Acquired Brain Injury Rehabilitation: Clinical Essentials
DONG (DAN) Y. HAN
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.)
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
Resolution of local brain edema
Improvement of local circulation
Recovery of injured neurons
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
Brain injury rehabilitation requires a comprehensive treatment program to:
Restore quality of life
Comprehensive Neurorehabilitation/Transdisciplinary Team
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)
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
“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
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.)
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)
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)
Assesses, diagnoses, and treats cognitive, communication, and swallowing disorders
Develops communication strategies
Teaches use of assistive devices
Assists in education of individual and family
Makes and fits orthoses
Manages comprehensive orthotic patient care
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
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)
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)
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.
Activities will gradually be adjusted on the basis of progress, starting with easier tasks or successive approximation graduating to more complex tasks.
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).
Appropriate amount of repetition is necessary to stimulate functional recovery.
New task or goal must be pertinent to the individual.
Successful therapy requires an interactive, patient-directed approach.
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).
Change in function in one task or area may improve function in a second area.
Plasticity in response to experience can interfere with improvement in function in a different area (Kleim & Jones, 2008; Lenze et al., 2012).