Running head: REFLECTIVE ANALYSIS 1

Reflective analysis: Traumatic brain injury

Gretchen Kempf

The University of Scranton

REFLECTIVE ANALYSIS

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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REFLECTIVE ANALYSIS

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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REFLECTIVE ANALYSIS

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 patient’s 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 (O’Connor, 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 patient’s 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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REFLECTIVE ANALYSIS

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 individual’s 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 individual’s 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 individual’s 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 patient’s 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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REFLECTIVE ANALYSIS

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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REFLECTIVE ANALYSIS

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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REFLECTIVE ANALYSIS

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 individual’s dysfunctions during evaluation assessments

could guide the occupational therapist’s 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 patient’s

capacity to process information and to transform it into purposeful actions. A relationship

between a patient’s improvement in cognitive status and involvement in other types of treatment

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REFLECTIVE ANALYSIS

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 patient’s

family. Occupational therapists began to integrate the role of educator into their practice and

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REFLECTIVE ANALYSIS

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 patient’s 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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REFLECTIVE ANALYSIS

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 OT’s 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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