Rehabilitation of Cara Occupational Therapy Presented by Julina Minter

1. Rehabilitation of CaraOccupational Therapy Presented by Julina Minter

2. Cara’s Condition • Mild to moderate traumatic brain injury (TBI) resulting in focal injury to the occipital lobe of the brain resulting in visual problems. • Complete lesion of the ninth thoracic vertebrae (T9) resulting in complete paralysis below the level of the injury. (Rushworth, 2009, ASIS website, 2012, Hughes & Millar, 2007)

3. Prognosis • Vision will not improve and will therefore need adaptive/ compensatory strategies put in place. • In patients with complete spinal lesions, muscles in the zone of partial preservation strengthen, which may result in significant functional change for Cara. (Trombly & Radomski, 2008)

4. Person- Environment- Occupation Model (PEO) Law et al Lawet al, 1996

5. Occupational Performance Issues: Occipital lobe damage • Person: Visual agnosia (colour agnosia, movement agnosia and word blindness), Visual field cuts, and Visual illusions • Environment: Inability to make sense of environment, difficulty locating objects, difficulty identifying colours and movement, inability to recognise words and drawn objects. • Occupation: Difficulty reading, cooking, Engaging in activities of daily living (ADL’s), such as bathing self, toileting and dressing. (Hughes & Millar, 2007)

6. Occupational Performance Issues: Lesion of T9. • Person: Complete loss of sensation and movement (paralysis) in lower limbs, whilst retaining most of upper body strength, respiration capacity and endurance may be compromised. • Environment: Difficulty accessing banks, stores, shops, friends houses, health professionals offices, inaccessible bathrooms etc. • Occupation: Car transfers, bath transfers, chair transfers, bed transfers, difficulty completing ADL’s Meyers, Anderson, Miller, Shipp & Hoenig, 2002).

7. Potential psychosocial issues • Loss of occupational roles • Loss of identity • Loss of autonomy • Social Isolation (due to stigma) • Loneliness (due to lack of social support) • Lack of self motivation • Body image concerns Molineux, 2004; & deRoon-Cassini et al, 2009; & Siegrist & Marmot, 2004).

8. Potential Psychosocial Issues • 5 stages of grief: Denial, anger, bargaining, depression and acceptance. • Depression (30% of people with an spinal cord injury (SCI) • Negative psychological sates (30% of people with a SCI). • Anxiety/ PTSD (13-14% of people with a SCI) • Hopelessness/ helplessness • Low self-efficacy • Poor coping skills • Low self-esteem (Pridgerson & Maciejewski, 2008; & Craig, Tran & Middleton, 2009)

9. Occupational Diagnosis • Cara has difficulty with functional mobility in the wheelchair and engaging in activities of daily living (ADL’s) due to paralysis of the lower limbs, visual problems, frustration, and lack of motivation. This has been observed as Cara allows the nursing staff to do as much for her as possible, and her expression of interest to learn bed and car transfers.

10. Barriers to Intervention • Lack of coping skills • Unmotivated • Frustration • Lack of self-awareness • Reluctant to talk about condition • Reluctance to become independent • self-limiting beliefs • Social stigma • communication between patient and professionals, (Favlo, 2005; & Nott & Chapparo, 2008).

11. Enablers to Intervention • Social supports from: - Partner -Friends -Community (stigma) -Healthcare professionals • Communicationbetween patient and professional- this gives a more client centered approach. Chandola, Marmot, & Siegrist, 2007; & Umberson & Montez, 2010; Street, Makoul, Arora & Epstein, 2009; & Isaksson, Lexell & Skar, 2007)

12. OT approach: Client- centred Throughout all interventions a client centered approach will be used. The client centred approach focuses on respect for and collaboration with the client, with the ultimate goal to empower clients by allowing them to direct the course of intervention and contribute to the process. (Meriano & Latella, 2008). (Meriano & Latella, 2008)

13. OT Intervention Plan • Interview/ Occupational Profile • Assessment • physical assessment of upper limbs • Functional independence measure (FIM) • Modified barthel index (MBI) • Catz-Itzkovich Spinal cord independence measure (Catz- Itzkovich SCIM). • Setting goals with the client • Intervention • Discharge (Radomski & Trombly, 2008; Meriano & Latella, 2008; Simmond & Flemming, 2003; & Turner, Ownsworth, Turpin, Fleming, & Griffin, 2008).

14. OT Intervention: SCI • ADL’s: • Bathing and showering • Personal hygiene and grooming • Dressing • Toileting (Bowel and bladder management) • Bed mobility • Transfers • Cognitive Behavioral Therapy • Strengthening/ Endurance (Meriano & Latella, 2008; Ozelie et al, 2009).

15. OT Intervention: SCI (Cont) • Balance • Wheelchair mobility • Community integration outings • Skin management • Equipment evaluation • Adaptive devices • Energy conservation techniques • Health and Nutrition (Ozelie et al, 2009)

16. Future interventions: Post-discharge • Assessing Community mobility: barriers and enablers of the home, community and work environment. • Home programs • Social activity programs • Education on intimacy issues • Vocational reintegration • Reintegrating Cara into society • Social advocacy (Radomski & Trombly, 2007)

17. Thank you for listening

18. References • American spinal injury association. (2012). Impairment scale. Retrieved from http://www.asia-spinalinjury.org/ • Craig, A., Tran, Y., & Middleton, J. (2009). Psychological morbidity and spinal cord injury. International Spinal Cord Society, 47, 108-114. doi:10.1038/sc.2008.115 • Chandola, T., Marmot, M., & Siegrist, J. (2007). Failed reciprocity in close relationships and health: findings from the Whitehall two study. Journal of Psychosomatic Research, 64(4), 403-411. • deRoom- Cassini, T. A., Aubin, E. S., Valvano, A., Hastings, J., & Horn, P. (2009). Psychological well-being after spinal cord injury: Perception of loss and meaning making. American Psychological Association, 54(3), 306-314. doi: 10.1037/a0016545 • Duncan, E. A. (2002). Foundations for practise in occupational therapy (4th ed.) Churchill, Livingstone: Elsevier. • Favlo, D. (2005). Medical and pshycosocial aspects of chronic illness and disability (3rd ed.). Sudbury, MA: Jones and Bartlett. • Guidetti, S., Asaba, E., & Tham, K. (2007). The lived experience of recapturing self-care. American Journal of Occupational Therapy, 61, 303–310. • Hammel, J., Magasi, S., Heinemann, A., Whiteneck, G., Bogner, J., & Rodriguez, E. (2008). What does participation mean?: An insider perspective from people with disabilities. Journal of Disability and Rehabilitation, 30(19), 1445-1460. doi: 10.1080/09638280701625534

19. References (Cont.) • Hughes, M., & Millar, T. (2007). Nervous System (3rd ed.). Kent, UK: Elsevier. • Isaksson, G., Lexell, J., & Skär, L. (2007). Social support provides motivation and ability to participate in occupation. Occupational Therapy Journal of Rehabilitation, 27(1), 23-30. • Law, M., Cooper, B., Strong, S., Steward, D., Rigby, P., & Letts, L. (1996). The person- environment- occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 1-15. • Meriano, C., & Latella, D (2008). Occupation for occupational therapists. Hamden, Connecticut: Blackwell Publishing. • Meyers, A. R., Anderson, J. J., Miller, D. R., Shipp, K., Hoenig, H. (2002). Barriers, facilitators, and access for wheelchair users: substantive and methodological lessons from a pilot study of environmental effects. Social Science and Medicine, 55, 1435-1446. • Milineux, M. (2004. Occupation for occupational therapists. Oxford, UK. Blackwell Publishing. • Nott, M. T., & Chapparo, C. (2008). Measuring information processing in a client with extreme agitation following traumatic brain injury using the perceive, recall, plan and perform system of task analysis. Australian Occupational Therapy Journal, 55, 188-198. doi: 10.1111/j.1440-1630.2007.00685.x • Ozelie, R., Sipple, C., Foy, T., Cantoni, K., Kellogg, C., Lookingbill, J., Backus, D., & Gassaway, J. (2009). SCIRehab project series: The occupational therapy taxonomy. Journal of Spinal Cord Medicine, 32(3), 283-296.

20. References (Cont.) • Pridgerson, P., & Maciejewski, P. (2008). Grief and acceptance as opposite sides of the same coin: Setting a research agenda to study peaceful acceptance of loss. British Journal of Psychiatry. 183, 435-437, doi: 10.1192/bjp.bp.108.053157 • Rushworth, N. (2009). Policy Paper: Falls-related traumatic brain injury. Auburn, NSW: Brain Injury Australia. • Siegrist, J, Marmot M. (2004). Health inequalities and the psychosocial environment: Two scientific challenges. Social Science Medicine, 58(8), 1463-1473. • Simmond, M., & Flemming, J. (2003). Reliability of the self-awareness of deficits interview for adults with traumatic brain injury. School of Health and Rehabilitation Sciences, 17(4), 325-337.doi: 10.1080/0269905021000013219 • Street, R. L., Makoul, G., Arora, N. K., & Epstein, R. M. (2009). How does communication heal?: Pathways linking clinician-patient communication to health outcomes. Patient Education and Counselling, 74, 295-301, doi: 10.1016/j.pec.2008.11.015 • Turner, B. J., Ownsworth, T. L., Turpin, M., Fleming, J. M., & Griffin, J. (2008). Self-identified goals and the ability to set realistic goals following acquired brain injury: A classification framework. Australian Occupational Therapy Journal, 55, 96-107. doi: 10.1111/j.1440-1630.2007.00660 • Umberson, D., & Montez, J. K. (2010). Social relationships and health: A flashpoint for health policy. Journal of Health and Social Behaviour, 51, 54-66. doi: 10.1177/0022146510383501