Therapies That Work
The particular course of therapy will set by the doctor and therapist based on the patient’s condition and abilities. This section is organized starting with activities a person might see from the onset of their injury and progressing as their abilities increase.
In an editorial that appeared in PT Magazine in October 1999, the publisher remarked:
"Physical therapists are good people to know. They’re educated in understanding the interaction of all your body parts. Their hands-on approach begins with examination, diagnosis, and treatment of the immediate problem. Then they teach you how to take care of yourself by showing you how to do exercises and how to use your body properly to gain strength and mobility and prevent recurring injury. You’ll find them advising on proper posture and body motion in the work place, treating injuries, consulting on fitness, and administering physical therapy in the home. Today physical therapists provide help for every part of the body to everyone from infants to the elderly — more than 1 million people every day!"
Our experience with physical therapists is that they spend some of their sessions on the long term goals with stretches, range of motion, and general strengthening and then spend the rest of the session working on specific exercises aimed at shorter term goals.
For example, if the intermediate goal is to walk then the PT will assess what the patient’s needs are in order to meet that goal and set a program up to address those needs. The PT will be able to identify the muscle groups that are required for the tasks you are working towards and develop a plan to strengthen and increase endurance.
Range of Motion - While in the hospital the brain injury survivor may first see the therapists to receive some Range of Motion exercises. The patient does not even have to be conscious when these exercises are started. The goal, as the name implies, is to maintain the body’s full range of motion. These Range of Motion exercises will continue throughout the time the person receives therapy. The difference will be the patient’s ability to participate in the therapy.
Early on after the injury these exercises are probably not your primary concern and may not look like they are doing anything. Let me impress upon you the importance. Without use and with high tone and contractures, tendons can tighten and shorten. It is very important to keep all of the joints flexible and the full range of motion. It is a much longer and arduous process to reverse the problems after the fact, prevention is the key.
Weight Bearing – Weight bearing exercises are another key component of PT. Weight Bearing helps loosen the joints, breaks up the tone, and helps fight osteoporosis. These exercises can start even with minimally conscious patients. Equipment may be used to assist the therapist.
• Tilt Table – When the therapists first try to do weight bearing your loved one may not be able to assist at all. If that is the case they may use a tilt table. A tilt table is a piece of equipment where the patient starts out lying on the table. Wide straps are used to secure them to the table and the table is then tilted up. The goal is to stand at ninety degrees for a period of time. If there is high tone or drop-foot the patient may not be able to make it to ninety degrees right off the bat.
A side note – Our daughter was having trouble tolerating the tilt table and was not able to come to ninety degrees. She had an acupuncture treatment and the next day her feet were able to relax and go completely flat allowing her stand while on the tilt table. (see more on Alternative Therapies)
• Standing Frame – If the person is able to actively participate in therapy the therapists may use a standing frame. This piece of equipment can assist a person standing by providing some support. The patient needs to be able to bear some weight. Through pads and straps the equipment provides support. Typically the standing frame can lift someone from their wheelchair. A Standing Frame is very nice for home since it lets you safely assist the person to stand.
• Walker – There are a number of styles of walkers that may be used. Some have arm supports, others have wheels. The common thread is that the person must have some trunk control in addition to being able to bear weight.
Sitting Balance – Other exercises physical therapists will employ will be around regaining sitting balance. They will help the patients work to regain head control, trunk control and weight bearing through the legs and even the arms.
• Mat Table – In the hospital or rehab unit you will see the therapists us a padded mat table for a number of their exercises. It provides a solid, safe platform to exercise on. There are different kinds of tables available, some that raise and lower electrically while others that fold down from the wall to save space.
When we brought our daughter home I built a mat table using 2x4’s, a sheet of ¾” plywood, and an old exercise mat. I made sure the height was the same as the wheelchair seat to aid in the transfers. Make sure you recess the frame back from the edge of the plywood so that you leave a lip on the table for the person to use to hold on to.
• Exercise Balls – Exercise balls are often used in therapy. One of the key reasons is that the ball requires you to use many different muscles to keep your balance and stay on the ball. There are different sizes of balls and even two-person balls available. There are also a wide variety of exercises that can be done on the ball both in and out of therapy.
Gait Training – Preparing to walk is a huge step back on the road to recovery. It is a step that every family hopes their loved one will take. The Physical Therapist is one of the key people to help get you ready. The therapist can assess your strengths and develop a plan to get you prepared to walk. A person with a brain injury may have some problems with their gait that need the therapist’s attention even if they can walk.
• Gait Trainers – This piece of equipment seems to be gaining acceptance. It consists of a lift with a harness that can support the person while they are on a treadmill. They may be ceiling mounted in the hospital and there are stand-alone units as well. The main benefit is that the equipment takes away the concern of the person falling. The amount of weight the person bears is adjustable.
Another benefit touted by one manufacturer is the fact that they see advantages in persons who are not ready to stand on their own using the gait trainer. Some of that articles talk about putting the body through the motions of walking can help speed the ability to walk again.
• Parallel Bars – Parallel bars have been used for a long time to help the patient support themselves while they practice walking. The difference in my untrained eyes is that the person needs to have more ability and strength to use the parallel bars than one needs for the gait trainers.
Strength Training - Building muscle strength is one of the key focuses of physical therapy. As mentioned above the Physical Therapist understands the musculature of the body and understands the movements necessary for certain tasks and can direct a set of exercises to strengthen those targeted muscle groups. At first, the strength training may start with just moving particular body parts. Later resistance may be added.
• Thera-Band – Thera-Band is a brand name of progressive elastic resistance exercise products. The bands come in different levels of resistance and the patient can progress as they develop more strength. The bands let the therapist be very creative and can be used in a number of exercises.
• Weights – As the patient progresses the therapist may want to add more resistance and add weight training to the mix. In the beginning it may be very light weights and then progress to heavier weights and on to weight lifting machines.
• Bikes / Pedalers – There are a number of devices used to allow the patient to pedal and develop more leg strength and coordination. There are the inexpensive units you use at home, recumbent bikes that can be used even by folks with paralysis when electrical stimulation is added. And finally, the standard stationary bikes you may be familiar with from the health club.
Equipment, Wheelchairs, Braces, AFO’s – Physical Therapists also can make recommendations for rehab equipment and adaptive devices. There are many types of wheelchairs and a myriad of accessories used to customize them and the Physical Therapist can help identify the necessary equipment and work with the supplier in the fittings. The therapist can also recommend bracing or AFO’s when required. They are the expert who understands the patient’s condition and can provide the orthotist with the background and information they need to create the braces. Finally, the Physical Therapist can also recommend rehab equipment that would be helpful.
Many insurance companies categorize these items as Durable Medical Equipment and often require a letter of medical necessity from your doctor with the request. Your therapist may help draft these letters and work with your doctor to answer any questions.
We have challenged our therapists to not be restricted by what they think the insurance will or won’t provide, instead tell us what they would recommend if money were not an object. Let us fight with the insurance companies but we want to know what the therapists think is necessary to help with the recovery.
Physical Therapy - Individual Exercises
The Occupational Therapists main concerns deal with preparing the patient for the activities of daily living (ADL’s). Sometimes that means regaining previous abilities while other times it may mean developing compensation techniques.
Occupational therapy is skilled treatment that helps individuals achieve independence in all facets of their lives. It gives people the "skills for the job of living" necessary for independent and satisfying lives. Services typically include:
- Customized treatment programs to improve one's ability to perform daily
Comprehensive home and job site evaluations with adaptation recommendations
Performance skills assessments and treatment
Adaptive equipment recommendations and usage training
Guidance to family members and caregivers
Establish and restore endurance and strength so that a person can bathe, dress, and feed himself or herself.
Help the client minimize over-stimulation and confusion in his or her environment.
Teach a person with TBI to compensate for problems with thinking, such as memory impairments.
Occupational therapy practitioners are skilled professionals whose education includes the study of human growth and development with specific emphasis on the social, emotional, and physiological effects of illness and injury.
Practitioners must complete supervised clinical internships in a variety of health care settings, and pass a national examination. Most states also regulate occupational therapy practice.
What can families and friends of a person with a TBI do?
- Become educated about the recovery process of a family member
Provide long-term support to a family member
Learn techniques to help the person manage cognitive and physical problems.
Help the person adapt his or her home to accommodate the effects of a brain injury.
Excerpts above from The American Occupational Therapy Association (AOTA) www.aota.org
The Occupational Therapist will use all kinds of household items such as hair brushes, tooth brushes, or forks and spoons to help the patient re-learn the skills they need. As the therapist identifies weaknesses they may use exercises and equipment similar to the Physical Therapist to overcome a deficiency.
The patient and family can help the therapist by identifying some of the areas the patient would like to work on. Does the patient like to cook, or paint, or other interests or hobbies. Doing something fun like playing a game or cards makes the therapy session a lot more fun while still exercising. Our experience has been that you can be more creative and inventive with OT.
Occupational Therapy Individual Exercises
Individuals experiencing problems with communication, swallowing or hearing can benefit from the specialized attention of certified speech-language pathologists and audiologists. Speech-language pathologists diagnose and treat a wide variety of disorders resulting from stroke, brain injury or other conditions. Therapy usually involves individual training and education in the ways an individual can compensate for speech and hearing or communication difficulties.
In our experience speech therapy is the most complex and slowest area to see improvement. You normally do not think about it but there are many muscles and so much coordination involved in swallowing or speaking. Then, if there is damage to the brain's language center recovery is even more difficult and complicated.
In therapy the speech pathologist utilizes any brain functions still present and helps the patient relearn some use of language. Treatment may involve intensive speech therapy with the focus on oral-motor skill development.
If the patient has difficulty in swallowing food, liquids, or even saliva, due to muscle weakness or paralysis there are a number of special diagnostic tools, including non-invasive x-ray procedures, to help evaluate the nature and extent of the condition. Videofluoroscopy is a video x-ray to show exactly what is happening when food and drink of different consistencies is swallowed. From the results of the video swallow, appropriate treatment recommendations are made.
With the guidance of a speech pathologist, treatment may involve incorporating compensatory strategies when eating (including chin tuck, frequent swallows or checking mouth), altering food consistencies (including soft, pureed or chopped) and specialized eating/drinking equipment.
A speech therapist may also help individuals with speech difficulties find alternative methods of communication. There are many different kinds of devices that meet different needs from the simple, non-electronic variety to the complex, computerized device. Devices may be controlled by a puff of air, a blink of an eye, typing on a keyboard, or a synthesized voice.
Excerpts above from Kessler Rehabilitation Corp.
Speech Therapy Individual Exercises
These exercises came from one of our readers Angela. Thanks Angela
These are actual speech exercises. I am copying this hand-out here. It is the best I've seen. I've kept mine over 5 years in a plastic protective sleeve. Highlight it. Just do a few exercises. Select new ones when you need a change.
Please practice the exercises checked
_____ times a day
_____ repetitions each.
MOUTH AND LIP EXERCISES
1. Open and close your mouth slowly/quickly. Be sure your lips are all the way closed. Repeat.
2. Pucker your lips, as for a kiss, then relax. Repeat.
3. Spread lips into a big smile, hold then relax. Try to make both sides of your mouth even. Repeat.
4. Pucker, hold, smile, hold. Try to make both sides of your mouth even. Repeat this alternating movement without holding.
5. Close your lips tightly and press together. Hold for 3-5 seconds. Relax and repeat.
6. Move your jaw from side to side as slow as you can. Relax and repeat.
7. Puff your cheeks up with air. Hold the air in for 3-5 seconds. Try not to nlet the air escape out of your lips or nose. Rerlax and repeat.
8. Same as exercise 15. Tap your right cheek with your index finger while holding air in your cheeks Try not to let air escape through your lips or nose. Relax and repeat.
9. Stick out your tongue so that it is in the middle of your mouth and it does not go off to the side. Hold that position for 3-5 seconds. Relax and repeat.
10. Stick out your tongue and move it slowly from corner to corner. Relax and repeat. Repeat moving your tongue quickly.
11. Stick out your tongue and try to touch your chin with the tongue tip. Relax and repeat.
12. Stick out your tongue as far as you can and try to reach your nose with the tongue tip. Don' t use your bottom lip or your fingers to help. Hold that position for 3-5 seconds. Relax and repeat.
13. Hold a spoon steady and upright (like a popsicle). Push your tongue tip against the back of the spoon. Relax and repeat.
14. While holding your head steady, pretend to lick a sucker moving the tongue tip from down to up.
15. Move your tongue all around the inside of your lips in a circle as completely as you can touching the upper lip, corner, lower lip and corner. Relax and repeat. Do the same exercise moving your tongue around the outside of your lips.
We Need Your Input!
Below are some of the activities and therapies that we have seen therapists use that seem to work. We want your ideas too.
Our experience has been that each therapist comes at things from a different point of view and with a different set of experiences. We learn something new from each person. We want this page to become a list of activities and exercises from families and therapists all around the globe.
When you submit a suggestion, just give us a little background on the patient’s condition and what activities have seemed to help. We are also looking for innovative ideas for equipment or homemade equipment alternatives that help.
Email to: Help@tbirecovery.org
As stated before, the Brain Injury Recovery Network does not give medical advice. If you see an activity below that you are interested in, talk with your doctor and therapist. Remember patient safety is the primary consideration.