Rehabilitation Issues in Traumatic Brain Injury

S. Khosrawi MD , PhysiatristDept. of Physical Medicine & Rehabilitation

Faculty of Medicine,IUMS

Third phase of medical care

“ Medical care can not be considered complete until the patient with a residual physical disability has been trained to live and work with what he has left.”

Rusk. 1959

Rehabilitation MedicineMair 1972“implies the restoration of patients to their fullest physical,

mental and social capability after an episode of illness or trauma”

BSRMA process of active change by which a person who has become

disabled acquires the knowledge and skills needed for optimal physical, psychological and social function.

• As an active process it is distinguished from services supplied to non participating patients (care) and from spontaneous improvements in a patient (recuperation).

• Advances in medical technology and improvements in regional trauma services have increased the number of survivors of TBI, producing the social consequences and medical challenges of a growing pool of people with disabilities.

• During this time, TBI rehabilitation has emerged as a subspecialty of interest to physiatrists, nurses, psychologists, and therapists.

Severity ? & Outcome ?• Measures of Injury Severity: depth and duration of coma duration of posttraumatic amnesia (PTA) Multimodality evoked potentials …

• The Range of Outcomes: Death to Complete Recovery

GLASGOW OUTCOME SCALE

• Good recovery: the capacity to resume normal occupational & social activities, although there may be minor physical or mental deficits.

• Moderate disability: (disabled but independent) able to look after himself at home, to get out and about to shops & travel by public transport. Some previous activities, at work or in social life, no longer possible by reason of either physical or mental deficit.

• Severe disability: (conscious but dependent)needs assistance of another person for some activities of daily living every day. Ranges from total care to assistance .

• Vegetative State• Dead

Mechanisms of Functional Recovery

Recovery is believed to occur at multiple levels: (from alterations in biochemical processes to alterations in family structure)

• Resolution of Temporary Factors (edema,electrolyte imbalance,…)

• Neuronal Regeneration & Synaptic Alterations• Functional Substitution• Learning of New Skills

The bulk of neurologic recovery from acute brain injury occurs within the first 6 months postinjury & can extend 2 years or more .

There probably is no final end point to the recovery process; rather, the pace of recovery slows, and its scope narrows.

Aims of Rehabilitation

• Promote Intrinsic Recovery• Assist Adaptive Recovery• Prevent Complications• Minimize Eventual Handicap

Early rehabilitation

Early input from rehabilitation has been shown to positively affect outcomes such as :

length of stay, duration of rehabilitation,

and improved functional status

at time of discharge from hospital.

11

The glass isn't half empty, The glass isn't half empty, it’s half full!it’s half full!

andand

You can teach 1/2 empty people You can teach 1/2 empty people to become 1/2 full peopleto become 1/2 full people

THE THE FOCUSFOCUS OF SUCCESSFUL OF SUCCESSFUL REHABILITATION REHABILITATION

IS ON IS ON STRENGTHSSTRENGTHS , ,NOT NOT IMPAIRMENTS OR DEFICITSIMPAIRMENTS OR DEFICITS

Changes After Brain Injury

• Motor coordination• Hearing and visual changes• Spasticity and tremors Fatigue and/or weaknessTaste and smell• Balance• Mobility• Speech• Seizures

Physical Changes

Cognitive Changes

Behavior Changes Memory

Decision making Planning Sequencing Judgment Processing speed Organization Self-perception Problem solving Thinking

Depression Mood swings Disinhibition Lack of response to social cues Problems with emotional control Difficulty relating to others Reduced self-esteem Stress, anxiety, and frustration

• The medical, physical, cognitive, and behavioral sequelae of TBI have been more clearly identified and classified.

• The physical sequelae of TBI such as paralysis, contractures, and heterotopic ossification have been lessened .

• Yet the neurobehavioral deficits (changes in behavior, mood, and personality) after TBI represent the most significant obstacles to community reintegration and the most difficult disabilities to manage effectively.

Some Component Processes Relevant to Mobility

• Component• Range of motion• Strength

• Balance and postural reflexes• Muscle tone• Visuospatial perception• Spatial attention• Concentration

• Memory• Planning, organization, and reasoning

skills• Initiation

• Role in Mobility• Must allow for required movements• Necessary for ambulation, wheelchair propulsion, or

switch operation• Necessary for safe ambulation and transfer and

adjustment to sudden perturbations• Must allow for effective use of strength• Necessary for environmental navigation• Necessary for awareness of both sides of space• Necessary for maintenance of locomotion in presence

of distractions• Necessary for using previous experience of routes and

locations• Necessary for mobility in unfamiliar environments and

using public transportation• Necessary for turning plans into action

FIM• The Functional Independence Measure (FIM), an

18-item rating scale, is the most widely used outcome measurement scale in medical rehabilitation.

• Because of the relative insensitivity of the FIM to cognitive and behavioral deficits, the Functional Assessment Measure (FAM) was developed to supplement it with more cognitively oriented items.

FIM+FAM• SELF CARE ITEMS • 1. Feeding• 2. Grooming• 3. Bathing• 4. Dressing Upper Body• 5. Dressing Lower Body• 6. Toileting• 7. Swallowing*• SPHINCTER CONTROL• 8. Bladder Manageme nt• 9. Bowel Management• MOBILITY ITEMS (Type of Transfer)• 10. Bed, Chair, Wheelchair • 11. Toilet • 12. Tub or Shower • 13. Car Transfer*• LOCOMOTION• 14. Walking/Wheelchair • 15. Stairs• 16. Community Access*

• COMMUNICATION ITEMS• 17. Comprehension-Audio/Visual • 18. Expression-Verbal, Non-Verbal • 19. Reading*• 20. Writing*• 21. Speech Intelligibility*• PSYCHOSOCIAL ADJUSTMENT• 22. Social Interaction• 23. Emotional Status*• 24. Adjustment to Limitations*• 25. Employability*• COGNITIVE FUNCTION• 26. Problem Solvin g• 27. Memory• 28. Orientation*• 29. Attention*• 30. Safety Judgement*

• *FAM items

FIM+FAM Scale

• 7 Complete Independence (timely, safely) • 6 Modified Independence (extra time, devices)

• 5 Supervision (coaxing, prompting)• 4 Minimal Assist (performs 75% +)• 3 Moderate Assist (performs 50%+)• 2 Maximal Assist (performs 25% +)• 1 Total Assist (performs <25%)

NO HELPER

HELPER

The rehabilitation needs of the survivor of severe TBI often begin at site of emergency care

but are not likely to end for many years.

What Do Patients Need?•Assessment/Evaluation•Behavioral Services•Community/Family Education•Companion Services•Durable Medical Equipment•Emotional Support •Financial Assistance•Housing•Individual/Family Counseling•Legal Advice•Life Skills Training

•Long-term Residential•Personal Care•Recreation/ Socialization•Special Education •Supported Employment•Substance Abuse Treatment•Rehabilitative Therapies•Transportation•Vocational Services

THE ASSESSMENT AND TREATMENT-PLANNING PROCESS

Standards of care for TBI organized on a team model to promote coordination and

information sharing across disciplines, & creation of a unified treatment plan.

Interdisciplinary TBI Team (Interdisciplinary Rehabilitation Approach)

• Patient/family• Neurosurgeon • Orthopaedic surgeon• Urologist• Plastic surgeon• Physiatrist• Psychitrist • Psychologist• Nurse

• Occupational therapist• Physiotherapist• Orthotist/Prosthetist• Rehab. Engineer• Vocational therapist• Speech therapist• Social Worker• Dietetics• Podiatrist• Chaplain• Recreational therapist• sex therapist

Continuum of Care for TBI / Polytrauma (Continuum Rehabilitation from onset to community)

Trauma Care

Long-Term Care

Subacute Rehab.

Acute Rehab.

Post-Acute Rehab.

Community Rehab.

Outpatient Specialty

Care

• Acute inpatient rehabilitation is typically provided to individuals who are able to participate actively in treatment.

• Subacute rehabilitation, which is less costly and less intensive, may be given to those who are vegetative, slow to recover, or cannot tolerate intensive therapy.

• A day treatment program may be provided to individuals who can be managed at home but continue to display a variety of physical or neurobehavioral problems.

Comprehensive Inpatient Rehab UnitCriteria for Admission

• Need an intensive, interdisciplinary program, in two or more functional domains (mobility, activities of daily living, bowel and/or bladder management, cognition, communication, swallowing, others.)

• Be willing and able to participate in about 3 hours of therapy daily. (Potential and motivation )

• psychological and mental status to participate in program • Be medically stable. • Have the potential for making progress in ability to move,

take care of themselves, activities of daily living, cognition, communication and perceptual-motor functions

Applicants cannot be admitted to the rehabilitation program if any of the following

conditions exist:

• Severe cardiac limitations• Extensive decubitus or other extensive skin ulcers that would

limit the patient’s participation in a rehabilitation program• Comatose status• Chronic confusion or disorientation.• Addiction to narcotics or drugs unless related to recent

medical problems• Severe mental illness

Acute rehab. in Coma , Vegetative State

& minimally conscious state

• the main goals for rehabilitation are to optimize medical stability & preserve bodily integrity

• Prevent complications:chest physio.,bed sore care , UTI,…

• Aggressive treatment of hypertonia and contractures

• Splints & positioning • Regular evaluation

SOME MEDICAL PROBLEMS AFTER TBIHeterotopic Ossification:• Index of suspicion• Avoid microtrauma to soft tissues• Combined approach by PT, OT, Nursing.• Range-of-motion exercises are indicated to prevent

ankylosis. If ankylosis seems inevitable despite exercises, it should be encouraged to occur in the most functional position.

• Positioning• Treat associated spasticity.• Drug therapy- Indomethacin, bisphosphonates.• Radiotherapy, Surgery.

Spasticity and Contractures:

Indications for Treatment of Spasticity

• Interference with active movement• Contracture formation or progression in a

posturing limb• Interference with appropriate positioning or

hygiene• Self-inflicted trauma during muscle spasms• Excessive pain on range-of-motion exercises or

during muscle spasms• Excessive therapy time devoted to contracture

prevention rather than functional activities

Motor Disturbances

• Weakness can be addressed through active assistive range-of-motion and progressive resistive exercises.

• Ataxia is notoriously difficult to treat. A weighted walker or wrist cuffs may be of modest benefit.

• Orthoses and adaptive devices may assist weak or ataxic patients in performing functional tasks.

• Dexterity exercises may be used to increase manual speed and coordination.

New advancements• A number of automated systems for guiding

motor-related therapies are in development. These computerized devices deliver movement exercises via various forms of virtual reality, and make use of various kinds of displacement and force sensors to monitor performance. Such devices may prove to be able to enhance the frequency and intensity of movement therapy while reducing personnel costs, and may also allow for remote monitoring of therapy via telerehabilitation .

Telehomecare

videophone & its removable camera (advantageous for viewing pressure sores) is displayed in the picture on the right. Audio/video cables connect the videophone to a personal computer, allowing skin images to be stored as graphics files.

Bladder Dysfunction

• BEHAVIORAL TREATMENT OPTIONS : scheduled (timed) voiding regimen(to void before reaching their full bladder capacity), bladder training is done by progressively increasing the time between voiding by 10 to 15 minutes every 2 to 5 days until a reasonable interval between voidings is obtained

• Intermittent catheterization, usually combined with anticholinergics

Critical Illness Neuropathy• Axonal neuropathy.• Results from systemic inflammatory response

syndrome (SIRS)• Seen in patients in ICU in context of severe sepsis or

multiple trauma.• Presents as lower motor neuronal weakness of

limbs.• Potential for recovery is generally good.• May lead to residual functional handicap.• Management includes: splinting, positioning,

passive ROM, muscle strengthening and hydrotherapy.