘silent epidemic’ in the world of healthcare. Even though TBI contributes to a third of all injury-related deaths, 75% of TBIs that occur annually are considered mild – meaning that injuries may not be readily obvious, hence ‘silent’. 

TBI can result from contact injuries to the head that can be open or closed, or may occur from an inertial injury – in which the brain moves around in the skull. Some of the most common causes of TBI include falls, MVAs, violence, and sport injuries. After sustaining this type of injury, individuals can find themselves experiencing challenges that are brought upon by persistent symptoms. These challenges can impact reintegration into the community. How to find resources for those post TBI is a question we get a lot!

Check out this guide for therapeutic intervention based on the Rancho Scale!

As OTs, PTs, and SLPs we are equipped to address physical, cognitive, and behavioral disruptions during rehab in a hospital setting – but our role should not end there! We should be familiar with and adopt community resources for those living with TBI into our POC to fully and holistically serve our clients.

Let’s explore some of these TBI resources & how to find them.

1. Support groups:

 Support groups are instrumental to the recovery process for our patients with a TBI and these resources likely exist in YOUR area! Being surrounded by peers who are/have experienced the same challenges will foster a community feel and allow patients to share personal stories to connect with one another. This connection can combat social isolation, which is often reported by both patients and caregivers of those with TBI. 

Introducing the idea of a support group might not be your patients favorite idea, but educating them on the psychosocial benefits and providing them with plentiful options might be just the encouragement they need to take this step in their recovery journey. 

• Providing them with both virtual and in-person options will grant them the autonomy to choose a support group they feel comfortable with – REMEMBER group conversations will involve vulnerability so patient comfort is a MUST

• If support groups are not your patient’s jam, there are resources that offer both forums, chat spaces, and other formats that might be preferred

• Facebook groups (and other social medias) are another way to create a sense of community for these patients and their family. Use with CAUTION when sharing personal information on these public pages.

Therapists and rehab personnel might have to be the heroes that connect patients and their families to local transportation services that can support the reintegration into the community. Add these resources to your toolkit to be better prepared if transportation is a burden for your patient and their families. 

There are online services through the Modivcare that can provide patients with non-emergency medical transportation in order to make access more readily available. Use this link to create an account and an application to set up scheduled transportation in your local area.

Here is a great resource to find both in person and virtual support groups for individuals with TBI. Use this link Scroll to your state and ‘shop’ around for local groups using the links provided.

Check out this website that presents state-by-state options for support groups both virtual and in person that offers groups for caregivers, people with TBI, as well as other groups including male/female only.

Caregivers are a population we as therapists MUST consider when providing holistic care after a brain injury. Caring for individuals with a TBI can leave families feeling lost, stressed, and confused. Here is a great source to provide to caregivers with tips discussing: caregivers mental health, assistive technology, and managing challenging behaviors.

Here is another great source to provide to families that demonstrates how to find nonprofit, private, and public programs/services by state. This tool will assist caregivers in finding specific services local to them and their loved one.

*Note: this site is not specific to brain injury but is a great resource to locating specific organizations that can help!

2. Vocational Aspects

Employment rate for individuals with a TBI is reported to be only 10-40%. Community reintegration might involve return to work or seeking new employment opportunities after a brian injury. As a member of the rehab team, it is important we are prepared to provide information relating to work and financial literacy to ease the transition back into the community and ultimately everyday life! It is important to remember that work can often times provide patients with a sense of purpose and fulfillment – clinicians are well placed to have a working knowledge of community resources to present to patients with TBI in order to meet their vocational needs. Here are some virtual resources you can offer up to your patients to help them find employment and help them understand their options for financial stability. 

• This resource is chalked full of great information that breaks down insurance (car, health, etc.), loss of wages/compensation, government programs etc. for this population. Developing financial literacy can provide patients and their families a firm foundation for financial stability.

• Need tips to ‘stay afloat’ after a TBI? This source provides 10 FANTASTIC tips for managing finances discussing topics such as: budgeting/saving strategies, applying for disability, and more! These ideas can be incorporated into your POC to maximize independence in IADLs and empower families to feel in control of their finances.

• Another wonderful tool that helps individuals with disabilities locate jobs or perhaps jumpstart a new career. This inclusive platform will look at the patient’s skills/experience and collaborate with them to find work- use this link, click ‘find jobs’, and create an account to get started!

3. Transportation 

Transportation is an incredibly important part of community reintegration and finding RELIABLE and SAFE transportation services can be challenging. These patients will often have regular doctor appointments, therapy sessions, as well as everyday social events that will need to attend. Special considerations for finding transportation include: 

• Cost – can the family afford to pay for these services and if not how can they receive financial support? Check out this source that details the different financial supports available disabled individuals

• Equipment necessary- if the patient has physical limitations that require lifts, space for wheelchair transport, and other supportive devices for car transfers.

• Training of personnel- locating companies with necessary training to perform these transfers and support patient safety is a MUST.

There are online services through the Modivcare that can provide patients with non-emergency medical transportation in order to make access more readily available. Use this link to create an account and an application to set up scheduled transportation in your local area.

Nowadays, companies like Uber and Lyft are popular among anyone and everyone getting from place-to-place conveniently and reliably. Rehab teams can educate patients and their families on how to use these apps to promote independence in locating and managing transportation within the community. 

4. Additional Services: Addiction & Substance Abuse 

After sustaining a TBI, patients are 10-20% more likely to engage in new substance misuse behaviors and if they were misusing prior to the injury they are even MORE at risk for continuing this behavior post injury. We can’t forget the risk of developing addictions to opioids due to pain experienced after injury as well. Using drugs and/or alcohol can complicate the process of community reintegration by promoting self-isolation, unhealthy coping mechanisms, and difficulty establishing a routine. If you suspect your client is misusing drugs or alcohol, these resources can help guide conversations with patients/families as well as give them the tools to overcoming these challenges. 

• Here is your GO TO resource for providing information about substance-abuse after a brain injury! There are fact sheets, treatment programs, online trainings for caregivers, and other resources compiled in this Resource Toolkit that rehab teams can print and distribute to families. 

• There are plentiful facilities that offer inpatient addiction services as well as phone consultations to devise a plan centered around the patient’s needs – here’s an example!

• Many of these resources consider the impact of mental health on the development of substance-abuse and incorporate addressing the link between the two. Here is another nationwide service that can link patients to local centers to provide treatment!

Ultimately, we want readers to recognize that there are existing services and resources to assist with returning to life post TBI. As practitioners, it is important to be prepared and become familiar with local and nationwide services that can support community reintegration. We encourage you to create a list of supportive services within your area and create handouts outlining these services to provide your clients with the tools to be successful after they leave the hospital and return to the important things in life.

Continue adding to your knowledge base regarding brain injury by earning your CBIS, use this link to learn more and register.

Terrell Kane

Terrell is a doctoral capstone student working with ARC Seminars to complete a qualitative research study tailored towards benefiting the profession of occupational therapy. He is earning his OTD degree from Gannon University located in Ruskin, FL.

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As an OTD student in Tampa, I have researched thoroughly the existing community support services for those post TBI in the Tampa Bay area. We know there are common challenges faced by those who are returning to their day-to-day life after sustaining TBI, but how do we help connect these clients to these services? I have collected a pool of really great specific TBI resources in the Tampa area that include: psychosocial support, work & financial literacy, transportation, and additional services. 

1. Psychosocial Support

Isolation and lack of social support can leave clients feeling alone during the rehab process but also after returning home and to daily life. Providing opportunities for clients AND caregivers to meet individuals who are experiencing similar challenges, can afford them the support and feeling understood that is often longed for. Some Tampa specific resources for our TBI patients, include support groups that meet to talk about their story, their needs, their struggles and how coming together either in person or virtually can make a HUGE difference in the lives of patients and their caregivers. 

• Tampa South Brain Injury Support → Weekly; virtual meeting

• Florida Brain Injury Support Groups → Categorized by city; both virtual & live; weekly

2. Work and Financial Literacy

There is only a 10-40% reported employment rate after sustaining a TBI in the United States and this is a great opportunity for clinicians to provide tips and tricks to navigate financial waves and establish stability. These resources are Florida/Tampa specific and can really jumpstart the process of locating employment while prioritizing patients’ with TBI interests and skills!

• Websites like Inclusivity can connect you to Success Enablers that assist those with disabilities in finding jobs based on skills/experience as well as training job sites to be more accommodating and accessible. 

• Other resources like theworkathomewife are specific to Florida and also provide career centered return to work assistance.

3. Transportation 

If the goal is to reintegrate these patients back into the community, we MUST consider the HOW. As caregivers may be limited by financial burdens associated with transportation, physical limitations impacting ability to safely perform transfers, caregiver availability with work, and/or equipment necessary to transport their loved ones. Access to transportation can limit patient’s ability to attend rehab sessions as well as events within the community.

Having reliable and safe transportation can mitigate isolation, empower patients to feel a sense of normalcy, and participate in the activities they want and need to. Here are some Tampa specific resources to provide to patients and their families

Non-Emergency Medical Transportation (NEMT) → Great option for clients with Medicaid & suitable for those in wheelchairs

Lyft & Uber → Some wheelchair accommodations available; accessible mobile apps

Wheelchair Transport Service → Serving Tampa Bay and surrounding counties

4. Additional Services 

TBI Specific Services in FL

As no two TBIs are the same, it is necessary to consider other potential resources that individuals may need to reintegrate into the community. There are several state and federal entities that work to support individuals with TBI. Here are some links to Florida specific supportive services: 

• Brain Injury Association of Florida

• Brain and Spinal Cord Injury Program – Florida Department of Health
  • Provide all eligible Florida residents who sustain a traumatic brain or spinal cord injury the opportunity to obtain the necessary services that will enable them to return to an appropriate level of functioning in their community

Addiction & Substance Abuse Services

As we know there is a link between substance misuse and TBI, we have to be prepared to help these patients find assistance when navigating addiction and TBI.

• Crisis Center of Tampa Bay → provides drug and alcohol treatment and prevention referrals to local providers in Florida, 24 hours a day, 365 days a year

• HOTLINE: Call 1-800-662-HELP (4357)

• Florida Alcohol and Drug Abuse Administration (FADAA) → non-profit membership association representing substance abuse prevention and treatment providers 

This collection of resources can be used by rehab professionals in and around Tampa, FL in order to support community reintegration post TBI. The continuum of care after the patient leaves the hospital is CRUCIAL to the success of the rehab process.

Save these resources and distribute them to your Tampa patients and continue expanding your educational repertoire by becoming a Certified Brian Injury Specialist.

Terrell Kane

Terrell is a doctoral capstone student working with ARC Seminars to complete a qualitative research study tailored towards benefiting the profession of occupational therapy. He is earning his OTD degree from Gannon University located in Ruskin, FL.

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One of the most intimidating issues for caregivers, families, and the person affected by brain injury is: personality changes.

Personality changes are reported by family, friends, and caregivers to be the biggest contributor to caregiver burden and burnout – even more so than continence issues or mobility issues. How often have we heard that this person is ‘no longer themselves’ after their injury? Here, we are going to examine whether personality changes with brain injury – how we can adjust our expectations – and tips for therapists and families to navigate this tricky field.

How common are personality changes after brain injury?

A study published in the Archives of Physical Medicine and Rehabilitation found that 59% of persons with severe brain injuries demonstrated changes in personalities as rated by their significant other. That’s pretty significant! So what does the clinician need to know?

What kind of changes to personality might you see post brain injury?

Poor Frustration Tolerance

When a person is tired or stressed, new situations, or when they are in a bad mood, they may have trouble with their ability to handle frustration. A person who has had a traumatic brain injury (TBI) may become more likely to lash out in anger and become physically or verbally aggressive.

Trouble following through with tasks

People who have suffered a TBI  may have difficulty staying focused or paying attention. Attention is the foundation of all other cognitive skills. Having trouble paying attention can frequently result in additional issues and challenges, such as: a greater propensity to become distracted, difficulty completing tasks, difficulty switching attention from one task to another, difficulty remembering and learning new information, difficulty maintaining lengthy conversations or focusing on one conversation when multiple people are talking.

Poor self-awareness in social situations

Everyone has issues with self-awareness to some degree;, but people who have experienced a TBI  are not truly adept at assessing our own capacities. Damage to brain structures that allow us to self-monitor can make it harder to be aware of oneself after a TBI. It can be difficult for people with TBI to adjust their perception of what they can and cannot do because they may lose the ability to self- monitor how well they perform everyday tasks. Self-awareness difficulties following a TBI are thought to be primarily caused by damage to the brain itself, but emotional coping and adjustment issues can also have an effect on self-awareness.

Irritability

Family members of people who have a TBI often say that the injured person has a “short fuse,” “flies off the handle” easily, is irritable, or has a quick temper. Studies show that up to 71% of individuals with TBI have issues with increased irritability. The person with the TBI might scream, use bad language, throw things, slam doors, slam fists into things, or threaten or hurt family members or others.

Anger

After someone experiences a TBI, one of the most common issues is anger. When someone with  a TBI struggles with anger, a number of factors often come together. Often times, people with TBI are angry because of the injury itself and/or the issues that may have arisen as a result, such as physical disabilities, the loss of a job, friends, money, and control over one’s life. Also, people who had anger challenges prior to their injuries could continue to have magnified issues after.  People who are unfamiliar with the survivor’s injury are often quick to assume that the person can control how they are reacting, when in fact, they cannot.   To put it another way, the brain regions that normally prevent a person from acting or feeling irate have been damaged and cannot perform their duties as effectively. This means that the person’s tolerance for anger is lower, making it easier and more intense for them to get angry. We can tell that the brain injury is directly responsible for this impulsive anger when:

• Anger episodes may be in response to minor events.

• The person experiencing the anger episodes is surprised, embarrassed, or distressed by them.

• Anger is often made worse by physiological stress, such as fatigue, pain, or low blood sugar.

Need help understanding how to navigate these tricky areas? Check out this course

Aggression

Aggression  following a TBI is more common than you might think. Research in The Journal of Neuropsychiatry and Clinical Neurosciences conducted a study in 2009 to evaluate 67 individuals who had suffered a TBI for the first time. Within 3 months of the injury, over 28% of them displayed post-TBI aggression (primarily verbal). In most cases, the aggression was associated with the onset of depression among other psychosocial problems. When things don’t go as planned or when there are disagreements with family or coworkers, they are frequently cited as having a short temper. Outbursts of verbal or physical aggression may outburst when this is associated with poor behavioral control.

Read this real life story about Hope, an OT and wife of a person with TBI

How can we help patients, families, and ourselves to deal with personality changes post brain injury?

There are three main ways to assist with managing personality changes post TBI:  stay present, calm, and don’t argue; provide structure; and make a plan and meeting their needs.  Keeping those things in mind is definitely easier said than done, but it’s important to remember that recovering from a brain injury is a process, meaning the person will continue to evolve and change and we, as the caregivers/professionals, have to evolve and change with them. 

For more information on these strategies see this article:  Agitation and Brain Injury (TBI):  How to Manage

It’s also important to have the person with the TBI continue to receive therapy in some form to assist with self-awareness and improving overall insight. This can come in form of physical, occupational, or speech therapy in a structured clinic setting or also from a neuropsychologist who is well versed in managing people who are recovering from a TBI.  If therapy is not possible at the moment, there are a wealth of resources available online to assist you. 

For more information on tips to improve social skills in something with an acquired brain injury, see this article:  Social Skills Post ABI – this took is a game changer!

As a loved one of the person with the TBI, it’s key that you adjust your expectations and almost ‘grieve’ who the person was before their injury.  It’s important to meet them where they are in that moment, and not where you want them to be, or where you think they should be.  Self-care is very important – seeking out therapy for yourself is just as important as therapy for your loved one.  It’s ok to need some help with adjusting – no one is expected to seamlessly transition after a major life altering event. 

The entire family is affected when someone sustains a TBI. According to research, caregivers of people with TBI may experience feelings of burden, distress, anxiety, rage, and depression.  And interestingly enough, personality and behavior changes are stated by caregivers to be the largest things that contribute to caregiver burden. Recognizing how stressful this situation can be and seeking support services are important if you are caring for a partner, spouse, child, close friend, or other relative who has a TBI.

As a caregiver, you will probably find it challenging to obtain sufficient and appropriate services for your loved one. It’s important to know that you will need to continually advocate for your loved one, as well as yourself.  Staying well informed and grounded are going to be the most important things that will help you continue assisting your loved one with managing their brain injury

Interested in becoming a CBIS? Check out the Certified Brain Injury Specialization (CBIS) Training

Allison Frederick

Allison Frederick, M.S., CCC/SLP, CBIS-T has been a practicing speech-language pathologist for over 10 years.  Allison graduated from Bloomsburg University of Pennsylvania in 2007 and has worked in subacute, LTC and intensive inpatient rehabilitation. She is passionate about the brain injury population and making higher-level neuro education available to everyday clinicians.  Allison hosts a brain injury journal club which you could find here for free for all interested.

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When your patient has pusher syndrome, it can be exhausting… to say the least!  They have an overwhelming compulsion to push themselves over, and in the beginning of their rehab journey, it seems like nothing will stop them from this incessant pushing. 

So why do they do it? 

Pusher syndrome can be categorized as an impairment in body orientation perception.  When a patient who has pusher syndrome is sitting upright, in midline – they feel as though they are leaning (approximately 18 degrees) toward their unaffected (strong) side.  So, in order for them to feel like they are sitting straight, they push themselves toward their affected (weak) side to get themselves to what they think is midline.  And, as we have all seen… they often overcompensate! 

Also, if a patient has other impairments happening concurrently, such as visual, proprioceptive, and motor impairments, this makes knowing the correct body orientation even more difficult. 

Let’s explore this a bit further and see how we might be able to help!  Who does this affect and how can we stop the pushing, once and for all!

Want to upgrade those stroke skills? Check out Inpatient Stroke Rehab: 14 Strategies to Get Your Patient Home!

Who gets Pusher Syndrome and who doesn’t?

Any patient can experience pusher syndrome after a stroke, no matter where the stroke occurred in the brain.  Depending on the source you look at, there is a wide variety when it comes to the exact number or percentage of patients that pusher’s occurs with.  However, a consistent finding is that pusher syndrome is more prevalent when the stroke occurs in the right hemisphere vs. the left.  This could be due to uprightness being controlled more by the right side of the brain.  Pusher syndrome also requires more time for recovery when the stroke occurs in the right hemisphere.  So, knowing that any of our patients could be experiencing this phenomenon… let’s make sure we are prepared to help them overcome it!

5 Strategies to Help our Patients Overcome Pushing

Strategy #1: Re-orientating them to true vertical

First thing’s first – since they have a skewed perception of vertical, we want these patients to relearn where they are in space.  There are several different ways to achieve this.  If their vision is mostly intact, we want to provide visual feedback in the beginning.  Teach them to use their eyes, when their bodies and brains are sending them mixed signals.  Place a mirror in front of them, use vertical lines on the mirror or in the environment for them to line up with, use yourself as a guide by sitting in front of them and having them match your posture.  These are great forms of external attentional focus, which we know is going to produce better motor learning and retention! 

Read this article to find out more about motor learning!

When reorienting someone with pusher syndrome back to vertical, make sure you start with their head and eyes.  If they are not able to hold their head in midline due to spasticity or weakness, orienting their body to midline is going to be a difficult task.  The same applies if your patient has a field cut (or other visual impairments).  Addressing these things first is of utmost importance in order to have success in pusher syndrome rehab. 

In the beginning of the rehab process, when pushing is strong, simply placing them in front of a mirror may not do the trick.  You may need to give them physical support. 

Our first instinct, with pusher syndrome, is to sit on their weak side (the side they are pushing toward)… and push back!  But this is the opposite of what we should do!  Remember, they feel as though they are leaning toward their strong side, so we want to provide a sense of security for them… so they don’t have the urge to push.  We want to provide support from their strong side.  This seems counterintuitive, but we need to retrain their brain that they will not fall, even though they feel like they are leaning.  This could come in several forms.  You could position their strong side next to a wall, so they see and feel that even if they are leaning in that direction, there is no way they will fall… because there is a wall there. 

You could also place large bolsters or the tall end of a wedge next to their strong side.  This would give them the feedback of support, but still allow you to position yourself in front of them or on their other side if needed.  You could also have them weight bear through their elbow onto the object you’ve placed next to them, so they have to actively lean toward the side they want to push away from.  Whether they are positioned next to a wall or bolster, you want to have your patient with pusher syndrome attempt to lean outside of their base of support toward their strong side, all while educating and verbally and visually orienting them to midline.  This could look like rolling a large therapy ball toward their strong side or reaching for various objects.

As your patient with pusher syndrome progresses, and the pushing is less strong, you want to wean the amount of support you provide, so they can adjust the amount they are pushing (and eventually abolish it!).  This may mean placing their “pushing hand” on something mobile like a rolling stool or rolling table during their transition from sit to stand – this almost eliminates the possibility of them pushing as the stool moves instead of them!  And with practice, your patient will learn to modulate how much pressure they put through that hand. 

You can also have your patient with pusher syndrome sit backward in a chair.  The support they are relying on in this strategy is more medial and the chair back itself can serve as a vertical environmental reference.  During this phase of pusher syndrome rehab, you can now have your patient attempt to actively reach outside of their base of support toward the strong and weak sides.

Strategy #2: Provide knowledge of results

So, how do we know if our patient with pusher syndrome is understanding our education and training?  How do we know if they are going to carryover the skills we are teaching them?  We need to allow our patients to *safely* fail.  That’s right!  We need to find out if they know what is happening.  Even during that very first meeting, during our evaluation… we can push back against their push and ask, “What will happen if I let go right now?”  If your patient says, “I will fall over!” – this is a good sign!  They have more awareness that something is not right and will be more engaged in finding a solution with you.  If they say, “Nothing,” try to gently show them that they will fall over if you let go.  They may get it right away, they may slowly learn this with repetition, or they may never gain this awareness. 

Those patients with pusher syndrome that never learn that they are pushing… are going to be your trickier patients. 

Strategy #3: Utilize different positions and functional activities

Daily routines and activities require us to get into all sorts of different positions throughout a normal day.  So, we want to make sure that we are training our person with pusher syndrome to match what they would need to do in daily life.  But utilizing different positions and functional activities, this will provide various versions of proprioceptive and visual input to help retrain the misperception of vertical. 

One school of thought is to initially facilitate weight shifting or weight bearing toward the strong side in order to allow the person’s brain to habituate.  Here are a few examples of how you can facilitate this.

When having your patient with pusher syndrome lie prone, make sure their strong arm is down by their side (to prevent pushing) and rotate their head toward weak side.  Similarly, when propping them in prone on elbows position, do not allow their strong arm (elbow) to extend and instead facilitate weight bearing/leaning through the elbow.  You can also hold their weak elbow straight and provide manual approximation to facilitate a weight shift toward their strong side.

When working in quadruped, you can have their weaker side resting on a slightly higher surface to facilitate more weight bearing on the strong side, then also complete active assisted weight shifts in all directions.  When in tall kneeling, try to have their affected side resting on a slightly higher surface, similar to what you will do in quadruped. 

Now, you might be thinking… we’re trying to orient them to true vertical!  Why would I put them on an uneven surface on purpose?  That’s a great question!  You would think that we would want to use a level surface all the time for them to know what level is.  But… we want them to learn that they are able to lean toward their strong side, lean on their strong side, and move to their strong side without falling.  We want to habituate them to moving in that direction again.  This will all contribute to them relearning where midline is. 

Gait training can happen a few different ways.  If you are using a body weight support system, you can adjust the straps of the harness to offset the pushing.  So make the straps slightly looser on the strong side in order to facilitate more weight bearing toward that direction.  If you are training over ground, it would be a great idea to utilize an assistive device that provides bilateral upper extremity support, such as a platform walker or EVA walker.  This will not only provide more stability, but will allow you to integrate both sides of the body and avoid the pushing behavior. 

You may also need two (or more) people to assist with over ground walking, depending on how strong your patient’s urge to push is!  The first helper should stand on the strong side, in order to provide the patient with visual and tactile feedback that they are not going to fall in that direction, even though they feel as though they are leaning over.  The second helper should stand on the weak side (the side they are pushing toward) as a safety precaution in case the first helper is not able to manage the pushing from the strong side.

Strategy #4: Complete bed mobility and transfers toward both sides!

If we want to make a right turn… we don’t make three lefts – we make a right!  So why are we always wanting to train our patients in one direction?  I know in the beginning of rehab, we normally start by transferring toward someone’s strong side (as it usually allows them to be more successful).  In pusher syndrome, you may choose to transfer toward their weak side first (since they are already prone to moving in that direction). 

However, you must eventually train them to move in all directions!  Remember – we need to reorient them to true vertical… so they don’t continue to push.  If they only ever move in one direction, they will not be aware of the “mistakes” they are making.  Transferring/rolling/etc. toward the strong side will definitely take more time with a patient with pusher syndrome… but it’s worth it!  Even though it’s tempting, don’t rush through the transfer… let them work it out!  In the long run, they will be able to do more of these tasks independently and relearn midline faster! 

Strategy #5: Use outcome measures

We all know that these patients usually take longer to meet their goals and therefore need more time in rehab!  And sometimes it’s hard to get the time we need.  Outcome measures can assist you in showing the small increments of progress that you might need to highlight for insurance companies to approve the time you need! 

Here are a few to check out:

Burke Lateropulsion Scale

Scale for Contraversive Pushing

For more information about pusher syndrome and these outcome measures, visit – Pusher Syndrome – Physiopedia (physio-pedia.com)

What is my patient’s prognosis if they have Pusher Syndrome?

The good news is, that most patients who have pusher syndrome are able to achieve the same type of outcomes as those without pusher syndrome.  However, this does not mean that we want to leave it unchecked.  A patient with pusher syndrome will take significantly longer to achieve those outcomes.  And with the limited amount of time we have in acute and subacute rehab settings, we must set our patients up for success in every way possible!

What else can I do?

Continue to educate yourself on pusher syndrome and other stroke interventions!  The more skilled and intentional we become with our interventions, the faster our patients will reap the benefits!

If you’re interested in learning more, check out Inpatient Stroke Rehab: 14 Strategies to Get Your Patient Home.

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Ruth Polillo

Ruth Polillo, MSPT, CBIS: Ruth graduated with a Master of Science in Physical therapy degree from Thomas Jefferson University in 2005, and has gained experience in every setting a therapist can work in.  She is a co-founding member of ARC & an enthusiastic presenter! Ruth is passionate about continuing education and making hands-on clinical skills available to clinicians.

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There are a few ways you can prepare for the CBIS exam – you can do self-study with The Essential Brain Injury Guide 5.0 (the CBIS textbook/reference), OR you can attend a CBIS training session with a Certified Brain Injury Specialist Trainer (CBIST). 

So you have studied and even taken a CBIS course, but what to expect now? 

In order to take the CBIS exam, your application has to be approved by the ACBIS – you can’t take the exam in the online ACBIS portal until you get the seal of approval from them.  You can check your applications status either in the ACBIS application portal, or by emailing acbis@biausa.org.

The ACBIS now utilizes an automated proctoring system so you can take the exam whenever you feel ready – keep in mind though that if you take the exam at night or on a weekend, you’re going to have to wait until the next business day to get any type of assistance in the event there’s a technical hiccup.  In the ACBIS portal, there’s instructions on how to check and prepare your computer to make sure everything is going to work well when you’re testing

Need to take a review course? Check out – the Certified Brain Injury Specialist live course AND Exam!

Who is eligible to take the exam?

• Applicants must have had 500 hours of currently verifiable direct contact experience with people with brain injury.  Experience can be paid employment and/or academic internship.
• Qualifying experience must include formal supervision or have been conducted while the applicant operated under a professional license.
• Volunteer work and other personal experience does not qualify.
• Applicants must have a high school diploma or equivalent.

How does the exam work? 

The exam is 70 questions, multiple choice with 5 possible options.  Be sure to read each question carefully as there can be some tricky language such as “except”, “all of the above”, “none of the above”, and “A and B ONLY”.  You must achieve 80% or above on the exam to obtain your CBIS credential.

Still have questions? Have a look at our CBIS FAQ page!

How long should I study for the CBIS exam?

This is a question that we get often, but that there isn’t a direct answer for… Do some self-reflection and see how you learn best.  Think back to the last time you had to study for an exam in college – did you notice yourself re-writing your notes or making your own outline?  Did you use a highlighter and post-it flags?  Did you repeat stuff aloud as you were reading it?  If you feel you’re more of a ‘visual’ learner, you may find yourself using highlighters and rewriting the outline to structure things so it makes more sense to you. 

People who take a CBIS course will also connect with others in the class and form study groups – it’s never a bad idea to get to know your fellow participants!  There’s no prescribed amount of time it takes to prepare – again, you have to think back to the last time you were in college and how long it took you to feel prepared for your classes, assignments, and exams. 

If you took a prep course, it’s a good idea to schedule the exam within 2-3 weeks of the end of course so the information is still fresh in your mind.  Taking time to prepare is good, but taking too much time can blur all of that good info you’ve got stored in your noggin.  

Are there any resources to help me take the CBIS exam or prepare?

ARC Seminars offers a 2 day, 13 hour long exam prep course that comes with a variety of resources, study guides, and as well as access to an experienced CBIST who can help you navigate preparing for, and obtaining your CBIS credential.  

The CBIS prep course has a live and a self-paced version – so whatever your study style, we have something for you! Have a closer look right here – CBIS Training course & Exam

You can also find a Facebook Group with lots of CBIS and CBIS hopefuls, where you can ask questions, get study tips, and discuss clinical situations with other neuro peers! Check it out right here!

You can contact us below if you have any more questions, or reach out to Allison@arcseminars.net. Good luck!

Allison Frederick

Allison Frederick, M.S., CCC/SLP, CBIS-T has been a practicing speech-language pathologist for over 10 years.  Allison graduated from Bloomsburg University of Pennsylvania in 2007 and has worked in subacute, LTC and intensive inpatient rehabilitation. She is passionate about the brain injury population and making higher-level neuro education available to everyday clinicians.  Allison hosts a brain injury journal club which you could find here for free for all interested.

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