Categories of Care: What They Are, and Why They Matter

Using Help to Pinpoint Proper Care Following Brain Injury After a brain injury, many survivors require help in one form or another. Some people require extensive support, while others need only a limited amount of services. This is often reduced with time and rehabilitation, but chronic complications with some injuries may create an increased need for assistance years after a diagnosis is made. Identifying the help that is needed is often a fluid, unfolding process; but being aware of the different categories of caregiving options can provide guidance when searching for the correct level of support. In persons with brain injury, the amount of outside assistance required to carry out essential functions in everyday life is formally known as acuity. An interdisciplinary team of neurological professionals can help determine a person’s acuity by identifying what, if any, supports are needed. By reviewing documentation and collaborating with caregivers who provide supporting information about behaviors they observe from their clients or loved ones, risks, and care needs are identified relating to three specific areas:

  • Tasks of Self-Care: Personal care activities like dressing and bathing are often referred to as basic activities of daily living (BADL). More advanced tasks that require deeper thinking elements, such as scheduling or budgeting, are considered independent activities of daily living (IADL). If an individual needs assistance when carrying out either — or both — of these categories of self-care tasks, they are in need of what’s called attendant care. Attendant care provides hands-on assistance with physically managing daily routines that may be limited by weakness, fatigue, or thinking problems like memory or attention. Generally, attendant care is hands-on care provided to make up for physical limitations of an injury.
  • Replacement Services: Some survivors struggle with effectively carrying out typical responsibilities around the home, such as yard work, childcare, or home repairs. In these cases, they may need to assign or purchase these services for others to do. These needs are called replacement services, and are considered another category of caregiver support.
  • Protective Supervision: Brain injury can create an inability for individuals to recognize problems or advocate for help. Protective supervision is care that stands in reserve, monitoring for emerging risks, and stepping in with support when an injured person demonstrates behaviors that might lead to harm if left unchecked. Protecting a person from fall risk when he or she is unaware of poor motor skills, monitoring a meal for choking risks, or providing orientation support for a person with confusion are examples of why protective supervision is often necessary.
Acuity isn’t only about identifying the type of help an individual needs, however. Acuity also determines the coverage and intensity of this assistance. In other words, it identifies how much and how demanding the support can be. Coverage refers to the portion of the day or specific times when help is needed. This may be expressed as supervision hours (e.g. up to six hours daily), or for specific events or portions of the day, like during mealtimes or supervision during waking hours only. Intensity considers the demand of a caregiver’s attention. In hospitals and rehab facilities alike, this is often referred to as a ratio of supporting persons to the number of people they are helping. People with severe injuries may need someone to provide assistance exclusively to them (1:1 support), while others may be safe with an assistant who helps them along with two others at the same time (3:1 support). Intensity also factors in the distance these caregivers can be from their patients; whether that be to stay within an arm’s length at all times, or simply making sure an individual is within their line of sight. Being familiar with each category of care — and identifying exactly where a patient falls within them — can greatly help when advocating for the correct and necessary support an individual needs. Professional assessments that pinpoint the precise what, when, and how much help a person requires, as well as careful documentation by healthcare providers and caregivers that support these findings, not only improves opportunities for ongoing coverage from funders, but also allows a person the best chance at success and fulfillment in their lifestyle following brain injury. Martin J. Waalkes, Ph.D., ABPP(rp), CBIS-T
Director of Neuro Rehabilitation
Licensed Psychologist

Hope Network Neuro Rehabilitation

To Drive or Not to Drive? Getting Behind the Wheel after a Traumatic Brain Injury

Driving is the ultimate symbol of independence and control. Losing the ability to drive after a traumatic brain injury (TBI) may feel devastating and can greatly affect a person’s quality of life during recovery. But considering that driving is one of the most dangerous activities we do on a daily basis, the decision of if and when to return to driving can be complex. Safe driving requires a number of skills which may be altered after a TBI including:
  • Visual acuity and perception
  • Memory to recall directions or destination
  • Hand-eye coordination
  • Reaction time
  • Safety awareness and judgment
  • Sustained and alternating attention
  • Range of motion and strength of arms, legs and neck
  • Confidence behind the wheel
  • Anxiety level
Research indicates that 50-70% of people with moderate to severe TBI will return to driving regardless of recommendations from their healthcare team or safety concerns (Schultheis & Whipple, 2014) (Classen, 2009). That’s why it’s important for TBI survivors to discuss and address return to driving with their healthcare team openly and honestly. As a first step in the path towards returning to drive, therapists are able to incorporate pre-driving skills into therapy sessions. These pre-driving therapy sessions focus on remediating, refining and strengthening any of the above skills that may impact driving ability or safety. Many rehabilitation providers offer pre-driving screenings or programming to jumpstart the process. After pre-driving skills are mastered, TBI survivors can benefit from working with a Certified Driving Rehabilitation Specialists (CDRS) for on-the-road training. These experts also assist in obtaining and practicing the use of adaptive equipment. Various types of equipment such as hand controls and adaptive steering wheels can be used if traditional foot pedals or wheels are not optimal. A CDRS can even help coordinate securing an adaptive vehicle with ramp access and modified seating if necessary. Safe return to driving after a traumatic brain injury is possible with the right training and resources. The first step toward safely getting behind the wheel after a traumatic brain injury is starting a conversation with the rehabilitation team.

References:

  • Classen, S. e. (2009). Traumatic brain injury and driving assessment; and evidence-based literature review. American Journal of Occupational Therapy, 580-591.
  • Schultheis, M. T., & Whipple, E. (2014). Driving after traumatic brain injury:evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Reports, 176-183.
Angela West, MSOT, OTRL
Occupational Therapist + Therapy Best Practices Coordinator
Special Tree Rehabilitation System

What Is A Concussion and How Do We Treat It?

One of the hot topics right now in the world of brain injury is Concussion Prevention and Treatment. In order to fully be able to discuss this topic, we first have to understand and answer this question: What is a Concussion? Newer research has shown that a concussion happens from acceleration or deceleration of the brain inside of the skull. This can happen from activities such as a hit directly to the head or body as in contact sports, falls, military activity, or motor vehicle accidents. This acceleration/deceleration of the brain causes stretching of the brain tissue and creates an excitatory response that places the brain in an energy deficit resulting in any of the below symptoms. Symptoms are typically temporary and usually dissipate by 8-10 days. What are some signs and symptoms of a concussion?
  • Loss of Consciousness (only occurs in ~10% of all concussions!)
  • Seizures
  • Delayed verbal/motor responses
  • Confusion/Disorientation/Memory deficits
  • Lack of focus/Concentration
  • Speech disturbances such as slurred speech
  • Balance/Incoordination
Sports are one of the leading causes of concussion resulting in approximately 3.8 million concussions per year in the United States. Rugby, ice hockey, football, and soccer are the top high-risk sports for both men and women due to the amount of contact. The large number of concussions sustained from sports has led to a push for prevention measures such as advancements to helmets. Research has shown that the use of a properly fitting helmet may reduce the risk of the severity of the symptoms of a concussion; however, there is lack of evidence supporting the use actually reducing the number of concussions sustained. Since concussions cannot be completely prevented, we now need to look at treatment! Due to the wide variation of symptoms that can present following a concussion, a comprehensive treatment plan should be utilized. The brain accounts for approximately 2% of our body weight and it takes approximately 20% of our blood supply! Why is this important? A concussion can temporarily reduce blood flow to the brain by up to 50%! This makes exercise one of the most crucial treatment options for an individual following a concussion. Treatment will be based on the presentation of symptoms and following Return-to-School and Return-to-Play guidelines and only moving to the next stage if they are symptom-free for 24 hours. What kind of treatments should be used?
  • Rest
  • Nutrition
  • Physical Exercise
  • Visual and Vestibular Retraining
  • Cervical Spine-Alignment and Musculature Issues
  • Balance Retraining
What does the Return-to-School and Return-to-Play Guideline look like?
  • Rest Initially 24 hours
  • Light Cognitive Activity
  • Half Day of School
  • Full Day of School
  • Clearance for Physical Activity
  • Light Non-Contact Sport Specific Activity
  • Higher Intensity Non-Contact Sport Specific Activity
  • Full Contact Sport
  • Return to Competition
An important fact to remember is that typical concussion symptoms dissipate in 8-10 days; however, the brain metabolic state (no longer being in an energy deficit) does not return to its own baseline until 22-30 days after an injury. Why is this important? Three words: Second Impact Syndrome. If there were to be another concussion prior to the brain reaching its metabolic baseline, the effects of the first concussion can now be compounded, thus placing the individual at an increased risk for permanent deficits or even death. Comprehensive Baseline Testing can assist with not only making sure all aspects of the individual's brain function, including both physical and cognitive aspects, have returned to their baseline. The testing also significantly assist clinicians in the Return-to-Play decision. Early comprehensive treatment of concussion can also decrease the time that symptoms are experienced thus reducing the likelihood of Post-Concussion Syndrome (where the concussive symptoms last greater than 2 weeks). In summary, a concussion can and should be treated with a comprehensive approach and in a collaborative effort between the individual and their family, a trained rehabilitation professional, a physician, school administrators, and coaches. This collaborative approach will help minimize the possible long-term effects of a concussion.

References:

  • Prien, Et al. “Epidemiology of Head Injuries Focusing on Concussions in Team Contact Sports: A Systematic Review” Sports Med. 2018 Apr:48(4):953-969.
  • Langlois Et al. “The epidemiology and Impact of Traumatic Brain Injury: A Brief Overview” Journal of Head Trauma Rehabilitation: September-October 2006: Vol21. Issue 5. Pg 375-378.
  • Patel, Et Al. “Aerobic vs anaerobic exercise training effects of the cardiovascular system” World J Cardiol. 2017 Feb 26:9(2):1324-138.
  • Viano Et al. “Concussion in professional football: biomechanics of the struck player part 14” Neurosurgery. 2007 Aug:61(2):313-327.
Karley Glashauser, PT, DPT, CBIS, CF-L1 Physical Therapist, The Lighthouse Neurological Rehabilitation Center

Karley graduated with her Doctorate of Physical Therapy from Central Michigan University in May of 2009. She has been employed at The Lighthouse Neurological Rehabilitation Center, Caro location, since July of 2009. Karley has continued education in the areas of Hippotherapy, NDT, and Concussion Management. Karley is also a CrossFit Level 1 Trainer at Davison CrossFit and Flint CrossFit with a special certification in Adaptive CrossFit.

Celebrating Brain Injury Awareness Month

Brain injury is often referred to as an “invisible” injury or disability since the effects of the injury are not always visible or immediately evident. However, to anyone who has suffered a brain injury, or to those that care about someone who has, the effects of brain injury are complex and can pervade many aspects of the individual’s life. Brain injury can be difficult to understand, the symptoms can be significant, and the rehabilitation process can be extensive. We are proud to join brain injury survivors, caregivers, and supporters in celebrating Brain Injury Awareness Month. For decades, the Brain Injury Association of America (BIAA) has led a nationwide public awareness campaign during the month of March to de-stigmatize brain injury through outreach and education.
According to the Brain Injury Association of Michigan (BIAMI), in Michigan alone, 58,500 people sustain a brain injury each year. The truth is that no one plans for a brain injury, but brain injuries can happen to anyone, at any time. Please join us this month as we spread awareness and educate others on the definition of brain injury, its causes, and where to seek proper rehabilitative care.

What is a Brain Injury?

Just as there are no two people alike, no two brain injuries are the same. An acquired brain injury is an injury to the brain that has occurred after birth; these injuries are not a result of heredity, nor are they congenital or degenerative. There are two types of acquired brain injuries, non-traumatic and traumatic. A non-traumatic brain injury is caused by damage to the brain by internal factors, such as lack of oxygen, exposure to toxins, pressure from a tumor, and so on. A traumatic brain injury is an injury to the brain that is caused by an outside force or impact that is sudden and damaging.

Common Causes of Brain Injury

  • Stroke
  • Anoxia/hypoxia (lack of oxygen to the brain)
  • Neurotoxic poisoning (ingestion of insecticides, solvents, lead)
  • Tumors
  • Virus/infection
  • Seizures
  • Falls
  • Motor vehicle accidents
  • Struck by an object
  • Sports
  • Improvised Explosive Device (IED)
  • Assault

Brain Injury Recovery

Following a brain injury, it is imperative to receive the proper rehabilitative care. Brain injury survivors can experience an array of cognitive, physical, and emotional/behavioral challenges. These symptoms can often concur feelings of hopelessness in survivors and caregivers, but there is hope. The goal of brain injury rehabilitation is to maximize function and encourage survivors to achieve their fullest potential. Origami Brain Injury Rehabilitation Center brings together a team of experts from the following disciplines including physiatry, psychiatry, psychology, physical therapy, occupational therapy, speech-language pathology, recreational therapy, rehabilitation nursing, vocational, and more in order to tailor a care plan to the needs of each survivor. The rehabilitation journey begins with a thorough assessment to identify the individual’s exact needs and goals. At Origami, survivors and their support systems are an essential part of the interdisciplinary team and the rehabilitation journey. It is important brain injury survivors and caregivers know they are not alone on this journey. If you have a question about brain injury or if you are interested in learning more about brain injury rehabilitation, please visit our website at origamirehab.org or call us at 517-336-6060. For those looking for support, visit BIAMI's Support Group page or call them at (800) 444-6443. Origami Brain Injury Rehabilitation Center is a 501(c)(3) non-profit organization located in Lansing, Michigan. Origami provides comprehensive rehabilitation care for survivors of brain injuries and their families. Through their compassionate and innovative services, Origami creates opportunities and transforms lives.

How to Decrease Your Risk of Falling Following a Brain Injury

Along with ringing in the New Year, January is sure to bring plenty of snow and ice! The onset of slippery conditions can cause an increase in incidences of falls. Though the majority of falls only result in mild injuries such as muscle soreness or bruising, approximately 10% of falls result in a trip to the emergency department. Some falls may be unavoidable, but being informed of the risks and actively making changes can reduce the risk of falling. With 30-65% of people with brain injuries reporting balance deficits at some point during recover, it is especially important for survivors to be aware of the facts that make them more susceptible to falling. Factors to Consider: Are you over 65 years old? Approximately 1 out of 4 people over the age of 65 experience a fall every year, with falls being the leading cause of injuries in this population. Do you take multiple medications? Individual medications or interactions between multiple medications may cause an increase in risk of falling. Researchers have found that certain classes of medications including sedatives and antidepressants may contribute to increased falls risk. If you notice an increase in falls with the start of a new medication, be sure to contact your physician. Have you fallen more than once in the last year? Previous falls are an indicator of an increased likelihood for subsequent falls. If you have previously fallen it is very important to take preventative measures to avoid reoccurring falls. Do you have vision deficits? Vision is an important component of balance, and having vision deficits significantly increase the risk of falls. Blurred vision, double vision, and other visual impairments are common after a brain injury; therefore, it is important to follow up with your optometrist or ophthalmologist if you suspect any changes in your vision. They may make changes to your eye glasses or refer you to an occupational therapist for vision therapy. Do you have impaired sensation in your legs? It is common to experience decreased sensation or proprioception, the perception of movement and positioning of our body, following a brain injury or due to other chronic conditions such as diabetes and peripheral neuropathy. This can cause individuals to trip on objects or lose their balance. Are you depressed? Studies have shown a correlation in increased falls with depression likely due to cognitive, sensory, and motor changes that may occur with brain injuries. Consider talking to your physician, social worker, or counselor if you believe you are experiencing depression. Do you experience dizziness? Dizziness can be a symptom of many conditions including damage to the vestibular system, changes in vision, medication symptoms, or other medical conditions. If you are experiencing dizziness it is advised to consult with your physician. They may refer you to an Ear Nose and Throat Specialist, ophthalmologist or to a vestibular physical therapist depending on the cause. Are you mostly inactive? A decrease in activity can lead to poor cardiovascular endurance and flexibility, as well as weakened muscles, which can increase your risk for falls. Ask your physician if you are able to participate in a regular exercise program, and consider consulting a physical therapist or another expert for a custom exercise program to meet your needs and goals. Do you experience incontinence?Incontinence is associated with an increase in falls due to impulsive and unsafe behavior occurring when a sudden urge to urinate occurs. Depending on the type of incontinence and the severity, different techniques such as utilizing caregiver assistance, bed pans, pads, or Kegels may be appropriate. A pelvic floor specialist can aid with decreasing episodes of incontinence. If you answered yes to any of these questions, you might be at an increased risk for falling. Many brain injury survivors may have answered yes to many of the above questions; because of this, individuals who have experienced a brain injury have a significant increased risk of falling. Although some risk factors such as age are out of our control, many others may be modified to reduce your risk. If you believe you or a loved one is at an increased risk for falling, there are some simple modifications that can be made to decrease the risk:
  • Remove tripping hazards such as rugs or uneven thresholds in your home
  • If you use an assistive device, make sure you are using it correctly
  • Wear supportive shoes with a rubber sole to prevent shuffling feet and slipping.
  • Use night lights in order to increase visibility at night. Alert systems can be used for individuals requiring more assistance.
  • Shovel snow and apply salt to reduce the risk of slippery sidewalks
These tips can reduce your likelihood of falling and incurring an injury. If you have notice any recent changes or have questions regarding your balance, please contact your physician.

Emily Wolf, PT, DPT

Physical Therapist, The Lighthouse Neurological Rehabilitation Center

References

  • Kallin, Kristina, et al. "Predisposing and precipitating factors for falls among older people in residential care." Public health 116.5 (2002): 263-271.
  • Lord, Stephen R., Hylton B. Menz, and Catherine Sherrington. "Home environment risk factors for falls in older people and the efficacy of home modifications." Age and ageing 35.suppl_2 (2006): ii55-ii59.
  • Peterson, Michelle, and Brian D. Greenwald. "Balance problems after traumatic brain injury." Archives of physical medicine and rehabilitation 96.2 (2015): 379-380.
  • Thurman, David J., Judy A. Stevens, and Jaya K. Rao. "Practice parameter: assessing patients in a neurology practice for risk of falls (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology." Neurology 70.6 (2008): 473-479.
  • Woolcott, John C., et al. "Meta-analysis of the impact of 9 medication classes on falls in elderly persons." Archives of internal medicine 169.21 (2009): 1952-1960.

Emily graduated from Arcadia University with a Doctorate of Physical Therapy. Her academic focus was primarily on treatment of adolescents and adults post-concussion. She has been practicing as a physical therapist at The Lighthouse Neurological Rehabilitation Center in Kingsley, Michigan since 2017.

Seizure Disorder and Brain Injury

November is Epilepsy Awareness Month, a time of the year to help promote awareness and educate the general public about epilepsy and seizures. One of the common challenges seen with brain injury is seizure disorder – more commonly known as epilepsy. Epilepsy and seizure disorder are terms often used interchangeably, but there are distinct differences. Seizures are the individual events of a sudden loss of control of functions associated with normal brain activity. They are sudden, temporary episodes of brain dysfunction, caused by the abrupt, non-purposeful discharge of electrical activity in the brain. Typically lasting 1-5 minutes, they are characterized by changes in sensation, emotional experience, motor control, and levels of consciousness. Epilepsy is the general term for a variety of neurological conditions characterized by recurrent unprovoked seizures – it’s the fourth most common neurological disorder in the United States. And, approximately 110,000 people in Michigan are diagnosed with epilepsy. In about 60% of cases, there is no known cause. Among the remaining 40%, brain injury is one of the most frequent causes. Most common with brain injuries are partial seizures, which typically arise from scar tissue from the injury. Partial seizures affect only one portion of the brain and have more limited symptoms such as visual distortions, odd sensations, unexplained emotional experiences, or non-purposeful behaviors or jerking movements. Sometimes, partial seizures spread and become generalized (Grand Mal), before they resolve. Grand Mal seizures involve a loss of consciousness and uncontrolled shaking as all muscle groups receive an overload of messages for movement. If a person has more than one seizure in a short period of time without recovering consciousness, or does not resolve a seizure episode within 5 minutes, it is called Status Epilepticus – and is a medical emergency. There are many types of seizures. Any initial occurrence of a seizure warrants medical attention as it is a sign that something is not right with the brain. Common causes are electrolyte imbalance, dehydration, fever, sleep deprivation or exhaustion, a new neurological injury such as bleeding or hydrocephalus, medication or illicit drug side-effects, or genetic predisposition. Some seizures are idiopathic, not known to be caused by anything in particular. Other times, seizures may have no clear physiological component, thought to be caused by neuropsychiatric features. Careful diagnosis of new-onset seizures is critical to appropriate treatment. Approximately 10% of individuals with brain injuries severe enough to require hospitalization have seizures. Seizures at the time of injury are quite common, but are not always an indicator of later problems with seizures. Seizures associated with the time of injury possibly represent a different type of convulsive phenomena. In later appearing seizures, those with open head injuries are associated with a higher risk. There are relationships between the severity and occurrence of injuries. Individuals with a severe traumatic brain injury are 29 times more likely than the general population to have epilepsy. When seizures appear later in recovery they are often more persistent, with 80% experiencing at least one more seizure. When seizures occur, or where sufficient risk factors are present, medication may be required to prevent or control them. In about 80% of cases, seizures can be controlled with medication. For others, surgery may be used to eliminate the likely source of irritation. Behavioral strategies associated with maintaining a healthy lifestyle such as good sleep, diet, hydration, and appropriate medication use are also critical. The effects of substance misuse, like alcohol withdrawal, and misuse of some types of medicines, can also increase seizure risk. There are many implications associated with seizure disorder including safety risks, loss of driving privileges, mortality risks, mental health vulnerabilities, as well as the social stigma still unfairly endured by persons with epilepsy and brain injury. Accommodations can help minimize these influences on adjustment. Support may include allowing additional time for tasks, pacing activities to limit fatigue, managing stimulation levels from noise or distractions, facilitating transportation or providing safe activity alternatives. Such supports help keep people with brain injury and seizures active and included, participating as part of their communities. First aid for seizures is largely supportive, providing protective monitoring with vigilance to provide assistive resuscitation in extreme events. While sometimes a frightening and challenging symptom to manage, people with epilepsy and brain injury have many resources and treatment options to support the successful management of these symptoms. Web Resources:
Martin J. Waalkes, Ph.D., ABPP(rp), CBIS-T
Licensed Psychologist
Director of Neuro Rehabilitation
Hope Network Neuro Rehabilitation
Dignitas
Eisenhower Center
Special Tree
Community Connections
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Lightouse Neurological Rehabilitation Center