Neurorehabilitation for Traumatic Brain Injury

Daniel Friedland, M.A. Clinical Psychology, Consultant Clinical Psychologist/Neuropsychologist, Registered Clinical Psychologist with the HCPC, Full Practitioner Member of the Division of Neuropsychology

Introduction
Traumatic brain injury (TBI) has been defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force.1 Alteration in brain function includes amnesia for events before the injury (retrograde amnesia), amnesia for events following the injury (post-traumatic amnesia), loss or decreased consciousness following the injury, and neurological deficits (change in vision, aphasia). Evidence of brain pathology includes the results of neuroimaging.

TBI can be divided into two main categories: mild TBI (mTBI) and moderate-severe TBI. mTBI is generally defined as one in which the individual does not lose consciousness for more than 30 minutes, post-traumatic amnesia does not exceed 24 hours, and the individual’s Glasgow Coma Scale score is 13/15 within 30 minutes of the injury. If any of the above criterion are exceeded, or there are trauma-related abnormalities on neuroimaging, then the TBI tends to fall into the moderate-severe range.2

Why is the distinction between mild versus moderate-severe TBI so important? Cognitive difficulties following mTBI have been shown to be short- lived whereas cognitive difficulties following moderate-severe TBI can be temporary, prolonged or permanent. Cognitive difficulties which persist following mTBI are hypothesised to be caused by non-TBI factors including chronic pain, depression, post-traumatic stress disorder, and malingering.3

Rehabilitation of mild traumatic brain injury (mTBI)
Early education is considered an important element of managing mTBI. This can occur as early as the first admission to the A & E Ward following the mTBI. This usually takes the form of head injury advice sheets. Rest and graded return to activity following a mTBI are also important elements in the recovery process. According to SIGN guidelines all patients who have suffered a mTBI should be offered reassurance about the nature of their symptoms and advice on gradual return to normal activities after an uncomplicated mTBI.4 This early education and treatment approach following mTBI would tend to fall under the NHS auspices within the UK.

Specific treatments for mTBI at the later stages includes pharmacotherapy, cognitive rehabilitation, and psychological therapy. In terms of pharmacotherapy, studies have looked at the effectiveness of medication for headaches, as well as depression, and anger. Cognitive rehabilitation involves looking at cognitive compensatory strategies for memory difficulties, and strategies for managing planning and problem solving difficulties. The most researched psychological
therapy is cognitive behavioural therapy.5 According to the SIGN guidelines a referral for cognitive behavioural therapy following mTBI should be considered in patients with persistent symptoms who fail to respond to reassurance and encouragement from a GP after three months.4 There is growing interest in identifying oculomotor and vestibular disturbances in individuals with persistent symptoms following mTBI, and treating these specific difficulties.6

It is important to note that in general by the time an individual who has suffered a mTBI is seen for treatment in the medico-legal process the presentation can be quite complex. Treatment can be challenging, and the key is trying to determine the causes of the symptoms e.g. chronic pain, disrupted sleep, vestibular issues, low mood, anxiety, or a combination of these factors and to target these factors in the neurorehabilitation process.

Rehabilitation of moderate-severe traumatic brain injury
There are a wide range of outcomes following moderate-severe TBI. This includes death, low awareness state, severe physical and cognitive impairment, severe cognitive impairment, neuropsychiatric impairments, mild cognitive difficulties, or a full or almost complete recovery.

Neurorehabilitation can occur at the acute stage following a TBI in hospital, in the in-patient setting, and in the community. Community rehabilitation can include out-patient sessions, sessions within the home, group sessions, or combinations of  neurorehabilitation in these different community settings. In terms of neurorehabilitation in the community, there is evidence of beneficial outcome for patients with TBI who have access to the following: firstly, interdisciplinary rehabilitation. This can include neurology, consultants in rehabilitation medicine, neuropsychiatry, neuropsychology, neuro-occupational therapy, and
neuro-physiotherapy. Case management and support worker input can also be invaluable in neurorehabilitation, particularly when the individual has significant cognitive difficulties and/or neurobehavioural impairments. Secondly, on-going family and carer support. Thirdly, neuropsychology rehabilitation which focuses on
the management of cognitive, psychological, and neurobehavioural impairments with both clients and the family. Fourthly, community rehabilitation which may even be beneficial many years post injury.4

Neurorehabilitation should have regular goal setting between client and the team which is regularly reviewed.7 However, flexibility is required and some clients do not respond well to goal setting. It can require lots of skill to even keep these clients engaged in neurorehabilitation process.

It is important not to underestimate the degree to which a TBI leads to identity changes. As one client recently said “In an instant you become a different person”. TBI leads to reduced self-esteem, loneliness, depression.8 Young adults fall behind their peers which leads to loss of self-esteem. The key is to try and help the client engage in meaningful activities to build up their self-esteem.

In terms of cognitive difficulties, memory strategies predominantly include compensatory strategies i.e. the use of diaries, smartphones, calendars to help one’s client manage their prospective memory difficulties. Executive difficulties include difficulties with organising, planning and problem solving, sequencing, and thinking in a flexible manner. Executive difficulties are particularly challenging in neurorehabilitation. There is some evidence to suggest that training in formal problem solving strategies and their application to everyday situations can be beneficial. Group based programmes may also be considered for the remediation of executive and problem solving deficits.9

Neurobehavioural impairments can include a range of difficulties including disinhibited behaviour (impulsive behaviour, verbal outbursts, physical aggression, swearing), apathy (loss of drive, loss of spontaneity). In terms of disinhibited behaviour this can be managed through a combination of medication and individual sessions to manage disinhibited behaviour more effectively (provided the client has sufficient insight). The wider system may also need to be included in terms of managing disinhibited behaviour. Apathy is particularly hard to rehabilitate successfully, and unfortunately the prognosis is often poor.

TBI is linked to an increased rate in depression and anxiety.10 The key therapy is Cognitive Behavioural Therapy which helps the client try and challenge negative thinking. Acceptance and Commitment Therapy is a relatively new type of therapy which encourages the client to adopt a more compassionate approach to their feelings and negative thoughts. The combination of medication and therapy must also be considered in conjunction with Neuropsychiatry.

TBI affects the whole family. The family responses include various stages including: initial shock, emotional relief one the family member has survived, bargaining, acceptance or working through, and finally acceptance and restructuring . Spouses/partners take on more of a parental role. There is a high rate of marital breakdown following moderate-severe TBI i.e. approximately 30% but other studies point to rates of up to 78%.8

There are several ways to help families. This includes family education about brain injury, support groups for family members, family therapy, and couples counselling. The needs of children are often neglected, and play therapy may be appropriate for young children to help them adjust. The key is to engage family in the rehabilitation process but also to encourage independence in the individual who has sustained the TBI.8

Further aims of neurorehabilitation include reducing risk. This includes reducing the risk of depression, offending/prison, being taken advantage of financially, and relationship/family breakdown. These outcomes are less easy to measure but are crucial parts of the neurorehabilitation process.

An important question is why can neurorehabilitation “fail”? There various reasons including the client not being ready to engage in the neurorehabilitation process, a lack of co-ordinated team approach, complex family dynamics, and severity of deficits/lack of insight. Malingering is another factor which needs to be considered if neurorehabilitation is not working in situations where it would be expected that improvement should occur.

The role of neurorehabilitation in the medico-legal setting
Neurorehabilitation in the medico-legal setting is important for several reasons. Firstly, the process of neurorehabilitation can help identify neuropsychological impairments more clearly in the functional setting than in a standard cognitive assessment. This is particularly the case for executive difficulties i.e. difficulties with planning and problem solving, organising, and self-monitoring. These executive difficulties manifest more clearly in day-to-day functioning then in standard
cognitive testing, and the process of neurorehabilitation can help identify the issues more clearly.11

The Mental Capacity Act (2005) has identified the stages required in order to determine whether an individual has capacity with regards to a specific decision. This includes being able to understand the information about which the decision needs to be made, the individual needs to be able to retain the information, they need to be able to weigh the information as part of the decision making process, and they need to communicate this decision.12 Determining capacity in medico-legal cases has become a central issue, and in particular the capacity to litigate, and the capacity to manage financial affairs. Capacity to manage financial affairs, or rather the lack of capacity to manage financial affairs has a significant impact on costs awarded. Consideration of how the individual has participated in the neurorehabilitation process can be particularly helpful in helping decide on capacity issues. In terms of financial capacity, neurorehabilitation often focuses on this area, and can therefore provide useful information for the Expert in terms determining capacity issues.

Prognosis is a key issue in medico-legal cases. Recovery following traumatic brain injury depends on numerous factors including age of the individual, the severity of the traumatic brain injury, premorbid intelligence, and polytrauma.13 However, the impact of neurorehabilitation is another factor which has an impact on recovery following traumatic brain injury. Thus, the outcome following neurorehabilitation can be a crucial factor in determining the prognosis for the individual following a traumatic brain injury.

Conclusions
Diagnosing the severity of the TBI is the crucial first step in the neurorehabilitation. This will guide the neurorehabilitation process required as outlined above. This can sometimes be fairly straightforward particularly in cases of severe TBI. This can be more complicated in cases where it is not clear whether the client has sustained a mild or moderate TBI. Neuroimaging can be helpful in this regard particularly if trauma-related abnormalities are found on neuroimaging, which would point to a moderate TBI. In cases where a definitive answer cannot be reached treatment of symptoms may be the most pragmatic way forward.

In terms of neurorehabilitation it is important to note what client’s value. Carlozzi (2011) sought views from clients who sustained a TBI, as well as care- givers and clinicians in focus groups. Health related quality of life results were in the following order. Firstly emotional health e.g. anxiety/depression/anger. Secondly, improved social participation e.g. relationships/leisure/vocation. Thirdly, physical/medical health e.g. fatigue/pain/motor functioning. Fourthly, cognitive health e.g. executive functioning/memory. Finally, managing personality change e.g. self centredness/impatience/impulsivity/ lack of empathy.14 These are key areas that any neurorehabilitation team needs to keep in mind when setting goals with clients and families.

It is important to be realistic what we can achieve in neurorehabilitation. Return to work and positive relationships are important goals, otherwise the neurorehabilitation can focus on increased community participation. Management of risk is essential in the neurorehabilitation process. Finally we need to help clients rebuild their identities, as well as helping families cope in a new and challenging situation.

Reference List
1. Menon DK, Schwab K, Wright DW, Maas AI. Position statement: definition of TBI. Arch Phys Med Rehabil. 2010 91:1637-40

2. Malec J, Brown W, Leibson L, et al (2007). The Mayo Classification System for TBI Severity. Journal of Neurotrauma. 2007 24:1417-24.

3. McCrea, M; (2008) Mild TBI and Postconcussion Syndrome: The New Evidence Base for Diagnosis and Treatment Oxford University Press, New York.

4. Scottish Intercollegiate Guidelines Network (2013). Brain injury rehabilitation in adults A national clinical guideline. SIGN: Edinburgh

5. Comper P Bischop SM, Carnide N, Tricco A. A systematic review of treatments for mild traumatic brain injury Brain Inj . 2005; 19:863-80.

6. Friedland, D. Postconcussion syndrome/disorder or mild traumatic brain injury: diagnostic issues and treatment. Advances in Clinical Neuroscience & Rehabilitation, Volume 15, March/April 2015, p26-27

7. Royal College of Physicians and British Society of Rehabilitation Medicine. Rehabilitation following acquired brain injury: national clinical guidelines (Turner-Stokes L, ed.). London: RCP, BSRM; 2003

8. Ponsford, J.L., Sloan, S.M., Snow, P.C., 2013, Traumatic brain injury Rehabilitation for everyday adaptive living, Psychology Press, Hove, East Sussex and New York.

9. Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, et al. Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil 2005;86(8): 1681-92

10. Bryant RA, O'Donnell ML, Creamer M, McFarlane AC, Clark CR, Silove D. The psychiatric sequelae of traumatic injury. Am J Psychiatry. 2010 Mar;167(3):312-20

11. Manchester, D., Priestley, N.M. & Jackson, H. (2004). The Assessment of Executive Function: Coming out of the Office. Brain Injury v18 no.11 pp1067-1081.

12. Mental Capacity Act (2005) Code of Practice (2007) London

13. Lezak,M; Howieson,D; Bigler,E; and Tranel,D. (2012) Neuropsychological Assessment (Fifth Edition). Oxford University Press

14. Carlozzi N, et al Health-Related Quality of Life in Caregivers of Individuals With Traumatic Brain Injury: Development of a Conceptual Model. Arch Physical
Medicine. 2015 Volume 96, Issue 1, p105–113 

Mr Daniel Friedland runs the Neurorehab Clinic at PPCS and has been working in neurorehabilitation since 1999. The PPCS Neurorehab Clinic provides assessment and neurorehabilitation for individuals who have suffered an acquired brain injury including traumatic brain injury, stroke, hypoxic brain injury, and neurological infections. We have access to Neuropsychiatry, Psychiatry, Neuropsychology, and Clinical Psychology within our service. We have excellent external links with Neurologists, Neuroradiologists, Case Management Services, and Support Worker Agencies. Mr Friedland also acts as an expert witness in medico-legal claims.

For further information regarding PPCS and the
Neurorehab Clinic:
Website: http://www.ppcsltd.co.uk
Telephone: 0207 9350640
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.