Running head: REFLECTIVE ANALYSIS 1

Reflective analysis: Traumatic brain injury

Gretchen Kempf
The University of Scranton


























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Introduction

This paper presents a comprehensive, historical review of the literature on the
rehabilitation techniques, evaluations and practices utilized by occupational therapists in the
treatment of patients living with a traumatic brain injury (TBI). During historical eras when the
literature on TBI is scant, this paper broadens its focus to examine the literature dealing with the
use of occupational therapy (OT) in the treatment of patients with severe disabilities or injuries
similar to TBIs.
1910-1929
An address given by Thomas B. Kidner in 1925, in his capacity as president of the
American Occupational Therapy Association, explicitly recognized OT as a critical therapy to be
utilized for a wide variety of diseases and disabilities. Kidner also declared OT to be one of the
essential features of any hospital (Kidner, 1925). Prior to the widespread utilization of OT
techniques in hospitals, patients usually were confined to bed and experienced almost no activity
during a hospitalization. Occupational therapists involvement in the rehabilitation of severely
disabled patients helped to transform hospitals into the modern-day multi-faceted institutions,
which provide active, intensive healing and rehabilitation services. (Kidner, 1925).
Although occupational therapists (who were referred to at the time as reconstruction
aides) had began caring for patients who were severely physically and/or mentally disabled prior
to the start of World War I, their role greatly expanded during the time of the United States
involvement in that war. Many soldiers suffered head injuries, which involved both physical and
psychological injuries to the brain. In addition, the introduction of the automobile and a rise in
industrialization during this period of American history caused a spike in the number of patients
injured in accidents (Woodside, 1971). Patients who suffered TBI at this time were commonly
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put in isolation and had very low survival rates. Engagement in occupations, however, began to
emerge as an effective primary therapeutic technique. Thanks to this therapeutic breakthrough,
patients with TBI and other severely debilitating conditions now could realistically hope to
perform functional tasks again. Since this time period also saw a rise in the creation of
remunerative occupations for individuals with disabilities, those functional tasks could be
performed for monetary wages (Hall, 1917). These employment experiences also served to
underscore the relationship between engagement in occupation and effective rehabilitation by
demonstrating that the more useful the employment task was, the more effective it was
therapeutically (Hall).
By 1921, there were fifty times the number of hospitals, with twenty times the number of
beds, than there were in 1870 (Woodside, 1971). At this time, physical rehabilitation theory
began to move toward a collaborative approach, where all hospital disciplines, including OT,
worked together to enable TBI patients to perform occupations (Warner, 1921).
1930-1939
The experiences collected by hospitals during, and immediately after, World War I
served to open the eyes of many health professionals to the usefulness and effectiveness of OT,
but it also forced the new profession of OT to define its role in the medical domain and to
standardize training and practice (Offutt, 1930). From the existing literature, it appears that the
1930s were the decade when activity-based treatment began to have an enormous impact on the
medical domain. This era witnessed a blossoming of the foundations of OT in the treatment of
severe physical disabilities including TBI (Low, 2002).
OT educational programs became established throughout the United States, allowing
therapists to gain knowledge about severe disabilities, including TBI (Kidner, 1930).
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Continuing education classes were established to allow occupational therapists to refresh their
knowledge and skills and to learn about new approaches and techniques (Kidner, 1930). In
general hospitals, OT began to recognize human motivation as a key factor in the recovery
process. Occupational therapists learned to assess a patients spiritual and mental needs in
addition to their physical needs (Sands, 1930). The profession recognized that successful
approaches to a hospitalized patient with severe injuries or disabilities hinged on the rapport
between the patient and the occupational therapist (Spackman, 1937).
1940-1949
The 1940s saw major advancements in rehabilitation for patients with TBI partly due to
improvements in brain surgery techniques (Goldstein, 1944). The resulting increased survival
rate allowed more individuals to receive rehabilitation therapies and treatments. The
advancements in brain surgery, and the consequent increases in medical knowledge about the
brain and brain injuries, likewise enabled occupational therapists to increase their knowledge
base. Therapists began to differentiate among the different causes of brain injuries and grew to
understand that damage to a specific part of the brain required specific techniques and
approaches to rehabilitation (OConnor, 1944). Common symptoms linked to TBI were
identified and detailed (Friedland & Margolin, 1947). During this decade, therapists learned that
successful rehabilitation approaches required careful investigation into, and detailed
understanding of, the individual defects (Goldstein). Occupational therapists categorized TBIs
into groups based on the nature of the patients observed deficits so they could embark on a
rehabilitation or treatment approach shown to be particularly effective for patients in that
category. Treatment approaches ranged from medical treatments (such as massage, exercise, and
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hydrotherapy) to occupation-based treatments designed to expand mental and physical capacities
(Goldstein).
Because defects in mental capacities were often observed in patients with TBI, OT for
such patients began to take place in specialized hospital units or in connection with psychiatric
departments (Willard & Spackman, 1947). Occupational therapists strived to ensure that
rehabilitation was client-centered and directly correlated to the individuals deficits and
occupational needs (Morrissey, 1949).
1950-1959
Further advancements in surgical techniques during this decade, and an increase in the
survival rate of patients with TBI, permitted the development of OT rehabilitation approaches
that were tailored to an individuals specific needs. The 1940s were the first time that
neuromuscular mechanisms were introduced into treatment techniques. These reinforcement
techniques for guided resistive exercise were developed to increase the development of voluntary
motion in muscle that had been paralyzed after a TBI (Kabat & Rosenberg, 1950).
Although the motivation of the patient had emerged in previous decades as an area of
consideration, during the 1950s it was deemed by the OT profession to be a primary basis of the
process of rehabilitation (Garret & Myers, 1951). Occupational therapists learned that without
the goal-directed behavior produced by motivation, an individuals ability to apply themselves to
their rehabilitation program was hindered and the therapist must respond accordingly with
appropriate treatment interventions (Garret & Myers). It was noted that meaningful, interesting
activities seemed to increase a patients rehabilitation by increasing individual participation
(Dunton, 1951). Effective therapy also seemed to require each selected activity to have a
purpose (such as to enforce a certain movement or to strengthen a specific muscle) (Licht, 1952).
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As survival rates for patients with TBI and other severe disabilities continued to climb,
rehabilitation programs increasingly were based on the philosophy that such patients deserve
services which will enable them to overcome or alleviate their deficits, rather than merely keep
them alive (Deaver & Jerome, 1959). Occupational therapists thus were charged with ensuring
that such patients leave rehabilitation with increased independence.
1960-1969
By the 1960s, TBI was a well-recognized diagnosis both in the United States and
internationally (Lewin, 1968). During this decade, the primary objective of OT branched into
three objectives: to eliminate the physical disability if possible, to reduce or alleviate the
disability to the greatest extent possible, and to retrain a person with residual physical disability
to live and to work within the limits of their disability to the hilt of their capabilities (Rusk,
1962). OT professionals learned that the success of TBI rehabilitation was affected by self-
conception, family reinforcement, and financial concerns, in addition to the previously identified
factors of the severity of the injury, motivation of the individual, and careful selection of
activities (Litman, 1962). While external factors continued to influence rehabilitation outcomes,
treatment techniques delved into the nervous system. Occupational therapists used knowledge of
learning, plasticity, and facilitatory/inhibitory systems to widen therapy approaches (Moore,
1968).
In this decade, the practice of OT began to spread outside of hospitals into new settings.
In a 1967 study conducted by P.S. London, it was determined that many TBI patients were
discharged from hospitals when the hospital had exhausted its physiotherapeutic facilities,
regardless of whether the patient had achieved a successful rehabilitation. Such patients were
then directed to rehabilitation centers and programs for an additional period of time. This led to
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the development of practical positions for occupational therapists in sheltered workshops,
schools, nursing homes and other such facilities. As the number of occupational therapists was
relatively small at this time, this increased demand for services stretched the resources of the
profession to its limit (Moore, 1967).
1970-1979
Throughout the 1970s, the psychological effects of physical disability during the
rehabilitation process became an area of interest. As earlier noted by London (1967) one of the
most distressing aspects of TBI was the alteration of personality. In the 1970s, three distinct
stages of grief were identified (denial, mourning, and adjustment), which helped health
professionals to better understand the grieving process after TBI (Vargo, 1978). Although the
time spent in hospitals and rehabilitation programs for patients with TBI had lengthened over the
years, the physical rehabilitation process was still relatively short in comparison to the time the
individual would continue to live with the disability (Vargo). The time period necessary for
reaching maximum physical rehabilitation often was not adequate for psychological adjustment
to occur. The identification of distinct psychosocial stages occurring after a TBI greatly assisted
OT professionals in helping patients to navigate successfully the psychological portion of total
rehabilitation (Vargo).
In 1974, the Glasgow Coma Scale was introduced as a tool for evaluating the
unconscious TBI client. Identifying the depth of a coma allowed occupational therapists to better
predict rehabilitation outcomes (Teasdale & Jennett 1976). There also was a clamoring by OT
clinicians for research that would identify the causes of the symptoms commonly associated with
TBI (Lewin, 1970). Adults living with aphasia as a result of TBI also were the subject of much
research during this period, with occupational therapists discovering that a verbally-oriented
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treatment approach could be quite effective in certain cases (Schwartz, Shipkin, & Cermak,
1979).
1980-1989
In 1983, the incidence of adult head injuries was approximately 40 times more prevalent
than spinal cord injuries and roughly 422,000 new severely injured patients were being
hospitalized each year in the United States (Panikoff, 1983). Although the incidence of TBI was
increasing, standardized evaluation and treatment guidelines were still limited for occupational
therapists working with this population. The literature from the 1980s demonstrates the
expanding role of OT in TBI rehabilitation and the creation of new treatment techniques, but also
makes note of the many unresolved questions (Giles & Fussey, 1988; Panikoff, 1983). The need
for quantitative studies to measure the effectiveness of interventions was critical to both the
selection of a treatment approach by an occupational therapist and the determination to
discontinue treatment approach.
The assessment of the effects of TBI as a starting point for rehabilitation continued to
remain a fairly complex issue. The tests that had been introduced by former researchers and
therapists were of little use in the planning for rehabilitation training (Askenasy & Rahmani,
1988). Research began to show that an individuals dysfunctions during evaluation assessments
could guide the occupational therapists determination of whether the rehabilitation program
should be cognitive, physical, and/or perceptual (Askenasy & Rahmani; Rosenthal, Griffith,
Bond, & Miller, 1983). Cognitive rehabilitation had been introduced in the 1970s but became
quite popular as a treatment approach in the 1980s. This approach aimed to broaden the patients
capacity to process information and to transform it into purposeful actions. A relationship
between a patients improvement in cognitive status and involvement in other types of treatment
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began to emerge as well (Askenasy & Rahmani). The role of the occupational therapist further
expanded when the assessment and training of the brain-damaged driver was identified as a
specialized area in which occupational therapists were best suited to offer treatment as compared
to other health care professionals (Jones, Giddens, & Croft, 1983).
1990-1999
As the roles of occupational therapists continued to expand, the need for continuing
research became more urgent. Much of the research in the 1990s focused on the comparison of
various treatment and evaluation processes for patients with TBI. Systematic research allowed
practicing occupational therapists to examine and identify factors that contributed to, or
hindered, progress. It also improved communication among disciplines in the rehabilitation
process by clarifying goals and standardizing procedures that led to successful intervention
outcomes (Kreutzer & Wehman, 1996). This abundance of research expanded the guidelines and
rationale for OT evaluations and treatment approaches in cases of TBI. Occupational therapists
carefully observed patients with TBI in multiple settings and documented the number of cues
required for initiation of treatment activities. These areas of research helped therapists to
develop therapeutic goals that would lead to optimal functioning of the individual (Zoltan, 1990).
OT treatment approaches in the 1990s continued to focus on cognitive and behavioral
aspects of TBI. Treatments relied heavily on environmental approaches rather than self-mastery.
As the outcome issues of TBI were still not fully understood, the manner in which a person
would behave after such a severe injury was still somewhat unpredictable (Giles & Clark-
Wilson, 1992; Lehr, 1990). An additional role for occupational therapists was created during
this decade when it was discovered that rehabilitation often overlooked the needs of the patients
family. Occupational therapists began to integrate the role of educator into their practice and
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worked to incorporate the family into the rehabilitation process. Additional research which
validated evaluation and treatment goals allowed occupational therapists to express the reasoning
behind each intervention, which, in turn, helped to decrease fear of the unknown in family
members (Krefting, 1990).
2000-2013
Most research conducted prior to the 2000s focused on the severity of TBI and suggested
a strong correlation between severity and long-term outcome. This focus served to increase the
knowledge of occupational therapists, but there was still a need for research into factors other
than severity of the injury (Whiteneck, Gerhart, & Cusick, 2004). An emphasis on the role of a
TBI patients environment enabled the OT profession to identify general environmental barriers
and the interventions which would reduce the negative impact of these barriers (Whiteneck,
Gerhart, & Cusick). Clinicians came to realize that a measure of life satisfaction would be a
useful supplement to the traditional measures of rehabilitation outcomes and an urgent need for
more research in this critical area was identified (Corrigan & Bogner, 2004).
Two OT intervention approaches for TBI rehabilitation treatment recently have been the
focus of research, namely, cognitive and functional approaches. Cognitive approaches aim to
assist clients in their return to work, school, or independent living by addressing cognitive and
behavioral deficits. Functional approaches teach individuals with TBI by doing (Giles, 2010).
The existing literature identifies the need for additional studies to identify categories of TBI
patients who respond positively to each approach (Giles, 2010). Research also is ongoing into
the effectiveness of treatment approaches delivered by occupational therapists via telephone or
computer interface, which techniques have the potential to increase accessibility and to reduce
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costs of psychotherapy for the TBI population (Arundine, Bradbury, Dupuis, Dawson, Ruttan, &
Green, 2012).
Goal setting continues to be the essence of rehabilitation in the modern day practice of
OT (Doig, Glening, Cornwell, & Kuipers, 2009). The literature emphasizes that the utilization
of a client-centered approach by occupational therapists treating patients with TBI adds meaning,
purpose and a sense of empowerment to treatment sessions. This approach, used in tandem with
other appropriate approaches, has been shown to aid occupational therapists in the customization
of treatment sessions for their clients with TBI (Doig, Glening, Cornwell, & Kuipers).
In summary, as knowledge of TBI has increased over time, the profession of OT has
flexibly responded to meet the needs of both patients and their families/caregivers. The unique
challenges presented by this patient population have helped to propel the development,
refinement and expansion of occupation-based treatments and approaches. The historical record
of the interface of the OT profession with patients with TBI and similar conditions serves as
testament to OTs present commitment to the guiding principle of supporting health and
participation in life through engagement in occupation (American Occupational Therapy
Association, 2008, pp. 625).







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