Acquired Brain Injuries

Definition of Acquired Brain Injury

An acquired brain injury (ABI) is the result of any type of damage to the brain after birth. ABI can be divided into two main categories: either traumatic or non-traumatic origin (Faccio et al., 2023). Both origins cause disruption of brain activity that results in a multitude of symptoms of varying degrees, which can affect normal brain function. Per the International Classification of Diseases, young adults, people of socioeconomic deprivation, and older adults are most at risk for ABI in the general population (Sharma, 2023).

Traumatic Brain Injury

A traumatic brain injury (TBI) is a brain injury acquired by an external force or penetration to the brain that disrupts normal function due to the injury. In the United States, approximately 1.7 million people suffer from some form of TBI with varying degrees of severity (Padilla & Domina, 2016).

Causes of TBI can include:

  • Motor vehicle accidents

  • Falls

  • Concussion

  • Violence from assault

Non-traumatic Brain Injury

Non-traumatic brain injury is a brain injury acquired from an internal force that disrupts normal brain function (Faccio et al., 2023).

Non-traumatic brain injuries are commonly caused by things such as:

  • Anoxia/hypoxia

  • Infectious disease of the brain

  • Seizure

  • Alcohol and drug use

  • Stroke

  • Brain cancer

Effects of ABI

An ABI can result in an array of impairments, including cognitive, psychosocial, and physical functions depending on the severity of injury, treatment, or the resources available to the person (Faccio et al., 2023; Seneviratne et al., 2022). ABI can cause consciousness disorders, difficulty with movement, and behavioral problems such as agitation, aggression, or apathy (Norwood et al., 2022). Loss of consciousness can cause respiratory problems, as well as trouble with mobility, swallowing, and communication, which are all residual effects from an ABI through the ascending reticular activating system also known as the center of consciousness (Faozi et al., 2021). In addition, the effects warrant the need for rehabilitation and can be observed through phases of recovery: acute, sub-acute, and post-acute (Sharma, 2023). With such variety in potential effects from an ABI, there is a need for support from family and caregivers to aid in rehabilitation and independence with daily living.

Below is a TEDx Talk from occupational therapist Shawn Phipps, PhD, MS, OTR/L, FAOTA as he explains the CAPE Recovery Model and the importance of occupational therapy and neuroplasticity when recovering from a brain injury.

Common Occupational Therapy Assessments for ABI

Through the rehabilitation process with occupational therapy following an ABI, many different assessments are utilized to gauge the level of function, independence, and quality of life and to meet the needs of the therapist’s patients (Dirette & Gutman, 2021). Below are common assessments that can be performed with the ABI survivor.

Please note that which assessments are performed or utilized is up to the professional discretion of the therapist based on clinical judgment.

Physical Assessments:

  • Commonly measured with a goniometer to address flexibility of a joint.

  • 6-point scale to measure the degrees of spasticity.

  • Assessment used to measure dexterity in the fingers through placing and removing pegs from a board.

  •  Self-reported assessment to measure symptoms of the upper limbs.

  • Gross manual dexterity assessment of placing blocks one at a time into a container.

  • Balance assessment to indicate fall risk in adults.

  • A walking test for 6 minutes to assess aerobic capacity and endurance.

Activities of Daily Living Assessments:

  • An observational assessment to examine neurobehavioral impact on activities of daily living

  • Through use of photographs, the assessment is used to aid patients in identifying important or lost activities to aid in increasing engagement.

  • Observational assessment of motor and process skills through activities of daily living.

  • Assessment to measure independence and mobility with activities of daily living.

  • Assessment measures motor and cognitive function and the level of independence and amount of care required for the person with activities of daily living.

  • Observational assessment used to plan occupation-based interventions.

Cognitive Assessments:

  • Assessment for functional cognitive performance through observation of daily task performance.

  • Measures mild cognitive dysfunction based through visual-spatial abilities, executive function, naming, memory, language, attention, orientation, and abstraction.

  • Cognitive measurement through consciousness, orientation, simple attention, language, constructional ability, memory, calculation skills, and executive skills.

  • Assessment measures the degree of self-awareness.

  • Screening to determine dementia or mild cognitive impairment.

  • Assessment used to measure cognitive skills required for performance of daily activities.

  • A scale that measures the behavioral characteristics and cognitive deficits to help prepare a treatment plan.

Emotional Assessments:

  • Assessment measures the self-perceived occupational performance of daily care and tasks.

  • Assessment of quality of life-based on behavior, participation, mental health, and social relationships.

  • Assessment used to detect depression.

Caregiver Assessments:

  • Assessment that measures the physical, social, and emotional aspects of caregiving.

  • The Index measures and screens for strain with long-term family caregiving.

  • The assessment is intended to gauge the types of difficulties faced as a caregiver.

  • The interview assesses the self-perceived overall stress and strain of caregiving.

Behavioral Assessments:

  • Measures the behavioral agitation during the acute phase of recovery.

  • Assesses motivation for participation through Likert scale questions for self-perception.

  • Self-perceptive quality of life measurement for TBI survivors.

Common Interprofessional Cognitive Assessments

The Ranchos Los Amigos level of cognitive functioning and the Glasgow Coma Scale are commonly used assessments of neurologic status in the recovery of people with brain injury. Both assessments are used to indicate level of consciousness and cognitive status and are used to gain insight into a patient’s condition and recovery after a brain injury.

    • Scale used to describe cognitive and behavior levels used throughout the recovery of a brain injury from a coma (Lin & Wroten, 2022).

    • Scaled Level I- Level X

    Level I: No Response: Total Assistance

    • No response to external stimuli            

    Level II: Generalized Response: Total Assistance

    • Responds inconsistently and non-purposefully to external stimuli

    • Responses are often the same regardless of the stimulus

    Level III: Localized Response:  Total Assistance

    • Responds inconsistently and specifically to external stimuli

    • Responses are directly related to the stimulus, for example, patient withdraws or vocalizes to painful stimuli

    • Responds more to familiar people (friends and family) versus strangers

    Level IV: Confused/Agitated: Maximal Assistance

    • The individual is in a hyperactive state with bizarre and non-purposeful behavior

    • Demonstrates agitated behavior that originates more from internal confusion than the external environment

    • Absent short-term memory

    Level V: Confused, Inappropriate Non-Agitated:  Maximal Assistance

    • Shows increase in consistency with following and responding to simple commands

    • Responses are non-purposeful and random to more complex commands

    • Behavior and verbalization is often inappropriate, and individual appears confused and often confabulates

    • If action or tasks is demonstrated individual can perform but does not initiate tasks on own

    • Memory is severely impaired and learning new information is difficult

    • Different from level IV in that individual does not demonstrate agitation to internal stimuli. However, they can show agitation to unpleasant external stimuli.

    Level VI: Confused, Appropriate: Moderate Assistance

    • Able to follow simple commands consistently

    • Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however unable to retain learning for new tasks

    • Demonstrates increased awareness of self, situation, and environment but unaware of specific impairments and safety concerns 

    • Responses may be incorrect secondary to memory impairments but appropriate to the situation

    Level VII: Automatic, Appropriate: Minimal Assistance for Daily Living Skills

    • Oriented in familiar settings

    • Able to perform daily routine automatically with minimal to absent confusion

    • Demonstrates carry over for new tasks and learning in addition to familiar tasks

    • Superficially aware of one’s diagnosis but unaware of specific impairments

    • Continues to demonstrate lack of insight, decreased judgment and safety awareness

    • Beginning to show interest in social and recreational activities in structured settings

    • Requires at least minimal supervision for learning and safety purposes.

    Level VIII: Purposeful, Appropriate: Stand By Assistance

    • Consistently oriented to person, place and time

    • Independently carries out familiar tasks in a non-distracting environment

    • Beginning to show awareness of specific impairments and how they interfere with tasks, however, requires standing by assistance to compensate

    • Able to use assistive memory devices to recall daily schedule

    • Acknowledges other’s emotional states and requires only minimal assistance to respond appropriately 

    • Demonstrates improvement of memory and ability to consolidate the past and future events

    • Often depressed, irritable and with low frustration threshold

    Level IX: Purposeful, Appropriate: Stand By Assistance on Request

    • Able to shift between different tasks and complete them independently

    • Aware of and acknowledges impairments when they interfere with tasks and able to use compensatory strategies to cope

    • Unable to independently anticipate obstacles that may arise secondary to impairment

    • With assistance able to think about consequences of actions and decisions

    • Acknowledges the emotional needs of others with stand by-assistance.

    • Continues to demonstrate depression and low frustration threshold

    Level X: Purposeful, Appropriate: Modified Independent 

    • Able to multitask in many different environments with extra time or devices to assist

    • Able to create own methods and tools for memory retention

    • Independently anticipates obstacles that may occur as a result of impairments and take corrective actions

    • Able to independently make decisions and act appropriately but may require more time or compensatory strategies

    • Demonstrate intermittent periods of depression and low frustration threshold when under stress

    • Able to appropriately interact with others in social situations

    • The Glasgow Coma Scale is used to describe level of consciousness of the patient using eye-opening, verbal response, and motor response (Jain & Iverson, 2023)

      • Scale of the GCS is 3-15, 3 being the worst and 15 being the highest. 

    Best eye response (4)

    1. No eye opening

    2. Eye opening to pain

    3. Eye opening to sound

    4. Eyes open spontaneously

    Best verbal response (5)

    1. No verbal response

    2. Incomprehensible sounds

    3. Inappropriate words

    4. Confused

    5. Orientated

    Best motor response (6)

    1. No motor response.

    2. Abnormal extension to pain 

    3. Abnormal flexion to pain 

    4. Withdrawal from pain

    5. Localizing pain

    6. Obeys commands