Living with Brain Injury


Living with Brain Injury: A collection of insights we wish we had known along our journey with brain injury

“My brain is scrambled”, my husband sighs in frustration.

This is my cue to pause, step back, and reassess. Picturing Kyle’s overstimulated thoughts as a messy breakfast item is his lighthearted way of reminding me, “hey, I’m in here. I just need a little help sorting me out”.

While I would like to believe my work as an occupational therapist (OT) would make me a model spouse to a person living with a brain injury, I would be mistaken. Through assisting my husband with navigating living with a brain injury, I have gained small insights into caregiver burden, and grief that all the knowledge and training in the world cannot fully prepare you for.

Kyle is living with post-concussion syndrome (PCS- or mild brain injury) because of several concussions sustained during his time as a collegiate platform diver. PCS is a cluster of persistent symptoms a concussed person may experience, such as: problems with attention, memory, fatigue, sleep, headache, dizziness, irritability, or changes in mood or personality” (Kolakowsky-Hayner et al., 2010).

For those who experience a mild traumatic brain injury (mTBI), about 10-15% will experience any number of those listed symptoms chronically. Because these people may appear “normal” after initial recovery many struggle to manage the daily tasks and roles required for success in their environment.

In his junior year of college, Kyle sustained three concussions within roughly three months.

Initially he thought he had recovered, however, the repeated trauma within a short time frame left him with difficulty thinking, severe migraines, sensitivity to light, emotional instability, and difficulty managing his basic self-care. Life changed drastically. He medically withdrew from classes, moved back home for support, and began working with a concussion specialist. After several months of treatment and rest, he was able to return to school to finish his degree.  We got married, and started a new chapter in Tampa, FL. We both believed the worst had passed and things were “back to normal”.

living with brain injury

As life progressed, Kyle still endured occasional migraines, light sensitivity, and difficulties managing stress, but he was able to maintain a full-time job, a new role as a spouse, and engage in several sports related hobbies. Over a year after his presumed “recovery”, things began to change. The migraines became more frequent, his stress management was at an all-time low, and his short-term recall was getting increasingly worse.

For example, he would stare at the oven for several minutes knowing he planned to heat dinner – but was unable to turn it on to get started. Headaches and constant ringing in his ears would keep him awake for hours at a time, and sleep was very hard to come by.  He was emotionally withdrawing from daily challenges and would often catastrophize the most basic of problems. Fear that this was going to be our ‘new normal’ began to overtake us…

We decided to seek out medical management from a concussion specialist…again. After the initial shock of realizing we would likely be “managing” Kyle’s symptoms instead of “curing” them, we came to the realization we could make some small changes in our daily roles, routines, and communication to make a big impact on our quality of life.

living with brain injury therapyIn addition to Kyle’s regular visits to his concussion specialist, he also utilizes an acupuncturist, chiropractor, and photobiomodulation (lasers!!!) therapy for ongoing management of his PCS. At home, we began focusing on simplifying daily routines, lowering stress, focusing on overall wellbeing, and prioritizing communication. We were able to persist, but not without the help of our family, friends, and professionals who offered their continued support and guidance.  It truly does take a village.

Nearly a year later, Kyle is continuing to work full time, play recreational sports and is a proud new dog dad. While we continue to evolve, we have grown throughout this process (and probably will continue to).

We have morphed into better listeners, more supportive partners, and are increasingly empathetic towards the challenges of others.

We are strong in our belief that if we keep an open mind and positive outlook, we can continue to be successful in managing the daily challenges that Kyle’s PCS throws at us.

With all of this in mind, Kyle and I would like to share some of the lessons we have learned along the way. Our hope is to encourage, inspire, and empower persons with BI, their caregivers, and the professionals who are fortunate enough to work with them.  There is space within BI for joy, connection, humor, and growth. According to Kyle, “you can always see the light in every situation… even if you are photosensitive”.

Tips – and a few guiding thoughts:

Slow down

living with brain injury slow down

“It’s hard to explain that you’re confused about why you’re confused… it doesn’t make sense.”  During the several times discussing points for this piece, Kyle would mention how hard it is for him to explain his symptoms, their impact, and the toll they take on his relationships, roles, and self-worth. Our advice is to slow down. Slow down when things get tricky… when your person with BI becomes overstimulated, stressed, and runs into a “mental block”.

I often tell patients and family members to double the amount of time you usually need for a task after injury. You must drastically reduce your commitments, expectations, and daily goals to provide the time needed to best serve your person and facilitate success. This takes lots of practice and even more patience.

I particularly struggle with this since I like to set goals far above what even a neurotypical person may be able to complete in a day. Through mutual patience, reminders, and constant support from our loved ones, we continue to work towards a healthy balance of getting what needs to be done finished while pacing things to allow Kyle to be successful.

Healing is not linear

living with brain injury planning your day

Healing ebbs and flows.  One day may be 2 steps forward, while others may be one step backward. Kyle is at his best when he maintains a sleep schedule, exercises regularly, and has assistance with managing his daily stressors. I double check schedules, appointments, and provide reminders for various self-care things Kyle needs to do to keep moving forward.

With time, Kyle may need less support and oversight to be successful. One of the many things I do as a caregiver is to adjust the routine as needed to ensure Kyle’s success during the day. Each person’s brain is different, and every injury presents with unique characteristics that continually evolve as time marches on. What works for us may not for you, and that’s ok! A few strategies that have helped us along the way include checklists, identifying triggers that intensify symptoms, and limiting screen time.  Try ‘no TV Tuesdays’… it’s wonderful.

Ask questions, and advocate

living with brain injury advocate

Because people with BIs don’t have obvious physical signs, it’s important to recognize and advocate for your person. As Kyle’s mother best describes, “You feel completely discounted because people can’t see your injury. If you had crutches, you would give them a break.” While you do not need to go around shouting who has a BI from the rooftops (HIPAA, anyone?), it’s important that you educate, advocate, and openly discuss the challenges associated with BI as appropriate.

This could look something like researching public spaces with less stimulation or visiting at quieter times to reduce stress potential. It may also look like asking a restaurant manager for a quieter table, a doctor to provide a written copy of medical advice, or a cashier to be patient as you may need extra time to pay. In general, most of us want to be helpful to others and people do best when they’re well informed.  In those spaces that are not particularly comforting for a person with a BI, ask for accommodations – it can’t hurt!

It takes a village

Whether it’s a support group, online forum, or good friend who commits to regular coffee dates, finding support is key. Kyle finds support in mentors, his fishing and hockey buddies, and his most trusted friends. As a caregiver, I find mine in my sister, co-workers, and in reading other’s stories of overcoming and living with brain injury. Together, we find great comfort in our parents, spirituality, and our pets.

My mother-in law, Valerie, has been supporting Kyle’s recovery from day one. Her insights and encouragement help me to refocus on the important things by using her daily mantra, “we are choosing joy today”. Whatever support looks like to you and your person- find it, lean into it, and stay committed to investing in it. These will become the communities you cry with through hard moments and celebrate the victories.

 

Same team

It is easy as a caregiver to feel you need to micromanage each step of your loved one’s life. While this comes from a loving place, it is easy to get lost in this role and almost forget what your original purpose in the relationship is. Kyle often reasserts his independence in tasks when I rush in to “fix it” before he has even struggled. When it’s possible, let them try.

Allow self-efficacy – partnership and independence flourish within reasonable boundaries. We are thankful Kyle has recovered to the point of being able to work, drive, and function successfully within his roles with only minimal assistance, but we understand this may not be everyone’s story. We aren’t advocating for you to stop helping or supporting your person as needed, but we would like to challenge you to set goals toward the restoration of meaningful roles. This could look as simple as asking them to help fold the laundry, or as complicated as picking up milk on the way home from work. Show gratitude for the help they provide and remember you’re a team.

The ability to succeed alongside you will promote connection, confidence, and healing in all parties involved.

Put your own mask on first

You cannot help someone when you are not healthy. I cannot stress this one enough.  It’s hard to hear, and even harder to implement. As an OT, I work with family members and loved ones towards realistic plans for managing the burdens that come with caregiving. While caregiving can take any number of forms, one thing everyone has in common is the risk of burnout.

Initially when Kyle’s symptoms began to worsen, I put my own needs on the backburner.  I neglected both my physical and mental health and was not in a good place.  Several months ago, I went back to counseling to help me reorganize organize myself. We began our health journey, disconnecting regularly from screens, and decompressing from daily stressors. As a result of prioritizing my own health, and implementing one small change at a time, we are both better. I am better able to handle my own challenges while supporting his progress. Take the walk. Drink your water. Practice self-care and love. Ask for help when needed.

 

While living with brain injury is not something we would wish on any person, we are thankful for the lessons we have learned along the way. Finding joy and intimacy in each small moment and accomplishment has forged greater meaning in our relationships with each other and our support teams.

As Kyle continues his healing journey, we aim to grow in compassion, resilience, and understanding. We hope something from this piece may be helpful to you. We encourage you to use what is helpful to you and throw out whatever does not serve you.

 

Acknowledgement

This piece has been written in collaboration with, and inspiration from, my lovely husband Kyle:  who daily manages PCS… and being married to me. Both he does beautifully.

Hope Kennedy Blackwood;  MOT, OTR/L 

 


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CITATIONS

Kolakowsky-Hayner, S. A., & Reyst, H. (2019). Glossary. In The Essential Brain Injury Guide, Brain Injury Association of America.

Shoulder Subluxation and Stroke: Can These Three Methods Save a Shoulder?


Shoulder subluxation after stroke can be quite puzzling for therapists to treat.  Can these three treatment methods save a shoulder?

How a shoulder subluxation rears its ugly head can vary greatly–it may develop more quickly with some patients than others, it may be painful or even go completely unnoticed.  As therapists, regardless of the how or when, we consistently try to prevent shoulder subluxation from happening and reduce the severity if it does happen… but are we truly being effective? 

Should we be grabbing that sling to support their shoulder?  Does e-stim help reduce the degree of translation? Is taping effective for prevention?  Let’s dive in and strengthen our evidence-based application.

For strategies on how to help your patients maintain dignity and respect when dealing with dysphagia after stroke, download our ‘Say This, Not That’ handouts here!

Why does Shoulder Subluxation Happen?

shoulder subluxation

Glenohumeral subluxation happens in up to 81% of patients post-stroke.  The shoulder joint is multiaxial and has three degrees of freedom–flexion/extension, abduction/adduction, and internal/external rotation .  The joint relies on the rotator cuff musculature–supraspinatus, infraspinatus, teres minor and subscapularis– as well as other surrounding musculature to keep everything aligned and to give the joint the ability to have smooth and efficient arthrokinematics. 

During the initial period post-stroke, when the affected side may be flaccid, the rotator cuff musculature is not able to provide the stability it normally does to the joint.  This instability combined with the pull of gravity and improper positioning can lead to lengthening of tissues and the separation of the humeral head from the glenoid fossa, also known as a subluxation.

Flaccidity is not our only enemy when it comes to developing a subluxation.  Even if your patient has some degree of active movement in their affected arm, spasticity can also be a factor in developing a subluxation as it often creates a significant imbalance in the movement patterns of a joint or limb.  If the spasticity is strong enough, it can even pull the humerus out of alignment.  

Subluxation may also be influenced by other predisposing factors, according to some research.  One study found that “subluxation occurs more frequently in patients with a known presence of fluid in the subhumeral and subdeltoid bursae and in patients with reduced functional capacity.”  This is interesting to think about and can lead us to the conclusion that there are multiple factors that can help us identify those who are at more risk of developing a shoulder subluxation… versus assuming the patient is at risk solely because they present with hemiplegia.    

What Interventions are Available…and What Do They Do?

Slings

Prevention & Management:  Slings are what we grab first, right?  In fairness, a sling or orthotic has been shown time and time again to be effective at reducing shoulder subluxation while it’s in place and worn correctly.  But there is no evidence that using a sling can prevent a shoulder subluxation from happening or that it can have a long-term effect on the reduction of an already existing subluxation.  One study compared 3 groups (2 with sling and 1 without sling) and found that shoulder subluxation seemed to reduce over time in the group of patients who did not wear a sling. This information alone should make us rethink our ‘one-sling-fits-all’ mindset!

Clinical Application:  It goes without saying that more research needs to be completed (as with many areas of practice), but we should always be striving to tailor our choice of interventions, so they are specific to our patient’s needs.   In the case of a sling, there is still a useful application even if it’s not going to make a difference in the degree of shoulder subluxation.  A sling could be beneficial in protecting your patient’s limb during transfers, or it may be helpful in reduction of pain associated with subluxation.  But if there is no pain and the limb seems to stay in a good position during functional mobility…leaving the sling out of it may be the way to go!


Taping

Prevention & Management:  There is minimal evidence clarifying whether taping is effective at prevention of shoulder subluxation, but there is plentiful research that indicates that taping methods–both kinesiology and inelastic tape–can reduce present shoulder subluxation and reduce pain associated with it.  Other studies found that while unable to prevent subluxation, specific techniques have been found to result in improvements in shoulder flexion and proximal arm function.

Clinical Application:  With taping showing consistent results in the reduction of shoulder subluxation and pain, this should be a staple in your stroke rehab toolbox!  There may be a few reasons you wouldn’t move forward with this, such as patients with fragile skin or sensitivities to adhesives, but with the equipment being both inexpensive and accessible… we need to be moving our thoughts away from slings and more toward taping!


E-stim

e-stim unitPrevention & Management:  Some studies have shown that e-stim combined with other treatments or approaches has been effective in preventing and reducing subluxation in the acute phase of stroke but has not been effective in the chronic stage.  

Clinical Application:  Therapists have been using e-stim for many different indications for decades and we all know well that parameters matter if you want to achieve a specific purpose or goal.  The main consideration for e-stim with shoulder subluxation is timing!  If we can provide this treatment early in the patient’s recovery from stroke, we will have a better chance of preventing and managing shoulder subluxation.  If you can utilize e-stim during the acute or subacute phases in stroke rehabilitation, go for it!  


Where Do I Go from Here?

Make sure to look at your patient as a whole and see what they specifically need in their plan of care–a blanket plan of action will not be as effective as a patient-centered plan of care.  If you are treating your patient in the acute or subacute phase of stroke rehab, e-stim may be a great starting point as a preventative measure.   If shoulder subluxation is unfortunately already present, taping would then be a smart move to prevent further separation & pain prevention.  If that limb looks unstable during transfers or is causing high pain–it may be time to consider our old friend the sling. 

So, it’s all about being up to date with the latest research in combination with the clinical presentation and needs of your patient–if something is not working well enough to meet their needs, do not be afraid to move on and try something else!

 

If you are interested in learning more about Stroke Rehab and upgrading your practice, check out our fantastic, 7 Contact Hour course, In-Patient Stroke Rehab: 14 strategies to get your patient HOME!  to get great techniques and tips to get your patients back to where they want to be: back home!

 

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Fall Prevention: It is So Much More than Rug Removal


I’m definitely not saying rugs aren’t public enemy #1 when it comes to fall prevention–in fact my peers have joked before about my personal vendetta against the throw rug.  But fall prevention is a much bigger issue–falls are the #1 cause of injury, hospital visits due to trauma and death from injury among people 65 and older.  It’s time we take fall prevention one step further (but seriously, get rid of those throw rugs, people).

Falls are a Serious Cause of Injury

Especially if you’re working with geriatric populations. It is estimated that in a year, one out of every three older adults will experience a fall per year and that every ~11 seconds, an older adult in the US will be treated for injuries related to a fall.  Falls result in almost 3 million injuries treated in ED’s annually, including over 800k hospitalizations and 27k deaths.  If all of this wasn’t enough to stress the severity of falls–they also account for 48% of all acquired brain injuries. There are losses associated with falls that aren’t represented in many data points that are important for practitioners to be cognizant of– loss of mobility, independence, functional decline, mental health and overall quality of life–all things we aim to prevent or protect for our patient populations.

Well that’s intimidating—Who specifically is at risk for falls?

Is it helpful if I say everyone?  On a serious note, it is important to recognize that not just elderly people are at risk for falls.  People challenged with low vision, polypharmacy, balance and gait issues, and any impaired memory or mental status are all at increased risk for falls both within the home and community.  It may seem obvious that people with a history of falling are at increased risk–but even the first initial fall doubles the likelihood of subsequent falls–so it is worth the mention.  People with ill-fitting footwear are also at an increased risk for falls, so be sure to exercise extra caution with your slipper-loving patients.

Check out ‘Slippin’ on Slippers: How to reduce falls through footwear’ to learn more about footwear’s role in falls!

Fall Risks Within the Home

It can be terrifying for patients to consider the possibility of falling within their home–what is normally a safe space for them is suddenly a potential danger.  For good fall prevention interventions within the home, it will be important to empathize and respect your person’s potential hesitancy to make changes.  After all, if someone came into my home and tried to tell me my Target haul of decor was a potential safety hazard, I probably wouldn’t invite them back.

For fall prevention within the home, generally you will want to be sure that paths, stairways and any thresholds are clearly lit, secure and free of clutter.  If there are concerns about low vision or impaired perception, contrasting colored tape can be used to mark steps and thresholds.  Bilateral, sturdy handrails are ideal for any stairs or inclines.  Encourage your patients to reduce or eliminate floor clutter including shoes, decorations, power cords and the like.  Poorly lit areas and low-visibility areas like a tight bedroom space also present a fall risk.  Encourage your person to consider properly installed grab bars in the bathroom and educate them on safe use.  And it almost goes without saying–those loose throw rugs are a huge fall risk and should be secured down at all edges if your person is unwilling to part with them.

Fall Risks Within the Community

Falls within the community are difficult to track and therefore underreported, however people with good community mobility are naturally at a higher risk for outdoor and community falls.  Uneven pavement on sidewalks, lack of sidewalks or interruptions in sidewalk continuity and sloped surfaces are potential sources of falls.  Areas with poor lightning, poor drainage and potential for ice also increase the risks for community falls.  If you are working with a person that is an active driver, consider referring them to the CarFit program and ensuring their balance is strong enough for getting in and out of their vehicle.  Balance will be an important area to look at for persons mobile at the community level–looking at you, uneven sidewalks–to be sure they can navigate walking spaces that are not necessarily the safest.  Footwear with proper fit and traction for grip will also help reduce the likelihood of a slip and fall.

 

 

Assessments for Fall Prevention

There are a plethora of outcome measures for use to determine a persons’ potential risk of falling–check out these two resources here & here for some great measures.  These outcome measures should always be used in combination with skilled observation and clinical judgement in order to best determine someone’s fall risk and preventative steps to take.  Having a strong understanding of your person, their habits and lifestyle will aid you greatly in enacting fall prevention measures.

What fall prevention interventions can I use?

It goes without saying that your interventions should be tailored to the needs and priorities of your person, so keep that in mind while we suggest the following starting places.  In addition to the aforementioned education & environmental modifications, there are a few great interventions to check out for fall prevention.  Primarily, recognize that there is a way to fall right.  Reviewing and practicing with your person how to fall correctly, get up from a fall and ways to protect their body best in case of a fall is an excellent harm reduction method.  This can take some of the fear out of the potential of falling and empower your person to feel more secure in their ability to recover safely should a fall happen.  Reactive balance training can be a great way to improve your person’s ability to recover their balance and prevent falls in addition to strengthening full-body.  In addition to this, balance rehabilitation approaches in general are always a key intervention point for fall prevention.

Okay, I got it. Fall prevention is serious and not just limited to in-hospital and in-home measures…where can I find more information?

Thrilled you asked!  The National Council on Aging has amazing resources & educational information valuable for both clinicians and families.  USC Leonard Davis school of gerontology has excellent resources including state-specific links, considerations for patients of different ethnic backgrounds and economic backgrounds, and fantastic resources for home modifications.  They host an expert in home modifications for fall prevention monthly, so be sure to not miss out!

Learn More About Practical Aspects to Fall Prevention ?

At ARC Seminars, we’re here to empower clinicians to treat intimidating conditions. To continue your education and further develop your skills to treat patients with the best care possible, register for our self-paced webinar Update Your Care Plan: Balance Rehab today!

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Keeping Your Cool:  How to Stay Calm at Work in Healthcare


Someone once was quoted as saying “You can’t control what happens to you.  You can only control how you react to it.”  This statement couldn’t be more true… but especially when it comes to clinicians, working with those who have sustained a neurological injury.

Controlling your reactions is easier said than done. To stay calm at work requires not only patience, but also some intense self-reflection.  It is very easy to get wrapped up in your emotions when you are working in a high pressure, high stress environment (i.e., healthcare).  Not only do you have to manage the patients and their families, but there is also schedules, equipment, co-workers, deadlines… the list goes on.  The question that probably always crosses your mind is “How do I maintain my composure when something intense is happening?”.

Suppressing your emotions is any given situation is not healthy, but it is important to remember that there is a time and a place for everything… emotions included.

Our priority should be facilitating a calm environment filled with mutual respect and support for our patients as they recover.  At the end of the day, that is why we are all in healthcare, right?  Modulating our own behavior can have a positive effect on our patients, especially those who are having difficulty regulating their own behavior.

So how can we maintain a calm, cool, and collected demeanor in the face of adversity?  The Crisis Prevention Institute (CPI) is a really great resource regarding verbal de-escalation techniques and management.  CPI was founded in 1980 to give people the tools to better manage conflict, and they believe that empathy, compassion, and meaningful connections are powerful tools to maintain a safe working environment.

CPI suggests the following as being the “Top 10” De-escalation Tips:

  1. Be empathetic and nonjudgmental
  2. Respect personal space
  3. Use nonthreatening nonverbal
  4. Keep your emotional brain in check
  5. Focus on feelings
  6. Ignore challenging questions
  7. Set limits
  8. Choose wisely what you insist upon
  9. Allow silence for reflection
  10. Allow time for decisions

The tips listed above are really great actionable items you can use to stay calm at work, when someone becomes agitated, confrontational, or upset (these can also be useful outside of work as well!).  We need to keep in mind that our patients are probably experiencing the worst time in their lives – we are unfortunately meeting them when they are not at their best, and are probably going to be unable to reason and regulate their own behavior/reactions to things. It is up to us, the professional, to take a step back and have empathy for our patients (and their families!).

Interested in learning about becoming a Certified Brain Injury Specialist? Download the FREE, 16-page Starter pack right here!

In addition to those things from CPI that can be done in the moment when things are escalating, there are also other things we can be doing at work to ensure we will stay calm and be ready to implement our training when needed:

Get training… often.

A ‘one off’ training focusing on de-escalation is not sufficient.  A training like CPI is a great tool to have in your toolbox, but it is just that… one tool in your toolbox.  There are other programs out there as well such as Handle with Care, and NAPPI.  You have to choose the training that is being going to fit the needs of your team, and your patient population.  Also, consider how you learn best.  Some people enjoy going to a live, in person seminar while others prefer a self-paced course that can be completed on their own time at home.  There is not one ‘magic training’ that is going to be a one size fits all and it is very important you do your homework to see what is going to fit you best.  Lastly, make sure the ongoing education needed is something that is going to be feasible for you and your team/facility.  You do not want to set yourself up to fail with something that is not going to fit into your schedule well.

Function as a team.

Management of crisis situations should not and cannot fall onto one person.  It truly does ‘take a village’ to be successful and ensuring all members of your team are adequately trained and comfortable with your facility’s plan is paramount to success.  If you see a colleague in situation that appears it is going to escalate, hang around and hang back.  Stay within an earshot so that way you are able to assist if needed.  Try and let your colleague know that you are there for them to increase that overall feeling of security.  It can also help to have a designated group of staff that will respond to a crisis situation.  There truly is safety in numbers and knowing that your team has your back will enable you to more effectively manage that crisis situation.

Decompress.

It is important that you build in some time to decompress after a crisis situation.  Emotions are running high, and there is a solid chance that your heart is beating in over drive.  Talk a walk outside, sit in a quiet space, or put on some comforting music so you are able to come down and refocus. The situation that you just handled did not go from 0 to 100 in .2 seconds, and you are not expected to come back to zero instantaneously.  It is more than ok to tell your work colleagues that you ‘need a minute’ to stay settled and calm, and that you will be available at a later time in the day.

Set aside time after you decompress from the crisis situation to discuss why and how the situation escalated how it did.  It is very important to talk through the good, the bad, and the ugly to further refine your process and response.  Constructive criticism and feedback should be welcome and viewed as an opportunity for you to refine your skills and self-reflect instead of punishment.  There is always going to be something that could have been better handled in each situation – no one is perfect (and that’s ok!)!

Self-care.

This term is a bit overused at times, but it is something that is vital for you to continue to be your best, calm self in the face of a crisis.  Taking a break from your 9-5 can assist you with being fresh and positive at work.  Self-care takes many forms, and can range from taking a short walk outside, to planning a relaxing vacation, to listening to some true crime podcasts in your down time.  You are no good to your patients and colleagues if you are not being good to yourself first.  You have PTO, USE IT!

As you can see, to stay calm in the face of a work crisis is so much more than just attending a one-time workshop on effective communication skills.

Getting training and education and just one piece of the self-regulation puzzle.  Taking a step back and looking at the bigger picture for the patient is always necessary.  Ask yourself “What am I doing to contribute to this person’s recovery?  How can I better conduct myself to ensure a calm, safe environment?”.  Remembering that it is not all about you, but the patient, can put things into a different perspective and assist you with how you can change your behavior.  The best thing you can do is treat everyone you encounter with a mix of warmth, professionalism, and respect… Remember, people may forget what said… people may forget what you do… but people will never forget how you make them feel – Maya Angelou

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves.

How to Guarantee Better Motor Learning through Task Specific Training


Task specific training in motor learning can not only make your treatment sessions more functional and engaging but taking this approach can actually facilitate better learning of the task at hand!

A basketball player will not achieve the skill level that gets them to the pros by playing H-O-R-S-E… they have to play the game!  A musician will not make the band by improving their grip strength and learning music theory… they have to play the instrument!  And this same concept rolls over into the rehab world.  We can do all the exercises that we want, but exercise alone will not improve function.  The patients have to practice the actual tasks!

You may be thinking… “But what about all the impairments?  They can’t possibly improve on a task if they don’t have the strength, balance, endurance, etc!  We have to build them up first.”  But I say that you can eat your cake and have it too!  Get creative and simulate functional tasks in a way that will still address the patient’s individual impairments and provide opportunity for the practice that will improve the skill. This way, task specific training to enhance motor learning will become second nature to you!  Here are some practical examples to improve your motor learning game!

Read this article to find out more about providing the best feedback to facilitate motor learning!

Task: Self-feeding with coordination impairment

If you note that a patient is having trouble feeding themselves because of impaired coordination, you may have them start to work on all the fine motor/coordination tasks under the sun, hoping it will carry over into building independence with self-feeding.  Things like peg boards, graded clothes pins and putty will certainly get their hands and fingers moving and will improve their overall coordination with those tasks, but during each meal… you may not find as much improvement as you were hoping for.

Better approach to improve self-feeding task specific training

Practicing the actual task of eating is the most obvious way to complete task specific training of self-feeding and improve motor learning, however this only allows your patient finite opportunities to practice this skill throughout the day. 

Other ways to simulate eating may be of benefit as well!  You could have the patient practice lifting an empty cup to their mouth, then gradually fill it with more liquid as they gain more control.   Or you could have them transfer a small amount of liquid from one cup to the other before lifting it up to take a drink.

With the use of utensils, a patient could practice each part of the task, then put it all together.  They could start by picking up small pieces of play dough with a fork and transferring it to another dish, then they could cut the play dough with a fork (or a fork and knife) before picking it up. 

For using a spoon, you could first see how well they are able to balance the liquid in the spoon without spilling by having them scoop water from one container to another.  All the while, making adaptations and trialing various equipment and techniques for when they get to practice the real task of self-feeding.

Want to learn how to do oculomotor testing in 10 mins or less? This essential assessment can change your whole approach to balance rehab! Watch the webinar, right here

Task: Walking with hemiplegia

With a patient that has difficulty walking due to weakness on one side of their body, you will need to move forward with treatments that strengthen the affected limbs.  Seated exercises with free weights or theraband, will certainly improve the strength of the muscle groups targeted… however a better way to move forward with strengthening to improve walking with hemiplegia would be pre-gait activities. 

Weight shifting, box taps, and minisquats are straightforward ways to improve strength in preparation to maintain control in stance on the affected limb.  Kicking a ball, hip flexion and extension using a skate to eliminate friction and gravity, and marching will strengthen their affected limb and also better prepare them to manage swing phase during gait training.

Better approach to improve walking

But to really facilitate better walking and better motor learning, you must have them practice walking!  Now, you are going to see patients of all ability levels, so simply having them get up and start is not always realistic.  But often times, your patients will surprise you and may be able do things you don’t expect them to do if given the opportunity.

For a person who requires more assistance, you may need to utilize a body weight support system.  This can usually be completed on a treadmill or over the ground.  The treadmill is definitely going to allow your patient to get more steps in (more practice) as the speed of the treadmill will set the pace.  However, over ground body weight support walking is very beneficial as well! 

With either option you will have both hands free to better facilitate activation of the muscles needed at each phase of the gait cycle.  A second helper can facilitate the timing and degree of weight shifting during each step. Body weight support gait training is an excellent option to get patients up and walking before you may have thought they were ready to – and therefore they get more training specific to walking! 

If you don’t have a body weight support system available, you may find success using other very effective and supportive techniques such as using a platform rolling walker or an EVA walker.  These will offer the patient more stability than a regular rolling walker or hemi-walker and again will allow you more freedom to facilitate where you need to.

Find out more about body weight support systems here!

Task: Toileting – Clothing management with balance impairment

If you’re working with a patient who is having trouble managing their clothing because they just keep losing their balance, your first inclination is going to be to work on their balance! Now, you may have them stand at the therapy table and complete a task that requires them to only use one hand on their assistive device, so they are not as reliant on upper extremity support.  You may have them reach outside of their base of support in order to complete the task.

These sorts of activities will certainly help a patient to improve their balance and it will even improve their standing tolerance however there are a few more things that are involved with managing your clothing during a toileting task. So, these activities may help to an extent but in order to really get to the heart of the problem you need to be stimulating the activity itself or completing the actual activity.

Better approach to improve toileting motor learning

A better way to train your patient how to manage their clothes clothing and maintain their balance all at the same time is to either break it down into its parts and simulate the activities or complete the actual activity itself.

There are a few different ways that you can simulate taking down and pulling up pants. Part of the task requires the patient to have one hand on their assistive device and use the other hand to manage the clothing. This usually requires the patient to alternate between hands so they can get one side of the pants and then the other.

To simulate this task (since there are only a finite number of times that you will be able to bring your patient in the bathroom) … You can complete activities like placing clothes pins at the bottom edge of the back of their shirt and ask the patient to remove them – alternating right and left.  This allows the patient to remove one of their hands and reach behind them as if they were straightening out the top of their waist band… Grasp onto the clothes pin and remove it. Another aspect of managing clothing is being able to bend forward and squat down far enough to either pull your pants down past your knees or reach down and pull them up.

A way that you can simulate this part of the task is by having the patient lift and lower items to and from the floor or from a low stool so that it forces the patient to do the same type of transitional movement as when they’re pulling their pants up and down. If they are getting to the point where they can balance adequately enough, you can have them step into a hula hoop and raise the hula hoop up to their waist and then place it back down on the ground. Sometimes, the resistance of the actual clothing can pose a balance challenge to the patient.

If they have stretchy pants or an elastic waist band that they have to pull and stretch to get over their hips, a way that you can simulate this is to put a piece of theraband around the person’s knees and have them pull it up over their hips as if it were a pair of pants. That would give them that resistance that the pair of pants would give and would allow them that opportunity to practice the more task specific activity. Now, the best way to practice managing your clothing with toileting is to actually practice pulling down your pants and pulling them back up.

Most therapy gyms have available and oversize pair of shorts or an oversized pair of pants that are used for ADL practice in the gym setting. So again if you’re not having the opportunity to actually take the person into the bathroom during an episode of toileting… You can break out these practice pants and have the person stand up, pull pants up, pull them back down, and sit down – and they can utilize all of the strategies that you have been stimulating with them.

Task: Carrying packages walking with a cane

Something that is very practical to day-to-day life but we don’t always incorporate into our treatment plan is carrying items when you’re walking with an assistive device such as a cave. There are several ways that you could start to work on this such as having your patient carry various dumbbells while walking, making sure to vary the weight and size of the dumbbells to simulate various objects that someone may need to carry.

Better approach to carrying items while walking

task specific training motor learningBut as with all the other tasks discussed here, the best way to facilitate motor learning and improve the skill of carrying packages and items while walking with a cane is to have them complete the task specific training. Now that may sound overly simplistic… But there’s a very great opportunity here to determine the best way that a person can accomplish this safely.

You may want to explore different shopping bag options – a plastic bag could be used, a reusable shopping bag can be used, a small box or a brown paper bag. If someone has trouble grasping the handles of the plastic shopping bag it may be more beneficial for them to put items in a brown paper bag and carry it close to their bodies, as this will eliminate the need for them to grip the item so heavily and it will also keep the weight of the item closer to their center of gravity and balance will not be as big of a challenge for them.

After determining what type of package or a bag is best suited for them to carry… You can then work on how they will safely pick it up in order to carry it and then how they can safely place it back down when they get to their destination. It will also give you the chance to see what their endurance level is like with this task. Will they only be able to carry items for short distances? Or will they have the stamina to carry them for longer periods of time?

This is important depending on where the person lives and what their environment is like. A person who has a home with a short driveway where they only need to carry items in from the car to the house wouldn’t necessarily need to build up stamina in this way… However, if someone lives in a home where they are mostly walking everywhere, they may need to walk several blocks from their home to the grocery store.

This would also present you with another opportunity to introduce various ways of carrying multiple packages such as a rolling grocery cart so the person can put several bags in and pull the cart behind them. It also requires a certain amount of coordination and balance if they are normally utilizing an assistive device such as a cane.

No matter what you were doing with your patients to have them improve on their impairment and their skills… You are certainly going to benefit them and help them reach their goals! But knowing that there are certain principles of motor learning that can help us tailor treatments more specifically to what our goals are is a very powerful thing. Whenever possible you always want to do the activity that you’re trying to improve or simulate the parts of the activity that you’re trying to improve. The more task specific, and the more specific the training the better the results for motor learning of the skill and retaining what they’ve learned!

If you liked what you learned here about task specific training for motor learning, make sure to check out our 3-CEU Update your Care Plan: Balance webinar!  We discuss some other principles of motor learning and how to best choose interventions based on your comprehensive assessment!

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂

Post-concussion syndrome: Signs, Risks, and How to Proceed in Rehab


As physical therapists, occupational therapists and speech pathologists, we often encounter clients who have symptoms of post-concussive syndrome. But what is the best course of action, and how do we manage this common- yet incredibly disruptive- condition?

What is post-concussive syndrome?

Persistent post-concussive symptoms (PPCS) is also called post-concussive syndrome, and is an area that physical, occupational and speech therapists have a valuable role to play. It technically refers to the lingering symptoms that can be experiences after a concussion/mTBI- usually including three or more signs and symptoms. PPCS is the most common neuropsychiatric consequence after sustaining a TBI– although the magnitude of the condition may differ. PPCS may also be misdiagnosed- such as in those who dismiss their persistent headaches as situational tension headaches/migraines, when they may be linked to injuries related to the concussion such as vision impairment, neck/cervical issues or sensory integration difficulties.

Symptoms may linger for 7-10 days, weeks, months or even years after injury to be qualified as PPCS. Impairments can include headache, dizziness, cognitive and/or vision difficulties, pain, and sleep disturbances. This constellation of symptoms can also occur after moderate and severe TBI, and so post-TBI syndrome may be a more accurate description.

In the first few weeks after mild TBI, the prevalence pf PPCS has reported to vary from 40-80%. 10-15% of those affected continue to report symptoms for more than a year.

Clinicians such as physical, occupational and speech therapists who work with older patients at risk of falls, as well as in settings where trauma may be common, should be well versed in how to treat post-concussive syndrome.

Risk factors: post concussive syndrome

post-concussive syndrome physical occupational speech

 Interestingly, the severity of the injury does not appear to be associated with the risk of developing PPCS- although there are several factors that can increase the risk of developing PPCS after a head injury.

A history of depression and anxiety or PTSD; poor or absent social supports; lack of coping skills; loss of consciousness during the event; non-sporting mechanisms of injury; female gender; more advanced age and a history of previous concussion/TBI are all factors that may pre-dispose a client to PPCS.

Symptoms of Post-Concussive Syndrome

Post concussive syndrome is a collection of various symptoms, all of which may can benefit greatly from evaluation and treatment by a physical, occupation and speech therapist. Symptoms can include:

Post Traumatic Headache

Headache is an exceedingly common symptom experienced post mTBI, and can range from migraine type headache with photo and auditory sensitivity, to a tension-type headache that may be related to neck range of motion or cervical impairment. Vision issues may contribute to post traumatic headache and can easily be confused for other issues such as migraine or dizziness.

There has been an inverse relation reported between the severity of head injury and the occurrence of chronic daily headache- this study demonstrated that of those with mTBI, 80% reported chronic daily headache whereas for moderate and severe head injury, only 17% experienced chronic headache. For clinicians, this means that we will be more likely to expect headache in those after concussion, and having means of evaluation and treating headache will serve our patients well! Addressing headache is not always an area that physical, occupational or speech therapy feel comfortable in addressing- but we can make a powerful difference, through a variety of therapeutic interventions.

Download our Headache Management Cheat Sheet for FREE, right here!

Dizziness and Nausea

post-concussive syndrome physical occupational speech

Dizziness is the second most common symptom reports by those who have sustained a concussion. Vertigo is often reported immediately post injury, and can persist for months and become a chronic issue for some clients. Parsing the cause of the dizziness can be tricky, as it can be experienced differently- like lightheadedness, room-spinning, sensitivity to movement, syncope, double vision, and so on.

BBPV is a common culprit of post concussive dizziness, although there are also other causes such as vestibular migraine, central nervous system dysfunction, and cervical/neck impairment. Vision issues can also cause dizziness and nausea, post mTBI. Dizziness may be triggered by movements, exercise, visual stimulation such as computer or screen work, motion sickness, or difficult tasks such as schoolwork (in younger participants).

Dizziness, like the other symptoms experienced as part of post concussive syndrome, can be incredibly disruptive and debilitating. Thorough evaluation and assessment and intervention is essential to managing this symptom.

Cognitive impairment

Many cognitive domains have reported to be affected by post concussive syndrome, including executive function; memory; attention and processing speed. Even a single mTBI can result in pathophysiological changes in the brain. These impairments, as before, can also be linked to the headache, vision issues, and dizziness symptoms- which can impair concentration, attention, memory and executive function.

Research indicates that although there is a prevailing view that most symptoms of mTBI are resolved within three months, that approximately half of individuals with a single mTBI demonstrate long term cognitive impairment, which highlights once more the vital role of rehabilitation in this population.

Vision Changes

Eye problems are a very common result of concussion- and one that has been reported to affect 69-82% of patients’ post-concussion. Vision impairment post-concussion can include abnormalities of eye movement, such as accommodation, convergence, saccades and smooth pursuits. The person may also experience blurred or double vision, ocular pain, difficulty focusing on close work. Naturally, these issues are very unsettling to the person experiencing them, and have a huge impact on their occupations and daily life.

Your patient may experience these issues as dizziness, headaches, difficulty reading, and other functional difficulties. Vision impairment in post-concussive syndrome is closed linked to body position, the balance system, and attention/focus- there is a significant role for physical, occupational and speech therapists to work together in the treatment of this issue.

Convergence insufficiency and accommodative insufficiency are among the most prevalent diagnoses and respond very well to vision therapy and vergence exercises.

Watch a video of Convergence training with a Brock String right here!

Sleep Disturbance

Sleep wake disturbances, fatigue and insomnia are all commonly reported after mild concussions, with rates up to 50% at 6 weeks post injury. Insomnia and decreased sleep efficacy are more common in those post-concussion than more severe brain injury. Sleep problems can disrupt all areas of life and exacerbate some of the other symptoms that may present. Physical, occupational and speech therapists can educate those with post-concussive syndrome about sleep hygiene, healthful habits, energy conservation and stress management- all of which can help to contribute to better sleep and less fatigue.

What are the roles of rehab clinicians in post concussive syndrome?

The symptoms of post concussive syndrome are varied and multi dimensional, and need a collaborative effort from all rehab clinicians for best results! We have seen above how each symptom can inform the others, and for best results, physical , occupational and speech therapy work hand-in-hand to treat post concussive syndrome.

Role of Physical Therapy

Physical therapy have key roles in the treatment of post-concussive syndrome:

  • Dizziness
  • Balance impairment
  • Cervical issues
  • Fatigue
  • Pain issues- headache, neck pain, etc.
  • Visual reflex integration/Gaze stabilization/oculomotor assessment and intervention

Skilled evaluation of the cause of vestibular impairment is essential for appropriate and effective treatment. Physical therapists may find themselves presented with a patient reporting dizziness, and need to differentiate the type of dizziness, cause, and from there the most effective intervention. To learn more about rehabilitation of dizziness and other post-concussive symptoms, click here!

However, the role of the physical therapists is not limited to balance and dizziness rehabilitation post concussion- they may also examine cervical issues and ROM to see whether this may be impacting other areas of function.

Oculomotor assessment and eye movement interventions, specifically with regard to integration into movement, are also essential for a physical therapist to know- but not always routinely included in treatment! If you want to see how to do an oculomotor assessment (with included HEPs!) in ten minutes or less, check out our link below!

How to do an oculomotor assessment in ten minutes (or less!)

Role of Occupational Therapy

The role of the occupational therapist in treating post-concussive syndrome may include:

  • Vision therapy
  • Sleep hygiene
  • Headache management
  • Energy Conservation
  • Return to work/school/play
  • Relaxation and stress relief

Occupational therapists are in a key position to integrate the skills that a client is rehabilitating into function. Vision therapy and working on visual/perceptual skills are essential to optimal functioning, and an OT can perform a thorough vision assessment to ensure visual issues are not underlying or affecting other areas.

Sleep hygiene, efficacy, energy conservation and fatigue management are areas the OT may set goals in. As before, an OT can be instrumental in evaluating and optimizing a person’s sleep habits to ensure more effective and functional engagement in their everyday activities.

Evaluation of headache, and establishing treatments and interventions to manage triggers, such as a migraine journal, sensory diet, modalities and lifestyle changes can also fall within the OT wheelhouse. This may be the single biggest positive change for many people post-concussion, owing to the debilitating nature of chronic headache.

Learn more about how to incorporate vision into your assessment and intervention in people post-concussion right here!

Role of Speech and Language Pathology

Speech therapy can be instrumental in setting a client with post concussive syndrome up for success. Through careful assessment and treatment of cognitive impairment, community re-integration and stress management techniques.

  • Cognitive evaluation and intervention
    • Attention and focus
    • Executive function
    • Memory rehabilitation
  • Community re-integration
  • Stress management
  • Communication skills: Reading, writing and computer use

Speech and language pathologists have a vital function in the rehabilitation and treatment of those with post-concussive syndrome, particularly in cognitive rehab. Cognitive impairment, as established, is prevalent even after one concussion- but may go unnoticed if its is more subtle and masked with other issues such as vision and headache. Given the fact that about half of those who sustain an mTBI go on to have a chronic cognitve issue, skilled assessment becomes even more urgent. Speech therapy may help with practical interventions and exercises to work on cognition, and referring on to neuropsychology as indicated.

Speech therapy are also uniquely positioned to assist with communication skills and difficulties, including vision impairment that may affect reading/writing and communication.

Want to learn more about how, as a Speech Therapist, you can be more effective in post-concussive treatments? Check out Practical Approaches to Concussion Management!

As you can see, all members of the rehab therapy team have equal and essential roles in the rehabilitation process post concussion. Post-concussive syndrome is a condition that can be incredibly disruptive: but benefits greatly from treatment- and we all have a part to play in ensuring success!

If you are interested in learning more about assessment and treatment of Mild TBI, check out ‘Practical Approaches to Concussion Management‘! This powerful seminar provides skills and tools to be able to assess, treat and manage concussion and the complications that may arise from it.

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Behavior plans in in-patient rehab: how to use them best


“Challenging behavior”, “Behavioral outbursts”, “That patient is behavioral- so be careful!”. You may have heard these terms and phrases over the course of your clinical career. Problematic as this terminology is- after all, behavior is simply a form of communication that we have to translate- clients who present with distressed behavior need delicate and compassionate care to ensure that their needs are met. And so many facilities and therapists may find themselves reaching for: a behavior plan!

Behavior challenges aren’t just limited to those people who have sustained a traumatic brain injury (TBI).  Persons who have sustained a cerebrovascular accident (CVA), have a progressive degenerative neurological disease (i.e., Parkinsons’ Disease), and even those with metabolic encephalopathy (due to sepsis, uncontrolled diabetes, etc.) can all have disruptions and changes in behavior- and may benefit from the skilled application of a behavior plan.

Behavioral changes are not intentional, and more often than not the person cannot necessarily control how they behave or react to their environment and those people in it.  But this can be a very challenging for both medical professionals and caregivers alike as we are all human and we all have feelings ourselves.  Being able to separate the behavior of someone recovering from a neurological injury from the person that they were prior to admission is a skill that is acquired and refined overtime for medical professionals and can be almost impossible task for the person’s loved ones to accomplish. 

So the questions are… how do we (the professional) assist with managing someone’s behavior throughout the course of their rehabilitation stay?  How do we promote stable and consistent behaviors that will improve their outcomes and their ability to live in the community?  How do we empower the person’s loved ones to be an active participant in this process?  There is no easy answer, or ‘one size fits all’ approach to these questions.      

Want to learn more about managing agitation post TBI? Check out this guide!

As the professional, we need to take a step back and look at the whole patient and all aspects of their care – we cannot just be concerned with our therapy session, or the small slice of time we have with the patient and call it a day.  We need to assist and empower all members of the care team to promote stable behavior in order for our patient to regain as much function as possible. 

One way to assist with promoting stable behavior throughout their rehabilitation is by making a behavior plan.  A behavior plan, in this sense, is essentially a list of strategies to assist staff members with having effective and productive interactions with someone who is having behavior difficulties following some type of injury.  It does not have to be complicated, have several pages, or even multiple parts.  It does require some work, though!  There is no standard cookie cutter approach to behavior management and a behavior plan needs to be tailored to a person’s needs, their current environment, and also to the caregivers of the person. 

Before an ongoing behavior plan can be formulated, something called the stability triangle should be considered. 

The Essential Brain Injury Guide 5.0 defines the stability triangle as a construct which is useful when identifying treatment priorities and establishing a treatment plan.  The stability triangle specifies three primary areas that must be addressed in order to for overall stability to be established and maintained, and it is applied in an ongoing manner to organize and guide treatment efforts at all phases of rehabilitation and recovery (EBIG 5.0).  The structure of the triangle itself emphasizes that each element if interdependent, yet without any one side, stability is ultimately or eventually compromised. 

The three sides to the stability triangle are:  establishing medical stability, establishing behavioral stability, and developing a stable activity plan.  Medical stability entails managing pain, sleep disturbance, seizure disorder, vestibular issues, medication use are just a few items to consider with medical stability. Behavioral stability entails addressing problematic behaviors such as mood instability, refusal, verbal and physical aggression, and a laundry list of other things.  A stable activity plans refers to empowering and enabling the individual to have meaningful interactions and routines.   All three sides are important, and the triangle cannot exist without each portion, but for the purposes of the discussion here, the focus is going to be on establishing stable behavior. 

Establishing behavioral stability is an ongoing process and needs to be managed by an interdisciplinary team. 

As it was mentioned before, we do not practice in silos and need to communicate and work with each other.  The first step in formulating a behavior plan is assessment.  In inpatient rehabilitation, our ‘assessment period’ is usually the first few days after admission – we are able to capture our patient’s current level of function, write goals, and formulate our plan of care.  As the patient progresses through the treatment plan, goals are adjusted, and the plan continues.  Unfortunately, behavioral assessment is not that cut and dry – it is a fluid process. 

A person’s behavior can change based on a variety of factors including, but not limited to, pain, fatigue, and time of day.  Formal assessment tools can be utilized (such as the Agitated Behavior Scale), but informal assessment (such as observation) should also be considered.  You can also assign a Rancho Level of Cognitive Functioning if appropriate to better identify someone’s current level of functioning.  Assigning someone a Rancho level can help provide common language between professionals and give you a starting point for management.

It is also important to get to know the person – call their loved ones and inquire about likes/dislikes, preferred food items, prior sleep schedule, prior hobbies, and ask someone to bring in familiar pictures and items from home.  Conferring with the person’s family and friends is part of the assessment process – remember, you want to consider the whole patient and not just their new state of being from their injury.  Having personal items from home can be incorporated into the person’s rehabilitation routine and also assist with behavior management when needed.  The assessment process will assist you with identifying how to be proactive for this person as opposed to reactive, meaning it will help you identify how to ‘get ahead’ of a person’s behavior as opposed to having to work ‘damage control’ if things get out of hand. 

After your ongoing, interdisciplinary assessment is complete, then you can move onto putting together a formal plan of action. 

You need to determine how and where you would like this plan to ‘live.’  Is it going to be an electronic document in the electronic medical record, or do you want a written paper plan that stays with the patient?  Keep in mind that these details may seem trivial, but if you want your colleagues to refer and use the plan for your patient you need to make it easily accessible.  A well written, thorough behavior plan is not any good if no one knows where to find it! 

When it comes to structuring a behavior plan, remember to keep it simple.  You want to make the plan easy to read and easy to follow.  One of your colleagues should be able to glance over the plan and take away the main points without much of a headache. 

The following items should be categories included in a behavior plan:  Supervision Level; Elopement Risk; Environmental Modifications; Signs of Escalation; Diversional Activities; Preferred Staff, family members, personal information (foods, drinks, conversation topics, music, etc.). 

  • Supervision level refers to if the person needs frequent check-ins (every 15 or 30 minutes) or if the person needs a 1:1 staff member for safety.  It’s helpful to indicate this on the plan to ensure that all members of the team know what the expectation is for that patient – to ensure that they are being provided the amount of supervision and support they need to maintain stable behavior. 
  • Elopement risk refers to whether or not the person is at risk for leaving the facility, especially if the person is very physically able.  Again, doing this helps communicate the person’s current status to all members of the team in order to help keep the person safe. 
  • Environmental modifications refer to what things can be done to the person’s surrounding area to help promote and maintain stable behavior.  Things like dim lights, private room, low sound, no tv, limited visitors, toileting schedule, and a set therapy schedule are all items that should be included in the environmental modifications category.  It is important that you consider items that can be modified at your particular facility and include them as options on the behavior plan. 
  • Signs of escalation refer to those things that a patient may demonstrate prior to having a behavioral episode or outburst.  These will vary from person to person, but some items to include as options on your behavior plan form could be yelling, cursing, hitting, refusing care, refusing food, restlessness, and kicking.  Again, it is important to have these items on a behavior plan so all staff members participating in someone’s care know what to be on the lookout for – remember, we want to be PROACTIVE. 
  • Preferred staff, family members, and personal information are pretty self-explanatory and definitely items that need to be included on someone’s behavior plan.  Having these people identified ahead of time will assist with everyone being proactive in finding those staff members who have a good rapport with the person in the event there is a behavioral issue.  Lastly, personal information refers to those items that someone prefers – food, music, pictures, etc. that can be comforting to someone in a time of crisis.

Want to see an example of a behavior plan? Download the FREE, 16-page Certified Brain Injury Specialist Starter pack, right here!

Once you have determined where your behavior plan is going to live (paper form vs. EMR) and how it is going to be structured, you need to implement it!  Now this part sounds simple enough – educate staff members, and then you are done – but it is not that easy.  The education of your colleagues has to be thorough and often – one quick in-service is not going to be enough.  Every staff member who is going to be participating in that person’s care – from the doctor to the nurse to environmental staff need to be on board with what works for that person.  You need to empower everyone to present themselves as a consistent, united front. 

The more consistent you are with utilizing the behavior plan the more likely behavioral stability will be promoted.  Family members also need to be educated as to where to find the plan, how to read the plan, and how to put the plan into action.  It may be helpful to schedule an early family training so they can see how you (the experienced clinician with good patient rapport) interact with and manage that person.  Lead by example! 

As the person is progressing through their plan of care and their treatment goals are being updated, the person’s behavior plan should also be updated.  The person’s needs will evolve over the course of their rehab stay and their behavior plan should reflect that.  Ongoing education with staff members and family is also optimal, to ensure everyone is a continued united front with promoting stable behavior.  By implementing and being consistent with utilizing behavior plans we can promote behavioral stability and maintain the stability triangle.  Remember, all sides of the stability triangle are needed to achieve good patient outcomes, which is why we do what we do as clinicians… we want to see people get better and get back to their lives!

Interested in learning more about all things brain injury? Consider becoming a Certified Brain Injury Specialist (CBIS)! Check out our offering: the Certified Brain Injury Specialist Training Prep Course for training and credentialing, and set yourself apart by obtaining this certificate… in 2 days!

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Autonomic Dysreflexia vs. Sympathetic Storming: How to manage in inpatient rehab!


In rehab, we can see a lot of different types of complicated conditions. Brain injury, spinal cord impairment, multiple trauma and chronic illnesses… these impairments can lead to their own host of complicated side effects. And one of the most intimidating issues that can rear its ugly head is sympathetic dysfunction or overactivity. This can be challenging to deal with, and even to understand- I have heard (and been guilty of!) mixing up autonomic dysreflexia and sympathetic storming in rehab, when I have encountered them. Here, we want to examine- what is the difference between these two conditions? What should I know? And how best can I deal with it as a rehab clinician?

First- a quick review that will help understand the reasons that these conditions can occur! Let’s revise the sympathetic system.

The sympathetic nervous system

The sympathetic nervous system (SNS) is a part of the autonomic (unconscious) nervous system. When we try to explain the SNS, the concept of ‘fight-or-flight’ is often brought up- an involuntary bodily response to protect us from perceived danger. The lack of conscious control of the SNS is key to its protective function- by producing its localized reactions to stimuli (internal or external), it prepares the body to deal with a potentially dangerous situation. The SNS will cool the body in response to external heat, by sweating; increase adrenaline to the muscles in response to stress; and narrow the focus/concentration of the mind in response to fear.

When triggered by a stressor, the SNS will kick into high gear- releasing a high level of epinephrine, increasing heart rate and cardiac output, pupillary dilation, skeletal muscle vasodilation and gastrointestinal vasoconstriction.

These functions of the SNS cause a cascade effect, and in an unimpaired system- sustained SNS overactivity can cause a variety of physiological consequences, such as hyperglycemia (which may lead to Type 2 Diabetes) and hypertension, which can lead to cardiovascular disease,

The effect of an overstimulated SNS system in a person with spinal cord or brain injury, however, can lead to an uncontrolled and dangerous response.

Learn more about managing Agitation post Brain Injury with this article!

Autonomic dysreflexia  

Autonomic Dysreflexia (AD) is considered a Medical Emergency in Rehab Medicine- and for good reason.  It is defined as a life-threatening condition, that can occur in patients with a spinal cord injury at the level of T6 (or above) because of unchecked sympathetic response.

The prevalence of Autonomic Dysreflexia is variously reported to range from 20 to 70%- in other words, an essential condition to be able to recognize, treat and manage, if you work in the rehab field!

Luckily for most people- AD can easily be prevented and treated if it occurs!

autonomic dysreflexia

Let’s have a look at how this condition presents in those post spinal cord injury. Some the symptoms of AD can include: high blood pressure, pounding headache, flushed face and sweating above the level of the injury, goosebumps, stuffy nose, and a slowed pulse (<60bpm). Normal Blood pressure in those with a  SCI above T6 runs lower than the average, with systolic in the 90-110 mm range. Therefore, if your patient is presenting with headache and a BP of 140 systolic, you should be very concerned about the possibility of AD.

These symptoms can vary based in the individual- but can lead to a serious event, such as a stroke, if not addressed immediately.

Autonomic dysreflexia is caused by a noxious stimulant below the level of the injury. This could be bladder related, as in (commonly) a kink in the catheter tubing, UTI, or other bladder irritation; bowel-related, such as pain from infections/hemorrhoids, distended bowel; other skin irritation like ingrown toenails, sunburn, overly tight clothing, or bruising/abrasions; or other stimulation such as menstrual cramps, sexual activity, labor, or bone injury/fracture.

Knowing the symptoms of Autonomic Dysreflexia for those who are at risk, the rehab clinicians treating them, and their caregivers- is paramount. The correct action must be taken quickly in order to avoid serious consequence.

What should a rehab clinician do?

Educate your patient about the signs/symptoms of AD.
Learn the person’s ‘typical’ resting BP, and explain that a reading of 20-40 mm HG above baseline is cause for concern (which may read like a ‘normal’ BP in a person without SCI!).
Move to a position that will cause blood to flow to your feet. Sit your patient up to 90 degrees, and lower the legs.
Loosen or remove tight clothing and socks/shoes.
Check the catheter (if applicable), and ensure that there is no visible blockage/distended bladder.
Examine for other noxious or painful stimuli.
Check the BP reading every 5 minutes to ensure that the readings are not worsening.
Certain medications can be used to manage the mixed signals with regard to blood pressure; and may require administration if removal of the visible noxious stim does not stabilize the patient- such as vasodilators, nitroglycerine, nitrates, and so on.
The majority of the role of the clinician, however, should be focused on prevention! Ensure that a bladder and bowel program/schedule is established and adhered to, educate your patient about protecting and examining the skin and limbs below the waist level.

 

Sympathetic Storming

Officially known as Paroxysmal Sympathetic Hyperactivity, which describes the sudden onset and recurrence of these ‘storms’; as well as the sympathetic system involvement and function, in the moment of attack. The paroxysms cause an increase (hyperactivity) of the circulating corticoids and catecholamines- or a stress response.

Sympathetic storming, or PSH is reported to affect 15 to 33 percent of people who have sustained a TBI, with symptom onset occurring within hours or even months of injury. It is most frequently associated with severe traumatic brain injuries, and even with non-traumatic injuries such as hydrocephalus, intracranial tumors, severe hypoxia and Intracerebral hemorrhage.

How does sympathetic storming present? PSH is a diagnosis by exception- a conglomeration of symptoms can be present, which may include: hypertension, tachycardia, tachypnea, hyperthermia, posturing, dystonia, and diaphoresis. Once any other metabolic or infections have been ruled out as causational, a positive diagnosis of PSH can be made.

Sympathetic storming can also be triggered by infections, unrecognized injuries, and other medical conditions, so evaluation and identification of triggers such as these are paramount to providing the correct response.

Just as discussed previously with AD, there is a strong need to focus on management of PSH, as there may be a risk of increased morbidity if left unaddressed. Secondary brain injury from hyperthermia, posturing that may result in energy expenditure and cardiac/skeletal muscle damage, brain bleeds from hypertension are examples of the adverse effects that may occur if PSH is left untreated.

As a clinician, recognizing the symptoms and signs of a sympathetic storming event is going to be crucial to getting the care they need.

What can a rehab clinician do?

Recognize symptoms:
Hypertension—increased blood pressure Tachycardia—abnormally rapid heart rate
Tachypnea—abnormally rapid breathing Dystonia—state of abnormal muscle tone
Hyperthermia—abnormally high body temperature, of central origin
Posturing—abnormal muscle stiffness/body positioning Diaphoresis—abnormal/excessive degree of sweating
Check your patient for cause- noxious stimuli and external triggers- and remove if applicable
Educate and empower caregivers and family members to spot an event
Address hydration, manage temperature, and increase comfort during an episode
Provide calming input: cool cloths, quiet conversation, soothing music and massage
Analyze triggers and avoid (once identified)
Treatment is largely pharmacological- alert physician, seek medical management

Why can these two conditions be confused?

So why and how can these two conditions be confused? Well, as these conditions are both related to dysfunction of the sympathetic system, they can be easily confused. In rehab, we often encounter patients who have had a spinal cord injury- a TBI- or sometimes, in the case of severe multi-trauma: both. It is incumbent on all in patient rehab clinicians who are working with the neurological population to be aware of the complications that may arise as a secondary impact of their condition- and sympathetic dysfunction can be one that we frequently encounter!

In order to provide best service, you should: familiarize yourself with the presentation of these dysfunctions; educate patients, family and caregivers about these conditions and how to recognize them; and develop a protocol for managing and addressing these complications as they arise.

Some useful resources that you may want to have in hand in YOUR rehab department:

Remember- we may be very likely to see these condition in in-patient rehab, when clients are newly presenting with a brain injury, spinal cord injury, or other insult to the sympathetic nervous system- but these issues can continue (or begin!) to occur in home care and in outpatient care as well. Hence, educating patient and family to recognize and act quickly is going to be of the utmost priority, at every stage of rehab and recovery!

Interested in learning more about the management of brain injury, autonomic dysreflexia and other rehab topics? Consider becoming a Certified Brain Injury Specialist (CBIS)! Check out our offering: the Certified Brain Injury Specialist Training Prep Course for training and credentialing, and set yourself apart by obtaining this certificate in 2 days!

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Driving post Stroke: How To Help Patients Reach This Goal!


After a stroke, a person usually has a long road of rehabilitation ahead of them before they can get back to their “normal life”.  One of the first things they want to know is when they can get behind the wheel again.  As therapists, this is not usually the first question that comes to our minds.  We are too busy breaking down their current disability into all its various impairments, so we can make appropriate goals and piece things together in order to help them become more independent with moving around and with basic needs of daily life.  However, to the patient…driving is often something that will make or break how they perceive the quality of their life after recovery from a stroke. 

 

Download our customizable Modified Multiple Errands Test packet to help integrate your post-CVA client back into the community!

After a CVA, there are several abilities that should be intact in order to be cleared to return to driving.  Here, we discuss the skills needed to return to driving post-stroke, and some considerations you may want to think about, as a clinician.

Return to driving after a stroke is a topic you may continuously educate your client about. Keep in mind, that all along the rehab journey, you may use the impairments observed in your patient as opportunities to educate them about the return to driving process.  You don’t want to avoid the subject or wait until the very end of their stay to talk about it.  For example, if they are unable to feel their right lower leg, you could say… “Mr. Smith, remember since we normally use our right foot to operate the pedals in the car, this could be one of the challenges to overcome before you’re able to get back on the road.  We will continue to monitor it here and facilitate recovery, but if you still have this impairment by the time you think you’re ready to drive… we may need a driver rehab specialist to look into what modifications are available to ensure everyone’s safety.”  (Rinse and repeat for any other impairment.)  OK – let’s dive in!

Stroke Impairments that will affect driving ability:

Cognitive Impairment

This may seem like an obvious barrier to on-road driving, but we must ensure that our patients have adequate cognitive skills after stroke recovery to handle the predictable and unpredictable conditions that pop up during a road trip. 

driving disability sign

Attention/Concentration There are so many distractions for any driver on the road…  When you mix in a variety of impairments that come along with stroke, it’s a whole new ball game!  If your patient has impairments in attention, they are most likely not going to be successful with any part of driving a vehicle.  Sustained attention is needed to keep our eyes on the road, keep our foot on the gas pedal at a certain pressure, wait for the light to turn green, etc.  If your patient has impairments in sustained attention, they will most likely not be able to focus on those basic pieces of driving just listed.  They will be easily distracted and will not be able to effectively complete the task.  Selective attention while driving may come into play when driving through a heavy rainstorm or hale storm.  Being able to tune out the visual and auditory stimuli of those severe weather conditions and being able to maintain focus on operating the vehicle is essential!  A combination of alternating and divided attention happens throughout the process of driving.  At times, the driver will need to use divided attention and “pay attention” to many different things all at once (i.e.  – oncoming traffic, operating the turn signals or wipers, listening to the radio or GPS, etc.) and at other times one will need to use alternating attention (i.e. – looking both ways before turning left, where your full attention needs to be placed on looking left, then looking right). As you can see, without intact attention… driving will be almost impossible!

Memory:  Do you remember how to drive?  Do you remember where you turned?  Will you remember to take your keys out of the car?  So many things to remember!  One main thing to consider when talking about memory and return to driving after stroke, is if the person can remember the modifications or different safely recommendations that you or other clinicians may be making after their stroke.  They may be able to remember the “normal” way of doing things, however after a stroke there are usually many modifications to daily life that are being recommended.

Decision making/Problem Solving/Judgement:  Being able to make appropriate decisions and problem solve through unforeseen situations while driving is crucial!  The light turns yellow… you must determine if you have enough time to go through or if you should stop.  The car in front of you is going too slowly… you must decide if it is safe to pass them.  You have a quarter tank of gas left… you must decide the best time to stop for gas.  The car in front of you stops short… you must decide if swerving to the shoulder is the right move.  The list goes on! 

Physical Impairment

Strength & Range of Motion:  Stroke often leaves people with asymmetrical strength, sometimes limited range of motion, and even atypical tone (either hyper or hypo).  If their right leg has been affected, their ability to push on the gas and brake pedals and move between them will be impaired.  Steering the wheel with one hand is certainly possible, but there are many things to consider regarding training and modification in order to make this safe.  And a consideration for anyone getting behind the wheel (post-stroke or otherwise) is their ability to adequately turn their head to look in their blind spot.    

Sensation & Proprioception:  Imagine that feeling you get when you sit on your foot too long and it completely “falls asleep”.  Now imagine you immediately hop in the driver’s seat and attempt to accelerate up to a stop sign then slow down and come to a stop… without the ability to feel your foot or where it may be located.  It would be challenging to say the least… and that is just the tip of the ice burg of what a person may be experiencing after stroke. 

Balance & Coordination:  You may have great strength and flexibility.  You may be able to feel every inch of every limb.  But when you try to move your foot from the gas pedal to the brake pedal… you over or undershoot every time.  When you try to make a smooth turn with the steering wheel, the movements are choppy and not uniform.  You can imagine how this would impact safe driving! 

Reaction Time:  Along with being able to place your foot directly on the brake pedal when needed, a driver needs to complete this maneuver quickly at times.  There’s a certain amount of anticipation that occurs with braking, however we cannot always predict if someone will stop suddenly in front of us, or if a car pulls out to turn without looking, or if a pedestrian or animal wanders out into the road.  All of these circumstances require a driver to react quickly!  After stroke, processing of sensory information and assessment of the environment may be a bit slower… and therefore production of the needed motor response with also be delayed.  Adequate reaction time is needed to ensure safety of everyone involved… and seconds count!

Visual/Perceptual Impairment

Visual Acuity:  Many people drive and wear glasses.  Requiring correction of vision does not eliminate anyone as a driver, however after stroke we would want to make sure that vision is still adequate to see everything necessary to drive safely.  Street signs, GPS, pedestrians, lines on the road, other cars, and anything else in the environment… we all have to be able to see what we are doing and what is ahead of us and around us.  Visual acuity requirements to drive vary by state, so make sure to know what your state requires in order to assist your patients to assess baseline and get an idea of where they stand.

Visual Fields (Peripheral vision):  Depending on where the stroke occurs, it could bring with it some other visual difficulties, such as field cuts.  There are already certain areas considered to be “blind spots” in driving… however is a person’s visual fields are not all intact this will leave them with a larger “blind spot” they may have to compensate for.  When we drive, most of our visual attention is forward, on the road ahead.  But it is important to be able to rely on peripheral vision to alert us of danger and see things coming in order to act appropriately. 

Oculomotor function:  As mentioned above, most of the time we are looking straight ahead while we drive.  However throughout the time a driver is behind the wheel, they are required to quickly move eyes from one target to another (saccades), stay focused on a street sign while the car is in motion (smooth pursuit), or stay focused on any number of things in the environment while the car is moving and/or their head is moving (VOR).  If a patient has any kind of oculomotor dysfunction after stroke, they will not last very long in the driver seat without becoming dizzy or nauseous. 

What’s the next step to getting behind the wheel?

Provide Preliminary results: 

As you can see, there are many roadblocks a person can have to getting back to driving after stroke.  Many times, clinicians will defer to the physician when patients ask if they can start driving again.  And this is mostly due to simply not knowing how to answer the question.  But, if you break it down by impairment, you really can provide the patient with a lot of useful information!  Become familiar with what rehab driving school will be assessing and start to work on the areas that your patient struggles with.  Many of the things looked at are the impairments listed above.  Then talk to your patient about where they may fall short.  Be open and honest about what you are seeing and encourage them to follow up with a rehab driving school to determine if there are any modifications related to their specific impairments that would be appropriate.

Refer to Driver Rehab:

Rehab driving school is where you will find the experts… the Driver Rehab Specialists.  A Driver Rehab Specialist is a professional who plans, develops, coordinates, and implements driving services for individuals with disabilities.  This could be a member of the allied health community or a driving instructor who has taken courses related to the field or obtained a credential in driving rehab.  A great resource to find an OT Driver Rehab Specialist has been put together by the AOTA.  Information about where to find driving school and Driver Rehab Specialists (including general information about the credential) can be found on the Association for Driver Rehabilitation Specialists website. Read this insightful article for more information, if you are interested in becoming a Driver Rehab Specialist.

When it comes to getting our patients back to living their best lives, we can always take a step toward their goals… driving included!  Start with what you know.  Evaluate their abilities post-stroke, and educate them about what is generally needed for driving.  Then drill down to where they may struggle most and refer them on to the experts for a more comprehensive assessment and recommendation.   

For more great ways to help your patients meet their goals after stroke, check out our course ‘Inpatient Stroke Rehab: 14 Strategies to get your Patient Home.’ This powerful and practical 7- credit course will supercharge your practice with those post-stroke, and help you get the most desired outcomes possible!

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Agitation and Traumatic Brain Injury (TBI): how to manage


If you work with patients recovering from a Traumatic Brain Injury (TBI), you know that on occasion they may need a bit of behavior modification for- agitation.  TBI symptoms can have quite a wide range, including physical impairments, cognitive impairments, and social/emotional challenges.  Usually at some point in the rehab process with TBI, you will see unwanted and disruptive behaviors come and go.  Knowing how to approach the agitated patient and de-escalate the situation is key in order to be able to move forward with your goals for their care.

Why agitation happens in Traumatic Brain Injury:

One reason that agitation happens in the Traumatic Brain Injury population is that it can be part of the recovery process.  When someone sustains a TBI, they will start to go through stages of recovery that are characterized by the Rancho Levels of Cognitive Functioning

Per the Rancho Scale- if someone is at a Cognitive Level I (no response), they do not respond to any outside stimuli.  They are essentially in a coma.  When they move into Cognitive Level II (generalized response), they will start to slowly and inconsistently respond to stimuli.  Cognitive Level III (localized response) is characterized by the person’s ability to react more specifically to what they see, hear, and feel; they may begin to be awake on and off throughout the day; start to recognize family and friends and start to follow simple commands.  And Cognitive Level IV (agitated and confused) is where most clinicians run into trouble. 

brain injury

At Cognitive Level IV, the person will appear very frightened and confused; they may not understand how they feel or what is going on around them; they will have a hard time following instructions and may overreact by hitting and screaming; and they will be very focused on their basic needs.  This stage seems to last forever when you’re helping them through it, but in reality, will run its course and they will move into the next stage within a relatively short time period. 

There are four more Cognitive Levels the person can move through, with the last one being Cognitive Level VIII (purposeful and appropriate).  This person may still have some lingering difficulties but will be aware of them and be able to apply compensatory strategies to function in day to day life.  For a great description of all the levels as well as what family and friends can do to help at each level, check out this great resource.

If you would like to find out about the benefits and the process of becoming a Certified Brain Injury Specialist, download the CBIS Power Pack HERE!

Outside of the natural healing process, another reason someone with a traumatic brain injury experiences agitation- could be the same reason that we may also become agitated. They’ve been triggered! 

Now, this may look much different than your average trigger and people who have not sustained a TBI may have the ability to effectively use coping strategies and work through it.  Your patient will not be able to self-regulate very well at this point and they may not even be able to communicate that something is bothering them. Some triggers for a person with TBI may be:

Pain

There are several reasons a person with TBI could be experiencing pain.  A likely culprit could be persistent headache.  We know that even mild TBI symptoms consist of headache, so in someone that has sustained a severe TBI, this could be exacerbated further. 

There may also be other orthopedic sources of pain depending on the mechanism of their injury.  Fractures, surgical incisions, and other wounds could be causing ongoing pain for your patient.

Some non-verbal signs and symptoms of pain include restlessness, moaning, labored breathing, and agitation.  Since this person may not be able to communicate this specifically, it’s important to speak with the patient’s physician to find out if any medical interventions would be appropriate to include for pain management.   

Medical Appliances

Some patients in this stage of recovery have a few add-ons that can be rather uncomfortable – such as helmets, PEG tubes, trachs, IVs, oxygen, etc.  These are not things that they likely had prior to sustaining a TBI and these types of medical devices are usually uncomfortable to deal with for anyone – with or without a TBI!  These patients are going to feel this discomfort… not be able to communicate the discomfort… and most likely be confused as to what it is and why it is there to begin with.  Understandable that this may cause a bit of agitation for someone post brain injury!

Basic needs

agitation

Eating, sleeping, and using the bathroom are often things that a patient after TBI needs assistance with.  If they are NPO, they may still have a feeling of hunger and want nothing more than to be given something to eat.  And when they can’t have it, this could cause agitation.  If they are on a PO diet, they may not like the texture or not like the food choices and this will cause agitation as well.  The person with TBI may not be sleeping well or may have their days and nights mixed up.  So, when you are trying to do any kind of treatment with them, they end up being too tired… and end up agitated.  They also may now have difficulty with continence.  They have an uncomfortable feeling in their body, but they are not quite sure what it means or how to communicate it or they have an accident and become uncomfortable due to being soiled.  They are not able to anticipate these types of issues or problem solve their way through them… so they become agitated!

Overstimulation

Loud noises, bright lights, crowded areas, temperature changes, among other things can overwhelm a patient’s system and cause them to go into an agitated state.  This could be easily identified by tracking the circumstances that are present when agitation occurs and seeing what sets them off.  This could even include people that are in their environment – sometimes there are certain personalities that clash or even the tone of a person’s voice could be too loud or is perceived as noxious by the patient after TBI.    

Disorientation

As the title of Cognitive Level IV states, these patients will be confused and agitated.  They often require frequent reorientation to place, time, and situation and often perseverate on wanting to leave or go home.  They don’t remember who you are, where they are, why they are there… and this can be scary!  They want to leave and when they are not permitted to do so, this could escalate the situation.  

To learn more about resources available to the patients and families affected by TBI, check out the Brain Injury Association of America.

There are many other things that could cause agitation in someone recovering from a Traumatic Brain Injury, and the most important thing is to pay attention and recognize patterns of behavior that may be occurring, so you can put an appropriate behavior modification in place and help them through the recovery process.  It’s important to respond to brain injury-related agitation consistently and professionally. 

Try these 3 tried-and-true strategies to help you and your patients through this challenging stage!

Strategy 1: Stay present, stay calm, and don’t argue

Ok, so that may sound like three separate strategies… but they are all related to building rapport, building trust, and teaching your patient what your expectations are.  Staying present means that you don’t leave and end the session simply because your patient is agitated and is yelling at you.  They may be trying to refuse therapy and yelling for you to get out of their room… but however counterintuitive it may seem at the time – the best thing to do is stay with them and “ride the storm.” 

Here is an example of how the same scenario can be handled different ways and why staying present and calm will be the best choice in the long run. 

Imagine the simple scenario described above.  You go into your patient’s room at their scheduled time and they start yelling, refusing, maybe even threatening to throw something at you. 

  • If you…Leave and mark that session as missed, you have taught the patient that they are not expected to participate in your plan of care for them.  They simply have to act out a bit and they will be able to get out of participating.  Even when they move past the confused and agitated stage and progress with their recovery, they will be less likely to want to participate with you as this has now become a learned behavior and they may not feel that you expect much from them.
  • If you… Start to argue and correct the inappropriate behavior, you have taught the patient that you are a source of anxiety for them.  You are not someone they can be vulnerable with and they will not tend to trust you.  It doesn’t matter in that moment if what they are saying is completely wrong – in their mind, they are right and if you try to correct them by arguing with them you will only heighten their level of agitation.  It’s very much worth doing a self-assessment when we speak to any of our patients, as we may not always come across how we intend to.
  • BUT: If you… Stay present, stay calm, and don’t argue you will get the best result by far!  This requires extreme patience and is very difficult to do at times.  But if you remain calm and continually reorient them and redirect them to the situation and what your purpose is, they will eventually learn that you can be trusted and they will learn that you expect them to participate in your session during the scheduled time.  This may not happen during the first attempt, this may not happen during the second attempt… but if you ride it out with them, they will come around!  Some examples of things you may say are as follows:

“Mr. Smith, I see you’re upset.  You are in rehab because you have a brain injury.  This is your therapy time.  I’m going to stay here with you.  Let me know when you’re ready.”

agitation brain injury

This allows you to show empathy by acknowledging that something is wrong.  You are reorienting them to the situation by reminding them why they are there and what time it is.  You are reassuring them that this time with them is important to you and that you are going to follow through.  And you hand them a small amount of control back – they will tell you when they are ready instead of you telling them to do something now.

“Mr. Smith, this is your therapy session.  I’m here with you until 1:30. We need to work on [x, y, and z] during this session.  What would you like to work on first?”

Here you are telling them what to expect while you are there.  They now have an end time, which makes your purpose and presence more concrete.  They don’t have to wonder how long they have to work.  You let them know what your goals for the session are, which again makes the session feel more concrete.  And you allow them to have a choice.  You are there for a specific reason, but you are not going to run things – you are allowing them to direct how the session goes as long as you accomplish [x, y, and z].

“Mr. Smith, please don’t speak to me that way.  I am being polite to you, please be polite to me.  I am your therapist.  You are in rehab because you had a brain injury.  I’m here to help you get better so you can go home.”

Now, you may see how this could come across as argumentative given that you’re telling them not to do something.  However, if delivered in a calm and even tone this is quite effective in pointing out the inappropriateness of how they are acting.  There is nothing wrong with calling them out on what they’re doing as long as it’s approached the right way.  This type of cueing may even take a few practice runs in the mirror or some role playing with co-workers.  This will also reorient them to why they are there and what the “end game” is… going home – which may be motivating to some patients. 

You will know what the exact wording needs to be based on the needs of your patient.  The main thing to remember is to stay present and calm and work to build the trust and rapport you need to help them stay calm and be present in their own recovery.  While you are using these strategies, there may be some down time and “waiting it out” when not much “therapy” is going on.  But this is well worth the time spent in the beginning in order to get the outcomes you’re looking for in the end.  You will gradually teach the patient how to treat you by remaining consistent and continually reorienting and redirecting them.

Strategy 2: Provide Structure

When someone sustains a TBI and is going through the cognitive stages of recovery, they are confused at times, disoriented to time and place, don’t always remember who their caregivers are or what they’ve done throughout the day.  Since they are unable to organize and process all of this information, it can be useful to provide structure to them in a few different ways.  Helping them keep track of things will give them a sense of comfort and security and may help prevent agitation before it occurs.

  • Calendar – Having a monthly calendar readily available is going to provide an easy and consistent way to reorient the patient to time and also keep track of activities and appointments that are coming up.  Often times, if unexpected things happen to or around a person with a TBI… this could send them into a tailspin!  They usually have very little flexibility of thinking due their injury (and depending on what stage of recovery they are in) and the more concrete you make their day, the information you present to them, their environment… the more chance you have of holding back the anxiety and agitation.   Giving them the ability to anticipate things that fall outside the realm of a “normal day” will be a life saver!
  • Daily Schedule – You don’t want to leave the day to chance.  Your patient has lost so much control over their bodies and their lives, that a simple thing like knowing what to expect throughout the day will help them feel more settled and less anxious.  They will know what to expect and have more time to process the information and complete whatever preparation they may need to.  A great place to start is their therapy schedule.  Coordinate with all the therapists and with nursing to see when each therapy would fit best in the day for that particular patient.  Write it down and provide it to the patient, so they always know when to expect you.  And if this has to change for any reason, make sure to tell them ahead of time!  As they start to recover and are able to participate in more high-level activities, you can add other things to their daily routine.  These things may be a wake up and bed time, morning and evening routine, making a call to a family member, going on a community outing, going to an appointment, etc.  The more they know in regards to how the day will unfold, the better.  And since it is written down, they won’t have the pressure of trying to remember what is next.  They can look at it as many times as they need to.
  • The Care Team – As much as possible, try to have the same therapists, nurses, aides, etc. work with the patient on an ongoing basis.  As mentioned previously, these patients (especially if they are at a Cognitive Level IV) will be confused and disoriented and will be fairly untrusting at first of the people trying to care for them.  Seeing the same faces day in and day out, building trust, and establishing expectations will be key in preventing and de-escalating episodes of agitation.  And on the clinician side of this factor, it is much easier for us to know how to approach someone, how to anticipate needs, what strategies work (and which ones don’t) if we are the ones seeing them each day.  If the patient with a TBI has to get to know a different clinician each day for their whole recovery period and those clinicians have to try their best to get to know everything that is going to make the session or treatment go as efficiently as possible… progress is going to be rather slow, if not non-existent.  Consistency and structure in the care team is what you want to strive for.

The three examples above are some of the more natural ways you can incorporate structure when you’re starting to formulate your plan.  They are a good place to start, but any type of structure you can provide will be helpful in decreasing brain injury-related agitation and helping your patient with TBI feel more confident in themselves, and with what they see around them.  Try to always give instructions in a concrete way, so nothing is left to chance and provide information in writing (if they are able to read and comprehend) so they can review it at will.  

Strategy 3: Make a Plan & Meet their needs

So, this may seem oversimplified.  Meet their needs.  As healthcare professionals, we want to make a difference and help people… we always strive to meet the needs of the patients we work with.  However, when you’re working with the TBI population and you are at the point where behavior modification is needed – it may not be so obvious what their needs are!

Step 1: Identify triggers – When your patient with a Traumatic Brain Injury starts to have episodes of agitation, you want to carefully track what preceded the episode, what is in and around their environment, who is caring for them, etc.  By paying close attention to these sorts of things, you can easily identify what undoubtedly sets them off.  There will still be times that the agitation seems to be insidious, but for the most part you will be able to find out what circumstances are troublesome for that specific patient.  This type of tracking is best done with input from the interdisciplinary team.  So, if your facility has a daily huddle or a daily clinical meeting – this type of information should be brought up then so everyone has the opportunity to ask questions that are relevant to them and that others may not have thought about.  Sample questions that should be explored are:

  • Were they found to be incontinent?  Were they wet or soiled?
  • Were they in the same position for a long time?  Could they have been uncomfortable?
  • Did they feel too hot or too cold?
  • Were there any loud noises?  Or other environmental irritants?
  • Was someone trying to work with them when the behavior started to escalate?  Or were they alone?
  • When was the last time they ate? (if not NPO)

There are a whole host of other questions to ask depending on the needs and circumstances of the patient and the episode of agitation.  But having a quick discussion as a team will be the fastest way to identify what is triggering them.

Step 2: Identify needs – Once the triggers are identified, you can more easily identify what the patient needs.  If the patient seems to always be found as incontinent when the agitation ramps up, they may need to be toileted more often.  If the patient seems to get restless after a certain amount of time in their chair, they may need rest breaks in bed.  If they seem calm in their room but hate being in the therapy gym with other people, they may need a quiet space to start treatment in.  If light seems to bother them, sunglasses may be in order!  If they are constantly asking for something to eat, maybe giving them double portions at their meals would be appropriate. 

These patients will have needs, just like all the other patients that we work with.  Unfortunately, agitation is the person with brain injury ‘s way of saying they need something, or something is wrong.  Once we identify why they are acting out, we will know what to do!

Step 3: Make a plan – All the information discussed above will go into a behavior modification plan.  This plan should be easily accessible to all clinicians caring for the patient and should be initiated as soon as possible.  You can include things like:

  • Names of people on their care team
  • Names of caregivers or contacts
  • Therapy schedule and/or out of bed schedule
  • Toileting schedule
  • Environmental modifications
  • Triggers of agitation
  • Strategies for de-escalation
  • What types of external memory aides are being used
  • Any other special instructions

As your patient with a TBI moves through recovery, there are going to be times that are challenging and there are going to be behaviors you observe that are irrational and sometimes quite explosive!  Agitation in brain injury is not uncommon… however no one (you or the patient) has to simply suffer through this time.  If we take a step back and make sure we are building trust and rapport, providing structure, and meeting their needs… we can all experience a smoother transition through the Rancho Levels of Cognitive Function.

If you are interested in learning more about assessment and treatment of Mild TBI, check out ‘Practical Approaches to Concussion Management‘! This powerful seminar provides skills and tools to be able to assess, treat and manage concussion and the complications that may arise from it.

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