Cognitive and Functional Rehabilitation in Brain Injury

1
Cognitive and Functional Rehabilitation in Brain
Injury

• Hilary Siebens, M.D.
• Department of Physical Medicine
• Rehabilitation
• Harvard Medical School
• Spaulding Rehabilitation Hospital
• Boston, Massachusetts

2
Neurosurgical Diagnoses Under Consideration

• Brain Tumors
• Intracranial Hemorrhage (intraparenchymal and
  subdural)
• Severe Traumatic Brain Injury (TBI)
• Subarachnoid Hemorrhage
• Hydrocephalus(primarysecondary)

3
Pathophysiology

• Primary Injury tumor, hemorrhage, diffuse
  axonal injury,contusions
• Secondary Injury ICP, edema, systemic
  factors (hypoxia, hypotension)

4
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
• Neuronal Regeneration
• Synaptic Alterations
• Functional Substitution
• Learning of New Skills Whyte,Rosenthal 1993

5
Definitions in Rehabilitation

• Disease (atherosclerosis in peripheral arteries)
• Impairment - organ level (below the knee
  amputation)
• Disability - person level (inability to walk
  without a prosthesis)
• Handicap - societal level (inability to walk
  up stairs with prosthesis) International
  Classification of Impairment,Disease, Handicap,
  WHO 1980

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Domains of Concern in Rehabilitation

• Medical Stability (goal being acute hospital
  discharge ASAP to right setting with right
  rehabilitation program)
• Understanding of Cognitive Deficits
• Understanding of Behavioral Issues
• Physical Performance Deficits
• Patients Living Environment
• Prevention of Complications(from
  cognitive/behavioral/immobility factors)

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Element of Time

• Recovery/adjustment occurs over a trajectory of
  weeks, months, and years
• Rehabilitation interventions depend on amount of
  time since injury onset

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Medical Stability Issues(1)

• Neurological (seizure prophylaxis, agitation)
• Cardiovascular (central dysautonomias,
  HTN,orthostasis)
• Pulmonary (aspiration, impaired cough)
• Gastrointestinal (swallowing,dehydra- tion,nutri
  tion,GI bleeding,bowel incontinence, elevated
  LFTs)

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Medical Stability Issues(2)

• Dermatologic (pressure sores,rashes)
• Hematological (anemia,coagulopathy)
• Endocrine (pituitary-SIADH/DI, immobilization
  hypercalcemia)
• Genitourinary (infection, incontinence)

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Seizure Prophylaxis in TBI Rationale

• prevention early when seizures may cause greatest
  harm(prevention of seizure-induced edema )
• prevention of loss of employment, accidental
  injury, loss of driving privileges
• medicolegal concerns if not done
• antiepileptic medications may arrest
  epileptogenesis

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Seizure Prophylaxis in TBI Risks

• cognitive effects significant with phenytoin and
  phenobarbital and may be greater than
  carbamazepine (memory etc.)
• possible impairment of neurological recovery
  (documented in animals) in humans during critical
  periods in recovery

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Orthopedic/Musculoskeletal Issues

• Spasticity removal of nocioceptive
  input therapeutic techniques
  medications neurolysis
  orthopedic procedures
  neurosurgical procedures
• Fractures
• Heterotopic Ossification (HO)

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Cognitive Impairments

• Arousal and Attention
• Learning and Remembering
• Frontal Executive Function
• Language
• Visuospatial Perception and Construction

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Cognitive Remediation

• Deemphasis on computer software
• Deemphasis on rote retraining exercises
• More naturalistic approach in real-world,
  community environment training
• More holistic approaches produce most convincing
  outcome data J Whyte,M Rosenthal 1993 in
  DeLisa JA et al Rehabilitation Medicine-Principles
  Practice p.825

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Behavioral Impairments

• Disruptive, combative, disinhibited behavior
• Reduced initiation
• Depression
• Awareness Deficits
• Sexual Dysfunction
• Social Dysfunction Whyte,Rosenthal 1993

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Physical Performance Deficits

• Activities of Daily Living (ADLs)
• Instrumental Activities of Daily Living
  (IADLs)
• Advanced Activities of Daily Living (AADLs)

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Living Environment

• Physical (stairs, bathroom layout, community for
  resource availability)
• Social (intimate, family, friend, and community
  relationships - help or hindrance)
• Financial Supports (personal, community)

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Treatment Settings for Rehabilitation Management

• Acute Care Hospital
• Acute Inpatient Rehabilitation Hospitals
  (Spaulding, etc..)
• Skilled Nursing Facilities (TCU at SRH, units in
  freestanding SNFs)
• Outpatient Rehabilitation Services (MGH, SRH,
  etc..)
• Home Health Services (MGH SRH HH Agency, etc.)

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Research Frontiers

• Medications trend to ABA design rather
  than RCT
• Functional Outcome Measurement
• Traumatic Brain Injury Model System Project

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Research Frontiers Medications

• acute period blocking of neuronal calcium
  channels inhibition of free
  radicals seizure prophylaxis trials
• postacute period dopamine agonists in low
  functioning post -TBI valproic acid for
  maladaptive behavior post -TBI

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Research FrontiersFunctional Outcomes

• Use of Functional Independence Measure (FIM) from
  the Uniform Data System (UDS) includes 13
  motor items includes 5 cognitive/behavioral
  items used in rehabilitation hospitals and
  some nursing homes

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Functional OutcomesBrain Dysfunction - 1990

• UDS Data N 2814 Mean onset(days)
  37 Admit FIM(median) 64 Discharge
  FIM(median) 105 Mean LOS(days)
  42 Discharge to Home 80 Discharge to
  Acute 7 Granger CV et al Am J
  Phys Med Rehabil 19957462-66.

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Functional OutcomesBrain Dysfunction - 1995

• UDS Data Traumatic Non-traumatic N
  7,345 4,493 Mean onset(days) 26
  28 Admit FIM(median) 60 65 D/C
  FIM(median) 101 93 Mean
  LOS(days) 30
  24 Discharge to Home 81 77
  Discharge to Acute 4 8 Fiedler RC
  et al Am J Phys Med Rehabil 19977676-81.

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Functional OutcomesChanges 1990-1995

• Shorter Acute Hospital LOS (37 to 27 days)
• Lower Admission FIM (median 64 to 61)
• Lower D/C FIM(median 105 to 99)
• Shorter Rehabilitation LOS(42 to 28 days)
• Same discharge to Home

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Research FrontiersTBI Model Systems Research

• Multi-center study of outcomes
• Results from data set starting to be published
• Standard data collection from acute
  hospitalization, rehabilitation hospitalization,
  and one year follow-up Dahmer ER et al J Head
  Trauma Rehabil 1993812-25.

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Rehabilitation after Brain Injury

• for more information contact osullivan_at_
  helix.mgh.harvard.edu Spring 1997