TBI’s biggest challenge? Managing patients’ anger
TBI’s biggest challenge? Managing patients’ anger
Rehab facility trains staff in behavior management
People who have had a traumatic brain injury (TBI) often become impulsive, angry, and easily irritated by others, and this change in their behavior and personality can be one of the most challenging aspects of working with the TBI population.
For example, a recent study published in Neurology found that 32% of stroke patients had an inability to control their anger or aggression, which suggests that this symptom is one of the main post-stroke behavioral manifestations.1
Researchers also found that stroke patients tended to exhibit spontaneous anger and aggression that sometimes was provoked by other peoples’ behavior and that was also closely related to motor dysfunction and dysarthria. The study was of 145 patients at three to 12 months post-injury at the outpatient clinic of Asan Medical Center in Seoul, Korea, between July 2000 and December 2000.
Rehab professionals long have recognized this trait among their TBI population. In some TBI programs, staff training includes some behavioral management skills.
"It’s so much a part of brain injury that we’re teaching behavioral management," says Claire McLaughlin, OTR, staff occupational therapist at Bacharach Institute for Rehabilitation in Pomona, NJ.
Behavioral issues among TBI patients can be particularly challenging as therapists are attempting to reach clinical goals during a therapy session, McLaughlin says.
Therapists benefit from TBI training
"It’s challenging especially when you have someone who gets agitated quickly or has internal distractions," McLaughlin adds. "So you try to get the patient to focus and work on attending to a conversation or simple task."
It’s been the TBI staff’s experience that rehab therapists who have not been trained specifically to deal with a TBI population will have difficulty working with these patients, McLaughlin notes.
"When you have someone with poor attention or impulsiveness, it can cause a therapist to become frustrated," she adds.
This is why behavioral management training and cross-training for rehab staff are so important. Here’s how Bacharach Institute’s TBI training incorporates behavioral management training:
• Deal with big misconceptions.
Therapists may become frustrated with a patient who has a poor attention span or who is impulsive because it’s difficult to complete the task at hand. However, it’s a misconception for the therapist to think the patient is choosing to behave this way, because it’s likely the brain-injured patient just doesn’t have the attention span to sustain concentration on the activity, McLaughlin says.
"The therapist just needs to be more on his guard and be more prepared to react to the person doing something unsafe, such as getting out of the wheelchair quickly," she explains.
If a patient is paying more attention to something else going on in a room than to therapy, the therapist should not think the patient is purposely being disruptive. Rather, the patient has become distracted and needs to be redirected in a simplified manner to the therapy task, McLaughlin says.
"When someone is becoming agitated, you need to use your intuition and assess whether there’s an escalation in the patient’s voice," McLaughlin says. "If there is, you need to back off with demands on the person and calm down the person’s environmental distractions so the person can get back into control."
• Offer strategies for improving the TBI patient’s behavior.
Although the rehab facility’s brain injury and general rehab rooms are separate, the treatment area is the same, and this means brain injury staff will need to pay special attention to the environmental stimuli in every therapy situation, McLaughlin says.
Brain injury staff also must educate patients’ families as much as possible and encourage them to spend more time involved with their loved ones’ rehab care, she says.
"We teach the family the strategies, and they can help to make rehab less intimidating and anxiety-provoking for the patient," McLaughlin says.
Start off quietly; then add distractions
The education geared toward both family and patients may also include several homemaking sessions in which each one is geared to increase the challenge. This way, the therapist can help the family assess what the patient is capable of doing and what the patient will need assistance doing once he or she is at home, she adds.
"Start off with a quiet environment to give the best cooking training, and as the patient does more in the kitchen, you can add distractions to see what the patient can do," McLaughlin says.
When a patient becomes frustrated, this can be a sign that the patient does not understand how to do a task. It’s also a clue that a therapist can use to find out what the problem is.
For example, a patient might be overreaching for an object and not sustaining a grip on it, or the patient might be turning it the wrong way and then tightening it instead of loosening it, McLaughlin explains.
"What you want to do is first call the patient by name to get his attention, and then explain to him by a hands-on approach what they need to do," she adds. "Or you can give the patient verbal cueing on what needs to be done."
Be sensitive to nonverbal cues
• Prepare staff for the times when a patient’s agitation rises.
"Observe a patient’s frustration level," McLaughlin advises. "If a patient’s frustration is rising, then that’s usually a sign that they’re not doing a task correctly, so the therapist will have to step in to analyze what they’re doing wrong and then cue them tactically, visually, or verbally on how to perform it correctly."
Most importantly, therapists need to be sensitive to nonverbal cues that a patient is agitated and that something has triggered an angry episode, says Lisa Rocco, MPT, CBIS, CCCE, clinical educator supervisor and physical therapist.
Rocco learned the importance of these precautions the hard way. A patient of hers who was 6’5 had cornered his mother against a wall. As Rocco approached the patient from the side, he grabbed her arm and twisted it, causing numbness in her hand.
"So you can be prepared, but sometimes still get into a precarious situation, so you need to know your limits," Rocco says. "And you need to know when a patient is going to act out and be aggressive."
Reference
1. Kim JS, Choi S, Kwon SU, Seo YS. Inability to control anger or aggression after stroke. Neurology 2002; 58:1106-1108.
Need More Information?- Claire McLaughlin, OTR, Staff Occupational Therapist, Bacharach Institute for Rehabilitation, 61 W. Jim Leeds Road, Pomona, NJ 08240. Telephone: (609) 748-5420.
- Lisa Rocco, MPT, CBIS, CCCE, Clinical Education Supervisor and Physical Therapist, Bacharach Institute for Rehabilitation, 61 W. Jim Leeds Road, Pomona, NJ 08240. Telephone: (609) 748-5412.
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