Physical Therapy Following Traumatic Brain Injury (TBI)


[ Music ]>>Interviewer: The Brain Injury
Guide and Resources is a tool for professionals,
community members and family to understand Traumatic
Brain Injury, as well as how to promote better living for
those who live with a TBI. In this interview we
will talk with Jeff Krug, clinical instructor of physical
therapy in the MU School of Health Professions, to
learn about physical therapy after a Traumatic Brain Injury. And Jeff, thanks a
lot for being with us. We appreciate it.>>Jeff Krug: Glad to be here.>>Interviewer: Jeff, at what
point would a physical therapist become involved with a
patient following a TBI?>>Jeff Krug: Right. Physical therapy gets
involved right away in the acute care setting. So they’ll see people even when
they’re unstable medically. Or, you know, kind of
a scary environment where patients are
attached to a lot of tubes. And we’re still trying to
make sure they’re healthy. And then we’ll also see them
once they’re transferred to rehabilitation centers. So then we start to really focus
on the things the person needs to do to get back home. And then we’ll see them as
out-patients, so they’ll come in for out-patient
therapy as well. Maybe come in once or twice
a week, sometimes more. We’ll see them in home health
and actually work with them in their home environment. So physical therapy
covers a wide range of environments in
this population.>>Interviewer: What can you do
for a person in the early stages when they’re still in
the acute care facility?>>Jeff Krug: Right. The main focus then is keeping
people flexible and doing things like range of motion
and stretching them out, keeping their muscles
loose, monitoring their skin to make sure that there’s
no skin breakdown or sores. So we might help with the
positioning program the client has. We’ll do some basic
exercise lying in bed if the client is able to
do that and able to kind of tend to what we’re doing. We’ll also make sure that as far
as the positioning program goes, not only maintaining
skin integrity, but keeping the flexibility
aspect. Not just stretching, but
positioning plays a huge role. Often after damage to the brain
or an injury to the brain, people develop some
abnormal tightness, something we call muscle tone. And so we play a
role in positioning, sometimes even using things
like casts and splints to try to keep people as flexible as
possible so when they can get up and move around, their
muscles haven’t tightened up and they’re not limited.>>Interviewer: What
are the overall goals of physical therapy?>>Jeff Krug: Right. Our main goals are mobility. So it kind of is
what it sounds like, it’s all about the
physical functioning. So we focus on the big things
like getting in and out of bed, getting on and off the toilet,
In and out of a wheelchair, in and out of the car. And then the big one,
of course, is walking, which is a prime goal
for a lot of people, so we’re fortunate
in that regard. It’s very motivating. So we focus mobility. And then what we really do
is we analyze the aspects that affect mobility. So are there problems with
strength, with flexibility? Is there abnormal muscle tone? How could we decrease
it if it’s too high, or increase it if it’s too low? Are there sensory
problems, balance problems, coordination problems? So all of those basic
impairments that result in problems with what we
call functional limitations or functional activities
like mobility.>>Interviewer: So as a physical
therapist, you really have to do some analysis at
the outset to figure out what the patient needs
before you actually engage in the therapy obviously, right?>>Jeff Krug: Right. We do a very thorough
assessment, o covering all those aspects that I mentioned we have some
specific tests that we use. And then there’s even some
specific outcome measures for this population,
where instead of assessing just
strength or sensation, we’ll actually assess some
movement activities, some tests and measures that have
been studied and found to be reliable and valid. And so then we could take
a baseline measurement on a person, how they do with
some basic mobility skills. We could test them again
later and see what kind of a change we’re getting, and
also determine are they at risk for falling, what’s
their mobility like?>>Interviewer: What
are some other things? We talked about the
early stages. What are some other things
that you could do for a person with a TBI as they progress
through their therapy?>>Jeff Krug: Right. As a person moves into rehab,
the goals really become about what does that person
need to do to get back home? And of course, everybody
wants be a return to normal, so they want to be able to
move like they did before. They want to be able to
do all the activities that they did before, and so
we’re going to try to make that as possible,
you know, as we can. Sometimes that means
compensating and teaching the
person different compensatory strategies. Maybe one side of
their body moves well, and the other side
has some limitations. Teaching them to use
the side that’s intact, more specifically
though, what we like to do in rehab especially is
focus on regaining function. So we have some specific
treatment approaches that we have learned and gone to
continuing education and studied so that we can use
those approaches to regain the movement
that has been lost.>>Interviewer: I would think
there would be some differences in working with a child, an
adult and an older person. Is that right?>>Jeff Krug: Yeah. Absolutely. Some of it’s just the interest that people have
at different ages. When you’re working with
a child it becomes more about play activities. When you’re working with someone
who’s middle-aged it becomes about, you know, work
and home activities. And likewise, with
an older adult, it’s some of the same homemaking
or things that they do around the house or being
able to do social activities. But maybe it’s different
in that, you know, our bodies change as we
get older, so how we move. So with kids it becomes how
can we engage those kids? What can we do? We not only have to come up
with what we’re actually trying to treat, but we also have to
come up with fun ways to do it. So it becomes about
incorporating play into actually getting the
movements that we want.>>Interviewer: All right, Jeff. Let’s take a look at how you
might work with a client.>>Jeff Krug: Great. [ Music ]>>Interviewer: And joining
us now is Evelyn who’s going to help us with our
demonstration. And Jeff, how would
you help this client?>>Jeff Krug: Right. Well, with a Traumatic Brain
Injury we could have a wide variety of presentations. Some clients are
functioning at a lower level where they may not be
responding to a lot of cues, following a lot of directions,
have very limited movement. Therefore, our treatment
would be really focusing on their positioning
when they’re lying in bed or in a wheelchair, things to
keep them flexible, splints and positioning devices,
range of motion. But for our purposes,
we’re going to go ahead and have Evelyn kind of
simulate a common presentation that we see with a brain injury,
and that’s where one side, her left side, is going to be
a very strong side with lots of good movement, and on the
right side we’ve got both legs, both extremities
are a little weaker. Her arm is a little bit tighter. She’s holding it in
a position like this. And so that’s a common
presentation with one-sided weakness
and abnormal tightness. And so we’ll focus on that. And so with Evelyn we will
work on some bed mobility, lying down, rolling,
sitting back up. But we’re going to start with
some more upright activities, and these are critical
to brain injury recovery, especially with physical
therapy. We want the body to start to
feel things like it did before. Be lined up and symmetrical
in sitting and in standing, so it starts sending
messages back to the brain telling
the brain where it is. And hopefully that
gets the movement to start to happen again. And so we would start with
some sitting activities, and that would involve
some postural things. So I may sit on the side of
Evelyn, or I may actually get up behind her and
actually kneel behind her and encourage her body
to be upright and lined up equal weight on
left and ride side. And so I may use my hands or
even other parts of my body just to kind to bring her
upright, stretch her out, make sure she’s leaning
to both sides. I’ll talk to my fellow
team members, especially the occupational
therapist, and discuss the best methods
of maybe relaxing this arm and getting it to loosen up,
and putting it in a position where she’s putting
weight through it. That helps to kind of stretch
it out and relax it as well. And then I could focus on
what’s going on at the trunk. We can strengthen
the trunk muscles. We can work on some balance
things while we’re here, some reaching, some
weight shifting, and then once Evelyn
demonstrates some improved skills here, we would
progress to where what we want to do is go from a sitting
position to a standing position. And so again, with a Traumatic
Brain Injury a variety of abilities are there, so the person’s cognition
may be impaired. They may not be able
to follow directions. They may not understand what I
want from them, a nd therefore, I may have to demonstrate. Or better yet, in physical
therapy we use our hands and we use our bodies, especially in neurological
rehab, to guide the movement. And so that’s what I’m going
to do is I’m going to go ahead and tell Evelyn what I want,
maybe even demonstrate, ut then also guide her
through the movement. And so the first thing we’ll do
is we’ll say, “You know, Evelyn, I want you to go ahead
and stand on up.” And so we’ll go to her legs and
make sure they’re on the floor, we definitely want that so she’s
getting weight through her legs, sending those sensory
messages to the brain. We’re going to make
sure it’s symmetrical. We may even take her weaker leg
and move it back a little more than the other leg so that
we’re forcing that leg to do more of the work. And so now what we’ll do is
kind of guide Evelyn forward and when she gets far enough
forward, I’ll say to her, “You know, if you feel like
you’re coming off the table, go ahead and stand up.” Now, Evelyn may do like
she just did and go and activate those muscles
and come to a full stand. Or it may be that she’s a little
bit weak, and so her leg wants to give way a little bit. Her hip falls backward. You see her trunk coming
forward, so it’s my job to kind of support her and guide her
back into an upright position. I’m using my leg to block her
knee so it doesn’t give way, I’ve got an elbow on her
hip keeping her in place, I’ve got a hand on her
chest, so we’re getting that upright, good
aligned posture. And then from here what we can
do is we can shift our weight a little bit, and start to actually put more
weight on this right leg. Typically, people like to
rely on their strong side, so they’ll lean onto
the strong side and not give the weaker side
a chance to do anything. But I’m going to guide her
and help her to come over here so this leg gets the opportunity
to feel this activity like it did before and maybe
start to resume functioning. If her leg wants to
give way a little bit, what I can do is I can do
a little bit of tapping over the muscle, I can
rub along the muscles. A lot of times that will
help to stimulate it and get it to fire a little bit. We can press downward
a little a bit. That’ll activate some of
the muscles in her trunk, in her hip and her leg. We can shift our weight
side-to-side, but also forward and back to start to get that leg coming forward
over the foot. Maybe stretch that
out if it’s tight down around the ankle area. And then from here, once
Evelyn’s demonstrated that she can hold this
posture fairly well, what we might do is
ask her to go ahead and shift all her
weight over to this side and step forward
with the left leg. And then shift and step back. So now when she shifts
and steps forward, the entire body weight is
going over this right leg. Lots of sensory feedback to
the brain, lots of stimulation to get those muscles firing and
working again, now standing, shifting our weight,
stepping and walking. Those are things we’ve done
throughout our entire life. They’re kind of automatic. And so what we’d really like
to do, at this point we’ve kind of broken walking into pieces. We’re just doing the
shifting and stepping here. And we’ll probably
get a decent response, but we might even get a
better response from here if we went ahead
and just started, if I provide some support
and started her walking. It’s an automatic activity. Our brain recognizes that
it’s something we’ve done for a long time, so we’ll
try to tap into that as well. Now, when it’s time to rest
or we finish the activity, we’ll go ahead and make sure
she’s nice and controlled. Slow sitting, very symmetrical, working the muscles
not only coming up but also going back down. So those are some really good
basic starting activities for a person at this
level just trying to get the body moving
like it did before.>>Interviewer: All
right, Evelyn and Jeff. Thank you so much for
that demonstration. And we thank you for
watching this interview on Physical Therapy After TBI, service of the Brain
Injury Guide and Resources. [ Music ]

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