A professional’s guide to neurological occupational therapy services
by Joanna Bresi-Ando
This guide has been put together to assist Case Managers understand the services an occupational therapist with a neurology specialism can offer a person with neurological impairments.
An occupational therapist who works with clients with neurological impairments is likely to have experience of working with a broad range of conditions that fall under two distinct headings; acquired brain injury and progressive conditions.
This guide will deal mainly with conditions arising from acquired brain injuries.
Definition of Acquired brain injury
The definition of acquired brain injury according to the Royal College of Physicians (RCP)/British Society of Rehabilitation Medicine (BSRM) is
Acquired brain injury is an inclusive category that embraces acute (rapid onset) brain injury of any cause, including:
- Trauma – due to head injury or post-surgical damage (e.g. following tumour removal)
- Vascular accident (stroke or subarachnoid haemorrhage)
- Cerebral anoxia
- Other toxic or metabolic insult (e.g. hypoglycaemia)
- Infection (e.g. meningitis, encephalitis) or other inflammation (e.g. vasculitis)
(RCP/BSRM 2003, p7)
Impairments associated with an acquired brain injury
There are a variety of impairments associated with a brain injury that can occur depending on the injury location.
Commons impairments are:
- Motor impairments of limbs, such as weakness, altered tone and reduced co-ordination.
- Problems affecting speech and swallowing.
- Sensory impairments such as
- Hearing loss
- Visual problems, including reduced acuity and visual field loss
- Cognitive problems, especially impairments in memory, concentration and orientation.
- Language problems such as aphasia.
- Reduced control over bowels and bladder.
- Emotional, psychological and behavioural problems.
Acquired brain injury is a sudden onset and is likely to have major long lasting effects on the person and their family; therefore it should be borne in mind that not all impairments are evident at the onset of injury and may arise weeks and months later.
The role of an occupational therapist in neurological rehabilitation
The aim of an occupational therapist is to enable clients to manage their day to day tasks and activities in a way that contributes to their physical, social and emotional well-being.
The occupational therapist will work with the client to address dysfunction using interventions that may look at altering the way a task is performed, adapting the physical environment, teaching the person a new skill or working with them to regain old ones.
When to instruct an OT on your case?
It may be that your client has had a period of rehabilitation as an inpatient or with a NHS community therapy team, whatever their history it is worth bearing in mind the document “National Service Framework for Long-term conditions” and in particular Quality requirement 5 – Community rehabilitation and support, which states:
People with long-term neurological conditions living at home are to have ongoing access to a comprehensive range of rehabilitation, advice and support to meet their continuing and changing needs, increase their independence and autonomy and help them to live as they wish.
(DoH, 2005)
If your client has not been able to return to their previous level of function and activity following their brain injury whether due to physical, cognitive difficulties or a combination of the two, then consider making a referral for occupational therapy.
Intervention may consist of a “one off” initial assessment of your clients’ needs and recommendations on how they can regain their independence or it may consist of a period of rehabilitation where the occupational therapist works with your client to set client focused goals and then provides regular therapy sessions to work towards those goals.
Another factor to be taken into account when considering a referral is, what else has your client got going on in their life?
Rehabilitation is a two way process, the success of which depends largely on 2 main things:
- The skill of the therapist to find out what is important and meaningful to your client and then set goals and rehab around this and
- The client’s readiness to engage in therapy at that specific time, because they want to recover and have the motivation to do so.
There are numerous factors that can impact on readiness for therapy, conditions such as anxiety and low mood (particularly if these existed before the injury) worries about finances and personal relationships to name a few.
Therapists often talk about a person’s “rehab potential” what they normally mean is that they feel the person has the capacity to increase their level of function by learning, retaining and using information (new or old).
However, even if a person has rehab potential, that does not mean that they are ready for that rehab and have the capacity to engage at that time.
Occupational therapists assess the whole person and will often pick up any issues around ability to engage in therapy, so if the occupational therapist suggests that now is not the time for therapy, this does not mean never, it means that in order for your client to get the best out of therapy, consider it for a bit later on down the line.
Sometimes it is not practical to postpone therapy until the client is able to engage, in these circumstances it is worth considering involving other professionals e.g. (neuro) psychologists and ensuring that the 2 professionals are involved at the same time with your client to ensure collaborative working.
Rehabilitation
Recovery from a brain injury can be a long, slow arduous process and being realistic and open about what to expect and the level of recovery with the client and their family is an essential part of the rehab process.
A comprehensive initial assessment by the occupational therapist should cover areas such as:
- Past and current medical history,
- Current impairments and how these impact on daily activities,
- Goals (short-term and long term) that the client and family have,
- A physical functional assessment and also if indicated a
- Cognitive screening test.
Examples of therapy that an occupational therapist may provide are:
- Working on impaired motor functions by getting the client to complete daily activities such as dressing, meal preparation or completing domestic tasks such as vacuuming.
- Working on cognitive skills through the practice of complex activities such as planning a journey and completing it by public transport or by planning to cook a meal and shopping for the ingredients.
- Vocational activities, such as a return to work or study or being able to participate in volunteering opportunities.
Conclusion
An occupational therapist with a neuro specialism has the skills to understand the challenges faced by those with neurological impairments and have the unique skills of creating individualised solutions for your clients.
They focus on what is meaningful to the client and work with them to achieve their goals through using activity and occupation as the therapeutic medium.
An acquired brain injury can be a life altering event however, with the support of an occupational therapist, issues with a person’s physical, mental and environmental wellbeing can be addressed and an improvement or return to independence can be achieved.
This guide has provided an overview of how a Neuro Occupational therapist can help your clients. If you would like more information, please contact one of our client managers at The OT Practice via telephone (0330 024 9910) or email (enquiries@theotpractice.co.uk).
Commonly used phrases
Amnesia – loss of memory
Anoxia – Complete oxygen starvation. A situation in which the oxygen supply to the tissues is cut off completely, as opposed to Hypoxia where there is partial loss of oxygen to the tissues.
Apraxia/Dyspraxia – Difficulty with planning and performing purposeful movements, while same time still able to move and be aware of your movements.
Ataxia – Awkward, clumsy movements due to a loss of coordination of the muscles.
Brain plasticity – The ability of intact brain nerve cells to make new connections and on occasion take over functions of damaged cells.
Closed head injury – Damage to the brain where there is no penetration from the scalp or skull through to brain tissue.
Cognition – a term used to encompass intellectual skills such as thinking, remembering, planning, understanding, concentrating and using language.
Diplopia – Double vision
Disinhibition – A reduced ability to regulate emotions and urges to speak appropriately in social situations.
Executive functions – The ability to think, reason and pull together complex information, then make considered judgements and decisions.
Hemianopia – The loss of vision in half of the right or left visual field.
Open head injury – An injury where there is penetration of the scalp and skull through to brain tissue.
Spasticity – An increase in muscle tone following brain injury, it can produce tightness or stiffness of the limb muscles and interfere with movement and walking.
Useful resources
Acquired brain injury: a guide for occupational therapists – College of Occupational Therapists, 2013.
Headway – The Brain Injury Association – www.headway.org.uk
The National Service Framework for Long term Conditions – Department of Health, 2005
United Kingdom Acquired Brain Injury Forum (UKABIF) – www.ukabif.org.uk
