brian pentland
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Acquired Brain Injury
Early rehabilitation and long term outcome
British Society for Disability and Oral Health
B Pentland
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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
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Acquired Brain Injury Traumatic brain injury (TBI)
Haemorrhagic brain injury (HBI) Vascular brain injury (VBI)
Anoxic (& metabolic) brain injury (ABI)
Infective brain injury (IBI)
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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
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Epidemiology of Head Injury Age: 15-25 years
Sex: M:F ~ 3:1
Causes: Falls
Road Traffic Accidents
Assault
Sports
Work
Alcohol: ~ 50%
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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
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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
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Mechanisms of Injury Focal
Polar
Diffuse axonal
Secondary insults
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Focal Polar
Diffuse axonalSecondary
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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
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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
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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
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Risk factors-Post-traumatic Epilepsy
Penetrating (Missile) injury 33-50%
Intracranial Haematoma 25-30%
Early Epilepsy 25%
Depressed Fracture 15%
Prolonged PTA 35%
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Post Head Injury Behaviour Premorbid Factors
Effects of Injury
Environmental Factors
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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
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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
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Frontal Lobe Syndromes Disinhibition
Memory Impairment
Apathy
Anosmia
Adversive seizures Grasp reflex
Expressive dysphasia
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Temporal Lobe Syndromes Dominant lobe
± Dysphasia (receptive)
± Dyslexia
± Dysgraphia
Amnestic syndrome
Epilepsy: complex partial seizures
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Wernicke-Korsakoff Syndrome
Wernicke
± Abnormal eye movements
± Ataxia
± Confusion
Korsakoff
± Recent memory loss
± Confabulation
± Disorientation
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Pharmacological Interventions in Brain Injury
Depression/anxiety/emotional lability
Agitation
Apathy/low arousal
Spasticity
Epilepsy
Pain Bladder & Bowels
Infection & concurrent illnesses
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Early Rehabilitation
Definition & Practice
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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
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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
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Components of RehabilitationProcess
Assessment Formulation of Rehabilitation Plan
Implementation of Plan
Review & Modification of Plan Discharge Arrangements
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Assessment Cognitive, Emotional, Behavioural
Communication & swallow
Physical: neurological & general
Activities of daily living
Housing
Employment/education Leisure
Family & carer needs
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Core Rehabilitation Team Medical
Nursing
Physiotherapy
Occupational Therapy
Speech & LanguageTherapy
Clinical Psychology
Social Worker
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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
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Aims of Rehabilitation
Promote Intrinsic Recovery
Assist Adaptive Recovery
Prevent Complications
Minimise Eventual Handicap
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Promoting Intrinsic R ecovery
Neural Plasticity
± Diaschisis
± Substitution
± Axon sprouting
± Synaptic modulation
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Assist Adaptive R ecovery
Teach new ways of achieving function
± use of non-dominant hand
± use of diary
± breakdown of complex tasks
Aids & Adaptations
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Aids & Adaptations Walking stick-FES
Wheelchair independence
Pen & Paper-Computer
Car adaptations
Housing adaptations Access to work & leisure activities
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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
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Secondary Prevention of Stroke Antiplatelet
therapy
Anticoagulation
Hypertension
Hyperlipidaemia
Cigarettes/ alcohol
Obesity
Stress
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Discharge Planning Home assessment/home pass
Safety judgement Self-medication ability
Team meeting
± patient & family ± community staff (health & social)
Documentation
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Long Term Outcome
Post hospital & longer term
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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
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Factors influencing outcome Nature of ABI
± infarct vs. haemorrhage
± unilateral vs. bilateral/ brainstem
± extent of brain damage
Premorbid health(physical &
mental)
Family support
Age
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Issues related to age Employment
Dependants
Patient & family reactions to services
geared to the elderly
Driving
Sex
Exercise
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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?
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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
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Agencies involved Health
Social Work
Education
Employment
Housing
Voluntary
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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
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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