Rehabilitation Following Acquired Brain Injury

Rehabilitation PSY3CNN

Acquired Brain Injury (ABI)

  • Dr. Dana Wong, Associate Professor & Clinical Neuropsychologist

Learning Objectives

  • Demonstrate understanding of:
    • The key cognitive, emotional, and behavioral sequelae of acquired brain injury (ABI).
    • Activity limitations and participation restrictions associated with these impairments, in the context of the World Health Organization International Classification of Functioning (WHO ICF) model.
    • Processes & mechanisms of recovery from ABI.
    • Principles of person-centered, evidence-based neuropsychological rehabilitation for people with ABI.

Types of Acquired Brain Injury (ABI)

  • Trauma: Road traffic accidents, falls, gunshot wounds, sports-related injuries, military actions, physical violence, and other injuries caused by physical or penetrative trauma.
  • Strokes: Blood clots, bleeding in the brain, blocked vessels etc.
  • Tumours: Benign tumours, cancers etc.
  • Hypoxia/Anoxia: Lack of oxygen to the brain.
  • Infections: Infections leading to inflammation, e.g. encephalitis/meningitis etc.
  • Toxic/Metabolic Disorders: Toxic effects of alcohol/toxins on the brain, e.g. abuse of alcohol/illegal drugs.
  • Degenerative: Multiple Sclerosis (MS), Huntington's Disease, Parkinson's Disease, Alzheimer's Disease
  • Seizures

Traumatic Brain Injury (TBI)

  • "An alteration in brain function, or other evidence of brain pathology, caused by an external force" - Brain Injury Association of America, 2011

Pathophysiology of TBI

  • Blunt trauma associated with acceleration or deceleration forces results in a combination of translation and rotation.
  • This may cause scalp laceration, skull fracture and/or shifting of the intracranial contents.

Indicators of Severity of Injury

  • Duration of Coma
  • Depth of Coma
  • Duration of Post Traumatic Amnesia
  • Duration of Retrograde Amnesia
  • Evidence on CT scans
  • Evidence on MRI scans
  • Neurological deficit

Post-Traumatic Amnesia (PTA)

  • Period of confusion and inability to lay down new memories, following emergence from coma.
  • Duration of PTA is measured from the time of injury until recovery from amnesia, i.e. it includes the period of coma.
  • Of all the indicators of TBI severity, PTA is the strongest predictor of functional outcomes (e.g. independence, return to work).

Traumatic Brain Injury Outcomes

  • Cognitive changes: Difficulties with attention, processing speed, memory, executive functions (planning, goal-directed behavior, abstract reasoning, impulse control), self-awareness, social cognition & emotion perception.
  • Emotional changes: Mood swings, reduced emotional control, depression, anxiety, blunted or inappropriate affect.
  • Behavioral changes: Irritability, aggression, reduced frustration tolerance, impulsivity, disinhibition, socially inappropriate behaviors, apathy.

Stroke

  • Types:
    • Ischemic
      • Thrombosis: Clot in carotid artery extends directly to middle cerebral artery
      • Embolism: Clot fragment carried from heart or more proximal artery
      • Hypoxia: Hypertension and poor cerebral perfusion: border zone infarcts, no vascular occlusion
    • Hemorrhagic
      • Subarachnoid hemorrhage (ruptured aneurysm)
      • Intracerebral hemorrhage (hypertensive)

Stroke Outcomes

  • Cognitive changes: Difficulties with memory, attention, communication, visuoperceptual & visuospatial skills, praxis, executive functions, social cognition and emotion perception.
  • Emotional changes: Depression, anxiety, emotional lability (inappropriate or uncontrollable laughing or crying), reduced emotional control.
  • Behavioral changes: Apathy, impulsivity, irritability, aggression, reduced frustration tolerance, socially inappropriate behaviour.

Functional and Psychosocial Outcomes Following ABI

  • Reduced independence in daily activities
  • Unemployment / changed duties
  • Reduced participation in study/training
  • Reduced leisure activities
  • Social isolation
  • Difficulty with new/existing personal relationships
  • Depression, anxiety, loss of self-worth
  • Sexuality issues

Causes & Predictors of Depression & Anxiety After ABI

  • Directly related to brain injury
    • Site of damage (frontal, limbic regions, right hemisphere)
    • Disruption to neural networks & neurotransmitter systems involved in emotion regulation, initiation, motivation, etc.
  • Secondary factors associated with brain injury
    • Social isolation (poor social skills, loss of friends, reduced leisure activities)
    • Reduced independence
    • Change of identity & roles within family, workplace, community, etc.
    • Grief and loss reactions
    • Increasing insight into changed future
    • Cognitive inflexibility & concrete thinking style
    • Body image changes
    • Medication side effects
  • Premorbid factors
    • Previous psychological problems (e.g., history of depression and anxiety)
    • Personality factors
    • Coping styles
    • Substance abuse
    • (Lack of) family/social supports

Loss

  • I can’t ___ anymore
    • Walk
    • Talk
    • Think
    • Work
    • Socialise
  • And so I am
    • Worthless
    • Incompetent
    • Unlovable
    • Vulnerable

The Flipside: Post-Traumatic Growth

  • Included:
    • Having a sense of personal meaning (purpose & coherence)
    • High life satisfaction now
    • Social support
    • Activity levels
    • A high number of life events
    • Having pal new stable relationships after injury
    • Milder disability
    • Having religious faith
  • Having a high level of "purpose" best predictor of PTG.
  • There was no change in PTG between and 13 years after injury suggesting PTG is a relatively phenomenon once established after the early years.
  • Clinicians should be aware of PTG and how it is associated factors such as "meaning" and "purpose" as well as dental factors such as, social support, activity such as work, new and stable relationships, milder disability and a shift to spiritual values.
  • Clinicians can focus advice, resource and on supporting these developments.

Mechanisms of Injury & Recovery

  • “Neuroplasticity” refers to the ways in which neurons change their interactions with one another
  • Factors influencing ability of neurons to block degeneration and optimise neuroplasticity:
    • Age
    • Type of cell damaged (cells with short axons more vulnerable than those with longer axons)
    • Distance of lesion from cell body (greater distance = better recovery)
    • How many axon branches there are (more intact branches = better survival)
    • Presence of neurotrophic factors provided by healthy neighbouring cells or astrocytes

Mechanisms of Recovery

  • Spontaneous recovery: occurs to lesion area (through resolution of oedema, intracranial pressure etc)
  • Restoration / Adaptation: Neural pathways are reorganised within damaged area or through adaptation of nearby circuits. Neural pathways are restored through neuronal regeneration.
  • Compensation: Functions of these new pathways are adapted. Ability to form compensatory pathways depends on size of lesion & extent of local connectivity
  • Althoughitistheoreticallypossibleforlostfunctionstocompletelyreturninaplasticbrain,carefulbehaviouralanalysisshowsthisisrarely,ifever,thecase,ineitherlaboratoryanimalsorhumans.Claimsof“recovery”mustthereforebeevaluatedcritically,withtheexpectationthatthemostlikelyoutcomeisapartialrecoveryoffunctionalongwithconsiderablesubstitutionoffunction.Although it is theoretically possible for lost functions to completely return in a plastic brain, careful behavioural analysis shows this is rarely, if ever, the case, in either laboratory animals or humans. Claims of “recovery” must therefore be evaluated critically, with the expectation that the most likely outcome is a partial recovery of function along with considerable substitution of function.

Time Course

  • Recovery generally most rapid in the first 3-6 months after a brain injury
  • BUT may continue for many years
    • e.g. some cases reported of improved memory, insight, emotion regulation & function (eg return to driving) 10-15 years post-ABI
  • High individual variability in recovery curves
  • Extremely complex recovery process
  • Various functions follow different time courses of recovery because of differing anatomical & physiological substrates
  • Numerous other factors influencing recovery…

Biopsychosocial Factors Influencing Recovery

  • BIO-
    • Aetiology, severity & location of injury/illness
    • Individual differences in cerebral organisation
    • Age (older adults have less capacity to both regenerate and compensate – as compensation potential is already heavily utilised; injury to developing brain will affect developmental trajectories)
    • Gender
    • Genetics
    • Medical history/comorbidities
  • PSYCHO-
    • Premorbid intellectual functioning / “cognitive reserve”
    • Psychiatric history
    • Current lifestyle – exercise, diet, sleep, stress
    • Motivation & engagement in rehabilitation
    • Personality, self-efficacy & coping style
    • Beliefs, schemas and values
  • SOCIAL
    • Access to appropriate interdisciplinary rehabilitation
    • Social support (family, community, financial)
    • Enriched environment (esp in acute stages)
    • Cultural context

What is Brain Injury Rehabilitation?

  • Rehabilitation is a two-way interactive process whereby survivors of brain injury or illness work together with clinicians and others to achieve their optimum physical, psychological, cognitive, social and vocational well-being (adapted from McLellan, 1991)
  • “The use of all means to minimise the impact of disabling conditions and to assist disabled people to achieve their desired level of autonomy and participation in society” (British Society of Rehabilitation Medicine/Royal College of Physicians National Clinical Guidelines, 2003)

World Health Organisation International Classification of Functioning (WHO ICF) Model

  • Components:
    • Health condition
    • Body functions/Body structures
    • Activities
    • Participation
    • Environmental factors
    • Personal factors
  • Contextual factors

WHO ICF Model - Definitions

  • Impairment = performance on objective test
  • Activity limitation = difficulty performing an everyday activity
  • Participation restriction = not being able to do the things you want to do
  • Acquired brain injury
  • Home environment / Work/ Social supports
  • Premorbid cognitive & psychological characteristics

WHO ICF Model - Example

  • Impairment = poor performance on memory tests
  • Activity limitation = forgetting names and conversations
  • Participation restriction = avoiding group social events
  • Acquired brain injury
  • Busy work environment with lots of meetings
  • High achiever, perfectionistic tendencies
  • Contextual factors

Types of Neuropsychological Interventions

  • Psychoeducation (including feedback given after neuropsychological assessment)
  • Cognitive remediation/rehabilitation (encompassing restorative and compensatory approaches)
  • Psychological therapies (e.g., cognitive behaviour therapy)
  • Behaviour management (e.g., positive behaviour support plans)
  • Environmental modifications

Effective Interventions: Essential Characteristics

  • Person-centred & goal-directed
  • Evidence-based
  • Outcomes are measured meaningfully
  • Adequately “dosed” (frequency, intensity, duration)
  • Feasible in the context/location
  • Built-in focus on generalisability and maintenance
  • Cost-effective – good “bang for your buck”

Setting SMART Goals

  • S - Specific: Define the goal as clearly as possible - who, what, when, where, why
  • M - Measurable: Should be able to track progress on the goal and measure the outcome so it is clear when it has been achieved
  • A - Achievable: Can be achieved through client’s efforts in the specified time frame and it is within their capabilities
  • R - Relevant: Goal should be personally relevant and meaningful
  • T - Timely: Goal should include a time limit, e.g. to achieve the goal by the end of the intervention

Evidence-Based Practice (EBP) in Neuropsychological Rehabilitation

  • Clinicians should choose the appropriate neuropsychological intervention based on the best available evidence, the patient’s goals and preferences, the biopsychosocial case formulation, and their own clinical expertise.

Cognitive Rehabilitation: Restoration vs Compensation

  • Restoration
    • Repetitive drill & practice
    • Computerised cognitive training
  • Compensation
    • Internal strategies
    • External strategies
    • Individual & group approaches

Evidence-Based Memory Rehabilitation Approaches

  • Compensatory strategies
  • Systematic instruction
    • Errorless learning
    • Chaining
    • Vanishing cues

What is Systematic Instruction?

  • A method for systematically learning and remembering a novel task or skill (e.g., using a new smartphone app)

Systematic Instruction

  • Tasks are broken down into small steps and the person receives immediate corrective feedback for each step to prevent them making a mistake (i.e., NOT trial and error learning)
  • Helpful for those with intact procedural memory but impaired declarative memory
    • Errorless learning: Each small step of the task is mastered before the next one is added. The whole ‘chain’ of steps is rehearsed each time a new step is added
    • Chaining: Frequent prompts are given initially, and these are faded gradually as mastery of the task is achieved
    • Vanishing cues:

Psychological Therapies After ABI

  • Challenges in applying psychological interventions with people with ABI
    • Pleasant activity scheduling / behavioural activation for someone with major physical disability?
    • Changing patterns of thinking in someone with cognitive inflexibility?
    • Mindfulness in someone with attentional difficulties?
  • We now have evidence that psychological therapies such as Cognitive Behaviour Therapy (CBT) can be adapted to effectively treat depression, anxiety, fatigue and sleep disturbance post-ABI