Clinicians Will Walk Away With…

Treating Patients with Traumatic Brain Injury: Advanced Practice Across the Continuum of Care

Presented by: Jennifer Fogel, PT, DPT Shands Rehab Hospital Lindsay Perry, PT, DPT, NCS Medical University of South Carolina

Clinicians will walk away with…

• A basic understanding of neuroanatomy – Impairments and presentation based on affected area of the brain • Knowledge of Incidence of Brain Injury • What to consider when performing evaluation of patients with brain injury • A toolbox of evidence based outcome measures to be used across the continuum

1 Clinicians will walk away with…

• An understanding of considerations during acute management of patient with brain injury • Presentation of patients with brain injury according to Ranchos Levels and treatment considerations • Ability to apply Behavior and Cognitive Treatment strategies • An understanding and ability to apply principles of neuroplasticity to interventions • Importance of addressing community reintegration

Brain Injury

Non-Traumatic Traumatic

Tumor Stroke Aneurysm Primary Secondary Diffuse Focal

Contact Acceleration- Generalized i.e. Localized i.e. Deceleration Concussion Contusion

2 Craniectomy surgical procedure, boneflap placed in the abdomen.

Bilateral craniectomy, fronto-temporal lobes.

Brain Anatomy

3 Brain Anatomy Frontal Lobe: Reasoning, planning, problem solving, movement of the body, parts of speech, regulating emotions

Frontal Lobe: • Executive function is impaired • Changes in social behavior and or personality • Difficulty with problem solving • Mood changes • Perseveration (repetition) • Inability to focus on task • Inability to express language • Judgment and decision making

Brain Anatomy

Parietal Lobe: Sensation/feeling in body, some movement, spatial reasoning

Parietal Lobe: • Difficulty distinguishing left from right • Difficulty with math • Difficulty with hand /eye coordination • Inability to attend to more than one object at a time • Anomia- Inability to name objects • Agraphia- Inability to write • Apraxia- inability to carry out purposeful movements

4 Brain Anatomy Temporal Lobe: Hearing, memory and understanding speech

Temporal Lobe: • Difficulty recognizing faces • Difficulty understanding spoken words • Increased aggressive behavior • Persistent talking • Interference with long term memory • Impaired hearing • Increased or decreased sexual interest/behavior

Brain Anatomy

Occipital Lobe: Vision

Occipital Lobe: • Visual field cuts • Difficulty identifying colors • Hallucinations • Difficulty with reading and writing

5 Brain Anatomy

Cerebellum: Balance and coordination

Cerebellum: • Difficulty walking • Poor balance • Tremors • Dizziness/ Vertigo • Inability to coordinate fine movements • Inability to make quick movements • Dysarthria- poor articulation of speech

Brain Anatomy Brain Stem: Basic life functions like breathing, heart rate, blood pressure plus connection between brain and body for all functions

Brain Stem: • Basic life functions such as breathing, heartbeat, and blood pressure • Decreased breath capacity required for speech • Nausea and Dizziness • Insomnia • Abnormal breathing during sleeping (apnea) • Dysphagia- difficulty swallowing

6 Non‐traumatic Brain Injury‐ NTBI

Without trauma to the head • Anoxic injury –The brain does not receive enough oxygen • Toxic or metabolic injury – Occurs after exposure to unsafe substances • Encephalitis/Meningitis –Infection due to virus. • Tumors –location and removing of a tumor. • Stroke (CVA) – due either to rupture or blockage of artery taking blood to the brain. • Aneurysm – blood vessel wall balloons out due to weakness in wall.

Leading Causes of TBI 2006 ‐ 2010 Brain Injury Statistics Unknown/ Other • Every 23 seconds someone in the US sustains a 19% Falls TBI. Assaults 40% 11% • Every year, at least 1.7 million TBIs occur in the U.S. MVA 14% • 52,000 die, 275,000 are hospitalized and struck by/ against 1.365 million are treated and released from 16% the ER • About 75% of TBIs per year are concussions or other forms of mild TBI ‐ most of which go undiagnosed • TBI is a contributing factor to a 3rd (30.5%) of all injury‐related deaths in the United States. • Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated $76.5 billion in the United States in 2000.

7 Falls

• From 2006–2010, falls were the leading cause of TBI • 40% of all TBIs in the US that resulted in an ED visit, hospitalization, or death. • Falls disproportionately affect the youngest and oldest age groups: – More than half (55%) of TBIs among children 0 to 14 years were caused by falls. – More than two‐thirds (81%) of TBIs in adults aged 65 and older are caused by falls.

Incidence of TBI

• Males are about 3 times as likely as females to sustain a TBI. • Highest incidence is among persons: • 0‐4 years of age, 15 to early 20’s and >65 • Alcohol association • Major causes: Falls, Struck by/Against, MVA, Sports Injury, Fire arm related TBI • Unintentional blunt trauma (e.g., being hit by an object) 2nd leading cause of TBI, accounting for about 15% of TBIs in the US for 2006–2010 • Blasts are a leading cause of TBI for active duty military personnel in war zones

8 Primary Brain Damage • Damage that is complete at the time of impact • May include: – Skull fracture – Contusions/Bruises/Hematomas: point of contact where the force of the blow has driven the brain against the skull (i.e. SDH) – Hemorrhages: Internal bleeding in brain (i.e. ICH, SAH, cerebellar hemorrhages) – Lacerations: tearing of the frontal and temporal lobes or blood vessels of the brain (the force of the blow causes rotation across the hard ridges of the skull, causing the tears) – Diffuse Axonal Injury (DAI): arises from a shearing force that damages nerve cells in the brain's connecting nerve fibers (axons)

Secondary brain damage

• Damage that evolves over time after the trauma • May include: • Brain Edema • Low sodium • Increased intracranial • Anemia pressure • Too much or too • Epilepsy little carbon dioxide • Intracranial infection • Abnormal blood • Fever coagulation • Hematoma • Cardiac changes • Low or high blood • Lung changes pressure • Nutritional changes

9 Open vs. Closed Head Injury

Open Closed • Penetration to the • No penetration Coup-Counter Coup skull to the skull Injury with a DAI • Resulting from • Resulting from gun shot and stab falls, motor wounds, etc. vehicle crashes, etc. • May affect one area of the brain, or different areas

Evaluation Considerations

10 Systems Review

Where Cognitive do I Balance Start?

Strength

International Classification of Function

11 Common Physical Impairments

Presentation: Impaired Systems • Hemiparesis • Balance • Ataxia • Coordination • Apraxia • Proprioception • Abnormal Behavior • Sensation • Impulsivity • Perception • Decreased Safety • Vision/Hearing Awareness • Cognition • Affect/Mood

Impairments Specific to Gait

•Ataxia • Decreased hip • Hemiparesis extension • Decreased foot • Poor knee control in clearance stance •Hip Hiking/ • Decreased Trendelenberg proprioception/ • Narrow base of coordination support • Asymmetrical step • Poor postural control length • Altered stance and/or swing phase

12 International Classification of Function

Cognitive Impairments

• Difficulties with – Attention • Sequencing • Organization – Memory • Problem Solving – Initiation • Confabulation

– Comprehension

– Expression

13 International Classification of Function

Personal Characteristics of BI

• Slowed Response • Egocentricity • Suspiciousness • Loss of Control • Inflexibility • Over‐dependency • Impatience • Perceptual Problems • Irritability • Increased Sexual Focus • Depression • New‐Learning Problems • Outburst • Inappropriate Social • Lability (Crying) Behavior • Denial • Family Abuse • Perseveration

14 International Classification of Function

Neuroplasticity at the Systems Level: Functional Remodeling • Definition: reorganization of a given region or a change in the area(s) associated with a given function

• Possibilities: 1) Parallel pathway activation 2) Unmasking of silent neurons or pathways 3) Formation of new pathways/circuits

• Measured in humans by fMRI, EEG, PET, MEG, TMS

15 Functional Remodeling evidence:

• Increased activity in the contralateral hemisphere

– Shift of balance (laterality) from contralateral (ipsilesional) to ipsilateral (contralesional)

– Explanations: • Hypoactivity of lesioned tissue • Decreased interhemispheric inhibition from lesioned hemisphere to non‐lesioned hemispehere • Decreased excitability in the lesioned hemisphere • Incorporation of ipsilateral analogues (i.e. ipsilateral corticospinal tract)

Transcranial Magnetic Stimulation (TMS)

• The TMS current generates a changing magnetic field that induces an electrical field in the brain • This current provides a depolarization of nerve cells under the stimulating coil • Resultant motor evoked potential (MEP) is recorded with EMG • Possible side effect: seizure • TMS can be used to: – Noninvasively map the excitability of the cortex (single and paired pulse TMS) – Alter cortical excitability (repetitive TMS) • Treatment for: Depression, Epilepsy, Parkinson’s

16 Variables that Influence NP

• Experience (activity) • Sleep • Mood (Stress, Depression) • Hormones • Cardiorespiratory function • Diet • Pharmaceuticals

Experience Dependent NP (EDP) • Definition: – NP is the mechanism by which the brain encodes experience and learns new behaviors. – the mechanism by which the damaged brain relearns lost behavior in response to rehabilitation.

Principles: 1. Use it or Lose it 2. Use it and Improve it 3. Specificity 4. Repetition Matters 5. Intensity Matters 6. Salience Matters 7. Time Matters 8. Age Matters 9. Transference 10. Interference

17 Objective Measures

International Classification of Function

18 19 Objective Measures

• BERG • DGI • TUG • Functional reach test • Romberg • Tinneti POMA • Clinical Test of Sensory Interaction in balance (Foam and Dome)

20 International Classification of Function

Objective Measures • Berg: /56 – 0‐20 High fall risk – 21‐40 Medium fall risk – 41+ Low fall risk – 8 point difference is required to show functional change • DGI: /24 – Below 21 indicates fall risk and lower the score the increased fall risk • FGA: /30 – Adapted from the DGI, addition of gait with narrow BOS, EC and backwards

21 Objective Measures

• TUG – Timed Up and Go – Stand, walk 10 m, turn around cone and walk back – Timed from sitting to sitting – > 14 sec = high fall risk • FRT – Functional Reach Test – Standing Reach task – < 6 in = risk of falls

Romberg:

• Tests proprioception, vestibular, visual systems • The essential features of the test are as follows: – the subject stands with feet together, eyes open and hands by the sides. – the subject closes the eyes while the examiner observes for a full minute. • Romberg's test is positive if the patient sways or falls while the patient's eyes are closed. • Tests for sensory ataxia and rules out cerebellar ataxia

22 Tinetti Performance Oriented Mobility Assessment – Balance section • Sit to stand, sitting/standing balance – Gait section • Initiation, symmetry, path, trunk, BOS – Score: /28 total • <19: High fall risk • 19‐24: Medium fall Risk • 25‐28: Low fall risk

Clinical Test of Sensory Interaction in Balance (CTSIB)‐ (Foam and Dome)

– 120 total score – 3 trials each of each environment • Feet on firm surface EO • Feet on firm surface EC • Feet on foam surface EO • Feet on foam surface EC • Measures the Sway Index – a time‐based pass/fail for completing the CTSIB stage in 30 seconds without falling, or assigning a value of 1 to 4 to characterize the sway. – 1 = minimal sway – 4 = fall

23 Measures Validated for TBI

• FIM • FAM • HIMAT • Community Integration Questionnaire • Independent Living Scale (ILS) • Community Balance and Mobility Scale • Agitated Behavior Scale

FIM + FAM

• FIM : /128 – examines 13 physical functions, 5 cognitive functions – ceiling effect • FAM: – developed for patients with BI – 12 additional sections to FIM – covering cognition, such as community integration, emotional status, orientation, attention, reading and writing skills, and employability • FIM + FAM (30 activities) – completely assess cognitive and behavioral issues important for community reintegration

24 High Level Mobility Assessment Tool (HIMAT) • /54 • Assesses: – Skipping – Hopping – Stairs – Bounding – Running – Walking (obstacles, backwards, on toes) • Floor effect • No normative values at this time

International Classification of Function

25 Community Integration Questionnaire • consists of 15 items relevant to living, loving and working, or more formally: skill in home integration (H), social integration (S), and productive activities (P) • Scored to provide subtotals for each of these, as well as for community integration overall • The basis for scoring is primarily: – frequency of performing activities or roles – secondary weight given to whether or not activities are done jointly with others, and the nature of these other persons (for example, with/without TBI).

Community Integration Questionnaire • /29 (0,1,2 scale) • In its current format, the CIQ can be completed, by either the person with a TBI or a proxy, in about 15 minutes. • The most common method of data collection is an in‐person interview, but telephone interviewing is quite common, and the TBI model systems also utilize self‐administered CIQs. • A high score indicates greater integration in the community

26 Independent Living Scale (ILS)

• developed and refined over 15 years of clinical application in a post‐acute traumatic brain injury (TBI) rehabilitation setting. • 3 main areas: – ADL's‐ 17 items – Behavior‐ 11 items (scored on an hourly interval – Initiation‐ examines skills across 16 ADL sub‐scale items. • 100‐point scale • Rated on a 0‐6 assistance level rating • Observational data is collected by staff assigned to a given patient over a 1‐week period.

Community Balance and Mobility Scale (CB & M) • Measure for: – detecting dynamic instability – evaluating change in ability in the higher functioning ambulatory patient with TBI • Performance‐based measure with 13 items on a 6‐point scale. • Six of the items are performed on both right and left sides bringing the item total to 19 tasks. • Examples: – Walking & Looking – Running with Controlled Stop and Hopping Forward – Lateral Foot Scooting – Forward to Backward Walking and Crouch & Walk • Higher scores indicate better balance and mobility.

27 Putting it all together

Physical

Cognitive

Principles of Neuroplasticity/Motor Learning

Acute Management

28 Observation • What lines does the patient have connected? – External Ventricular Device – Lumbar Drain – ICP line – Helmet for OOB

• Does the patient require any protective equipment?

• How does the patient present?

• How will these observations drive your critical decision making for your assessment?

Observation

29 Assessment

• Impairments –Motor responses: Reflexes/posturing –Impaired senses –Imbalance –Weakness –Muscle Tone –Incoordination –Impaired cognition

Acute Care Functional Mobility/Activity • Physical Assistance level: –Bed mobility –Sitting tolerance/Balance • Performance of ADL while sitting –Supported –Unsupported –Transfers –Standing balance –Gait • Cognitive Capacity – Ranchos Levels • Assistance for cueing

30 Spasticity

• Abnormal muscle tone resulting in reduced range with high velocity movement

• Imbalance of muscle agonist/antagonist coordination

Spasticity

Advantages Disadvantages • Maintains muscle • Limits ROM tone/mass • Pain • Reduces bone loss • Interferes with daily • Promotes blood function circulation • Affects posture • Helps with • Increases risk for skin performance breakdown

31 Management of Spasticity

Physical Therapy Medical Management • Stretching program • Intramuscular injections • Orthotic devices • Intrathecal Baclofen Pump – Promote prolonged • Oral medication stretch of the – Baclofen muscle – Diazapam‐ anti‐anxiety • Serial casting – Zanaflex‐ muscle relaxer • Positioning

Positioning • Consider future functional goals

• Emphasize neutral positioning

• Protect areas prone to breakdown

• Emphasize proper techniques to combat extreme tone • i.e. positioning BLE into slight flexion if exhibiting increased extensor tone

• Use and apply positioning devices, splints appropriately and designate a wear schedule

32 Functional Mobility: Task Oriented Approach Functional Task Co treatments with Practice/Familiar Tasks OT: • Sitting tolerance • PT focus on gross – Monitoring vitals mobility/balance – Head and trunk control • OT focus on • Bed mobility execution of • Transfers ADL/cognition • Balance – Sitting/Standing • Gait

Prevention of Secondary Impairments

• Contractures • Infection • Skin Breakdown • Pneumonia • Disuse Atrophy • Deep Vein • Weakness Thrombosis • Heterotrophic • Sympathetic ossification “Storming” • Hydrocephalus • Endocrine Changes • Decreased endurance

This is vital across ALL settings

33 Special Considerations for Acute Care

• Evaluation is a continuous process between sessions • Primary Goals: –Preventing secondary impairment –Education –Safe, early mobilization • Initiating restoration/recovery • Initiating Neuroplastic/Motor Learning Principles –Communication and coordination of care –Effective DISCHARGE for the patient

Specific Goals • Endurance • Safe Discharge plan • Functional • Family education mobility/assistance – Rancho Levels level – ROM – Attention/Self – Transfers awareness – Positioning – Midline posture – Communication – Self care – Stimuli • Balance – Resources: websites, – Sitting/Standing community – Walking • Prevention of secondary impairments

34 Treatment Strategies

Acute Care: Rancho Levels I‐III

Rancho Level I‐III: Presentation

Level I ‐ No Response: Total Assistance • No responses to pain, touch sound or sight Level II ‐ Generalized Reflex Response: Total Assistance • general responses to all stimuli • but not purposeful Level III ‐ Localized Response: Total Assistance • consistent responses specific to stimulus (withdraws from pain, turns toward sound)

35 Rancho Level I‐III: Motor Control

• RL I – Spontaneous – No purposeful movements – Decorticate or decerebrate posturing • RL II – Emerging purposeful movement in response to stimuli • RL III – Purposeful, FSC, Focus/Attention – No complex/sequential tasks – Inconsistent responses

Rancho Level I & II: Treatment • PROM • Positioning/Splinting/Stretching – Specifically righting/balance reactions for RL II • Sensory Stimulation • Gross motor tasks – Simple VC, Familiarity, Low Stim

• Neuroplastic Principle: Repetition

36 Rancho Level III: Treatment • Set‐up low stimulation environment • PROM and AAROM/Positioning and Splinting • Stimulation to follow commands or elicit responses • Ecological Theory: allow exploration • Transfers, EOB balance and postural control/awareness of body, facilitation of purposeful tasks • Initiate Gait as appropriate

• Neuroplastic Principle: Saliency

Treatment Strategies

Sub‐acute: Rancho Levels IV‐X

37 Rancho Level IV ‐ Presentation • Confused/Agitated: Maximal Assistance

• Alert

• Aggressive or bizarre behaviors • Motor activities may be non purposeful

• Extremely short attention span

• Decreased attention with overstimulation

Rancho Level IV: Motor Control

• May not appear to be making progress due to frequent behavioral interruptions

• Performs simple, automatic and purposeful tasks

38 Rancho Level IV: Treatment

• Gross motor tasks • Transfers, EOB balance and postural control/awareness of body, facilitation of purposeful tasks • Functional Activities – Old skills patient is familiar with – Incorporate familiar objects • Redirect behavior throughout treatment!! – Decrease agitated episodes • Increase attention • Re‐orient to time and place frequently

• Neuroplastic Principle: Repetition, Salience

Rancho Level IV: Cognitive Treatment Attention Endurance Requirements Requirements

• Break up evaluation • Rest periods • Observe rather than “test” • “Guided” wandering • Use a quiet area • Use “old” skills • Allow patient to move, then re‐focus • Redirect to new task, or change your request for current task • Use prompt and praise, short and simple cues • Use charts to show progress and develop recall

39 Rancho Level IV: Cognitive Treatment Structure treatment Manage agitation • Establish a routine • Allow patient to move, • If agitated, do not then re‐focus increase demands • Avoid restraints if • Provide frequent possible orientation • Limit treatment time • Teaching new skills is • Do not escalate if unrealistic agitated • Automatic tasks • Be prepared with • Reflexive rather than numerous activities declarative learning • Model calm behavior

Rancho Level IV

Behavioral Considerations

40 Agitated Behaviors

• What is agitation? • Unpleasant state of extreme arousal (stirred up or excited), increased tension and irritability.

• What is aggression? • A form of agitation involving: • A direct verbal threat to harm oneself or another person • A physical assault directed at oneself or another person

Forms of Agitation

• Yelling • Pulling Tubes/IV/Dressings • Pacing • Laughing inappropriately • Perseveration • Inappropriate language • Biting • Sexual language/gestures • Hitting • Getting out of bed or climbing • Crying • Frequent hand movements • Threats • Refusing or noncompliant • Irritable • Wandering

41 Agitated behavioral scale

1.___Short attention span, easy distractibility, inability to concentrate 2.___Impulsive, impatient, low tolerance for pain or frustration 3.___Uncooperative, resistant to care, demanding 4.___Violent and or threatening violence toward people or property 5.___Explosive and/or unpredictable anger 6.___Rocking, rubbing, moaning or other self-stimulating behavior 7.___Pulling at tubes, restraints, etc 8.___Wandering from treatment areas 9.___Restlessness, pacing, excessive movement 10.__Repetitive behaviors, motor and/or verbal 11.__Rapid, loud or excessive talking 12.__Sudden changes of mood 13.__Easily initiated or excessive crying and/or laughter 14.__Self-abusiveness, physical and/or verbal

Agitated Behavioral Scale

• Assesses: – nature and extent of agitation during the acute phase of recovery from acquired brain injury. • Its primary purpose: – to allow serial assessment of agitation by treatment professionals who want objective feedback about the course of a patient's agitation. • Degree can be a function of: – either the frequency with which the behavior occurs or – the intensity of individual occurrences. • Can assist with identification of triggers

42 Agitated Behavioral Scale

• 1 = behavior is not present • 2 = slight – the behavior is present but does not prevent the other appropriate behavior. – Patients may redirect themselves spontaneously • 3 = moderate – need to be redirected to an appropriate behavior, benefits from cueing. • 4 = extreme – the individual is not able to engage in appropriate behavior even with external cueing

Agitated Behavioral Scale

• (Bogner et al, 2001; n=340 consecutive admissions to TBI unit; mean age=33 years) • For total or converted subscale scores: – Scores of 21 or below –within normal limits – Scores of 22‐28 – mild agitation • <23 = not likely to be violent

– Scores of 29‐35 –moderate agitation – Scores greater than 35 –severe agitation • >28 = likely to need pharmacological intervention

43 How to Prevent/decrease Aggitation

• Recognize the triggers • Decrease Stimulation • Give Choices • Redirect • Do not lecture or instill logic • Use a KEY person • No surprises • Model Calm Behavior, control YOUR reaction • Adhere to routine

Rancho V: Presentation

Confused, Inappropriate, Non‐ Agitated: Max assist for cognition – Gross attention span – Distractible – Redirection – Difficulty learning new tasks – May still be agitated from some stimuli – Social conversation may be automatic, but inappropriate – Wandering

44 Rancho VI: Presentation

Confused, Appropriate: Moderate Assistance • Inconsistently oriented to person, time and place • Long term memory better than short term • Emerging awareness of appropriate response to self, family and basic needs • Begins to recall past – Still difficulty remembering “accident” • Goal directed behavior with assistance • Unaware of impairments, disabilities and safety risks, max assist for new learning • Consistently follows simple directions

Rancho Level V‐VI: Motor Control

• Trouble following commands

• Difficulty learning new or complex motor tasks, but capable

45 Rancho Level V‐VI: Considerations

• Verbal/non‐verbal cues to direct behavior? • Can the patient be redirected? • Carryover for new or relearned tasks? – Memory? – Attention? • Confabulation? • Perseveration? • Impaired judgment?

Rancho Level V‐VI: Treatment

• Task‐oriented approach

• Impairments based contributing to task problems

• Systems approach

• Begin problem solving, increase participation

• Neuroplastic principle: Repetition

46 Rancho Level V‐VI: Treatment

• Maintain Structured treatment • Emphasize safety • Orient throughout Tx • Give one instruction at a time, speak slowly, allow patient time to process • Taxonomy of task: means of progression by systematically increasing task difficulty (Gentile) • Correct inaccurate responses with factual statements • Use of memory aides • Progress to community outings, participation

Rancho Level VII: Presentation

Automatic and Appropriate: Min Assist for cognition • Performs daily routine in highly familiar environment, structure • Non‐confused‐ consistently oriented • Automatic, robot‐like behaviors • Skills deteriorate in unfamiliar environment • Judgment impaired, over estimates • Lacks planning for future

47 Rancho Level VIII: Presentation

Purposeful, Appropriate: Stand‐By Assistance • Able to recall and integrate past and recent events • Independently able to attend to familiar tasks for 1 hour in distracting environments • Uses assistive memory devices for STM (i.e. to do lists) with SBA • Overestimates or underestimates abilities • Acknowledges deficits/impairments when they interfere however requires SBA to take appropriate action • Egocentric • Depressed/Irritable/Low frustration tolerance/Argumentative • Improved social interaction – Acknowledges other’s needs/feelings and responds appropriately with min A – Acknowledge inappropriate social interaction while it is occurring and corrects with min A

Rancho Level IX: Presentation Purposeful, Appropriate: SBA ON REQUEST • Independently shifts back and forth btw tasks and completes accurately for at least 2 consecutive hours • Uses assistive memory devices for STM (i.e. to do lists) • Acknowledges deficits/impairments when they interfere and takes corrective action but requires SBA to ANTICIPATE problem before it occurs and take action to avoid it • Able to think about consequences of decisions/actions with A when requested • Accurately estimates abilities but SBA to adjust to task demands • Improved social interaction – Acknowledges other’s needs/feelings and responds appropriately with SBA – Able to self monitor appropriateness of social interaction with SBA • May be depressed/Irritable/Low frustration tolerance

48 Rancho Level X: Presentation Purposeful, Appropriate: Modified Independent • Able to handle multiple tasks simultaneously in all environments but may require periodic breaks • Able to independently procure, create and maintain own assistive memory devices • Ind with familiar and unfamiliar ADLs, IADLs but requires more than usual time and/or compensatory strategy • Anticipates impact of disabilities/impairments on ability to complete ADLs, and takes action to avoid problems before they occur but may need more time or comp. strategy • Able to independently think about consequences of decisions/actions but may require more time or comp. strategy

Rancho Level X Continued… Purposeful, Appropriate: Modified Independent • Accurately estimates abilities, independently adjusts to task demands • Social Interaction behavior consistently appropriate • Acknowledges other’s needs/feelings and automatically responds appropriately • Periodic periods of depression may occur • Irritability and low frustration tolerance when sick, fatigued or under emotional stress

49 RL VII‐X Motor Control

• Patients able to understand and fully participate within their functional limitations

• Integrate all principles of Neuroplasticity as able

Rancho Level VII‐X: Treatment Social history/ medical history – Provide information accurately – Oriented Behavior: Purposeful, Appropriate, supervision to modified Indep. – FOCUS of treatment‐ PROGRESS higher level executive functioning – Ability to function in real‐life situations – Ability to make good decisions that address safety – Ability to follow 1,2,3 step commands – STM / LTM – Initiation of necessary actions – Insight into condition – Coordination, agility, speed – Attention, memory, problem‐solving, executive function – Advanced mobility skills, fitness, wellness – Vocational and Driving Assessment referrals – Incorporate Dual Tasking

50 Red Flags • Severe lability which interferes with treatment • Asks sensitive questions related to injury or accident • Sexually inappropriate / verbally inappropriate comments (therapist attire) • Suicidal threats • Inappropriate interaction between family and patient Direct these to the appropriate health professional

Family Training/Education

• Family wants patient to be cured

• Acute illness: broken leg ____^____

• Chronic illness: Brain injury __^^^^^^^^^ • Address the expectations

51 Family Training

• Opportunities for hands‐on facilitation of physical and cognitive assistance (overnight stays) • Education on community accessibility • Disease specific education • Setting up appropriate exercise program • Sorting laundry, books on shelves, putting groceries away • Cognitive home exercise program • Home‐based cognitive stimulation program http://main.uab.edu/tbi/show.asp?durki=49377

Emotion

• Adjustment issues • Depression • Self worth • Grief • Chemical Abuse • Ex. Athletes

52 Summary • Characteristics features for each rancho level – Behavioral – Cognitive – Physical/motor • Evaluation methods – Prioritize treatment plan • Implement motor learning/motor control/Neuroplasticity Principles – Ex: intensity, repetition, saliency • Use of participation as motivation • Family education is pertinent for every level

Behavior Management

53 Behavior • Behavioral changes including aggression, violence, impulsivity, loss of inhibitions, and agitation are common. • WHY is someone acting this way? – Attention Seeking • Are you meeting their needs? – Escape/Avoidance • Are they tired? – Communication • Are they frustrated? – Self‐Stimulation • Are they trying to calm themselves?

Behavior

Back to basics • Hungry/Thirsty • Tired • Pain • Bathroom • Overwhelming Environment

54 • Use clear and calm voice tone • UseDuring voice volume Aggressive lower than that of aggressiveBehaviors individual • Use relaxed, well‐balanced posture Hitting, Biting, Kicking, Yelling withScreaming, hands held Foul inLanguage front • Remove items that could be used as weapons • Escort from unsafe/ high stimulus environment (in hospital and after discharge at home) – Adjust lights, TV, noise and limit visitors

During Aggressive Behaviors

• Ask patient to tell you why he/she is upset • Maintain safe distance • Position self between individual and nearest exit • Call for assistance • Give the verbal command “STOP” • Be prepared to protect yourself using appropriate blocks or releases.

55 Redirection Techniques

• Jedi Mind Trick • Let’s Get Physical • Idle Hands • Changing environment • Memories‐ long term • Caution with Humor

Effective (Preventative) Intervention

• Adapt the environment • Decrease stimulus (i.e. noise) • Television • Lights • Limit family members • Temperature • Least restrictive environment/new environment if needed • Impose structure ‐ Do not give choices ‐ Example: Do you want to get up for therapy? ‐ Or: It’s time to get up for therapy! ‐ Create routine and establish schedule

• Preventative Dressing • Hair, Earrings, Glasses, Necklaces, Bracelets

56 Resources at the Hospital

• Busy vests and busy lap tray • Keep the patient active in wheelchair or walking around • Information Packet: “Relating to the Person with Brain Injury” • Memory Journal • Behavior Management Plan • “Team Focus” • Therapeutic Attendants (TA) • Games and activities (TA kit) • High/Low Activity Packet

What works ?

Interdisciplinary communication

Consistency of BI management care SUCCESS strategies

Daily structure

57 What is Team Focus?

• The team focus initiative is in place for patients with agitation and behavioral management problems. • The goal of team focus is to create consistency of care for the patient, increase interdisciplinary communication for use of optimal brain injury management strategies and allow for sufficient daily structure to make the patient successful.

Team Focus Strategies

• Consistency of care Consistent RN, therapist and T.A • Interdisciplinary communication EPIC tools, hand off communication, team meetings, T.A. communication tool, room signs • Optimal brain injury management Behavior management plan, low stimulation awareness, staff and family BI education • Daily structure Set schedule, activity kits, activity lists

58 Cognition in functional activities: Interdisciplinary Approach MD, RN, CM, SLP, OT, PT, TR Examples of teamwork:

• Mobility within function • General precautions. ex: • Sequencing Transfers weight bearing – to/from car or toilet • Cognitive motor • Communication boards activities • • Community outings Memory journals • • Discharge planning Dual Tasking • – Identification of DME Family Education • – Pressure relief strategies Services following discharge i.e. therapy, medical follow‐up

Effective Intervention

• Speaking with the patient • Keep it short Example: Roll towards me, Stand up • Give them time to process request/question • Give time to reset • Leave room and come back • Do not argue or reason with patient • Dealing with refusal or noncompliance • Provide clear and simple directions • Limit choices • Example: Do you want to get up for breakfast? • Or: It’s time to get up for breakfast!

59 After Inappropriate Behavior

• Verbal Intervention

– Call patient by name to orient them towards the staff member – Orient patient to where they are – Inform the individual that this behavior is unacceptable – Prompt the individual for alternative behaviors

After Inappropriate Sexual Behavior

• Inform patient that behavior is unacceptable • Use redirection and distraction • Tell them where they are

60 Role of Therapy and Medication Management • Understand effects and side effects of medications • Monitoring behavioral changes and level of arousal • Interdisciplinary communication • Common meds: – Haldol, Ativan, Keppra, Depakote, Seroquel, Steroids • Common side effects – Anxiety, depression, headaches, N/V, increased agitation, irritability, dizziness, lethargy, restlessness, tremors, muscle cramping, GI issues

Non agitated treatment approaches • Increasing arousal/lethargy • Coma‐near‐coma scale • Environmental stimuli • Gross motor stimulation • Increasing initiation • Giving pt a “jump start” • Motivation • Hobbies, interests, occupations • Family involvement • Progression from automatic to purposeful tasks • Slow processing ‐ give simple cues & extra time • Apathy ‐ Give interesting and familiar activity • Flat affect

61 Age Appropriate Care Related to Adolescents • Developmental stage and behavioral expectations • Build in age appropriate tasks • Identify effective behavior control factors staff and environment – Ex: Play station‐ reward point systems • Family participation

Treatment

Making a schedule • What is the best time of day • How long is long enough • What activities to target

Preparation before treatment • Prepare questions • Invite others to attend • Adjust time if needed

62 Treatment

• Attention • Task maintence • Mental flexibility

• During the visit/treatment session: • Remind patient to take notes or write down important information • Ask patient to explain directions/task back to you

Treatment

• Achieving max participation: – Be concrete about next steps – What will YOU do – What will THEY do – Have them repeat it – Agree to it

63 Treatment

• WATCH YOUR: – Nonverbal communication – Give simple terms and also define “medical language” – Rate of speech – Abstraction – Overload of information

– Build Trust from the beginning • Meet the patient where they are – Validate feelings, put aside your own feelings and wants

Treatment

• Everyone needs to read the behavior plan – Everyone works on every problem – “Four” priority goals in team conference

• Change your therapyNurses approach if they are not making progress Therapists Case Managers

Psych Doctors

64 Treatment Strategies

Interventions for Cognition

Samples of commonly used Cognitive‐Based Assessments

• Cognitive Performance test (CPT) • Allen Cognitive Levels (ACL) • Mini Mental State Examination (MMSE) • Montreal Cognitive Assessment (MoCA) • The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) • Executive Function Performance Test (EFPT) ‐ Top down

65 Cognition

3 GLOBAL ELEMENTS

Environmental Interpersonal Time Awareness Awareness Awareness

Cognitive Rehabilitation Therapy

• Process Training: Direct retraining (Restore)

• Strategy Training: Environment + internal & external strategies (Compensate)

• Functional Activities Training: Real Life

• Education: Cognitive weaknesses and strengths

*Combination of the 4 approaches  best rehabilitation (Society of Cog Rehab)

66 Cognition

• “Conscious mental activity that informs a person about his or her environment.” • Cognitive actions include perceiving, thinking, reasoning, judging, problem solving, and remembering. • These complex functions are regulated, controlled and monitored by the frontal lobe. • Cognitive deficit recovery peaks within six months to a year after the injury and gradually after that.

Theoretical Approaches

Adaptive (Strategy training) Top‐down • Adaptation of task and environment to capitalize on patient’s abilities • Compensation • Used when restoration is not likely • Should be practiced in different contexts • May need assistance to initiate (Mnemonics, Journals, Assistive Tech)

(Zoltan, 1996; Allen, 1989) April 26, 2010

67 Theoretical Approaches

Remedial (Restorative) Bottom up – Restorative – Focus on impairment underlying the disability – Utilizes repeated drills and exercises – Goal = promotion of new neural connections and recovery of function – Ability to restore depends on cognitive domain

(Zoltan, 1996; Allen, 1989) April 26, 2010

Cognition in functional activities • Facilitation of cognitive progress during ADLs, IADLs • Cognitive motor tasks • Compensatory strategies

Key word: Opportunities • Increased time • Error recognition • Self correction • Sequencing • Initiation • Safety • Problem solving • Time awareness/time management

68 Dual Tasking/ Cognitive Motor Tasks

“With the neurological population, walking becomes a task which cannot be performed without considerable attention.”

69 Cognitive motor interference • Do our current assessments consider cognitive‐motor interference and/or findings from dual task research?

• Cognitive‐motor interference and/or dual task research may influence our choice of assessments

• Performing a cognitive (or motor) task in isolation does not assure concurrent performance.

Factors Influencing DT Performance

Exec. Func.

Ambient Cond. Atten.

DT Deficits Gait Instruct Impair

Postural Cog Task Task

Task Factors

70 Dual Task Walking • Walking while performing a concurrent cognitive or motor task • Dual‐Task Cost – Relative measure of dual‐task performance: (dual task –single task)/ single task Benefit: (+) value Cost: (‐) value • Gait impairments (compared to single task) – Further reductions in gait speed & stride length – Decreased symmetry & coordination – Increased stride‐to‐stride variability

What does the research say? • Decline in both cognitive and motor function in subjects with CNS dysfunction during dual task conditions. (Hagggard et al., 2000) • Decrease memory accuracy and gait during dual tasks in healthy older adults. (Lindenberger et al., 2000) • Decreased postural control during dual tasks in cognitively impaired geriatric subjects. (Hauer et al., 2003)

71 Static/Dynamic Standing DT Interventions • Wii and standing tasks (balance‐ WS, or arm 3 2 movement) 4 1 • Tall kneeling or standing with cognitive task (i.e. card matching) • Sequencing with marked square task (1…4…2…3…2…1) • Braiding, sidestepping (harder with ball toss/hitting) • SLS, tandem, narrow BOS, airex pad, BOSU, tilt board and any cognitive/visual scanning task

Static/Dynamic Standing DT Interventions • Cognitive questioning and gait, standing, ball toss • Visual scanning in hallway‐ cone obstacle course, scavenger hunt • Sequencing step forward and back with or without ball toss • Ipad/Mondopad‐ any task you do standing – Visual scanning for sequencing (1,2,3,4), cancellation test, trail making

• Cuthbert JP1, Staniszewski K, Hays K, Gerber D, Natale A, O'Dell D. Virtual reality‐based therapy for the treatment of balance deficits in patients receiving inpatient rehabilitation for traumatic brain injury. Brain Inj. 2014;28(2):181‐8.

72 Rehab Approaches

 Therapist is in charge of continuous assessment of patient’s performance to see if DT task is too difficult (or unsafe) – May want to focus on single task first and then incorporate dual component – Focus: • Want patient to benefit from the physical task or cognitive task separately • Want to set patient up for success – Dual tasking can increase frustration with physical/cognitive impairments

Measureable Goals and documentation: Cognition Measurable: • Attention span (minutes, # of redirections) • # of episodes of increased agitation (violence verbal or physical) (Agitated Behavioral Scale) • # verbal, tactile cues for initiation, sequencing, safety, error identification and correction. Note changes in: Social Interaction • Resistance to care or cooperation • Frustration tolerance • Tolerance to wait for caregiver assistance • Pragmatics (topic maintenance, turn taking etc..)

73 Intervention Strategies Inpatient and Outpatient Settings

Conventional Sub‐acute Interventions • Functional tasks: Bed mobility, transfers, gait, W/C mobility, stairs, safety awareness • Core control and strengthening • Quadruped, tall kneeling • Positioning • Spasticity management – Serial Casting/ Bracing

74 Conventional Sub‐acute Interventions

• Neurological re‐ed/strengthening • Electrical stimulation/ Kinesiotape • Proprioception/balance retraining • Vestibular, Vision • Locomotor training using BWS on TM – Sensory Stimulation (Rancho 1‐3) – Pressure Relief Techniques – Behavior Plan/Contract

75 Conventional Chronic Interventions

• Focusing on increasing level of independence • Increased dynamic balance • Cognitive motor tasks • Dual tasking • Behavior Plan/Contract • Strengthening/ Neurological Re‐education • Functional tasks • Community reintegration strategies – ADLs, cooking, outings, crossing streets, driving – Vocational rehab

Is there MORE we can do?

76 Interventions • Plan for interventions to incorporate principles of Neuroplasticity, Motor Learning, Motor Control

– Planning Treatment Sessions

– Repetition of functional tasks

– Intensity

– Trial and Error Practice vs Errorless Learning

Planning Treatment Sessions

• Prioritize Treatment – Select interventions that are intensive, task specific repetitive and could create adaptations

– FITT guidelines: Dosage • Frequency: number of times per week/ total duration • Intensity: work load/challenge • Time: per session • Type: repetitive, task specific

77 Planning Treatment Sessions

• Measure your patient’s status, progress, and outcomes!! – Standardized assessment tools (www.rehabmeasures.org) – Measure many times through episode of care – Review available: • Standard Error of Measurements (SEM)‐ how much error within tool • Minimal Detectable Change scores (MDC)‐ how much change to see real change in function • Minimally Clinically Important Differences (MCIDs)‐ how much change for PATIENT to feel they see a change

Planning Treatment Sessions

• Explicitly Communicate with your Patient – Patient goals and treatment priorities – Explanation of activities – What does success mean? • Expectations for amount of repetition and challenge – Explain they might look worse – Explain the value of text‐retest for MEASURABLE change

– This is all dependent upon patients cognitive ability to understand!

78 Repetition of Functional Tasks

• What is task specific? – WB, stepping, efficiency, and balance are RETRAINED SIMULTANEOUSLY during LT – Walking is a continuous task, whole practice should be provided – Pre‐gait activities may not translate to improved walking – Evidence indicates that LT can be as effective if provided overground vs. on a TM • Task Specific LT examples: – Walking overground, backwards, sideways – Environmental obstacles‐ uneven surfaces, obstacle mgmt – Stairs, ramps, curbs – Dual tasking with gait‐ motor or cognitive – Gait with increased resistance‐ at limb or trunk

Repetition of Functional Tasks

• Grading LE tasks: – Speed – Loading (BWS or ankle weight) – Assistance – Intensity – Error – Assistive Device – UE support – Cardiovascular parameters – Accuracy: narrowed pathway, targets

79 Repetition of Functional Tasks

Task Specific UE Activities Grading UE Tasks • Movement component • Position of the patient of reach, grasp, • Position of materials manipulate and release • Weight of materials represent a whole • Size of objects sequence • Adaptive materials • Handwriting • Modifying time restraints • Playing games • Unilateral vs. Bilateral • Folding Towels • Precision or accuracy demand to destination • Manipulating coins • Typing

Increasing Repetition of Functional Tasks • Involve family and other members of the team: – RN staff practices several repetitions of sit to stand with patient throughout the day – Family ambulates with patient when not in therapy – Patient folds clothes 100 times throughout day – OT maximizes transfer practice while doing ADLs • Maximize HEP – Functional activities instead of ther ex – Pedometers • UE Functional Kits – Provided in rooms/homes – Theme that is a goal – Explicit instructions for reps

80 Intensity

• Definition – Power (required to achieve an activity) – Speed (of action performed) – Workload (work per unit of time, force or velocity)

• Implication – Intensity can be applied in many ways – Selective application maximizes stress to systems – Intensity and Trial and Error Practice are difficult to separate

• Examples: Fast Walking, Weights on LEs • Perturbations that inc challenge to neuromuscular system also inc intensity

Intensity • Challenge with time/speed or accuracy – Ex: # of reps in 30 seconds • Elastic resistance – Pull back on trunk to inc propulsion demands • Weights: Arms, legs, trunk • Environmental: Obstacle avoidance • Monitoring Intensity: – Calculate Target HR – Monitor other vitals (BP/RR) – # of successful trials – Pain – Borg’s RPE

81 Trial and Error Practice vs Errorless Learning • Clinical Implication – Errors may be helpful for learning – Increasing intensity or using external forces to increase error • Errorless Learning – Used in Memory Rehabilitation – More research needed re: motor rehabilitation • Determine whether the pt can adapt to the “error” – Application to specific diagnosis – Setting the patient up for success – Read pt‐specific psychological response to trials with error

Interventions to Maximize NP

LE interventions • Evidence for retraining functional walking ability: – When studies compare walking interventions to “conventional PT”, walking is better (stroke, SCI, LEAPS) – When studies compare walking on TM vs overground, or using “conventional” gait approaches, there is little difference • Application parameters – Faster may be better for some pt populations – High intensity is better – More practice is better – Usage of BWS

82 Interventions to Maximize NP UE interventions • CIMT – Daily for 14 days, 6 hours of task training; wearing constraint for 90% of waking hours – Participants: actively extend 10° at MCP and ICP and 20° at wrist; 3‐9 months post stroke (Excite trial) – Outcomes: Wolf Motor Function Test, Motor Activity Log • Modified CIMT – 3x/wk of OT; 5 days of restraint wearing for 10 wks • 30 min of OT + 5 hours of restraint – Participants: actively extend 10° at MCP and ICP and 20° at wrist – Outcomes: Fugl‐Meyer, Action Research Arm Test (ARAT)

Interventions to Maximize NP

• Field‐Fote and colleagues – Compared massed practice alone (MP) and MP combined with sensory stimulation (MP+SS) – Bimanual training combined with somatosensory stimulation led to improvements in: • Sensory function, ability to generate source, cortical reorganization with map of biceps brachii shifting and increasing in area and volume • Outcomes in other populations: TBI, CP, MS • Cortical Reorganization post UE training – Inc Cortical motor area sizes in the damaged hemisphere in Abductor pollicis brevis before and after CIMT. – Inc in cortical representation in the affected hemisphere – fMRI data demonstrate increase in non‐affected hemisphere – Similar findings in human SCI with UE tasks

83 Interventions to Maximize NP Rehabilitation Robotics • Repetitive practice lends itself to automation • Design of devices to provide appropriate sensorimotor stimulation – Consistent, reproducible assistance or variable assistance/mov’ts – Patterns that therapists cannot accurately perform – Objective quantification of mov’t patterns and user forces • Focus on devices to maximize CNS plasticity

• Therapist vs. Robotic Assisted Training in subacute stroke – Double improvements in “conventional” training vs robotic‐assisted training (similar in chronic stroke) • Alberto Esquenazi, MDa, , , Stella Lee, MPAb, Andrew T. Packel, PT, NCSc, Leonard Braitman, PhDd A Randomized Comparative Study of Manually Assisted Versus Robotic‐Assisted Body Weight Supported Treadmill Training in Persons With a Traumatic Brain Injury. PMR (2013), 5(4), 280‐90

Other interventions

• Evaluate whether other interventions are intense, specific, repetitious, and have potential to facilitate neuroplasticity – Functional Electrical Stimulation – Strength Training – Virtual Reality – Bilateral Training – Amplitude Based Training – Etc…..

• Know your patient’s psyche and tolerance of error

84 What is required for successful rehabilitation?

85 Cardiorespiratory Function

• Regular exercise in mid or late life decreases risk of dementia • Aerobic exercise in normal adults has been shown to improve cognitive performance • Aerobic training: – Promotes neurogenesis – Promotes angiogenesis – Enhances LTP

– Fogelman D1, Zafonte R. Exercise to enhance neurocognitive function after traumatic brain injury PM R. 2012 Nov;4(11):908‐13. doi: 10.1016/j.pmrj.2012.09.028.

Rehabilitation Guidelines

• Systematic

• Intensive

• Progressive

• Repetitive

• Measure outcomes

86 …plus Plasticity

• Use it or lose it • Use it and improve it • Specificity • Repetition matters • Intensity matters • Time matters • Salience matters • Age matters • Transference • Interference

Specific to walking recovery include…

87 Locomotor Guidelines

• Guideline 1: Maximize weight bearing on the legs

• Guideline 2: Afford the sensory experience consistent with walking

• Guideline 3: Optimize kinematics for each motor task

• Guideline 4: Maximize recovery and independence; minimize compensation

Community Re‐ integration

88 “What is Community Reintegration Anyway?” “Full community integration, or participation in society, is the ultimate goal of rehabilitation and of research conducted in the field of rehabilitation for persons with traumatic brain injury (TBI). Community integration has been traditionally defined by 3 main areas: employment or other productive activity, independent living, and social activity…”

*Article abstract from Journal of Head Trauma Rehab March/April 2010 Vol 25 Issue 2 pg 121‐127

Discharge Location Options:

• Independent Living • Living with Family • Supported Independent Living/Supervised Housing • Assisted Living Facility • Group Home • Transitional Living Services • Skilled Nursing Facility

89 Location Challenges:

• Person needs 24/7 Supervision • Behavioral/Psychological Issues –all involved must approach as in team effort • Removal of harmful weapons/objects • Keys to the car need to be inaccessible/monitoring of exit doors • Electrical equipment/cooking • Beware of access to alcohol/prescriptions • Location of facility –away from support system • Funding • Age group

Community reintegration

• Return to work/school – Disability services at schools/colleges – Center for Independent Living – Vocational Rehab – Volunteering – Return to driving • Participation in community outings • Information and personal invitation to local support groups • Resources

90 School/Employment Challenges: • Memory deficits/Retaining new information • Time management for assignments • Organization problems • Impulsive • Decreased response time • Disoriented on campus or in workplace • Decreased attention/Distractibility • Maintaining peer relationships • Behavioral Issues • Transportation **A person’s pre‐injury educational and/or career goals may have to be reexamined

Transportation Challenges:

Driving Community Services • Funding to pay for • Time frame for drivers eval (Voc scheduled rides Rehab can assist • Not living on bus routes with this) • Expense • Access to a vehicle • Having to rely on others • Interactions with law enforcement

91 Recreation/Leisure Options

• Recreation is especially meaningful for the individual who may be unable to resume a previous occupation or academic role after a TBI • Recreation activities often serve multiple purposes including improving skills, building morale, restoring self confidence, developing social relationships. • CTRS can review past leisure interests, skills and activities to explore both former and potentially new recreation activities. • Participation in familiar rec activities can reduce frustration/sense of loss…*caution however needs to be given to those activities with safety concerns, possibly the very activity that led to the TBI.

Recreation/Leisure Options • Family can assisted by identifying activities which are readily available and within capabilities and interests of the individual • Recreation options should include home and community activities. • This allows for daily structure with routine physical and cognitive stimulation • Park and Rec Dept, Day Camps, After School Programs, Private Organizations, Social Service Organizations, Fitness Centers (Supervised workouts), Adult Day Services, Support Groups, Religious Groups

92 Recreation/Leisure Challenges • Change in Friendships‐ former friends are not as available as they were before the brain injury • More difficult to establish new relationships due to changes in personality or behavior • Activities/Social interactions involving alcohol or drug use • Transportation • Funding

How can I learn more?

• Brain Injury Association of America (www.biausa.org) • Brain Injury Association of Florida (www.biaf.org) • Brain and Spinal Cord Injury Program (http://www.doh.state.fl.us/workforce/BrainSC/ind ex.html) • We encourage family members to become involved in support groups! There are many in Florida that are registered through the BIAF including one held at UF Health Shands Rehab Hospital, Gainesville FL, every month on the fourth Thursday night of the month at 6:00 pm. Please confirm dates with our case management department.

93 Special Appreciation to:

• Eugenia Rodriguez MOT, OTR/L • Ginger Myers, PT, DPT • Haley Russell, SLP, MEd/CCC • Amy Kinsey, CTRS • Kira Delaney, PT, DPT • Ilse Salcedo, OT • Laura DeGennaro, OT • Sara Kraft, PT, NCS, ATP • Mark Bowden, PhD, PT

Thank you!!

94 References

• http://tbims.org/combi/ciq/

• http://www.cdc.gov/traumaticbraininjury/statistics.html#1

• http://www.asha.org/public/speech/disorders/tbi.html

• http://www.resourcesonbalance.com/neurocom/protocols/s ensoryImpairment/mCTSIB.aspx

• http://www.ncbi.nlm.nih.gov/pubmed/17878768

• http://www.tbims.org/combi/

• http://www.dementia‐ assessment.com.au/symptoms/FIM_manual.pdf

• http://www.tbims.org/combi/himat/himatfaq.html

• McCulloch K. et al. Balance, Attention, and Dual‐ Task Performance During Walking After Brain Injury: Associations With Falls History. J Head Trauma Rehabilitation Vol. 25, No. 3, pp. 155–163. • Lehr R, P Jr., Ph.D. (2011).Brain Function. Retrieved from http://www.neuroskills.com/brain‐ injury/brain‐function.php • Zoltan B. (2007) Vision Perception and Cognition: A Manual for the Evaluation and Treatment of the Adult With Acquired Brain Injury. Thorofare, NJ: Slack Incorporated.