Approach to Management of Traumatic Brain Injury
Early rehabilitation consultation is important to address the prevention of complications and to assist in developing a plan of management in the critical care period and immediately afterwards.
Some of the most important things to consider are the prevention of joint contractures and skin breakdown during the critical period. Using proper positioning, splinting, and turning schedules should be part of the care plan in the ICU for any patient who suffers from reduced consciousness. The presence of spasticity and increased muscle tone in people with severe traumatic brain injury increases the importance of these measures. It isn’t possible to predict the long term functional outcome for any individual in the first week after their traumatic brain injury so these precautions should be used for everyone.
There isn’t any proof that sensory stimulation increases long term outcome. On the other hand, hearing familiar sounds and things like music are not harmful and may be soothing for both the family and the patient.
The Agitated Patient
Post traumatic agitation is a common phenomenon in the recovery from a severe traumatic brain injury and it comes from confusion and disinhibition. The features of agitation are not well defined; at one end, there can be psychomotor activity and at the other end, there is physical aggression and explosive anger. Early agitation indicates the possibility of problems with attention. This type of agitation is different from the episodic dyscontrol syndromes seen later on in recovery.
Medications used to treat agitation have included neuroleptics, lithium, antidepressants, psychostimulants, anticonvulsants, buspirone, beta blockers, and medication to increase dopamine. It is important to monitor the behavioral responses to interventions as systematically as possible. There are scales available to help track behavior that can be used when agitation is prominent.
Certain drugs may have more effect on cognitive activity than others. For example, Haldol was shown to significantly impair problem solving in a rat model when compared to taking olanzapine. Environmental controls need to be included in any intervention plan to treat acute agitation. Agitation may be because of too much noise and light or to internal factors, such as the need to urinate or having pain. It is important to remove any environmental triggers in order to provide a calming influence on the patient. If these do not work or if there is a risk of injury to staff, then medications should be attempted.
The Vegetative State
About ten percent of people hospitalized with traumatic brain injury are in a minimally responsive or vegetative state in the first month after the injury. At six months out, about 3 percent of people continue in a vegetative state.
In a minimally responsive state, the patient has generalized responses to the environment. The vegetative state means that the patient has no response to the environment although they may have sleep/wake cycles, roving eye movements, tearing, and even occasional vocalizations. The diagnosis of vegetative state cannot be made until the patient is twelve months out from the injury and still show no signs of recovery. Some people wake up somewhat but functional recovery is usually limited. Survival of the vegetative state depends on how well they are cared for but rarely lasts beyond ten years.
Early after injury, it is most important to evaluate the patient for responsiveness on a regular basis. Skin care, range of motion of the limbs and positioning devices, along with good nutritional and respiratory support are important for comfort and allow for functioning should the neurologic injury be recovered from. There is little evidence to support the effectiveness of coma stimulation programs; however, persons in a minimally responsive state of vegetative state deserve comfort, human contact and humane care.
Acute Rehabilitation of a TBI Patient
Much of the efforts during the acute rehabilitation stage of patients with moderate to severe traumatic brain injury are focused on basic self-care activities and treating other medical disorders. The emphasis is on regaining ambulation or at least the independent use of a wheelchair. Recovery of independent ambulation occurs during the first three months after the injury; only 14 percent of those not ambulatory at the three month mark will become ambulatory later on.
Cognitive rehabilitation is directed at orienting the patient and using simple memory strategies along with cuing. Family members can be involved to a great degree in training to compensate for the patient’s problems in learning and memory. More and more aspects of traumatic brain injury rehabilitation is going to later treatment as an outpatient with inpatient stays becoming progressively shorter.
Later Rehabilitation Interventions
The practice of community reintegration as a therapeutic and treatment paradigm was first embraced in the late 1970s and early 1980s. With dramatic improvements in medical technology and early management of severe traumatic brain injury, increasing numbers of young adult survivors with traumatic brain injury were leaving the inpatient rehab setting still in need of services to help them resume productive lives.
Programs need to address the survivor’s primary obstacles to better function, including significant problems with memory and new learning, poorly regulated behavior, reduced awareness of their own deficits and social impact. They often have trouble generalizing what they learned in one setting to real life situations. Ideally, comprehensive treatment can provide for optimal functioning of the patient.
Some techniques used to help these individuals include assisted employment, job coaching, and supported but independent living in group homes. The rise of rehabilitative medicine in the past 30 years has allowed further support and refinement of community integration models. When medical support is provided by a healthcare provider that looks at functional outcomes and at the complex relationship among biochemical, physical, emotional, cognitive, vocational, behavioral, leisure, and family concerns, the patients chance to achieve better functioning is maximized.
Intensive post-acute brain rehabilitation programs are characterized by the use of an interdisciplinary team with an emphasis upon the successful real life use of each patient’s abilities and skills, whether the program occurs in the patient’s own home or in a transitional residential setting or as part of outpatient programs in community settings. In each setting, successful outcome is measured by the patient’s ability to resume whatever levels of independence at home or at work that are possible, given whatever residual impairments they may have.
This comprehensive level of intervention is necessary for many people who survive a severe traumatic brain injury simply because the range and degree of residual changes in function are so profound in their impact on the patient’s function. In many cases, the injured person does not have obvious physical evidence of brain damage at 6-12 months post injury. This is why it is often called the “silent epidemic”. For most of these people, it will be the combination of cognitive and interpersonal deficits that make independent and successful reintegration into the community very difficult unless highly-orchestrated treatment is provided.
When one follows large groups of young and working-age people with traumatic brain injury for long periods of time, the actual degree of independent involvement in normal activities can vary considerably as can levels of emotional and psychosocial adjustment. The community options range from somewhat restrictive to fully reintegrated.
In general, it appears that for those patients who were able to return to some form of employment or productive activity outside of the home after their injuries, there is good preservation of richness in life with relationships with others, the formation of new friendships, travel and independence related to driving, and the use of community facilities such as cafes, libraries, buses, shopping, movies, restaurants and parks.
For patients who are not able to work, the scope of their community involvement may be less extensive. Contact with peers may occur through community day programs that provide social and educational support or through activities that are organized through family guidance. Memberships in church organizations, taking classes at a local community college, and participation in exercise programs through the YMCA may all be outlets for those who have returned to work and those who have not.
When people with severe brain injury who are not otherwise able to manage most of the basic activities of daily living are not able to live at home, they may benefit from living in a group home. Group homes can be houses in regular neighborhoods and are privately owned and operated. They can house 4-6 adults who have similar needs and are staffed 24 hours a day by trained caregivers.
Some patients are so severely impaired that 24 hour institutional care is the only solution. There can be outings or room to gradually increase one’s level of independence within the setting but there are usually serious behavioral issues or high levels of nursing care present that make successful placement outside of a nursing facility unsafe or unlikely.
Many severely injured patients who were unmarried young men or women at the time of their injury return to the care of their parent and become a part of their parents’ extended community. It isn’t clear where this group of patients will live after the death of their parents. Some may live with siblings, in a group home, or in an assisted living setting with regular contact and support from a case manager, family or friends. There is an increase in the development of dementia in these patients later in life.
The most common method of care is the clinic based, outpatient interdisciplinary treatment program with a dedicated core team, a comprehensive interdisciplinary evaluation phase that precedes treatment, well defined individual and group interventions and some form of work trial, where the integration of strategies and real world function can be fine-tuned. These programs can range from being exceptionally thorough and intense to a rather bare bones framework, but they usually have a strong psychotherapeutic sensibility.
The most comprehensive programs of this type usually have two treatment tracks. One is for those who intend to return to work or school and the other is for improving independence without a return to work as a goal. While both of these subgroups receive an extensive set of individual and group therapies in a full time format, the goals are often different. Family participation is encouraged through individual sessions with the patient or as a family group.
Staff involvement may include daily meetings to plan and prioritize patient care issues and approaches. A daily milieu-based community meeting of patients and therapists to review each person’s progress and issues for the day also occurs. There is a well-developed work trial for those patients capable of returning to work and strong support from vocational rehabilitation counselors on the treatment team. The goal is to help the patient get ready for the next phase of community involvement, mostly by improving functioning in the clinical setting prior to passing the mantle to school personnel or vocational rehab counselors in the community or to the family, patient and nurse case managers who will continue to oversee the case.
A second model of community reintegration is the comprehensive home rehabilitation format. In this model, all screening, evaluation, and treatment occur in the survivor’s home, neighborhood, community and/or place of work. There is no clinical setting and instead there is a flexible group of therapists on the case.
Since 24 hour supervision in the home or community is possible, people can be transitioned to home from acute care facilities or brief rehabilitation stays, no matter how cognitively impaired they are as long as they are medically stable and not physically violent. For some patients, it also means that they do not have to be discharged to a nursing facility if they are still impaired for more traditional outpatient treatment programs.
A third model of community reintegration is primarily an expanded version of vocationally based models. In this model, the patients are encouraged to engage with some kind of productive activity as soon as possible in the outpatient phase of treatment. Physical therapy, occupational therapy, or speech therapy may be provided to address specific deficits seen as obstacles to employment, but the emphasis is on addressing behaviors and strategies having an adverse effect upon work. If depression, anxiety, or other psychological concerns are found to present obstacles to employment, those issues are individually addressed.
The daily work of treating patients whose cognitive problems would otherwise preclude resumption of a normal life must go on. Controversies exist about the usefulness of cognitive retraining; namely, what it is, what mechanisms are at play, and how one measures their usefulness.
Some of the controversy is understandable when some practitioners would put a patient in front of a computer with little therapist intervention or input and would magically claim recovery of function and generalization of skills. However, it has long been possible to teach people how to think more effectively. Directed teaching, for example, has been shown to improve problem solving in people without brain injury.
A recent study was done on a large group of patients with traumatic brain injury. One group of patients was given extensive treatment in their homes and communities focused upon practical skills, while the other group received comprehensive therapy in a traditional clinical setting. The presence or absence of a formal cognitive retraining component made a significant difference to long term functional outcome in this study. The patients who received formal cognitive rehabilitation that targeted higher level cognitive rehabilitation performed better in their homes and communities than those who did not receive the training.
The point of cognitive rehabilitation interventions is not to assume that altered brain functions can be restored through the use of therapies. No one knows what role cognitive rehabilitation techniques may or may not play in the re-establishment of brain pathways. The goal of treatment is to improve the patient’s attention, memory, problem solving or other thinking issues in their everyday life.