Acquired Brain Injury Early rehabilitation and long term outcome

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 Diffuse axonal Secondary 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 Intracranial Haematoma Early Epilepsy Depressed Fracture Prolonged PTA 33-50% 25-30% 25% 15% 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 – – – – – – – – Falls Pressure Sores Urinary infection Chest Infection Musculoskeletal DVT Epilepsy Constipation • PSYCHOLOGICAL – Communication • dysphasia/intelligibility – Cognition • confusion/memory – Behaviour • agitation/apathy – Emotion • depression/lability 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 • • • • • • Spinal cord injury Brain injury Stroke Multiple sclerosis Muscular Dystrophy Neuro-oncology Disability related • • • • • • Spasticity Continence Mobility Pain management Sexual dysfunction Orthotics