Recovering From a Traumatic Brain Injury: Cognitive Rehabilitation

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Table of Contents

Introduction
Main body
Intervention
Dialectical Behavioral Therapy
Discussion and analysis of issues of engagement
Conclusion
References

Introduction

The patient in this case is a male aged 24 years unmarried Caucasian. He has a mother and stepfather. He also has a half brother and two half sisters. The father is not alive and the stepfather acted as the guide and mentor. Friends and relatives contribute towards the moral and social support of the patient. His educational background does not come out clearly. He mentions that he does not have a job but he has hope of getting one after being discharged from the army. This basically forms the simple structure of the family in terms of composition.

The family has a number of problems as presented by the patient. The PT recently experienced an ATV accident and has problems ranging from mobility, speech problems and memory deficits. He also has difficulties in concentration, his cognition is impaired, blurred vision and pain in the right shoulder. Therefore in brief that forms a summary of the problems the family is faced with. In the history of the patient there is evidence of sustained severe non-penetrating head injuries and the associated unconsciousness. This was about six months ago as stated by the patient.

Main body

Despite these problems, the family has a number of strengths that are worthy to be mentioned. First of all, it is vital to mention that the patient has demonstrated positive thinking in life and this is by his way of handling of the mobile phone. He is willing to undergo more treatment and have a quick recovery. This is very important as far as intervention measures are concerned. The patient has good coping strategies. The financial position of the family appears to be steady with an insurance amount of $50000 which has been given to him and a monthly salary of $2520.

As the records reveal the patient was in perfect health condition before the accident occurred. Neurological examination reveals that the patient is cooperative awake and alert.

The patient is being assessed at Polytrauma Social Work Assessment and Referral. In this agency a number of consultations are undertaken and they are very useful towards establishing the exact state of the patient in a number of ways. For instance it undertakes psychosocial assessment of the patient. In summary the agency contributes significantly in identifying the obstacles be they physical, social or mental that exists in the course of treating the patient. The agency therefore helps in the family intervention because from the perspective of assessment, the agency is in a better position to identify the specific areas of the patient that require agent attention to facilitate his quick recovery.

Assessment of the environment of the patient reveals a number of issues that are necessary in the intervention. To begin with, the patient does not have his real father , he depends on the stepfather for guidance and mentorship. He lacks the love from the blood sisters and brother because of the current family set up. There is evidence of social and moral support coming from the family and friends. This environment is also crucial for the intervention to work as anticipated. Even though the patient comes from such a family set up , it is important to note that that the family has recognized the current situation of the patient and further supports him with moral support that is essential fro his recovery. In terms of resources, the family has some resources at least which they can use in the course of his recovery. There is an insurance amount and also a salary which can ensure that the financial needs are met. The patient does not have many dependants that can also influence the intervention because of the environment they present internally. Externally the environment can be said to be conducive because there has been no evidence that the family is in conflict with any other party. Evidence based search PT being in his present situation cannot be considered to be in the best of health or can he hope to be after such a drastic event in his life. However his situation can be improved with some positively designed effort at helping him. The attempt is to maximize PT’s progress by improving his functional capacity so that he is able to do more and be able to think more clearly and feel better. Illnesses should not invade him due to lesser resistance and he must develop a sense of purpose for his life. Spirituality would provide him with that sense of purpose (Sussman, 2005, p.491). PT must be able to have good interpersonal relationship with whoever he meets or lives with. His sense of social responsibility needs to be developed. Indirectly, this is going to reduce the worrying and the caretaking demands of his family. His becoming well is going to diminish his expenditure on medical costs and insurance and prevent productivity loss where he may work. The social level pursuit of health aims at maintaining a good moral code (Sussman, 2005, p.491). Conscientiousness is the quality that must be cultivated. It would allow PT to be socially responsible, goal-directed, industrious and acting with restraint. The dialectic model of health behavior change has been suggested as a good method by Tesh. (Sussman, 2005, p.494). PT being an amiable and compliant personality would be benefited by it. The search for literature on rehabilitation therapies took me to various sites on the google search engine and to Proquest and Springer journals and books in an online library.

Intervention

“Cognitive rehabilitation is a systematic functionally oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person’s brain behavior deficits. Services are directed to achieve functional changes either by reinforcing, strengthening, or re-establishing previously learned patterns of behavior or by establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.’’ (NAN, 2002, Adapted from the American Congress of Rehabilitation Medicine).

Self reported life satisfaction is a topic which is being associated with the rehabilitation of persons after traumatic brain injury (Wheeler, 2007, p.14). The relationship between life satisfaction and social integration (a component of community integration) is significant. The factors which contribute to life satisfaction are employment, capacity of functional memory, bowel independence, marital status, family satisfaction and perceived responsibility for the TBI. (Corrigan et al, 2001). The most meaningful outcomes are the quality of life and social participation (Cicerone, 2004, p. 500). Research has found that intensive life skills, coaching in natural environments or community based treatment programs showed improvement at the 90^th day of follow up evaluation (Wheeler, 2007, p.19). Control subjects did not exhibit improvement. Self reported life satisfaction depended on individuals and were attributed to other factors beyond those of societal participation.

It was found that persons who had less satisfaction had faced adverse situations including physical, attitudinal and public policy barriers which were significant factors (Whiteneck et al, 2004). Life satisfaction was more when the interventions were employed in their own homes and own environments rather than therapeutic facilities (Willer et al, 1999, p.405.In any rehabilitation procedure, assessments of the cognitive functions before and after are essential to positively evaluate the change. The quantitative EEG (electroencephalography) is being increasingly used in TBI evaluations to substantiate the neuropsychological testing (Thornton, 2008, p. 103). The EEG allows an immediate assessment by a paper printout of the waveforms. The quantitative EEG (QEEG) saves the mathematical information of the waveform to the hard disk allowing mathematical analysis instead of a human judgment The strength of the brain waves are measured in microvolt, peak amplitude, spectral power and peak frequency. The relative powers at different locations on the scalp are identified in frequency ranges of delta, theta, alpha and beta (Thornton, 2008, p. 103). The coordination of brain activity across different brain regions within different frequencies can be assessed.

Impaired self awareness of deficits is seen following TBI. It depicts the poor rehabilitation outcome that the patient has. It could also mean that the patient had not reached functional independence or had greater maladaptive behavior. Caregiver stress also could be gauged from the inattention (O’Keefe, 2007, p. 59). Impaired self awareness is differentiated into metacognitive knowledge and online monitoring of performance during tasks. Emergent awareness is the ability of the patient to detect difficulties as they emerge and could be monitored online. It is different from intellectual awareness which enables a patient to recognize his deficits and anticipatory awareness where a patient can predict his difficulties and tell what they are. Executive function deficits are related to diffuse axonal damage or focal lesions or haemorrhages and simulate patients with pre-frontal lesions. The SART, Random SART and Fixed SART are instruments with digits differently arranged which attempt to improve the attention deficits seen. Tasks can be manipulated to test the sensitivity to inhibitory control processes or sustained attention processes (O’Keefe, 2007, p.60).

Dialectical Behavioral Therapy

This is a cognitive behavioral therapy instituted by psychologist Marsha Linehan in the late 1980s to treat borderline personality disorders. Since then it has been used for many other purposes. Strategies address emotion dysregulation (Harned, 2006, p.67).

The theory says that the responses of some people are different and based on their emotional levels. Some react in a more intense manner to emotional situations. Their arousal levels are higher and the response is intense when compared to normal people.

These are termed emotional sensitivity, emotional reactivity and slow return to baseline arousal. The family has difficulty in adjusting to the surges of emotion. The emotional sensitivity is due to the activation of the amygdala of the brain (Harned, 2006, p.69). The reactivity is due to the high amplitude of response. The slow return to normal is due to prolonged duration of emotional response. The DBT has two main theories embedded in it: the dialectical and biosocial (Harned, 2006, p.68). Strategies which change emotional dysregulation are chain analysis, mindfulness and opposite action. Having the patient analyzing a single target behavior is chain analysis. The aim is to observe how the patient does the analysis and what factors affect each stage of the behavior (Harned, 2006, p.71). The behavior could be one of suicidal tendency. The analysis also can be a manner of problem solving, contingency management and learning skills that control the emotions involved. Mindfulness is the core skill of DBT. It emphasizes a lifestyle development of participating in awareness. It exposes the patient to previously avoided emotions, thoughts and sensations. The skill helps the patient to focus on an emotion and improve attentional skill. Blocking an emotion or behavior with another is the purpose of opposite action. Cognitive modification occurs and the patient learns to change his own perception of emotional experience (Harned, 2006, p.72). Validation strategies are the genuine interactions with the patient to reduce emotional arousal and enhance learning.

The patient is helped to reach goals. Mechanisms of change may be related to the various strategies employed in dialectic behavior therapy. Mindfulness, opposite action and chain analysis influence the emotional exposure, response prevention and extinction. Validation reduces aversive arousal and enhances learning. Mindfulness improves attentional control and ability to turn away from emotional stimuli which could evoke an increased arousal. Mindfulness and opposite action could change the response to the emotional experience and alter the cognitive effect. Chain analysis could help the patient to learn skillful behavior responses which would assist him divert his attention from classical stimuli.

Discussion and analysis of issues of engagement

Psychosocial assessment has revealed that PT has a PTSD with traumatic amnesia along with insomnia, attention deficit and speech impairment and is finding it difficult to maintain good interpersonal relations at home, work and with his friends.

Cognitive rehabilitation forms one of the major interventions in a person like PT recovering from a traumatic brain injury. Cognitive functions like attention, memory and problem solving are to be restored through rehabilitation. The goal would be to help PT progress to the best and most independent level of functioning possible. The focus of therapy would be to regain lost skills and compensate for abilities that have been permanently lost due to brain damage. The most effective therapies now include family members who can provide information as to the condition of the patient prior to the event and his personal requirements. PT is ambulant and speaks his mind even though waveringly. (Cognitive rehabilitation, NIH). The services of the family may still be required as PT may not be aware of the errors that he is making. Reading and writing abilities may be more affected than the speech impairment and the understanding of spoken words. Mathematics or calculations also would be a problem. PT has speech impairment by which he speaks in s a slow, slurred manner and is unable to pronounce words in the same consistent way.

Here we have a patient who is recovering from traumatic brain injury and is ambulant though he has a residual gait problem and a frequently slipping upper arm which is partially dislocated, has a post traumatic confusion with cognitive deficits of attention lapses, memory deficits and insomnia. He appears to make no complaints about problem-solving deficits but we can expect this and have to confirm from the family which consists of the mother and a peer figure, the stepfather who is behind him for all his activities. His speech impairment does not affect him from speaking but it needs to be handled by a speech therapist. The generally optimistic attitude and young age favors rapid progress to recovery from his deficits.

He needs to continue his Trazadone for insomnia, nicotine patch to practice abstinence to smoking, the lubricant drops for his eyes and the buspirone for the mental confusion. PT has had a Traumatic brain Injury which probably has involved many portions of his brain and even damaged some parts permanently. His cognitive defects can probably be answered in this manner. The dialectic behavior therapy suits this patient and the following would be the distribution of treatment sessions planned for him.

The therapy is in stages and deals with the reduction of behaviors which directly affects his safety. The behaviors to be dealt with would also be given precedence according to whether they would be needed to increase capabilities for the other stages.

The main focus in Stage 1 is to stabilize the patient and achieve behavior control.

Suicidal and self injurious behaviors which threaten his life are first changed PT would learn a variety of skills to effectively control his emotional distress. He would be learning skills which would regulate and tolerate it.

Stage 2 helps to reduce quiet desperation. Avoidance of emotions and ability to experience a full range of emotions without going out of control is the change targeted.

Stage 3 focuses on achieving ordinary happiness by reducing disorders and problems.

PT would be feeling more comfortable after he resolves his ‘incomplete’ feeling and experiences joy and freedom in Stage 4. The various techniques elaborated earlier are employed to achieve the success of emotional control.

A plan has been made for the DBT sessions. Weekly psychotherapy sessions are being arranged at the Health Center close to his house. Apart from the emotional control, inattention and memory deficits, the quality of life that PT is aiming for would be discussed and necessary arrangements made to help his rehabilitation. Adaptive behaviors would be taught and the Post traumatic stresses would be reduced. His self respect would be enhanced and his image boosted. The therapist would be having telephone contact with him. The client and the therapist together improve many social skills. The weekly group therapy sessions would last around two and a half hours each. Modules would be used to learn skills pertaining to interpersonal effectiveness, distress acceptance skills, emotion regulation, and mindfulness skills. The group therapist would not have any contact with PT.

Conclusion

PT has asked if he could be given vocational training so that he could start to earn his living as he did not plan to go back to the army. This is being arranged too. PT must be taught to control his sleeping hours to the nighttime only so that he learns to sleep well at night. He must also be encouraged to participate in community gatherings and support groups apart from helping other TBI patients. The SART instruments and computers could be used to deal with his attention deficits. By performance of the above discussed, progress can easily be monitored.

References

Corrigan, J. D., Bogner, J. A., Mysiw, W. J., Clinchot, D., & Fugate, L. (2001). Life satisfaction after traumatic brain injury. The Journal of Head Trauma Rehabilitation, 16, 543-555.

Cognitive Rehabilitation, Brain Injury Resource Center, National Institute of Health. Web.

Hughes, Jamie Hacker; (2006), “Psychology and cognitive processing in post-traumatic Disorders”, Psychiatry 5:7, History, Epidemiology and Treatment, Elsevier.

Harned, M.S. et al. (2006). “Dialectical Behavior Therapy: An Emotion-Focused Treatment for Borderline Personality Disorder”. J Contemp Psychother 36:67–75 DOI 10.1007/s10879-006-9009-x Springer Science+Business Media, Inc.

NAN (National Academy of Neuropsychology). (2002). “Cognitive rehabilitation, official position of the National Academy of Neuropsychology. 2008. Web.

Sussman, S. (2005). “Foundations of Health Behavior research Revisited”. American Journal of Health behavior, Vol. 29, No. 6, Pg. 489, Proquest Education Journals O’Keefe, F.M. et al. 2007). “Characterising error-awareness of attentional lapses and inhibitory control failures in patients with traumatic brain injury”. Exp Brain Res 180:59–67.

Thornton, K.E. and Carmody, D.P. “Efficacy of Traumatic Brain Injury Rehabilitation: Interventions of QEEG-guided Biofeedback, Computers, Strategies, and Medications”, Appl Psychophysiol Biofeedback 33:101–124 DOI 10.1007/s10484-008-9056-z Springer Science+Business Media, LLC 2008.

Whiteneck, G. G., Gerhart, K. A., Cusick, C. P. (2004). Identifying environmental factors that influence the outcomes of people with traumatic brain injury. The Journal of Head Trauma Rehabilitation, 19, 191-204.

Willer, B., Button, J., & Rempel, R. (1999). Residential and homebased postacute rehabilitation of individuals with traumatic brain injury: A case control study. Archives of Physical Medicine and Rehabilitation, 80, 399-406.

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