Acquired Brain Injury Rehabilitation: Clinical Essentials

CHAPTER 16

SILKE BERNERT

DONG (DAN) Y. HAN

NEUROREHABILITATION

In order to highlight intervention models for conditions mentioned in previous chapters, this chapter is formulated differently from the rest of this book. Paradigms of neurorehabilitation are explained, and the interdisciplinary and transdisciplinary nature of brain injury rehabilitation is explored.

Because acquired brain injury (ABI) is a concept inclusive of many types of injuries, the definition can differ between clinical and pedagogical models, rendering it rather controversial. For the purpose of this chapter, we will use definitions published by the Commission on Accreditation of Rehabilitation Facilities (CARF) and the World Health Organization (WHO):

Acquired Brain Injury is an insult to the brain that affects its structure or function, resulting in impairments of cognition, communication, physical function or psychosocial behavior. ABI includes both traumatic and nontraumatic brain injury. . . . Nontraumatic brain injuries may include those caused by strokes, nontraumatic hemorrhages (AVM, Aneurysm), tumors, infectious disease, hypoxic injuries, metabolic disorders, toxin exposure. ABI does not include brain injuries that are congenital, degenerative, or induced by birth trauma. (CARF International, 2016)

Damage to the brain, which occurs after birth and is not related to a congenital or a degenerative disease. These impairments may be temporary or permanent and cause partial or functional disability or psychosocial maladjustment. (WHO, 1996)

ABI in this context is nonprogressive, and it does not include degenerative brain diseases such as Alzheimer’s dementia, Parkinson’s disease, motor neuron disease, or multiple sclerosis. As illustrated in prior chapters, ABI:

Is heterogeneous in cause, pathophysiology, affected brain areas, and presentation

Affects all body systems

Causes physical, cognitive, behavioral, or emotional impairments

Can result in fundamental functional impairments causing social changes for the individual

Optimal rehabilitation of ABI requires a multidisciplinary approach of trained rehabilitation specialists at appropriate timing and with appropriate intensity. Not only is brain injury an acute event but it also needs to be understood as a chronic condition with often acute onset. Promoting optimal rehabilitation for ABI throughout this entire chronologic span is a critical component of the discipline of physical medicine and rehabilitation.

A definition of physical medicine and rehabilitation is:

Medical Specialty involved in diagnosis and treatment of patients with painful or functionally limiting conditions, the management of comorbidities and co-impairments, diagnostic and therapeutic injection procedures, electrodiagnostic medicine, and emphasis on prevention of complications of disability from secondary conditions. (American Board of Physical Medicine and Rehabilitation [ABPMR], n.d.)

Brain Injury

ABI results in:

Loss of function by direct injury of brain areas

Loss of function by diaschisis—neurophysiological changes of one brain area caused by injury to a second remote area, resulting in deafferentation and alteration of the neuronal network

Recovery and Neuroplasticity

Early Recovery

Resolution of local brain edema

Improvement of local circulation

Recovery of injured neurons

Plasticity

Influenced by environment: Stimulation, repetition, intensity, and motivation

Neuronal regeneration, collateral sprouting, and synaptogenesis (Nudo et al., 2001)

Reversal of diaschisis

May enhance functional recovery or result in maladaptive response (Carrera et al., 2014)

Functional learning-associated reorganization/unmasking

Redundancy: Recovery of function due to uninjured areas involved in specific function now becoming more active

Vicariation: Healthy neural structures assume function of damaged areas

Substitution: Development of new strategies to compensate for deficits

Rehabilitation

Brain injury rehabilitation requires a comprehensive treatment program to:

Reduce impairments

Restore function

Restore participation

Restore quality of life

Comprehensive Neurorehabilitation/Transdisciplinary Team

Members

Rehabilitation physician/physiatrist

Medical specialty concerned with diagnosis, evaluation, and management of persons of all ages with physical and/or cognitive impairment and disability

“Leads multidisciplinary teams concerned with maximal restoration or development of physical, psychological, social, occupational and vocational functions in persons whose abilities have been limited by disease, trauma, congenital disorders or pain to enable people to achieve their maximum functional abilities” (ABPMR, 2015)

Rehabilitation nurse

Builds therapeutic relationship with patient and family

Responsible for medical monitoring and behavioral management

Reinforces use of skills learned during therapies and facilitates reemergence of patient independence

Assists with maintenance of motivation and education for patient and family

Neuropsychologist

“Uses psychological, neurological, cognitive, behavioral and physiologic principles, techniques and tests to evaluate patient’s neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal central nervous system functioning” (National Academy of Neuropsychology, 2001)

Assists in diagnosis and treatment

Implements therapy plans for groups, individuals, and family

Clinical psychologist

Evaluates and treats mental and emotional conditions after ABI

Assists individuals and their families with adjustment to the disability

Assists the individual in achieving optimal physical, psychological, and interpersonal functioning

Provides services consistent with the level of impairment, disability, and handicap relative to the personal preferences, needs, and resources of the individual (American Board of Professional Psychology, n.d.)

Physical therapist

Examines each individual and develops a plan, using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability

Works with individuals and their families to prevent the loss of mobility

Assesses individuals for appropriate mobility devices

Teaches individuals and their families how to manage their condition for long-term health benefits

Assists in education of individual and family (American Physical Therapy Association, 2016)

Occupational therapist

Examines each individual and develops a plan to enable people to participate in the activities of everyday life

Works with individuals and communities to enhance an individual’s ability by teaching the use of assistive devices and modifying the occupation or the environment to better support the occupational engagement

Assists in education of individual and family (World Federation of Occupational Therapists, 2013)

Speech-language pathologist

Assesses, diagnoses, and treats cognitive, communication, and swallowing disorders

Develops communication strategies

Teaches use of assistive devices

Assists in education of individual and family

Orthotist

Makes and fits orthoses

Manages comprehensive orthotic patient care

Case manager

Assesses, plans, and facilitates comprehensive patient care services

Assesses the needs and strengths of the individuals and their families or support systems

Develops personalized goals

Identifies resources for services

Monitors progress toward goals

Recreational therapist

Assists individuals and their families in the development of skills, knowledge, and behaviors for daily living and community involvement

Improves the physical, cognitive, emotional, social, and leisure capabilities (American Therapeutic Recreation Association, 2004)

Vocational rehabilitation specialist

Assesses an individual’s functional level and vocational potentials

Sets goals and plans interventions

Provides career (vocational) counseling, job analysis, and development as well as placement services

Coordinates individual and group counseling focused on facilitating adjustments to the medical and psychological impact of disability

Provides case management, referral, and service coordination

Implements interventions to remove environmental, employment, and attitudinal obstacles

Provides consultation about and access to rehabilitation technology (NHS Health Scotland, 2013)

Dietician

Assesses nutritional status and needs of individuals with various comorbidities, manages food services, and optimizes nutritional programs to promote health and control of diseases

Provides nutritional counseling to individuals and families

Physical and Cognitive Rehabilitation

Enhances intracortical reorganization to develop adaptive connection patterns while suppressing maladaptive responses

Rehabilitation professionals use a variety of techniques to specifically manipulate behavior and thereby modulate the neuronal network (Cramer et al., 2011)

Psychosocial Rehabilitation

Goal of optimal rehabilitation is the reintegration into family and community at the functionally highest level possible

Optimal rehabilitation of brain injury requires a team approach of a variety of experts

Guiding Principles for Rehabilitation

Guiding principles for rehabilitation include all areas of therapy, namely, physical, occupational, cognitive, and speech-language therapy.

Graduated Approach

Activities will gradually be adjusted on the basis of progress, starting with easier tasks or successive approximation graduating to more complex tasks.

Intensity

This is the amount of time the individual is engaged in active, goal-directed, face-to-face rehabilitation therapy over time.

More intensive training in animals resulted in increased brain reorganization.

Lack of training causes a decrease of reorganization (Jette et al., 2005).

Repetition

Appropriate amount of repetition is necessary to stimulate functional recovery.

Saliency

New task or goal must be pertinent to the individual.

Successful therapy requires an interactive, patient-directed approach.

Task Specificity

Task-specific training improves motor learning (Cramer et al., 2011).

Timing of Rehabilitation

Very early mobility after ABI may prevent medical complications (Klein et al., 2015; Titsworth et al., 2012).

Early functional rehabilitation in poststroke and traumatic brain injury (TBI) patients has been shown to improve functional outcomes and may decrease “learned nonuse” (Taub et al., 2006).

There may be an early optimal time window after the injury to achieve maximal neuroplasticity (Bernhardt, Dewey, Thrift, Collier, & Donnan, 2008; Biernaskie, Chernenko, & Corbett, 2004; Craig, Bernhardt, Langhorne, & Wu, 2010; Cumming et al., 2011; Griesbach, Gomez-Pinilla, & Hovda, 2007; Hu, Hsu, Yip, Jeng, & Wang, 2010; Maulden, Gassaway, Horn, Smout, & DeJong, 2005).