1 / 46

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.

elin
Download Presentation

Acquired Brain Injury Early rehabilitation and long term outcome

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Acquired Brain Injury Early rehabilitation and long term outcome British Society for Disability and Oral Health B Pentland

  2. 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

  3. Acquired Brain Injury • Traumatic brain injury (TBI) • Haemorrhagic brain injury (HBI) • Vascular brain injury (VBI) • Anoxic (& metabolic) brain injury (ABI) • Infective brain injury (IBI)

  4. 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

  5. Epidemiology of Head Injury • Age: 15-25 years • Sex: M:F ~ 3:1 • Causes: Falls Road Traffic Accidents Assault Sports Work • Alcohol: ~ 50%

  6. 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

  7. 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

  8. Mechanisms of Injury • Focal • Polar • Diffuse axonal • Secondary insults

  9. Focal Polar Secondary Diffuse axonal

  10. 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

  11. 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

  12. 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

  13. Risk factors-Post-traumatic Epilepsy • Penetrating (Missile) injury 33-50% • Intracranial Haematoma 25-30% • Early Epilepsy 25% • Depressed Fracture 15% • Prolonged PTA 35%

  14. Post Head Injury Behaviour • Premorbid Factors • Effects of Injury • Environmental Factors

  15. 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

  16. 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

  17. Frontal Lobe Syndromes • Disinhibition • Memory Impairment • Apathy • Anosmia • Adversive seizures • Grasp reflex • Expressive dysphasia

  18. Temporal Lobe Syndromes • Dominant lobe • Dysphasia (receptive) • Dyslexia • Dysgraphia • Amnestic syndrome • Epilepsy: complex partial seizures

  19. Wernicke-Korsakoff Syndrome • Wernicke • Abnormal eye movements • Ataxia • Confusion • Korsakoff • Recent memory loss • Confabulation • Disorientation

  20. Pharmacological Interventions in Brain Injury • Depression/anxiety/emotional lability • Agitation • Apathy/low arousal • Spasticity • Epilepsy • Pain • Bladder & Bowels • Infection & concurrent illnesses

  21. Early Rehabilitation Definition & Practice

  22. 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

  23. 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

  24. 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

  25. Components of Rehabilitation Process • Assessment • Formulation of Rehabilitation Plan • Implementation of Plan • Review & Modification of Plan • Discharge Arrangements

  26. Assessment • Cognitive, Emotional, Behavioural • Communication & swallow • Physical: neurological & general • Activities of daily living • Housing • Employment/education • Leisure • Family & carer needs

  27. Core Rehabilitation Team • Medical • Nursing • Physiotherapy • Occupational Therapy • Speech & Language Therapy • Clinical Psychology • Social Worker

  28. Multiprofessional Rehabilitation Team • Interprofessional: Role blurring • Communication: Formal & informal • Documentation: Common language • Leadership: Co-ordinator • Training: Skills, standards & morale • Advocacy: Keyworker / Primary nurse

  29. Aims of Rehabilitation • Promote Intrinsic Recovery • Assist Adaptive Recovery • Prevent Complications • Minimise Eventual Handicap

  30. Promoting Intrinsic Recovery • Neural Plasticity • Diaschisis • Substitution • Axon sprouting • Synaptic modulation

  31. Assist Adaptive Recovery • Teach new ways of achieving function • use of non-dominant hand • use of diary • breakdown of complex tasks • Aids & Adaptations

  32. Aids & Adaptations • Walking stick-FES • Wheelchair independence • Pen & Paper-Computer • Car adaptations • Housing adaptations • Access to work & leisure activities

  33. 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 Prevent complications

  34. Secondary Prevention of Stroke • Antiplatelet therapy • Anticoagulation • Hypertension • Hyperlipidaemia • Cigarettes/ alcohol • Obesity • Stress

  35. Discharge Planning • Home assessment/home pass • Safety judgement • Self-medication ability • Team meeting • patient & family • community staff (health & social) • Documentation

  36. Long Term Outcome Post hospital & longer term

  37. 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

  38. Factors influencing outcome • Nature of ABI • infarct vs. haemorrhage • unilateral vs. bilateral/ brainstem • extent of brain damage • Premorbid health(physical & mental) • Family support • Age

  39. Issues related to age • Employment • Dependants • Patient & family reactions to services geared to the elderly • Driving • Sex • Exercise

  40. 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?

  41. 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

  42. Agencies involved • Health • Social Work • Education • Employment • Housing • Voluntary

  43. 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

  44. Disease related Spinal cord injury Brain injury Stroke Multiple sclerosis Muscular Dystrophy Neuro-oncology Disability related Spasticity Continence Mobility Pain management Sexual dysfunction Orthotics Organisation ofRehabilitation Medicine Services

More Related