Traumatic Brain Injury & Spinal Cord Injury

Psychosocial Issues and Occupational Therapy intervention with MDT Client Cara, an OT

perspective

Case Review of CaraCharacteristics: 28 year old Female

Marital status: Partner named Tim of 5 years

Living Arrangements: One Bedroom Apartment in Brisbane

Employment: Legal Secretary

Interests: Likes Cycling and member of cycling enthusiasts group

Injuries: Cycling Accident on way to work• Moderate TBI – unconscious on arrival• Spinal cord Injury – T9 complete paralysis • Fracture to the Occipital Lobe

Acquired Brain Injury(ABI) - TBI

• ABI- Is damage to the brain after birth- Traumatic or Non-traumatic• 22,000 Australians hospitalized for TBI in 2004-2005• 1 in 3 caused by motor vehicle accident• 74,300 residents in QLD have ABI• Functional Affects: - Physical- Cognitive- Emotional- Psychosocial

(BIA, 2012)

Spinal Cord Injury - SCI• 2 Types- Complete – can be paraplegic or tetraplegic- Incomplete – 5 subcategories- Functional ability T9 injury:- Independent in self-care, cooking,

driving with adaptive devices, mobility with wheelchair and bowel and bladder control

- 9000 Australians have SCI- 2005-2006 46% SCI from RTA- 15-30 years most common to sustain SCI (Spinal Injuries Association, 2012)

(Brain and spinal Cord Organisation, 2012)

How TBI and SCI affect all areas of daily functioning

Occupation: “ the everyday activities that people engage in that define who we are as a person, that bring meaning and purpose to our lives, creating health and well-being”.

TBI and SCI affects:

Self-care: all aspects dressing, bathing, toileting, eating and grooming

Productivity : employment, driving, home maintenance and shopping

Leisure: Cycling and social engagement

Rest and Sleep

Social relationships: friendships, family and support

Physical environment: accessibility, equipment and adaptive devices

OT Perspective of Cara using PEO

Person

EnvironmentOccupation

Complete paraplegia at T9Memory loss Visual lossBehaviour regulationLoss of sensor/motor ability of lower bodyBowel and bladder function loss

Self-care tasksMobilitySleep/restLegal secretaryGirlfriendRehabilitationcycling

HospitalOne bedroom apartmentWork environmentFamilyFriendsBoyfriend

Occupational Performance Law et al., 1996

Cara’s Occupational Diagnosis

Occupational Diagnosis:

“ Is a structured way of summarizing our OT diagnostic reasoning to help with intervention planning, by targeting and defining occupational performance issues specific to the person”.

(Rogers as cited in Molineux, 2004)

Cara’s Diagnosis:

Cara has difficulty with transfers for toileting and showering, she also is reluctant to talk about management of her monthly periods and is having issues within aspects of her relationship, such as sexuality and communication. This is due to her issues with possible vision loss, emotional and behavioral changes and her loss of lower motor and sensory function, due to the effects of her TBI, occipital lobe fracture and T9 Spinal cord injury.

Psychosocial issues Cara will face

“A psychosocial factor may be defined as a measure ment that potentially relates psychological phenomena to the social environment and to pathophysiological changes” .

(Hemingway & Marmot, 1999).

Psychosocial issues include:

- Loss of identity - occupational imbalance

- Social isolation - loss of self-awareness

- Relationship strain - Chronic pain

- Poor self-image - Depression and Anxiety

Psychosocial issue – Loss of identity

- Change significantly as a person due to injuries- Hidden disabilities including:

• Memory loss

• Concentration

• Emotional regulation

• Fatigue

• Loss of body function below T9

• Body image changes

- Social stigma attached to being in wheelchair and being labeled disabled

- Grief and loss “Why me”

- Role change

Psychosocial issues: Anxiety and Depression

• 6-77% depression post TBI• 18-66% Anxiety post TBI• 20-30% SCI suffer chronic pain depression• Result in poorer rehabilitation outcomes• Increased burdens• High divorce rates• Lower re-employment rates• Personality disorders and post-traumatic stress• Loss of independence, meaningful roles• Physical appearance “stigma”• Fear of unknown Summers et al., 1991

Psychosocial issue – Social Isolation

• Low re-employment rates• 12% returned to pre-injury employment• 30% returned to modified employment• Leads to depression• Affects relationships- Family- Partners- Friends• Loss of meaningful leisure occupations- Cycling• Stigma Associated with being in a wheelchair

Shames et al., 2007

What the OT does?• Informal interview

- Gather client information

- Establish rapport

- Needs of the client

• Assessment of client

- physical, cognitive and psychosocial

- Observational or standardised

• Goal setting/ discharge planning

- Strengths of client

- Client-centred

• Intervention strategies and treatment plan

• Re-evaluation / referral to outpatients or communityMeriano & Latella, 2008

Intervention Strategies- Self-Care and Awareness

• Assessing Self-care(Toileting, Dressing, Bathing) through observation

• Looking at Cara’s Level of self-awareness• Mobility issues• Equipment prescription• Simplification of tasks• Education around period

management

Intervention Strategies– Emotional Health

• Education around prognosis and expectations of therapy• Anxiety/Depression Management- Cognitive Behavioural therapy (CBT)- Relaxation techniques• Sleep Hygiene• Anger/ Frustration management• Education to Partner and Family• Sexual identity• Self-image

Intervention Strategies – Self-esteem/Body Image

• Pain management• Education Pressure care• Exercise and healthy lifestyle• Sexuality issues• Grief and loss of identity• Lower limb exercise to avoid contracture and

spasticity• Mobility issues

Intervention Strategies-Discharge planning

• Support networks

• Social engagement

• Independence in self-care

• Home environment modification

• Assistive devices/equipment

• Carer options

• Financial assistance

• Transport options

• Educate family and partner on expectations

• Re-employment

• Counseling

Barriers and Enablers to Intervention

Barriers Psychosocial issues Relationship issues Sleep deprivation Environment Communication Visual loss Depression/lack of

motivation

Enablers

Family Support Strong Upper limb Strength Environment MDT Support Communication

In summary• OT is important in identifying psychosocial issues

• Takes a client-centred and holistic approach

• Enables engagement within meaningful occupations

• Contributes significantly to outcomes of recovery

• OT focuses on occupational engagement to enhance health and well-being