1. Traumatic Brain Injury & Spinal Cord Injury Psychosocial Issues and Occupational Therapy intervention with MDT Client Cara, an OT perspective

2. Case Review of Cara Characteristics: 28 year old Female Marital status: Partner named Tim of 5 years Living Arrangements: One Bedroom Apartment in Brisbane Employment: Legal Secretary Interests: Likes Cycling and member of cycling enthusiastsgroup Injuries: Cycling Accident on way to work Moderate TBI – unconscious on arrival Spinal cord Injury – T9 complete paralysis Fracture to the Occipital Lobe

3. Acquired Brain Injury(ABI) - TBI ABI- Is damage to the brain after birth -Traumatic or Non-traumatic 22,000 Australians hospitalized for TBI in 2004-2005 1 in 3 caused by motor vehicle accident 74,300 residents in QLD have ABI Functional Affects: -Physical -Cognitive -Emotional -Psychosocial (BIA, 2012)

4. Spinal Cord Injury - SCI 2 Types -Complete – can be paraplegic or tetraplegic -Incomplete – 5 subcategories -Functional ability T9 injury: -Independent in self-care, cooking, driving with adaptive devices, mobility with wheelchair and bowel and bladder control -9000 Australians have SCI -2005-2006 46% SCI from RTA -15-30 years most common to sustain SCI (Spinal Injuries Association, 2012 ) (Brain and spinal Cord Organisation, 2012)

5. How TBI and SCI affect all areas of daily functioning Occupation: “ the everyday activities that people engage in that define who we are as a person, that bring meaning and purpose to our lives, creating health and well-being”. TBI and SCI affects: Self-care: all aspects dressing, bathing, toileting, eating and grooming Productivity : employment, driving, home maintenance and shopping Leisure: Cycling and social engagement Rest and Sleep Social relationships: friendships, family and support Physical environment: accessibility, equipment and adaptive devices

6. OT Perspective of Cara using PEO Complete paraplegia at T9 Memory loss Visual loss Behaviour regulation Loss of sensor/motor ability of lower body Bowel and bladder function loss Self-care tasks Mobility Sleep/rest Legal secretary Girlfriend Rehabilitation cycling Hospital One bedroom apartment Work environment Family Friends Boyfriend Occupational Performance Law et al., 1996

7. Cara’s Occupational Diagnosis Occupational Diagnosis: “ Is a structured way of summarizing our OT diagnostic reasoning to help with intervention planning, by targeting and defining occupational performance issues specific to the person”. (Rogers as cited in Molineux, 2004) Cara’s Diagnosis: Cara has difficulty with transfers for toileting and showering, she also is reluctant to talk about management of her monthly periods and is having issues within aspects of her relationship, such as sexuality and communication. This is due to her issues with possible vision loss, emotional and behavioral changes and her loss of lower motor and sensory function, due to the effects of her TBI, occipital lobe fracture and T9 Spinal cord injury.

8. Psychosocial issues Cara will face “A psychosocial factor may be defined as a measure­ment that potentially relates psychological phenomena to the social environment and to pathophysiological changes”. (Hemingway & Marmot, 1999). Psychosocial issues include: - Loss of identity- occupational imbalance - Social isolation- loss of self-awareness - Relationship strain- Chronic pain - Poor self-image - Depression and Anxiety

9. Psychosocial issue – Loss of identity -Change significantly as a person due to injuries -Hidden disabilities including: Memory loss Concentration Emotional regulation Fatigue Loss of body function below T9 Body image changes -Social stigma attached to being in wheelchair and being labeled disabled -Grief and loss “Why me” -Role change

10. Psychosocial issues: Anxiety and Depression 6-77% depression post TBI 18-66% Anxiety post TBI 20-30% SCI suffer chronic pain depression Result in poorer rehabilitation outcomes Increased burdens High divorce rates Lower re-employment rates Personality disorders and post-traumatic stress Loss of independence, meaningful roles Physical appearance “stigma” Fear of unknown Summers et al., 1991

11. Psychosocial issue – Social Isolation Low re-employment rates 12% returned to pre-injury employment 30% returned to modified employment Leads to depression Affects relationships -Family -Partners -Friends Loss of meaningful leisure occupations -Cycling Stigma Associated with being in a wheelchair Shames et al., 2007

12. What the OT does? Informal interview -Gather client information -Establish rapport -Needs of the client Assessment of client -physical, cognitive and psychosocial -Observational or standardised Goal setting/ discharge planning -Strengths of client -Client-centred Intervention strategies and treatment plan Re-evaluation / referral to outpatients or community Meriano & Latella, 2008

13. Intervention Strategies- Self- Care and Awareness Assessing Self-care(Toileting, Dressing, Bathing) through observation Looking at Cara’s Level of self-awareness Mobility issues Equipment prescription Simplification of tasks Education around period management

14. Intervention Strategies– Emotional Health Education around prognosis and expectations of therapy Anxiety/Depression Management -Cognitive Behavioural therapy (CBT) -Relaxation techniques Sleep Hygiene Anger/ Frustration management Education to Partner and Family Sexual identity Self-image

15. Intervention Strategies – Self- esteem/Body Image Pain management Education Pressure care Exercise and healthy lifestyle Sexuality issues Grief and loss of identity Lower limb exercise to avoid contracture and spasticity Mobility issues

16. Intervention Strategies- Discharge planning Support networks Social engagement Independence in self-care Home environment modification Assistive devices/equipment Carer options Financial assistance Transport options Educate family and partner on expectations Re-employment Counseling

17. Barriers and Enablers to Intervention Barriers  Psychosocial issues  Relationship issues  Sleep deprivation  Environment  Communication  Visual loss  Depression/lack of motivation Enablers  Family Support  Strong Upper limb Strength  Environment  MDT Support  Communication

18. In summary OT is important in identifying psychosocial issues Takes a client-centred and holistic approach Enables engagement within meaningful occupations Contributes significantly to outcomes of recovery OT focuses on occupational engagement to enhance health and well-being