TBI-OT Perspective

 

TRAUMATIC BRAIN INJURY

TBI-Cognitive Rehabilitation 

 Traumatic Brain Injury significantly damages the victim's physical, mental, and emotional functioning. These injuries, unfortunately, account for a considerable number of deaths and thousands of disabilities worldwide every year.

Traumatic Brain Injuries are usually caused by strong jolts to the head during car crashes, hard bumps, or slip-and-fall accidents. These injuries can greatly affect the brain's normal functioning. While some victims suffer minor injuries that heal within a few days, others suffer long-term consequences. Long-term or permanent symptoms can affect the victim's cognitive ability, behavioural pattern, and psychological health. These symptoms negatively impact victims' employment, recreation, relationships, ADLs (Activities of Daily Living), or engagement in any community activity. Cognitive disabilities are, without a doubt, the most distressing and disabling of all symptoms caused by traumatic brain injuries.

Cognitive therapy after Traumatic Brain injury is extensively practised to alleviate the symptoms and provide relief to Our cognitive therapy. We have extensive experience implementing industry-leading rehabilitation techniques for cognitive impairments. With this blog, we aim to shed light on the different cognitive rehabilitation techniques used to treat cognitive disabilities following a traumatic brain injury.

Cognitive Impairments vs Normal Person

Cognitive skills are our ability to think, remember and learn things. These involuntary skills play a vital role in our day-to-day lives, and their impairment implies that you lose many vital functions. Some of the cognitive skills include the abilities to:

• Stay focussed
• Communicate
• Concentrate
• Retain memory
• Process and comprehend information
• Control emotions
• Initiate tasks
• Plan and organize
  Judge, reason & make decisions

An impairment of the above-mentioned cognitive skills can have a significant impact on your daily life. Disorientation, short-term memory, and frustration are the typical problems you may face. It can also interfere with your ability to think and learn. But, cognitive therapy programs can potentially heal several of these dysfunctions.

What is cognitive therapy?

Cognitive therapy or cognitive rehabilitation therapy (CRT) involves techniques used to improve cognitive abilities. The cognitive abilities include problem-solving, memory, organizational, word-finding and executive skills. Cognitive communication is an effective therapy that enhances problem-solving, memory, attention, and thinking skills.

Cognitive rehabilitation usually involves multidisciplinary teams that assist patients in adapting to their cognitive deficits or reaching a complete recovery. Usually, the teams involve medical professionals such as neuropsychologists, physicians, speech-language pathologists, physical therapists, social workers, and occupational therapists. Multidisciplinary teams have proven to show great results in treating traumatic brain injuries.

CRT approaches

Cognitive rehabilitation techniques follow two approaches that have successfully brought along noticeable differences in Traumatic brain injury patients. They are Remediation and Compensation.

Remediation

The techniques involved in this treatment approach generally involve restoring, improving and strengthening the impaired cognitive skills. The goal of remediation treatment is to help patients improve their cognition after a TBI. For instance, patients are encouraged to focus on targets on a monitor to improve concentration. Variable parameters like increased task durations, speed, or pace of target movements are also used to monitor their performance.

Compensation

The compensation approach recommends ways to reduce the impact of cognitive impairments on patients. This usually involves techniques to overcome the barriers created by cognitive impairments. This may involve both internal and external approaches. For example, one of the internal treatments encourages patients to practice concentration by breaking down tasks into smaller segments. External compensation largely involves the usage of technologies like reminders, alarms or labelling of things. You can also take the help of other people.

Techniques

Cognitive rehabilitation therapy (CRT) helps the victim of a traumatic brain injury improve their mental function and ability to interpret information. Attention and memory exercises are major components of the therapy. Following are the most commonly used CRT strategies for TBI patients.

1. Memory Exercises: Memory is complex. It's a lot more than just being able to remember things. The process includes acquiring, processing, storing, and subsequently retrieving information. Short-term or long-term memory problems are common in TBI patients. As part of CRT sessions, memory exercises are often conducted for the patients. During this exercise, the patient is asked to read passages of information and is then given time to recall what they had read in the follow-up sessions.

2. Attention exercise: Attention exercises usually involve tasks that focus on three types of attention: Selective, divided, and sustained. While the selective attention task requires the patient to focus on a single thing, the divided attention task requires the patient to complete two or more tasks simultaneously. Sustained attention is concerned with a patient's ability to concentrate on an activity for a longer period.

3. Visuospatial Perception: TBI patients are more likely to experience changes in Visuospatial perceptions like impairment in constructional skill, body scheme or unilateral neglect. Visual restoration therapy improves vision in TBI patients by increasing neural plasticity and gradually enhancing conscious perception.

4. Language and communication: TBI patients have difficulty recalling words and processing languages. Usually, verbal and nonverbal information is processed during communication. But, in TBI patients, communication s is often delayed and characterized by reduced emotion. Also, they have difficulty understanding linguistic humour and self-centred talks. Speech-language therapy improves communication tremendously.

5. Executive Functions: An executive function is largely the brain's capability to carry out independent or self-serving actions. Metacognitive strategy training can treat executive dysfunction. The techniques include reducing errors through structured and repeated cues or continuous assessments.

Orthosis Paper Pattern

ORTHOSIS PAPER PATTERN

RESTING HAND SPLINT

Paper pattern:

A pattern is a template that is done before moulding. 

Why Paper pattern?

Before moulding any thermoplastic on your patient’s hand, we recommend you to begin with a pattern. A good pattern allows you to judge the correct amount of material needed for the specific orthosis. And it helps you to envision the shape and position of the finished product.


Steps involved :

• Draw an outline with the patient's hand
• Mark the anatomical landmarks
• Adjustments to the pattern
• Cutting out the pattern
• Trimming

1.Draw outline

First, position the patient’s hand palmar side down on a paper towel. If the patient cannot place their involved hand on the paper towel, you can draw an outline of the non-involved hand or draw a pattern of your own hand. You can always go back and make adjustments directly on the paper towel prior to cutting out the thermoplastic material.

Make sure that your patient’s hand is placed in a neutral wrist position and not radially or ulnarly deviated.
You can assess this by checking for straight alignment of the forearm bones with the third metacarpal.
Place the fingers close together and the thumb in wide abduction.
Draw an outline of the forearm, wrist, thumb and fingers with the pen or marker angled straight down on the paper
You can add extra 1/2-1 inch in the paper so that it will cover the circumference of FA (Forearm)

2.Anatomical Landmarks

Marking the anatomical landmarks is an important step in orthosis as it decides the proximal and distal edges of the splint. As we are looking at the dorsal hand, we have to imagine where the volar landmarks are placed.

These are some of the most helpful anatomical landmarks to mark:

• At 2/3 the length of the forearm – mark both radial and ulnar sides.
• The MCP joints of the little finger and index finger – the MCP joints of the little finger and index finger help you to find the distal palmar crease, which is angled to the ulnar side.
• The first web space – often a thin wedge of thermoplastic material wraps around through this web space to anchor the orthosis.
• The narrowest part of the wrist – adjust the width of the pattern to accommodate to the narrow wrist or else you will have to do a lot of trimming.
• The thumb IP joint – thumb orthoses typically allow for unrestricted IP joint motion.
• The PIP joints of each finger – MCP joint blocking orthoses typically allow unrestricted PIP motion.

3.Pattern adjustment

After drawing the relevant anatomical landmarks, remove the patient’s hand, and draw your specific orthosis pattern lines. The pattern itself may come from a picture or from your own idea of which specific joints need to be included in the orthosis.

Cut out the pattern and check the fit on the patient’s hand in the desired position. Draw any additional markings on the pattern to indicate necessary adjustments. You can add arrows to increase length or width, or make lines indicating where the pattern needs to be trimmed or shortened.

Making adjustments to the pattern will save time and cost when cutting out the thermoplastic material.

4.Cutting the pattern for orthosis

Once you have checked the paper towel pattern for fit, place it on an appropriately sized piece of thermoplastic material. Draw an outline, but leave enough space for cutting away the marked lines. These should not appear on the finished orthosis. You can use this marker to draw the outline, it will easily wipe off later on.


Prior to cutting out the material, determine whether you should preheat it and need common things for doing this Dorsal Resting hand Splint

• Thermoplastic
• Paper towel
• Pen
• Scissors
• Electric frying pan/water bath
• Heat gun
• (Tea) towels
• Self-adhesive hook Velcro

  

Trim the edges of the splint and fix the self-adhesive hook velcro for easy strapping based on the fit principle of hand splinting.

Any resting splint needs to be monitored by a qualified therapist.

Image source: CR to ptsonline.com

#hand Splinting #orthosis

#occupational therapy

#orthosis paper

#patternmaking 

 

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Splint Classification system by ASHT

CLASSIFICATION OF HAND SPLINTING

  KEY TO OCCUPATIONAL THERAPIST

Terminology: 

#  SCS-Splint Classification System 

# ASHT-American Society of Hand Therapists

The terminology in describing splint or orthosis has been reviewed but there is no one single system adopted universally.

 Joint efforts by doctors, therapists and orthotists had been set up to review the classification of splint. 

• Four ways of classifying hand splints have been introduced namely,
•  eponym, 
• acronym, 
• descriptive classification system and the 

classification system proposed by the American Society of Hand Therapists.

There was a debate in 1989 by ASHT’s to discuss the issues regarding the nomenclature system for splints.Historically, there were a number of splint classification systems, including grouping according to 

• purpose, 
• configuration,
•  mechanical properties, 
• material and 
• anatomical site.                                                  

However, every approach has its own strength and weakness.

Fig.ASHT Class.System

The art and craft of the hand splinting are the responsibility of the occupational therapists and may be referred as Architect of the splint.

These splints are designed based on the individual needs and it should not be any hindrance to their occupation. These systems include the use of rote memory or logical deduction in grouping of splints.

Descriptive system of classification: 

This system provided a more descriptive means of grouping splints based on three criteria:

1. the types of splinting forces employed and the spatial planes in which they occur,

2. the anatomic site of emphasis, and

3. the primary kinematic goal of the splint.

When describing a given splint, one can use three adjectives to delineate the “how”, “where”, and “why” of the splint.

The Descriptive Classification System provides more details and rationales of the splint. However, there is no rigid format, making the system difficult to follow. This will induce discrepancy in communication.

ASHT-SCS System: 

• The ASHT-SCS first divided splint/orthosis into “Articular” and “Non-articular”, which are subdivided into “Location”. Since articular splints involve joint movement so it has additional dimension on “Direction” of movement, which includes “Mobilisation, Immobilisation and Restriction” 

• The “Direction” indicates the primary intended movement or non-movement taking place on the extremity, rather than describing movement or non-movement taking place on the splint itself. 

• The articular branch is further divided into “Type” according to the number of joint levels affected secondarily. 
• In contrast to the primary joints, secondary joints are included in a splint to provide counterforce control, position, or stabilisation of joint(s) immediately adjacent to primary articular structures within the longitudinal kinematic chain. 
• The total number of joints included in a splint is noted in brackets at the end 
• The use of “Type” designation has the advantage of providing more information and implication of the splint. 
• Splints involving the MCP, proximal interphalangeal (PIP) and/or distal inter- phalangeal (DIP) joints could have the indications as shown in Table 2.
• The final level of SCS is the “Design Options”, which includes construction, traction type, force applied, etc. Since the style and design of a splint are of secondary importance in SCS, it is optional for including the design options in the splint name. 

Example shown in the table :

Common name will be Wrist extension splint hereby according to ASHT-SCS the name will be Wrist extension immobilisation;Type 0(1)

The ASHT-SCS is a comprehensive system, which caters nearly all important aspects of splinting nomenclature, such as anatomical site, movement and design.However, it requires training for users to get familiar with the system. 

The promotion of the system may be limited to members of the ASHT rather than other potential user.

For more details : Download this article

Note about Hand Splinting

HAND SPLINTING

 Definition:

A splint is a rigid or flexible orthotic device that positions injured part or affected body part in position and protect an injured part to support healing and to prevent further damage.

Purpose of splinting:

• Immobilization
• Support to promote healing
• Positioning or supporting during function
• Pain relief
• Substitute for weak muscles
• Correction and prevention of contracture & deformity
• Restoring or maintaining of range of motion
• Edema control

Classification:

Splints are classified based on the movement permissible as: 

• Static
• Dynamic
• Serial static
• Static progressive

Advantages of splinting:

Splint use offers many advantages overcasting.

• Splints are faster and easier to apply.
• They may be static (i.e., prevent motion) or dynamic (i.e., functional; assist with controlled motion).
• Because a splint is noncircumferential, it allows for the natural swelling that occurs during the initial inflammatory phase of the injury.
• A splint may be removed more easily than a cast, allowing for regular inspection of the injury site
• Aids in carrying out exercises 
• Aids in preventing muscle wasting as well as deformities

Common principles of splinting:

1. Anatomical principle
2. Fit Principle
3. Construction principle
4. Design principle
5. Other principle

Materials:

1. Aluminium(Strip/Sheet)
2. Thermoplast
3. Aquaplast
4. High Temp/Low Temp
5. Leather 
6. Rubber straps

DR KRISHNA NS 
Consultant Occupational Therapist and
Hand Splinting