Acquired Brain Injury

Early rehabilitation and long term outcome

British Society for Disability and Oral Health

B Pentland
 Acquired Brain Injury
Definition: An injury to the brain that has occurred since
birth. It may have been caused by an external physical
force or by a metabolic disorder(s). The term ABI
includes traumatic and nontraumatic brain injuries (such as
those caused by strokes, tumours, infectious diseases,
hypoxic injuries, metabolic disorders and toxic products
taken into the body through inhalation or ingestion.
Abbreviated from Commission for Accreditation of
Rehabilitation Facilities (CARF), 1999
 Acquired Brain Injury
• Traumatic brain injury (TBI)
• Haemorrhagic brain injury (HBI)
• Vascular brain injury (VBI)
• Anoxic (& metabolic) brain injury (ABI)
• Infective brain injury (IBI)
 Epidemiology of Head Injury
• 2,000 people /100,000/year attend hospital
• 300 of these will be admitted
• Prevalence of significant disability
estimated at 150/100,000
 Epidemiology of Head Injury
• Age: 15-25 years
• Sex: M:F ~ 3:1
• Causes: Falls
Road Traffic Accidents
Assault
Sports
Work
• Alcohol: ~ 50%
 International Classification of Diseases(ICD)
Codes for Head Injury

Fracture of skull, spine & trunk

N800: Fracture vault of skull
N801: Fracture of base of skull
N802: Fracture of face bones
N803: Other & unqualified fractures
N804: Multiple fractures including skull or face with other bones
Intracranial injury (excluding those with skull fracture
N850: Concussion
N851: Cerebral laceration and contusion
N852: Subarachnoid, subdural & extradural haemorrhage after injury
N853: Other and unspecified intracranial haemorrhage after injury
N854: Intracranial injury of other and unspecified nature
 Reasons for decline in head injury from
RTA in recent years

• Vehicle design
• Airbags & seat belts
• Motorcycle helmets
• Road design
• Speed limits
• Drink driving legislation
 Mechanisms of Injury
• Focal
• Polar
• Diffuse axonal
• Secondary insults
Focal Polar

Secondary
Diffuse axonal
 Neurological Sequelae of Brain Injury

Cranial Nerves: Anosmia; Vision; Diplopia/Strabismus;

Hearing & Balance
Motor: Paralysis (mono-, hemi-, quadriplegia); Ataxia;
Dyspraxia
Sensory: Anaesthesia; Abnormal Sensations; Pain syndromes
Autonomic: Bladder; Bowels; Cardiovascular; Respirartory;
Gut; Sexual Function
Endocrine: Pituitary Dysfunction
Spinal Cord Injury
Peripheral Nerve Injury
Medical & Orthopaedic Sequelae of Head Injury

• Skin: pressure sores; excess sweat

• ENT
• Chest: infection,emboli,injury
• Gut: ulcers
• Vascular: DVT
• Endocrine: amenorrhoea
• Fractures
• Heterotopic ossification
 Post-traumatic Epilepsy: Classification

• EARLY :within one week of injury

– Immediate = within 24 hours
– Delayed early = within 1 day to 1 week
• LATE : after first week post injury
 Risk factors-Post-traumatic Epilepsy

• Penetrating (Missile) injury 33-50%

• Intracranial Haematoma 25-30%
• Early Epilepsy 25%
• Depressed Fracture 15%
• Prolonged PTA 35%
 Post Head Injury Behaviour
• Premorbid Factors
• Effects of Injury
• Environmental Factors
 Post Head Injury Behaviour
• Premorbid Factors
– mental constitution
– personality
– antisocial behaviour
– alcohol/ substance abuse
– family dynamics
“It is not only the kind of injury that matters,
but the kind of head” Symonds 1937
 Post Head Injury Behaviour
• Effects of Injury
– Site of damage
– Extent of damage
– Emotional reaction to injury
– Epilepsy
• Environmental Factors
– Interpersonal relationships (staff, family, friends)
– Occupation / Leisure
– Litigation
 Frontal Lobe Syndromes
• Disinhibition
• Memory Impairment
• Apathy
• Anosmia
• Adversive seizures
• Grasp reflex
• Expressive dysphasia
 Temporal Lobe Syndromes
• Dominant lobe
– Dysphasia (receptive)
– Dyslexia
– Dysgraphia
• Amnestic syndrome
• Epilepsy: complex partial seizures
 Wernicke-Korsakoff Syndrome

• Wernicke
– Abnormal eye movements
– Ataxia
– Confusion
• Korsakoff
– Recent memory loss
– Confabulation
– Disorientation
 Pharmacological Interventions in Brain Injury

• Depression/anxiety/emotional lability
• Agitation
• Apathy/low arousal
• Spasticity
• Epilepsy
• Pain
• Bladder & Bowels
• Infection & concurrent illnesses
Early Rehabilitation

Definition & Practice

 Rehabilitation Medicine
Definition:

“implies the restoration of patients to their

fullest physical, mental and social
capability after an episode of illness or
trauma”
Mair 1972
 Rehabilitation

“is one of those words which have meaning

for most people who use them but the
meaning of which is not only universal
but may vary from sentence to sentence
with the same user”
Licht S 1968
 Rehabilitation
• Continuum from onset to community
– Starts from first contact between patient & professionals
– not a separate process from quality medical care
• Communication
– Patient & Family
– Interprofessional
• In-patient Team
• Primary & Secondary Care
Components of Rehabilitation
Process
• Assessment
• Formulation of Rehabilitation Plan
• Implementation of Plan
• Review & Modification of Plan
• Discharge Arrangements
 Assessment
• Cognitive, Emotional, Behavioural
• Communication & swallow
• Physical: neurological & general
• Activities of daily living
• Housing
• Employment/education
• Leisure
• Family & carer needs
Core Rehabilitation Team
• Medical
• Nursing
• Physiotherapy
• Occupational Therapy
• Speech & Language Therapy
• Clinical Psychology
• Social Worker
Multiprofessional Rehabilitation Team

• Interprofessional: Role blurring

• Communication: Formal & informal
• Documentation: Common language
• Leadership: Co-ordinator
• Training: Skills, standards & morale
• Advocacy: Keyworker / Primary nurse
Aims of Rehabilitation

• Promote Intrinsic Recovery

• Assist Adaptive Recovery
• Prevent Complications
• Minimise Eventual Handicap
 Promoting Intrinsic Recovery

• Neural Plasticity
– Diaschisis
– Substitution
– Axon sprouting
– Synaptic modulation
 Assist Adaptive Recovery

• Teach new ways of achieving function

– use of non-dominant hand
– use of diary
– breakdown of complex tasks
• Aids & Adaptations
 Aids & Adaptations
• Walking stick-FES
• Wheelchair independence
• Pen & Paper-Computer
• Car adaptations
• Housing adaptations
• Access to work & leisure activities
 Prevent complications
• PHYSICAL • PSYCHOLOGICAL
– Falls – Communication
– Pressure Sores • dysphasia/intelligibility
– Urinary infection – Cognition
• confusion/memory
– Chest Infection
– – Behaviour
Musculoskeletal
• agitation/apathy
– DVT
– Emotion
– Epilepsy • depression/lability
– Constipation
Secondary Prevention of Stroke
• Antiplatelet therapy
• Anticoagulation
• Hypertension
• Hyperlipidaemia
• Cigarettes/ alcohol
• Obesity
• Stress
Discharge Planning
• Home assessment/home pass
• Safety judgement
• Self-medication ability
• Team meeting
– patient & family
– community staff (health & social)
• Documentation
Long Term Outcome

Post hospital & longer term

 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 with only one activity-dressing, going out
to shop.
• Vegetative State
• Dead
Factors influencing outcome
• Nature of ABI
– infarct vs. haemorrhage
– unilateral vs. bilateral/ brainstem
– extent of brain damage
• Premorbid health(physical & mental)
• Family support
• Age
 Issues related to age
• Employment
• Dependants
• Patient & family reactions to services
geared to the elderly
• Driving
• Sex
• Exercise
 Longer term problems
• How long should physiotherapy etc
continue?
• Adjustment reactions change over time for
both patient & carer
• Psychosocial problems may become evident
or prominent many months after hospital
discharge- who deals with this?
 Post-Concussional Disorder (DSM IV)

• A: History of head trauma-cerebral concussion

• B: Difficulty in Attention or Memory (on testing)
• C: 3 or more of following- shortly after trauma &
lasting 3 months
– easily fatigued; disordered sleep; headache;
vertigo / dizziness; irritability / aggression;
anxiety / depression / lability; change in
personality
 Agencies involved
• Health
• Social Work
• Education
• Employment
• Housing
• Voluntary
 Triage of Rehabilitation
• Mild
– rapid physical recovery . No need of Rehabilitation.
• Moderate (intermediate)
– persisting disability but stable & recovery evident.
Likely to respond to / participate in Rehabilitation
• Severe
– immobile, medically unstable, nurse dependent.
Unlikely to respond to / participate in Rehabilitation
Organisation of Rehabilitation Medicine
Services
Disease related Disability related
• Spinal cord injury • Spasticity
• Brain injury • Continence
• Stroke • Mobility
• Multiple sclerosis • Pain management
• Muscular Dystrophy • Sexual dysfunction
• Neuro-oncology • Orthotics