Traumatic brain injury, (TBI) may result in life long impairments of an individual’s physical, cognitive, and psychosocial functioning, which severely impacts the injured person’s life, their families, and significant other. A major limitation within the field of TBI rehabilitation is the narrow focus of current medical restoration approaches; the focus tends to be on enhancing capabilities of the person with TBI to help them adapt to life circumstance.
However new models of rehabilitation emphasizes the parallel importance of environmental modification in order to create enabling condition for the individual. A multidisciplinary approach is key to helping people reclaim their lives and identity. Before discussing how rehabilitation can help people with traumatic brain injuries, an over view of basic brain physiology will follow as well as static’s.
Most TBI individuals suffer closed head injuries that cause both focal and diffuse damage. Focal trauma happens when the brain bounce against the inside irregular contours and bony ridges inside the skull causing tears, hemorrhages or bruise. Diffuse trauma occurs when the nerve fibers through the brain stem and into the brain are stretched or torn.
Both diffuse and focal injuries affect multiple systems but the symptoms and long-term effects of TBI are strongly influenced by focal injury. In addition, the brain functions as a whole by interrelating its component parts, therefore, if the injury disrupts a particular step in the brain function the sequence is broken and the deficit reveals it self in the TBI individual.
Beneath the forehead is the frontal lobe if damaged or bruised this area produces diminished or altered state of consciousness. Results in changes in personality creating an egocentric behavior; impulses and drive that desire immediate gratification, they have difficulty seeing how this behavior affects others.
Behaviors such as inappropriate sexual and social behavior can be seen. Also there maybe an inability to maintain two lines of thoughts simultaneously therefore The TBI person appears inconsiderate, non-empathetic, self-centered, and selfish even when their intention is otherwise. They suffer loss of memory for some habits and word meaning. They may also be plagued by a single persistent thought, may have difficulties focusing on a task, solving problems, and thinking. Difficulties are seen in planning sequences of complex movements to complete mult-stepped tasks, such as making a sandwich. Also, loss of self-esteem and self worth is common and can cause depression.
When the parietal lobe, located near the back and top of head, is damaged, deficits are dependent on which side of lobe is damaged; right, left, or bi-lateral. Damage to the left causes “Gerstamann’s Syndrome” (Suddarth, 1991, p.1137). and causes difficulty-distinguishing left from right. In addition the damage can affect ability to recall strings of numbers; difficulty doing math. Damage to right lobe results in neglecting parts of the body which can be seen in patient having difficulties in self-care, dressing, and washing. Bi-lateral damage can cause “Balint’s Syndrome” (Suddarth, 1991, p.852). Characterized by inability to control gaze.
The parietal lobes contain the sensory cortex also, which control sensation, such as, touch and pressure, and fine sensation such as, judgment of texture, weight, size and shape. When the body is stimulated the sensory cortex receive it information from receptors in skin, but when the lobe is damaged difficulty can be seen in intergrading different senses that allows for understanding a single concept and loss of touch perception.
At the very back of the head is the occipital lobe is where our vision center is, which is rarely damaged due to its position in the head. If damaged one of the strangest side effects is blind sight the person claims that they have no vision at all, but can, when asked, point to or identify objects at a distance unconsciously. Other effects include writing impairment, inability to recognize words, and identifying faces. Disorders causes illusions, which causes objects to appear larger or smaller than they are or different in appearance in color. It also causes visual hallucination.
According to the National Pediatric Trauma Registry, (NPTR) the brain cannot repair itself. It cannot grow new brain cells, called neurons, once they are damaged. In addition, NPTR states,
Ø Traumatic brain injury is the most frequent cause of disability and death among children and adolescents in the United States.
Ø Each year, more than one million children sustain brain injuries, ranging from mild to severe trauma.
Ø More than thirty thousand children have permanent disabilities as a result of brain injuries annually.
Ø Of all pediatric injuries cases in the United States, about one third are related to brain injury.
And according to The National Institutes of Health
Ø Those individual eighteen and over that are afflicted with adult-onset brain impairments is between two million five hundred thousand and three million seven hundred thousand.
The article by National Institute of Health (NIH) (1998) states in 1989, the US Congress passed a joint resolution proclaiming the 1990’s the “Decade of the Brain”. The resolution called for greater recognition of, and advances in, all areas of the neurosciences and other research-seeking causes, cures, and treatment for Americans of all ages afflicted with brain diseases and disorders.
Treating individual with head injuries can be challenging. Those with traumatic brain injuries present a myriad of clinical signs often related to trauma to other body regions. As with all emergency trauma patients, airway, breathing, and cardiovascular system dysfunctions must be stabilized first. The systemic effects of shock must also be managed appropriately to restore physiology indices of perfusion. This can be done by establishing a baseline and frequently reassessing the patient for changes and monitoring the patient’s neurological status.
A blunt cranial injury may cause hemorrhage, concussion; an injury to the brain produced by a violent blow that results in temporary or prolonged loss of function, contusion; bruising of brain, laceration, and cerebral edema; swelling of the cerebrum. These abnormalities may elevate intracranial pressure (ICP), and compress the cerebral arterial supply, which results in hypoxia; deficiency of oxygen reaching the tissue, wo!
rsen the cerebral injury and may cause secondary brain injury, such as, hypotension, hypoxia, anemia, hypothermia, and other abnormalities.
Acute Care, initially patient is admitted to Intensive Care Unit length; of stay will vary depending on injuries then patient is transferred to the Neurological floor; length of stay again varies usually around three weeks. Rehabilitation treatment is basically the same while in ICU and on the neurological floor. Patient is seen by a physical therapist.
Treatment is amid at the integration of reflexes and development of normal movement to promote skillful functional abilities by way of strength endurance, coordination, and range of motion through exercise, massage and hot or cold therapy. In addition, focus is also on preventing secondary complications. The physical therapist’s role primarily is to minimize physical disability, to hasten recovery, and to contribute to the patient’s comfort and well-being. Various diagnostic and functional activity testing is done to determine patients’ abilities to care for themselves. The occupational therapist also sees the patient,!
but focuses are on helping find ways to master everyday activities. It includes teaching patient that may have trouble swallowing how to eat or drink. Later in therapy focus is on showing patient how to use special tools to put on shoes and socks, close zippers, and button shirts. For patient going home the focus is on cooking and housekeeping. Respiratory therapist also cares for the patient the focus is on breathing retraining, through breathing and relaxation techniques, which teaches ways to conserve energy. The goal is to decrease respiratory symptoms and complication.
Education is also important in the acute phase of the rehabilitation program, which may include written material and or videos. In addition individual teaching session with the patient, family, and health care professional are important to review specific medications, treatments, and routines that will follow. Psychosocial counseling can also help the patient and family deal with a variety of emotions, including anxiety and depression, which can interfere with recovery. Relaxation exercise can be offered.
There are many differences in the scheduling, length of stay and individual components of rehabilitation programs for each patient, but most formal rehabilitation programs will have physicians, nurses, rehabilitation therapists, psychosocial staff, and dietitians all working together through out patients rehab stay. But some nontraditional therapy have become an intergraded part of the patient rehab stay and are helping to hasten the recovery process, such as, virtual, art, music, pet, and play therapy.
According to Adikins, Virtual therapy was inspired by NASA programs that prepared astronauts to make quick decisions and automatic movement in space. Rehabilitation centers are applying Virtual therapy to activities of daily living training. The goal is to help patients with TBI relearn how to do things automatically. These is done by having the TBI patient sit in a small room wearing gloves and goggles, repetitively practicing a task, such as opening a can of soup or spreading peanut butter on bread.
The more cans the patient opens or sandwiches made patient can increases their procedural memory, until it’s automatic. But when the patient is done instead of having piles of half-made sandwich and open cans to contend with, patient only has to take off goggles and gloves. According to Adkins traditionally, patients performed repetitive ADL’s until they reintegrated the information and perform the tasks seamlessly, a boring and potentially dangerous task, imagi!
ne a patient learning to pour a cup of boiling water or slicing a roast with virtual therapy endless repetition without injury. According to Adkins, while the technology is promising it still needs more research unlike art therapy that’s always been a medium to express out inner thoughts.
Art therapy is a specialized form of therapy that uses both psychological theory and creative process to help patients, according to American Art Association. Art therapy does not depend on patient’s ability to use words to describe their trauma. Instead, it works, with the ability to create images in the mind and to translate these images outward rather than through words, “express[ing] their most innermost thoughts visually through [tools such as, paint, clay, crayons, and paper] or some other art form rather than through words.” (Miller. 1999, p.B3)
Using art therapy can both settle emotional conflicts and foster self-awareness that allows for healing through a creative process. In addition art therapy can be used for all ages struggling with trauma. According to Miller (1999) “children have at least a temporary advantage in that they are less inhibited as artists than teenagers and adults” (p. B3). Art heals by changing a person’s physiology and attitude. Th!
e body’s physiology changes from one of stress to one of relaxation, from one of fear to one of creativity, and inspiration. And according to the New England Art Institute, “power of speed and personal growth is drastically increased when you engage image from the unconscious. When you step aside and let the image come through, the image themselves becomes the agent of transformation. Through creativity, the soul knows instinctively to heal itself.”
Music therapy also, has the power to heal. Therapist use music to promote, maintain, and restore mental, physical, emotional, and spiritual health. Which can be gained through guided imagery, active listening, singing, visual art, drama, poetry, and relaxation music. According to American Music Therapy, Music has nonverbal, creative, structural, and emotional qualities. Music facilitates contact, interaction, self-awareness, learning, self-expression, communication, and personal development.
Music’s clinical value provides a non-threatening vehicle of interaction and communication with patient. Activities include, singing which helps with speech impairment and improves patient’s breathing control. Listening to music helps develop cognitive skills such as, attention and memory. It also provokes memories and stimulates thoughts, images, and feelings, which can be further examined and discussed, later with the therapist. Composing facilitates sharing of feelings, by wr!
iting songs of healing for and with patient to bring self-awareness. Playing instruments can improve gross and fine motor coordination. Music provides a calming effect. It can be used for pain management the focal point is the music, in addition long after the session the patient continues to have soothing results. Music therapy can also be used to improve memory skill by adding familiar music to the learning process, which will act as a cue to remember.
Also when patient is learning, certain actions must appear before any learning can take place such as, attention span, following direction, and eye contact are necessary components to develop other skills. Attention span is often difficult for these patients because of the inability to filter out unimportant stimulus thereby not acknowledging what is important. Music can help the patient use as many senses as possible and provide motivation for the patient to continue to learn. According to the American Music Associati!
on This can be accomplished through high and low stimulus intervention. Ability to follow direction is often achieved by focusing on the intervention that uses sequencing skills, such as one step direction, and two step direction. For example a therapist will sing a song in which the lyrics will contain cueing directions such as, sit down, a one step direction, sit down and play with the drum, a two step direction. Music therapy influence a richer and fulfilling quality of life.
Pet therapy is another rewarding and enhancing therapy for patients with traumatic brain injury. Pets provide unconditional love and affection. In the hospital where patient may feel isolated, loneliness, loss, separation from home, and a sense of no longer being needed the comfort of pet therapy is a gift. In a study published by Jama vol 275, 1001 apr 3 96 the author states pet therapy provides a “significant positive” changes in patient well-being. According to Delta Society animals have a way of “accepting without qualification.”
They don’t care how a person looks or what they say. An animal acceptance is nonjudgmental. Pet therapy provides many benefits such as feeling “spiritually fulfilled” according to Delta Society, and for patients with low self esteem an animals can help them focus on their recovery rather than thinking about their injuries. According to Brain Injury Association, pets provide immediate feedback in the form of nip, scratch, or bark, this !
may help the patient correct or relearn more appropriate behavior with out the repeated embarrassment of a social mistake or verbal correction by staff members. Delta Society, also states staff members have reported that it is easier to talk to patient during and after animal visits. In addition animals help presented an air of emotional safety, if a therapist has an animal in his or her office it presence may open a path through the person’s initial resistance. Children are especially likely to project their feelings and experience onto an animal.