Overview

There are several different types of traumatic brain injuries (TBI), each of which can caused by events and traumas. However, all traumatic brain injuries result in neurological trauma - making occupational therapy rehabilitation an applicable and effective treatment.

Occupational therapy (OT) is not a cure for neurological trauma; however, it does address the specific outcomes of a patient’s TBI. TBI is uniquely displayed in each individual through observable and physiological symptoms, therefore OT must be tailored to each individual.

The article will discuss what TBIs are, the impacts that they can have on patients, and how OT can be used to assist patient rehabilitation. It is important to note that there is currently no cure for the neurological trauma caused by TBIs, but we will discuss how different types of OT work and support recovery and rehabilitation.^1,2

Traumatic brain injuries 

What are traumatic brain injuries? 

Not all head injuries are traumatic brain injuries (TBIs). A TBI is a type of injury caused by an external force which results in the brain being damaged through physical action or movement.^1,2 

There are two main classes of TBI:

Penetrating (open) TBIs: these injuries are the result of an external object piercing the cranium (skull) in what is often referred to as a ‘breach’ of the brain tissue layers (bone, muscle, skin, and protective layers).^3,4 External objects often involved in penetrating TBIs include metal poles, shrapnel, and bone fragments.

The damage caused by penetrating TBIs is typically localised to the region of impact. As such, it has a less significant impact on other regions of the brain.^1,3,4

Non-penetrating (closed) TBIs: also known as blunt-force trauma. Non-penetrating TBIs are caused by objects or events that exert signficiant external force on the head without penetrating the skull or coming into direct contact with the brain tissue. Non-penetrating TBIs can cause damage to several different parts of the brain at once, as sudden external forces can cause the brain to move within the skull very suddenly.^1,4

Common causes of TBIs

Penetrating, non-penetrating and TBIs can be further classified into mild, moderate, and severe injuries. The severity of a TBI depends on the type and magnitude of force exerted on the head. Whilst the brain can be damaged by a range of events, some of the more commonly seen causes of TBIs include:^5,6,7

• Falls: the most common causes of TBIs. Most commonly seen in young children and the elderly
• Road accidents: this includes accidents in vehicles such as cars, motorbikes, electric bikes, bikes, and scooters. These collisions are the most common cause of TBI for young adults
• Sports injuries: commonly seen in athletes. There is a particularly high risk of injury and TBI in sports such as football, boxing, skateboarding, hockey, baseball, and cricket
• Firearm-related injuries: these are most prevalent in regions of the world where firearms are more accessible
• Blast injuries: blast injuries are more common in warzones, war-torn areas, and countries which have access to materials that can trigger large blasts
• Shaken baby syndrome: TBIs are commonly seen in babies and young infants who have been violently shook

Possible outcomes of TBI 

All TBIs result in some sort of trauma to/within the brain; however, the severity of the trauma will depend on several factors, such as:

• Whether the TBI is penetrating or non-penetrating
• Whether the TBI is mild, moderate, or severe 
• The location of the trauma, or which region of the brain is most affected. Damage to some regions of the brain is associated with specific symptoms

The three factors listed above, particularly the region of the trauma, determine how severe a TBI is and what short- and long-term effects it will cause. Usually, neurological trauma causes ‘impairments’ - meaning that actions that were previously easy to perform will become difficult. Some impairments and changes to look for include:

• Physical impairments (mainly motor deficits). A motor deficit is a reduction or loss of voluntary movement in particular muscles. Movements commonly affected by motor deficits involve strength coordination (since tensing muscle is voluntary), balance, posture, walking, talking and swallowing⁸
• Sensory impairments can affect any of the 5 senses. The patient may experience blurred vision or visual field changes, hearing difficulties, tinnitus, changes in taste or smell, a complete loss of smell, and hypersensitivity to physical stimuli^9,10
• Cognitive impairments affect the brain, and vary significantly between individuals. Some patients will experience difficulties with their memory or concentration (as their attention span decreases drastically). Cognitive impairments can be summarised as impaired executive function, which means that an individual is unable to control their thought processes, lines of thought, emotions, or actions¹¹
• Emotional and behavioral changes are commonly seen after a TBI. Patients may experience mood swings, emotional fluctuations, anxiety, and/or depression). People with TBI often become more impulsive, irritable, and unstable. This can impact their behaviour, personality, and interactions with other people^12,13

Occupational therapy 

What is occupational therapy?

Occupational therapy (OT) is a type of rehabilitative therapy that aims to improve patients’ health and lives by allowing them to become more independent. OT is currently a very important part of TBI rehabilitation, since these injuries commonly affect parts of the brain involved in motor function.

The central aspect part of OT is setting goals for patients to work towards, as patients are encouraged to look ahead rather than fixate on individual sessions. Some of the goals set during OT for TBIs include:

• Restoring independence 
• Enhancing cognitive function
• Improving physical function
• Emotional and behavioral support

Occupational therapy for TBI

Activity analysis and task modification

• Activity analysis and task modification are the first stages of OT. An activity analysis aims to establish the patient’s ‘baseline’ abilities. This will detail what they are able to do without assistance, and what they struggle with
• After establishing activities that are difficult, task modifications are designed and applied. Task modification involves breaking down tasks or movements into smaller and less overwhelming steps
• Other occupational therapy approaches involve changing or adapting the patient’s environment to assist task completion; this helps patients slowly work from their baseline to full functionality

Cognitive rehabilitation

TBIs increase your chances of developing neurodevelopmental disorders, such as post-traumatic dementia, Alzheimer's disease, anxiety, depression, and epilepsy. Therefore, occupational therapists may implement cognitive therapies into their patient’s rehabilitation program. Examples of cognitive therapies include:^14,15

• Memory aids (for e.g., calendars, checklists, apps)
• Cognitive exercises to improve attention, planning, and problem-solving
• Environmental modifications to reduce distractions 

Sensory integration and perceptual training

Sensory deficits mainly affect the 5 senses and interactions with the environment. Occupational therapy aims to overcome these deficits by:

• Improving sensory processing through techniques such as visual tracking or auditory localisation exercises
• Addressing hypersensitivity and overstimulation through devices such as noise-cancelling headphones or nose plugs 

Physical rehabilitation and assistive technology

Physical rehabilitation helps restore individuals’ fundamental independence and reduce the physical restrictions they experience. Re-learning how to walk or use limbs after trauma also helps strengthen mind-muscle connection, making other every day tasks easier too.

Assistive technology is more commonly used in elderly patients who have suffered from TBI to help with their physical rehabilitation. These technologies include:

• Adaptive equipment, such as handle bars near chairs or toilet seats, reachers, dressing aids, or stairlifts
• Mobility aids, such as wheelchairs, walkers, canes or ramps

Emotional and psychosocial support 

It is clear that psychological support is an important factor affecting the success of rehabilitation after an TBI. Fostering a positive and supportive mentality in patients assists rehabilitation and can help prevent mental health disorders such as anxiety and depression. This positivity can be cultivated by emotional therapy approaches, such as:¹⁵

• Mindfulness
• Relaxation techniques, such as meditation, journalling and breathing exercises
• Stress management - this may include learning to sit with stress or adapt to it
• Group therapy for social reintegration

Summary

Traumatic brain injuries are commonly treated and managed with occupational therapy, which assists physical and cognitive rehabilitation after neurological trauma. This article has explored the life-changing consequences of TBIs, which can include physical, sensory, and cognitive deficits and emotional changes. 

Occupational therapy has been found to be helpful in assessing patients, helping them re-learn skills and learn strategies to live independently. With the loss of independence being one of the most significant impacts of TBIs, OT is a vital part of helping patients modify their activities and return to their previous lives.