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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 ABIincludes 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



R easons 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 axonalSecondary



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 FunctionEndocrine: 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

³It 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 MedicineDefinition:

³implies the restoration of patients to their

fullest physical, mental and social capability

after an episode of illness or trauma´

M air 1972



Rehabilitation

³is 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



Components of RehabilitationProcess

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 & LanguageTherapy

Clinical Psychology

Social Worker



Multiprofessional Rehabilitation Team

I nterprofessional : Role blurring

Communication: Formal & informal Documentation: Common language

Leadership: Co-ordinator

Training : Skills, standards & morale Advocac y: Keyworker / Primary nurse



Aims of Rehabilitation

Promote Intrinsic Recovery

Assist Adaptive Recovery

Prevent Complications

Minimise Eventual Handicap



Promoting Intrinsic R ecovery

Neural Plasticity

± Diaschisis

± Substitution

± Axon sprouting

± Synaptic modulation



Assist Adaptive R ecovery

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 publictransport. 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 outto 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 hospitaldischarge- 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 . N o need of Rehabilitation.

Moderate (intermediate) ± persisting disability but stable & recovery evident.

Likel y to respond to / participate in Rehabilitation

Severe

± immobile, medically unstable, nurse dependent.

Unlikel y 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

Disabilit y related

Spasticity

Continence

Mobility

Pain management

Sexual dysfunction Orthotics

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