Neurorehabilitation of the Upper Limb Across the Lifespan

Managing Hypertonicity for Optimal Function

Jodie Copley, Kathy Kuipers

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118871195
• Edition: 1
• Topic: Medicine
• Subtopic: Occupational Therapy

• A comprehensive guide to managing spastic hypertonia after brain injury and the first full overview of this area
• The ideal reference for therapeutic interventions that optimise arm and hand function to support goal achievement
• An extensive clinical manual for neurological practice, a key reference for students and qualified practitioners, and a valuable resource for all occupational therapists and physiotherapists working with brain-injured clients

Chapter 1
Seeing the Bigger Picture: Using Clients' Experiences to Shape Clinical Practice

Chapter objectives

• Discuss the impact of brain, injury on the lives of individuals and their families, highlighting the changes that clients experience over time and the subsequent need for long-term services and supports, particularly during times of transition between services.
• Outline requirements for effective collaboration with clients and caregivers, including principles and practices the clinician can adopt to ensure client-centred service provision that promotes clients' and caregivers' long-term quality of life.

Abbreviations

ABI	Acquired brain injury
CP	Cerebral palsy
TBI	Traumatic brain injury

1.1 Appreciating the client's experiences

To ensure that neurorehabilitation, or any other aspect of service provision, is effectively targeted and contributes to positive outcomes for clients in their life contexts, the clinician must step back and appreciate the wider picture of what occurs in the lives of individuals and their families after brain injury. Health professionals may, at times, feel that they have limited control over the organisational context and practical constraints (e.g. funding mechanisms, staffing levels, resource availability) within which they are working. Indeed, service evaluation, long-term research and government lobbying is often required to drive positive change in service provision models, availability and quality. Nonetheless, the individual clinician usually has some control over how he or she practices – what is emphasised and prioritised in encounters with the client and family, which clinical skills are developed and refined, who the client will be referred to after this clinical service has ended, and the communication that will occur with the client and family, as well as with subsequent service providers.

Therapy services are typically categorised according to the amount of time post-injury, the service purpose (acute care, rehabilitation, long-term community-based services, residential care) or a specific client age range (children and youth, adults, older people). Therefore, each clinician will be involved for only part of the client's story. Smoothing the pathway from one phase of service provision to the next requires a broader appreciation of the client's rehabilitation journey outside the clinician's own immediate service context.

To gain this broader perspective, the clinician can consider what has been learned from research into the experiences of clients and caregivers post-injury and their perceived long-term service needs. Although a variety of different factors come into play when working with clients with different diagnoses, research into chronic disability due to brain injury suggests some common themes across stroke, traumatic brain injury (TBI) and cerebral palsy (CP). Awareness of these ‘big picture’ themes can help clinicians develop practice habits and skills that support the client's quality of life and promote positive long-term outcomes. Research findings suggest that the following themes are important in guiding service provision.

1.2 Providing or assisting access to long-term services

1.2.1 What are the needs?

It is clear that quality acute care supports better outcomes for people with acquired brain injury (ABI). This is illustrated by the variation among stroke outcomes in different European countries depending on the resources devoted to the acute phase of treatment [1]. It has further been suggested that, in addition to advances in brain stimulation techniques and pharmacological interventions, early provision of intense interdisciplinary neurorehabilitation contributes substantially to better stroke outcomes [2]. In relation to children with CP, substantial progress has been made over the past two decades in developing coordinated interdisciplinary rehabilitation services [3] and research into related interventions has focused on provision of services early in life and throughout childhood [4].

Despite a concentration of resources within the acute and early rehabilitation phases of intervention, a growing body of research across different diagnostic groups indicates that people with brain injury continue to have therapy needs on a long-term basis, often for the duration of their lifetimes [5]. In a study of 60 people with TBI who were interviewed one year after their injuries, 38% identified significant restrictions to their lifestyle and work capacity and 15% were unable to care for themselves [6]. In a UK study of 1251 people ranging from one to five years post-stroke, approximately half of the participants reported a reduction in work activities and two thirds participated in fewer leisure pursuits than before their strokes [7]. In a comparison of the quality of life between people with recent (1–5 years) and extended (more than 5 years) brain injuries, the extended group reported more difficulties with instrumental activities of daily living, such as household tasks and community activities, indicating the need for continuous community living skills training [8].

As people with CP live longer, there are indications that atypical tone increases with age and secondary conditions, such as contractures and degenerative arthritis, are having lifetime effects [9]. In a review of long-term outcomes for adults with CP, Kembhavi et al. [4] identified that ambulation skills commonly deteriorated in adulthood and that joint deformities occurred regardless of mobility status or severity of the condition. Co-morbid diagnoses, such as stroke, multiple sclerosis and Parkinson disease, are not uncommon in adults with CP [9]. The recognition of these long-term issues within this client group has led to increased research into the impact of pain and fatigue on their participation in daily life activities [4].

In addition to these ongoing physical and rehabilitation needs, it is clear that emotional and psychosocial issues continue to be evident over time across all diagnostic groups. In a large UK study, one third of participants who had had a stroke between one and five years previously reported emotional problems [7]. Similarly, in a sample of French participants, two thirds of whom were more than one year post-stroke, depression was more common than in matched controls, and levels of both depression and difficulties in social interaction increased over time post-stroke [10]. Comparable difficulties were found in a study of people with TBI [11]. For people with stroke, emotional and social issues were more marked for those who had hemiplegia or were unemployed [10]. As such needs have become more recognised, it has become evident that promoting quality of life among people with ABI requires ongoing support of emotional and social role functioning, daily life activities and participation in enjoyable activities [12]. A similar breadth of needs can be identified for people with CP. Studies suggest that adults with CP commonly live isolated lives [13] and that those aged over 40 have been assessed to be lonelier than other adults [14]. Mental health issues, such as depression, are not uncommon in this population [9]. At a consultative clinic for adults with CP in New South Wales, Australia, while the main areas of need are neurological and musculoskeletal, depression and anxiety are also being identified [3].

Collectively, this research suggests that the service needs of people with brain injury change and increase over time and that services need to be responsive to these changes [5, 15]. It is further suggested that the degree to which these service and support needs are met will significantly impact clients' long term quality of life, psychological adjustment and participation in meaningful life roles [16–18]. The importance of ongoing service provision for adults with TBI is highlighted by the finding from one study that, for some people, the hope of continuous improvement over time played a critical role in developing a “new self” [6] (p.414). For example, one participant commented that “I'll keep improving, with hard work of course, for the next…10 years, or 20 years, no matter what…” (p.413).

1.2.2 Are the needs being met?

Despite increasing acknowledgement of long-term service needs, current service availability and access is falling short of the expectations of clients and families. Half of the participants in a UK study of people post-stroke reported unmet needs in relation to clinical services and information provision [7], while an Australian survey of carers of adults with TBI found that only 33% reported access to therapy services following hospital discharge [5]. In another study focusing on the transition of people with ABI from hospital to home, the services that were provided (even during inpatient rehabilitation) were considered insufficient in terms of timing, intensity and duration [15]. Adults with chronic lifelong disabilities have reported difficulty accessing services in the adult health system equivalent to those available when they were children [19]; similarly, young people with CP experience a marked reduction in rehabilitation services once they finish school [3]. People living in rural areas and those with non-compensable injuries also face restrictions to service access in ...

Table of contents

• Cover
• Title Page
• Copyright
• Acknowledgements
• Chapter 1: Seeing the Bigger Picture: Using Clients' Experiences to Shape Clinical Practice
• Chapter 2: What Happens to the Upper Limb After Brain Injury?
• Chapter 3: The Hypertonicity Intervention Planning Model for Upper Limb Neurorehabilitation
• Chapter 4: Making Sense of the Clinical Picture: Assessment and Goal Setting
• Chapter 5: Case Studies
• Chapter 6: Movement and Strength Training
• Chapter 7: Splinting
• Chapter 8: Casting
• Chapter 9: Botulinum Neurotoxin
• Chapter 10: Surgery
• Chapter 11: Case Studies Revisited
• Index
• End User License Agreement