Rehabilitation after Traumatic Brain Injury

Fary Khan, Ian J. Baguley and Ian D. Cameron

Series Editors: Peter B Disler, Ian D Cameron  

The range of severity of TBI is broad, from concussion through to persistent vegetative states. Most severe TBI in Australia follows motor-vehicle-related trauma. Whereas the introduction of safer car designs, airbags and other road traffic initiatives (eg, redesigning hazardous intersections, driver education campaigns, random breath testing, and reducing speed limits) have decreased the overall number of road fatalities, improvements in retrieval, neurosurgery and intensive care in the past few decades have enabled many people to survive injuries that previously would have been fatal. This combination of factors has meant that the challenge of TBI rehabilitation has not altered significantly in the past decade.

As there is a long timeframe for improvement, continuity of care is one of the most important goals in managing a person with Traumatic Brain Injury. Families often take on much of this responsibility, but some degree of contact with medical and rehabilitation services will often be required for the rest of the person's life. Often it is the general practitioner who is expected to coordinate this care.

Recent estimates suggest that there are about 150 people admitted to hospital with TBI per 100 000 population per year.4 This figure probably underestimates the true incidence of TBI because of classification and diagnostic errors, as well as under-reporting of mild injury. Even without errors in data collection, a high proportion of people with mild TBI do not present to hospital. Severe and moderate head injuries account for 12–14 per 100 000 and 15–20 per 100 000 population, respectively. The incidence of mild TBI has been reported as 64–131 per 100 000.

The incidence of TBI peaks in the age group 15–35 years, and is more common in males (male : female ratio, 3–4: 1). Much of this sex difference is thought to be related to risk-taking behavior and is therefore potentially preventable. In Australia, motor-vehicle-related trauma accounts for about two-thirds of moderate and severe TBI, with falls and assaults being the next most common causes. Sporting accidents and falls account for a far greater percentage of mild injuries. Alcohol is associated with up to half of all cases of TBI.

The forces inflicted on the head in TBI produce a complex mixture of diffuse and focal lesions within the brain. Damage resulting from an injury can be immediate (primary) or secondary in nature. Secondary injury results from disordered autoregulation and other pathophysiological changes within the brain in the days immediately after injury. Urgent neurosurgical intervention for intracerebral, subdural or extradural hemorrhages can mitigate the extent of secondary injury. Hypoxic or ischaemic injuries also significantly affect recovery and can be either primary or secondary in nature.

Measuring severity of Traumatic Brain Injury

The effects of TBI can be far-reaching and profound. While TBI can cause long-term physical disability, it is the complex neurobehavioral sequelae that produce the greatest disruption to quality of life. Cognitive and behavioral changes, difficulties maintaining personal relationships and coping with school and work are reported by survivors as more disabling than any residual physical deficits.

As with all rehabilitation, the goal is to help the person achieve the maximum degree of return to their previous level of functioning. TBI rehabilitation is best managed by a specialized interdisciplinary team of health professionals; although such specialized teams are available in all regions of Australia, some States have more comprehensive services than others. TBI rehabilitation often consists of two phases — inpatient and community management.

Community rehabilitation follows discharge from an inpatient rehabilitation service. Helping a person with TBI return to maximum independence and participation in the community is an extremely difficult task. Family support, education and counseling are vital and likely to be needed for a prolonged period The quality and availability of community services can be less than ideal and issues of cost may limit access. This applies particularly to adapted lifestyle-sustaining services.

Producing a global outcome measure after TBI is extremely difficult. Acute studies have traditionally used the Glasgow Outcome Scale with its broad categories of persistent vegetative state, severe disability, moderate disability and good recovery. This tool is too insensitive for use in rehabilitation, where the significant issues relate to functioning — how does the person function in self-care, and in daily activities in the community, at work or in the family? Are the disabilities physical, cognitive, behavioral or a result of psychological responses to these changes? Outcome measures exist for all of these areas. However, there are few evidence-based recommendations to guide TBI rehabilitation.

It is estimated that 70%–85% of all traumatic brain injuries fall into the mild category. While they rarely require inpatient rehabilitation, patients commonly report cognitive and behavioral changes from which they recover within 3–6 months10%–15% remain symptomatic in the longer term with a persisting post-concussion syndrome: physical complaints including headache, cervical pain, vestibular symptoms; changes in taste and hearing; difficulty with attention and memory; and irritability, insomnia and sleeping difficulties. Interpersonal relationships and work may also be affected. This large group of people with TBI can face many years of impairment, possibly affecting health, education, occupation, and social and emotional functioning. Treatment involves patient and family education, reassurance and psychological support

Patients within these categories show a broad range of possible outcomes, and it is generally not possible to predict the extent of recovery in the initial weeks after the trauma. Many patients with a dire early prognosis successfully return to competitive employment. Most will be independently mobile and be physically, if not cognitively, capable of self-care and normal community living.

Social disability.

A combination of deficits leads to a greater degree of social disability than would be expected from isolated single deficits. Neuropsychological assessments can help to delineate the extent and type of cognitive disability that a person may experience. This information can be used to help develop individualized compensatory strategies. Community living skills, domestic and household duties, communication (reading, writing, using the telephone), money management, time management, driving and public transport and social skills may require retraining. TBI can affect competency to make important financial decisions, to comply with medical management, to give informed consent, and to make other life decisions. An order to appoint a guardian or administrator may be required in specific situations. Guardianship boards or tribunals operate in all States and Territories of Australia.

Return to work is an important factor that contributes to satisfaction and quality of life. On first returning to the community, people with TBI may have reduced awareness of their cognitive deficits, and can fail or do badly if pressured to return to work, study or household responsibilities too soon. Vocational and leisure options may include retraining, reskilling, on-the-job training or supported employment services.

Behavioral changes may alienate family and friends, with families sometimes perceiving the person as a "difficult stranger". Aggression, substance misuse or lack of empathy particularly strain relationships for others, who may see the patient as unmotivated and lazy. Ignorance and misperceptions of families, coworkers and healthcare professionals about the effects of TBI may make matters worse. Behavioral management may be necessary to increase independence and reduce maladaptive social behavior: agitation, irritability, combative outbursts, lethargy and abnormal or foul language.

Drugs are sometimes useful in the management of Traumatic Brain Injury, particularly for mood disorders, such as depression and anxiety. Regaining insight into the changes caused by TBI is often accompanied by an increase in depressive symptoms. Depression is common following TBI, with a reported prevalence of 10%–60%.Increased suicidal ideation has also been reported to occur for many years after TBI.

Minimally responsive versus persistent vegetative state

Rehabilitation of children with Traumatic Brain Injury

Traditionally, children have been reported to have better outcomes than adults after TBI. However, while fewer focal deficits may be apparent, children appear to develop blunting across all areas of higher cognitive functioning. These deficits may not become apparent until later in the child's development. Children with TBI face difficulties because of impaired new learning, inability to take on social cues, and behavioral, educational and schooling problems. These problems pose difficulties for parents, teachers and healthcare workers. There may be a poor fit between the needs of children with TBI, and typical school educational programs. Parents are faced with many challenges, including coping with changed academic aspirations for their child. Specialist pediatric brain injury rehabilitation services are available in Victoria, South Australia, Queensland and New South Wales.

Traumatic Brain Injury is a condition that every GP can expect to see during his or her practice several times each year at least (based on US prevalence data). The GP needs to have a basic understanding of the major factors involved in recovery from and treatment of Traumatic Brain Injury. The GP plays a central role in the management of the TBI survivor and his or her immediate family, often at a closer distance than formal rehabilitation services. The GP also plays a major role in the person's adjustment to the changes wrought by Traumatic Brain Injury, and is usually the major source of information and counseling for both patient and family. In mild TBI, reassurance, education and psychological support minimize the likelihood of long-term disability. In more severe injury, it is important to target the most difficult problems or behaviors, remembering that successful treatment can be difficult and needs to involve the person's support networks. Substance misuse evaluation and treatment and anger management strategies can help to minimize social dysfunction. Improvements in function can occur over a prolonged timeframe. Specifically focused rehabilitation intervention may produce substantial functional gains, even several years after the original injury. It is then that referral for community rehabilitation case management can be particularly beneficial.

TBI is a heterogeneous disorder of major public health significance. Rehabilitation services, matched to the needs of people with TBI, as well as community-based non-medical services, are required to optimize outcomes over the course of recovery. Both the person with TBI and their social support networks should have access to rehabilitation services through the entire course of recovery, which will continue for many years after the injury. The services required will alter as the person's needs change over time. Survivors of severe TBI face the challenge of resuming a meaningful life for themselves and their families. However, severe TBI is not curable and medical and rehabilitation management may not ultimately be able to provide the improvement desired by the patient and his or her family.