April 15, 2011

Rehab for the Brain After Traumatic Injuries

Five questions and answers about traumatic brain injury

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Mary Hibbard, PhDRecent news coverage of pro-football legend Terry Bradshaw’s rehabilitation efforts for brain injuries is the latest in growing attention to Traumatic Brain Injury, with the recent shooting of Rep. Gabrielle Giffords, D-Ariz. as well as wounded service members returning from wars in Afghanistan and Iraq. Mary R. Hibbard, PhD, is a professor of rehabilitation medicine and director of psychology services at the Rusk Institute, New York Langone Medical Center, in New York. Dr. Hibbard serves on the boards of both the American Board of Professional Psychology and American Board of Rehabilitation Psychology and is past president of APA’s Div. 22 (Rehabilitation Psychology). Dr. Hibbard has worked in the field of TBI for several decades and maintains a private practice focused on neuropsychological assessment and interventions with individuals with acquired brain injuries. She has published and presented nationally and internationally in the area of neuropsychology, rehabilitation psychology and traumatic brain injury.

Q: Are all TBI the same?

Dr. Hibbard: The brain is the most complex organ in the body; recovery from injury to the brain depends largely on the areas of the brain damaged. As a result, impairments vary from a mild TBI (which includes events such as a concussion), to a moderate TBI to a severe TBI. This distinction is often ignored in the media, where TBI is often viewed as a single diagnosis with the same pattern of recovery. Recovery from TBI will differ for each individual and is dependent on the severity of the initial injury, the age of the individual at time of injury, and the intensity/timeliness of acute medical and needed rehabilitation interventions.  

Approximately 15 percent of individuals who suffer a TBI will experience a moderate to severe injury. These individuals typically experience a loss of consciousness and/or significantly altered mental state at the time of injury, require hospitalization for medical stabilization and then participate in intensive inpatient and outpatient rehabilitation services. The goals of rehabilitation are to maximize individuals’ functional gains post-TBI and maximize their community participation. Despite intensive interventions, many of these individuals are faced with lifelong physical, emotional and cognitive challenges that impact their maximal return to former community and social roles. 

The remaining 85 percent of people who experience a TBI will experience a mild injury. Often, the terms “mild TBI” and “concussion” are used interchangeably. These individuals typically experience alterations in their neurological state after injury (e.g., mental confusion, headaches, dizziness, visual changes, etc.) and are evaluated in an emergency room or a local doctor’s office. Of these individuals, approximately 85 percent recover fully over the next several weeks to months. Approximately 15 percent of those with mild TBI, however, will experience ongoing physical, cognitive and emotional changes similar to those with more severe TBI. These individuals typically are referred to an outpatient TBI rehabilitation setting for assessment and treatment. The goal of their treatment is to maximize their functioning with the aim of returning to work, school and former community roles. 

Q: Are there common challenges most individuals experience after TBI?

Dr. Hibbard: TBI-related challenges will vary based on the specific areas of the brain impacted by the injury, with predominant injuries in the area of the frontal and temporal lobes of the brain. Many TBIs result from inertial injuries; that is, the impact of the injury results in the brain being rapidly shaken, twisted and stretched. These rapid movements result in more generalized damage, a condition called diffuse axonal injury. Given these common etiologies of TBI, the majority of individuals exhibit a cluster of physical, cognitive and emotional symptoms post-TBI. Physical challenges can include paralysis or weakness, sensory changes (in areas of balance, vision, smell and hearing), impaired sleep patterns, fatigue and problems with language expression or comprehension. Cognitive challenges are the hallmark of TBI and typically include problems with attention and concentration, impaired memory and learning, slowed processing speed, and reduced problem-solving abilities. Emotional and behavioral challenges are also common and can include delayed onset of depression and/or anxiety, as well as problems with anger management, irritability and difficulty with emotional control. 

Q: Is there an expected course of recovery from TBI?  In the case of Rep. Gabrielle Giffords, for example, has her recovery progressed in a typical fashion?

Dr. Hibbard: Long-term recovery from TBI is dependent on many factors. Important considerations are the initial severity of the TBI, the areas of the brain impacted, the intensity of acute care received and the timeliness of needed rehabilitation. Additional factors such as the age of the individual at time of injury, the presence of a supportive family, the individual’s coping abilities, and their degree of personal resilience also play important roles in long-term adjustment and recovery following TBI.

Similar to those with other chronic illnesses, individuals with TBI typically require ongoing professional help by TBI rehabilitation specialists to ensure maximal recovery. According to media reports, Gabrielle Giffords experienced a significant brain injury. Excellent and timely medical interventions clearly enhanced her emergence from coma. Her early involvement in intensive TBI rehabilitation efforts, her supportive family and her own resilience have served and will continue to serve her well in her ongoing recovery process. It can be anticipated that Ms. Giffords will require ongoing rehabilitation as an outpatient to maximize her community reentry.

Q: Why is an interdisciplinary rehabilitation approach necessary for maximal treatment of individuals with TBI?

Dr. Hibbard: Research has shown that a comprehensive, interdisciplinary team approach to TBI treatment is the most effective means of addressing the diversity of needs of a person with a TBI. The major focus of TBI rehabilitation efforts is to provide intensive interventions aimed at acquired physical, cognitive and emotional impairments secondary to the TBI, while teaching compensatory approaches to augment identified physical, cognitive and emotional limitations post-TBI. All interventions are aimed at maximizing the functional independence of the person. Family members are viewed as key members of the rehabilitation team. 
Individuals with TBI are typically treated in either inpatient rehabilitation facilities, outpatient facilities or both. The TBI rehabilitation team involves a number of professionals working as a closely knit team who identify and treat the physical, cognitive and emotional changes experienced by the individual.   The inpatient TBI rehabilitation team consists of the patient and their family, a physiatrist (i.e., a doctor who specializes in rehabilitation medicine), rehabilitation nurses, rehabilitation psychologists, physical therapists, occupational therapists, speech-language pathologists, social workers and recreational therapists. The TBI team in the outpatient setting consists of many of the same professionals; however, the individual’s program is custom designed to address focused TBI-related rehabilitation needs.

In inpatient and outpatient settings, physical therapists address mobility, balance, and fine motor issues as well as the activities of daily living impacted by mobility issues. Occupational therapists address upper extremity mobility, visual disturbances, and activities of daily life impacted by underlying physical or cognitive impairments. Speech pathologists focus on communication breakdowns and cognitive underpinnings of communication impacted by the TBI. Social workers work closely with the family as the family prepares for discharge and community re-entry of their loved one. 

Q: What are the specific roles of the rehabilitation psychologist in TBI rehabilitation?

Dr. Hibbard: Rehabilitation psychologists in both the inpatient and outpatient TBI rehabilitation facilities assess an individual’s cognitive strengths and weaknesses as well as emotional/behavioral and adjustment issues. They will assess family coping as well. Cognitive and emotional assessments are typically repeated by the psychologist to monitor improvements in an individual’s functioning and shape future interventions by the psychologist and/or other rehabilitation team members. Based on assessment findings, the psychologist works with the individual and/or family to maximize their adjustment to TBI, educate about TBI and teach behavioral management strategies. The psychologist works closely with other treating team members to modify treatment approaches so as to maximize an individual’s recovery. Rehabilitation psychologists typically intervene with identified cognitive, behavioral challenges and mood disturbances, i.e., depression and anxiety that often emerge for either the individual or family during the course of TBI recovery.

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