Transcript Cognitive and Functional Rehabilitation

Cognitive and Functional
Rehabilitation in Brain Injury
Hilary Siebens, M.D.
Department of Physical Medicine
& Rehabilitation
Harvard Medical School
Spaulding Rehabilitation Hospital
Boston, Massachusetts
Neurosurgical Diagnoses Under
Consideration
Brain Tumors
 Intracranial Hemorrhage

(intraparenchymal and subdural)
Severe Traumatic Brain Injury (TBI)
 Subarachnoid Hemorrhage
 Hydrocephalus(primary&secondary)

Pathophysiology

Primary Injury
tumor, hemorrhage, diffuse axonal
injury,contusions

Secondary Injury
ICP, edema, systemic factors
(hypoxia, hypotension)
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

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
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
 Patient’s Living Environment
 Prevention of Complications(from

cognitive/behavioral/immobility factors)
Element of Time

Recovery/adjustment occurs over a
trajectory of weeks, months, and years

Rehabilitation interventions depend on
amount of time since injury onset
Medical Stability Issues(1)
Neurological (seizure prophylaxis, agitation)
 Cardiovascular (central dysautonomias,

HTN,orthostasis)
Pulmonary (aspiration, impaired cough)
 Gastrointestinal (swallowing,dehydra
tion,nutrition,GI bleeding,bowel incontinence,
elevated LFTs)
Medical Stability Issues(2)
Dermatologic (pressure sores,rashes)
 Hematological (anemia,coagulopathy)
 Endocrine (pituitary-SIADH/DI, immobilization

hypercalcemia)

Genitourinary (infection, incontinence)
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

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

Orthopedic/Musculoskeletal Issues

Spasticity
removal of nocioceptive input
therapeutic techniques
medications
neurolysis
orthopedic procedures
neurosurgical procedures
Fractures
 Heterotopic Ossification (HO)

Cognitive Impairments
Arousal and Attention
 Learning and Remembering
 Frontal Executive Function
 Language
 Visuospatial Perception and
Construction

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
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)
Living Environment

Physical (stairs, bathroom layout,
community for resource availability)

Social (intimate, family, friend, and
community relationships - help or hindrance)

Financial Supports (personal, community)
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.)
Research Frontiers

Medications
trend to ABA design rather than RCT

Functional Outcome Measurement

Traumatic Brain Injury Model System
Project
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
Research Frontiers
Functional 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
Functional Outcomes
Brain Dysfunction - 1990

UDS Data
N
Mean onset(days)
Admit FIM(median)
Discharge FIM(median)
Mean LOS(days)
Discharge to Home
Discharge to Acute
2814
37
64
105
42
80%
7%
Granger CV et al Am J Phys Med Rehabil
1995;74:62-66.
Functional Outcomes
Brain Dysfunction - 1995

UDS Data
N
Traumatic
7,345
Mean onset(days)
Admit FIM(median)
D/C FIM(median)
Non-traumatic
4,493
26
60
101
28
65
93
Mean LOS(days)
Discharge to Home
30
81%
24
77%
Discharge to Acute
4%
8%
Fiedler RC et al Am J Phys Med Rehabil
1997;76:76-81.
Functional Outcomes
Changes 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

Research Frontiers
TBI 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 1993;8:1225.
Rehabilitation after Brain
Injury
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for more information contact
[email protected]
Spring 1997