Chinese Proverb

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"I listen and I forget, I see and I remember, I
do and I understand."

• Chinese Proverb

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Army Occupational Therapy

• Functionally Focused Rehabilitation

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Purpose

• Depict how Occupational Therapists use their
  unique skill sets to devise and implement
  treatment with persons with traumatic brain
  injury
• Share current initiatives that will shape how the
  Army addresses issues surrounding traumatic brain
  injury

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Outline

• Overview of Occupational Therapy (OT)
• OT Tools of the Trade
• Compare and Contrast Acute vs. Sub-acute
  Treatment
• Future Implications/Summary
• Questions

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Just to get us rolling..
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OT Overview

• OT Practice Framework
• World Health Organization, position on definition
  of health and independence
• Occupation defined
• Simple
• Complex
• We are (being) what we do (occupation)
• We continually strive to repeat and improve upon
  that (becoming)

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OT Overview

• Minimize barriers
• Maximize skills/abilities
• In the Army
• Upper extremity rehabilitation
• Combat stress control (CSC)
• Ergonomics
• Various practice settings

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OT Tool Box

• Unique skill set best suited in the Army to
  address TBI at all stages

Peak Performance
Activity Analysis
MOHO
Mental Health
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OT Tool Box

• Peak Performance training
• Exposure therapy
• Biofeedback
• Mental Health
• Life Skills training
• Combat Stress Control training

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OT Tool Box

• Activity Analysis
• Adaptation vs. accommodation
• Grading (up/down)
• just right challenge
• Model of Human Occupation
• Balance of work, play, rest
• Being is Doing and Becoming

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OT Tool Box

• Leading experts agree that in the post-acute
  stages of MTBI exposure and/or cognitive
  behavioral training makes most significant impact
  on behavioral sxs
• AND that while gains in executive function
  (memory, attention, etc) may continue to be made,
  compensatory techniques are some of the most
  useful tools to persons with MTBI

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OT InterventionAcute Setting
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Precautions/Considerations

• Bed rest/Weight bearing status
• Contact precautions
• Helmet/protective splints
• Lines/monitors
• Ulcers/pressure areas
• Contractures
• Impulsiveness/Falls risk
• Inappropriate behaviors
• Over-stimulation

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Initial Evaluation

• Introduction
• Level of Alertness (Glasgow Coma Scale) Signs of
  Agitation
• Verbal/non-verbal (language preference), use
  alternate forms of communication
• Vision and Hearing (gross screen)
• Orientation

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Summary of DiagnosisTBI Scales
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Summary of DiagnosisTBI Scales
REVISED RANCHO LOS AMIGOSLEVEL OF COGNITIVE
FUNCTIONING SCALE
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Initial Evaluation

• ROM
• Strength
• Tone
• Coordination, gross fine
• Sensation
• Mobility/transfers
• ADL/IADLs

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Quick FIM Review

• 0Activity does not occur
• 1Total Assist (lt25 of task)
• 2Max Assist (25-49)
• 3Mod Assist (50-74)
• 4Min Assist (75 or more)
• 5Set-up/supervision
• 6Modified Independence (no helper)
• 7Complete Independence

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Initial Evaluation

• Balance
• Endurance
• Proprioception/kinesthesia
• Other
• Patient goals
• Interests
• Prior function (self and family/unit report)
• Social support

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Other Medical Treatment

• PT
• Speech
• Dietetics
• Adult Behavioral Health
• Social Work
• Neuropsychiatry
• Neurosurgery
• TBI Center (WRAMC)

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Goals-Acute

• At least Mod I in ADLs
• Appropriate behavior 100 of time
• Demonstrate awareness of cognitive/physical
  barriers to performance
• Much of treatment is externally driven by
  therapist

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Goals-Acute

• Patient Goals get back what I was
• Short Term Goals by 13 APR 05
• Brush teeth with RUE set-up in bed
• Wash face with RUE set-up in bed
• Effective use of communication board

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Goals

• Additional Goals, Short term
• Tolerate sitting upright in cardiac chair at
  least 2 hours/day
• Added progressive ADL, activity tolerance
  (endurance) and cognitive goals
• Long Term Goals 6 JUN 05
• Supervision in upper/lower body dressing
• Mod I in grooming
• Sit at EOB/armless chair Mod I x 30 min
  performing table top activity
• Perform standing activity Mod I x 15 min

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OT Treatment Examples

• Splinting and positioning
• Bed mobility, transfers, ADLs/IADLs
• Facilitation of normal muscle tone, teaching
  compensatory techniques to maximize independence
  (hemiparesis)
• Adaptive equipment

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Equipment Examples
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OT Treatment Examples

• Cognitive re-training/compensatory strategies
• Reinforcing appropriate behaviors
• Psychosocial support, facilitation of
  self-expression in meaningful ways
• Incorporation of family when appropriate

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Treatment Plan

• Frames of Reference (FORs)
• NDT/Bobath (rehabilitation)
• PNF
• MOHO

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Self-portrait
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OT InterventionSub-Acute Setting
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Sub-Acute OT Intervention

• Outpatient
• Consult vs. Screening
• Mini-mental
• Cognistat
• Rivermead
• ANAM
• Some overlap depending on functional level of
  patient and level of care supported by hospital

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Sub-Acute OT Intervention

• Same toolsadvanced outcomes and expectations
• Shift from extrinsic motivation to intrinsic
• Facilitate deeper awareness of self (abilities,
  limitations)

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Sub-Acute OT Intervention

• Continuing to work on utilization of
  organizational/memory aids
• Mastery of Life Skills
• Work-readiness programs
• Ultimate goal is RTD functioning in
  family/society successfully
• School/civilian employment

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Current Initiatives

• Work-readiness programs Ft.Campbell, KY in next
  3 months
• ANAM screening tool
• Researched, proven
• Pre/post deployment
• Follow-up
• Fast, objective/measurable, repeatable
• Peak Performance training

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(No Transcript)
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Mini-MentalVisual-motor Integrity
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Questions?