The feasibility of rehabilitation in brain damage

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Brain damage in general is a complex area to understand. Whether it is brain damage through sudden head trauma due to an accident or due to a biological disease it is equally difficult to understand. This is in large due to the complexity of the brain and the relatively little known about it. One of the interesting factors raised about the subject of brain damage is that of the feasibility of rehabilitation following brain damage. Many interesting factors have been illustrated over the years that demonstrate the feasibility of rehabilitation in patients.

In order to explain the feasibility, it would be appropriate to review the techniques used for rehabilitation and the success it has had on patients following brain damage. Furthermore it would also be appropriate to explain what factors most strongly affect recovery of functions and to also think of ways in which to improve the rehabilitation process. The first question that will be addressed is, to what extent is rehabilitation following brain damage feasible? This is an interesting aspect of brain damage because it cannot be put in general terms.

Recovery from a brain injury depends largely on the nature of the injury, the extent of damages and the quality of initial treatment. There are a variety of different medical approaches and techniques that focus on aiding the recovery of patients from brain damage, with different levels of damage needing separate approaches. Work on physical as well as cognitive recovery may take place at the same time. Or the patient may need work on one aspect more than the other before moving on to more complicated recovery procedures, such as regaining motor skills before attempting to walk.

Other aspects of rehabilitation that may take place include improving verbal skills and correcting memory and cognitive disorders. In order to understand the feasibility of rehabilitation these aspects will be explained further. Firstly one of the areas associated with trying to rehabilitate brain-damaged patients is that of behavioural problems. ‘Brain damage that affects the behaviour of an individual can often create obstacles for active treatment and community re-integration and functioning.

While the numbers vary somewhat across studies there are repeated findings that behavioural difficulties represent one of the more persistent and debilitating outcomes following a brain injury’ [1]. One such study that illustrated effective rehabilitation was that conducted by Feeney, T. J. & Ylvisaker, M. (2003). The experiment involved two participants aged 6 and 7 who had been injured 1 and 2 years earlier respectively. Both had sustained severe brain injuries. Both were enrolled in school and behavioural challenges emerged during the first year at school.

Feeney & Ylvisaker created a motivational assessment scale that created Specific definitions of aggressive behaviour for each child. Items from the Aberrant Behaviour Checklist specific to aggression were used to evaluate the intensity of the behaviours. As well the percentage of work completed in relation to specific assignments was measured. Following the assessment a baseline intervention phase was comprised to make adjustments to daily routine that reduced the children’s likeliness to behave inappropriately. Over a period of 5 days the frequency and intensity of the targets behaviour decreased further.

Furthermore a follow up at 1 and 8 years post treatment indicated that both children were doing well, suggesting that the experiment sustained validity over a number of years. Also a study from Hegel & Ferguson (2000) showed in their study on, different reinforcements on other behaviours to reduce aggressive behaviour that a 1 month follow up showed that the behavioural improvements to be maintained. On the other hand however some behaviour rehabilitative techniques have not proven to be as effective. A study conducted by Brotherton (1988) demonstrated a failure in long-term rehabilitation.

His study was aimed at improving social skills of individuals that had sustained closed head injuries. He focused on behavioural aspects that were lacking in different individuals and tried to improve on these areas with different techniques such as rehearsal, modelling etc. The results showed that, In general three of the participants showed some gain in at least one target behaviour under at least one condition. Two of the four participants showed gains in more than one behaviour, although not all gains were pronounced. At one year follow up there was noticeable loss of skill for the three initially successful participants.

For participant four no follow-up effect was noted, consistent with the lack of treatment effect. This study demonstrates that some rehabilitative techniques are not effective. Rehabilitation of cognitive functions is another aspect of brain injury, however it can take many forms and the success of rehabilitation depends on the methods used. The first form of cognitive disorder is that of mental power. Problems such as poor mental stamina or poor concentration are prime examples of mental power disorders. A particularly useful method that has been proven to rehabilitate patients successfully is that of fatigue management strategies [3].

The person’s sleep-wake cycle is analyzed to determine if daytime alertness can be improved. Many persons with brain injury have disturbed sleep-wake cycles, and some have true sleep disorders. Such disturbances can be corrected by behavioural therapies to improve sleep hygiene and remove impediments to sleep. Medical treatments also may be helpful. In some cases, the treatment is as simple as scheduling a brief nap. In addition, fatigue management includes working with the person to find the optimum balance between work and rest. Overwork or exceeding one’s limits may backfire badly in someone who has problems with mental stamina.

It may take many days to restore a person to the former level of function [3]. Other problems such as alertness, attention and concentration can also be treated medically. The use of medicines in recovery of cognitive functions is relatively new but there is no doubt that some people obtain meaningful benefits from this form of rehabilitation. Another area of cognitive recovery that has shown interesting results is the area that focuses on specific cognitive abilities. Impairment-specific interventions focus directly on the area of deficit such as when an individual has memory problems and is given memory training.

Impairment-specific interventions for speech/language problems, visual-spatial abilities and attention have shown some record of success [3]. However, memory training has shown mostly disappointing results, in contrast to memory treatments based on compensatory devices such as logbooks, which have shown good success [3]. The final form of cognitive disorder is that of executive deficits. It is understood that these types of disorder are best treated through real-life performance. The person with the brain injury may be observed within the community or work place and therapy occurs as the person is working.

An example of this would be job-coaching [3]. This involves the individual attending a job and the therapist intervening and training the sufferer when needed. This form of rehabilitation has proven to be successful in the past. Most studies of comprehensive rehabilitation programs have shown moderately positive outcomes, though even the most comprehensive programs do not help everyone. Up until now the argument has focused on rehabilitative techniques and their success. It would now be appropriate to look at some of the underlying factors that most strongly effect recovery of functions in brain damage sufferers.

The factors affecting recovery can be split into three main areas, economic, biological and behavioural. Firstly economic factors affect the chance of proper rehabilitation. For example the access to rehabilitation programs play a role in recovery. Many are unaware of the resources available. Furthermore many believe that adequate care for their loved ones is unaffordable. Bills for therapy, medical care, prescriptions, and nursing all add up and create financial strain on loved ones. “. In the United States, the annual cost of acute care and rehabilitation associated with recovery from brain trauma is estimated at $9 to $10 billion” [2].

The second factor that affects recovery is biological. The mechanisms underlying recovery of cognitive functions are not understood completely. It is understood that for weeks and possibly months there is actual healing in the brain after injury. Nerve cells that have died do not heal or recover, but injured ones can heal and return to active function. Also, some of the generalized effects of brain injuries, such as swelling, gradually subside, this can permit surviving nerve cells to resume function [3].

As well as this a process known as reorganization can take place in which surviving nerve cells actively take over the functions of dead nerve cells [3]. One of the positive biological factors that can affect recovery is the learning capacity of the nervous system. Damaged nervous systems are capable of learning new behaviours [3]. The learning may be slower post-injury, less complete and with a higher error rate, but there is no question that some capacity for new learning remains, in most cases.

However, the new learning may take many years of recovery, long after the biological healing processes are over. Behavioural factors can also affect recovery. A side effect to a patient’s brain injury may be that they have lost motivation. This makes it harder for recovery to begin because the key to recovery lies in the cooperation of the patient to respond to treatment. This problem has shown to be more likely with intelligent patients. Perhaps the reason for this is that the patient may be frustrated at not being able to do tasks that were once very easy to him.

The realisation that their ability to think quickly and tackle puzzles easily has deteriorated, this can severely effect the behaviour of a brain damaged patient and hinder recovery. Other factors also affect recovery. For example some of the technology used for brain injuries is not totally effective. CT or MRI scans do not always predict how severe an injury is. One thing they are good at though is being able to pick up bleeding in the brain. After illustrating both the rehabilitative techniques and factors affecting the recovery of brain injuries it would now be appropriate to suggest ways of improving the rehabilitative process.

It is apparent that some aspects of rehabilitation are unlikely to be improved however there are some areas in which improvements can be made. Motivational techniques could be introduced for brain-injured sufferers who experience difficulty dealing with injury. This could be done not only through the therapist but also by educating the brain injured patients loved ones, this would allow a constant flow of motivation for the sufferer which would perhaps reduce the time taken to recover from injury.

This of course would only be the appropriate for some sufferers but perhaps introducing this into a larger comprehensive program may also still have a positive effect. Another way to improve rehabilitation could be to obtain detailed background knowledge of the patient. This would not only allow treatment to focus on the areas that appear most affected but also explain what areas should be concentrated on the most. To conclude it would appear that the feasibility of rehabilitation depends on many factors.

Firstly it depends on the extent of the injury sustained by the patient. It also depends on the technique used to rehabilitate. It has been shown from studies such as that of Brotherton that some techniques are less affective. However other factors have also been proven to affect rehabilitation. Biological aspects such as swelling of the brain makes the rehabilitative process longer however it does not necessarily make it any less feasible because some patients can still report a 95% recovery.

For the majority of sufferer’s rehabilitation processes have proven very successful and they only get better as research through trial and error as well as continual medical improvements has shown. In order for the process to be improved perhaps aspects such as motivational skills being taught to families of sufferers could help. Also a more integrated program of recovery could be created in order for a more comprehensive treatment program. Finally a detailed research into the patient’s backgrounds could help in order to focus on the problem areas better.

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