Keywords
cognition - brain injury - rehabilitation - India
Introduction
Acquired brain injury (ABI) is an injury to the brain, which happens after birth,
which can be due to the physical trauma after traumatic brain injuries (TBIs); assaults;
neurosurgery; or also nontraumatic sources such as infections, hypoxia, ischemia,
encephalopathy, etc.[1] These injuries are characterized by a sudden onset followed by a period of organic
recovery before the improvements plateau and level off. Other progressive diseases
such as dementia in which injuries are not sudden are not included in definitions
of ABI.[2]
ABI can result in changes in neuropsychological as well as psychological functioning
that can be temporary or permanent. These can be cognitive, emotional, or behavioral
impairments. The consequences of ABI often require a major adjustment for the patient
and also his/her caregivers/family members around the new circumstances, and making
the adjustments that are critical in recovery and rehabilitation.[3] The complications that arise may include cognitive impairments such as short-term
memory loss, and physical difficulties such as fatigue, paralysis, visual, or hearing
impairment. Whatever the disability, ABI patients' lives change, and so do their family
members' lives. Patients with ABI do not necessarily experience a decline in intellectual
functioning, but rather they experience specific cognitive impairment in areas such
as memory, attention, concentration, communication, and behavior.[3]
Though the outcome of the injury depends largely on the nature and severity of the
injury, appropriate and timely treatment and rehabilitation play a vital role in determining
the level of recovery.[4]
Neuropsychiatric Sequelae after Acquired Brain Injury
Memory loss and memory disorders are one of the most common and prevalent cognitive
impairments experienced by patients of ABI.[5] People often struggle with memory problems following stroke, and this can lead to
difficulties in everyday life. The degree and kind of memory problems, mood changes,
and performance vary with everyday activities.[6] In a recent Cochrane review on 13 studies with 514 participants, the authors found
that seven trials were conducted with community participants, four with in-patients
and two with mixed community and in-patient samples. Most of the studies included
memory rehabilitation as the therapeutic activity for ABI patients.[7] However, some aspects of memory are directly linked to attention, and it is challenging
to assess what components are caused by memory and what by attention problems.[8] There is often a partial organic recovery of memory functioning following the initial
recovery phase; however, permanent impairments are often common.[9] ABI patients report significantly more memory problems when compared with people
without ABI.[5]
TBI is also associated with postconcussive syndrome (PCS). These can have symptoms
such as headaches, dizziness, noise intolerance, irritability, depression, anxiety,
emotional labiality, insomnia, etc. These can last for weeks or also till months after
the brain injury.[10] A study in which 53 symptomatic mild head injury patients were studied, they scored
significantly poorer than uninjured controls on neuropsychological tests.[11] In another study, motivational deficits were observed in patients following brain
injury. These patients also have lowered reward responsiveness and mood changes as
compared with controls.[12]
Persons with ABI have shown emotional and psychological difficulties such as depression,
issues with self-control, managing anger impulses, and challenges with problem solving.
These challenges also seem to contribute to psychosocial concerns involving social
issues such as social anxiety, increased loneliness, and lower levels of self-esteem.
Some of the most common problems faced by ABI patients include anger management, reduced
social contact, reduced frequency of leisure activities, increased unemployment, family
problems including marital difficulties, returning to work, obtaining financial independence,
driving, participating in social relationships, and self-acceptance.[13]
[14]
[15]
Rehabilitation of Patients with Acute Brain Injury
Neuropsychological rehabilitation (NR) focuses on improving the patients with brain injury in different areas of functioning
(cognitive, emotional, psychosocial, and behavioral) and helping in improving their
deficits. Wilson in 2008 focused on NR as a goal planning approach that was established
between the therapist, the patient, and his family members. Though there is a lot
of literature that recognizes the importance of emotional, cognitive, and psychosocial
functions, Wilson put all of these together and called it the holistic approach.[16]
Rehabilitation following an ABI has to be patient specific and cannot follow a set
protocol as there are a variety of mechanisms involved and different structures are
affected. Hence, rehabilitation should be individualized process that should involve
a multidisciplinary approach.[17] It should also be guided by the patient's needs and personal goals.[18]
Methods
Aim
The aim was to study the psychosocial functioning as the primary outcome in patients
with ABI after individualized neuropsychological intervention.
Setting/Participants
Eighteen patients after ABI were from the Departments of Neurosurgery, Neurology (Neurosciences
Center), and Psychiatry, for neuropsychological assessment and NR. They were referred
between 6 months and 1 year after their date of injury/ictus. The diagnoses were made
by the consulting neurosurgeon/neurologist/psychiatrist/clinical psychologist. These
patients underwent a prospective outpatient group study (on an OPD/outpatient level)
following an “ABA experimental design” where A was the baseline assessment, B was
the NR, and A was the post-NR evaluation. Of these, eight patients were diagnosed
as having severe TBI (diagnosed using the criteria of severity of TBI),[19] three of moderate TBI, three of mild TBI, and four of hypoxia (due to strangulation-attempted
suicide) (single causation).[20] These were patients after ABI (traumatic and hypoxic), aged between 18 and 50 years,
both sexes, all education levels, and hailing from both urban and rural background.
One of the prerequisites of NR was presence of a home-based therapist (immediate caregiver),
who could supervise the patient at home and could personally communicate his/her progress.
All individuals uncomfortable with the structure of the outpatient rehabilitative
service (nonconsenting) were excluded. Exclusion of cases also included individuals
with history of any previous penetrating head injury (PHI) other previous head injury,
any major psychiatric illness, mental retardation, associated injuries/life-threatening
injuries, or use of neuroprotective drugs.
Depending on the patients' chronological and mental age and reasons for referral including
presenting problems, different tools were used. The assessment for effectiveness of
rehabilitation outcome included the following:
-
Assessment of psychosocial functioning of patients using dysfunction analysis questionnaire
(DAQ)
[21] (which was the only outcome variable of the service) to see their overall functioning
at home, at the vocation/job, how they adjust or adapt socially, personally also their
subjective cognitive functioning. This measure was used to describe the benefit of
the NR in five areas: cognitive, personal, vocational, family, and social.
-
Other assessments included, as stated earlier, different neuropsychological tests
depending on the reason for referral and presenting problems. The same could not be
used as an outcome variable because these were different tests; hence, the information
could not be clubbed/compared.
Depending on the specific level of impairments in different areas and subjective complaints,
a patient-specific NR was planned. The NR mainly included basic skill training, functional skill training, neuropsychological
training with home-based rehabilitation modules in increasing difficulty level with
cognitive retraining for attention, memory, executive functioning, perceptuomotor
speed, motor dexterity, and individualized counseling. This was followed by individualized
counseling (including personal and family) ([Table 1]).
Table 1
Eclectic neuropsychological rehabilitation given to all patients (part A)
|
Neuropsychological rehabilitation
|
About tasks
|
Tasks
|
Function targeted
|
Remarks
|
|
1.
|
The basic skill training
|
|
Activity scheduling, daily planner
|
Methodize and time each activity of the day
|
Seemed to be helpful for planning neuropsychological rehabilitation.
|
|
2.
|
Functional skill training
|
|
|
3.
|
Cognitive retraining:
|
|
a.
|
Attention
|
Modules based on increasing level of difficulty of lists symbol and letter cancellation
tasks were used to retrain focused; divided and sustained attention.
|
Letter and symbol cancellations
|
Focused, sustained and divided attention
|
Was helpful for patients who showed impaired attention deficits on evaluation.
|
|
b.
|
Memory
|
Modules based on increasing level of difficulty of lists of words. These were timed
and followed an increasing level of difficulty. Omissions and commissions were noted.
The patient was given different modules for each week, and when a flooring effect
was achieved for each difficulty level, the next one with an increased difficulty
was introduced.
|
Memory aids (reminder diary), word learning and recalling
|
Immediate memory, delayed recall, new learning
|
Memory retraining was observed to be helpful for patients who had impaired memory
on the neuropsychological assessment.
|
|
c.
|
Executive functioning
|
Modules based on mazes in increasing level of difficulty for planning, and organization.
These mazes were made with increasing complexity to accomplish results as soon as
possible.
|
Mazes
|
Planning and organizing
|
Observed to be effective on ∼13 patients.
|
|
d.
|
Perceptuomotor Speed
|
Techniques, e.g., timed grain sorting were used, where the patient had to sort different
grains as soon as they could with an increasing level of difficulty.
|
Grain sorting
|
Visual acuity
|
Was observed to be helpful for patients eventually carrying daily household tasks
involving perceptuomotor speed including housekeeping, and tasks for independent living,
etc.
|
|
e.
|
Motor dexterity
|
Everyday tasks of buttoning and unbuttoning shirts were given. The timed task used
increasing level of difficulty ranged from buttoning and unbuttoning large buttons.
|
Buttoning and unbuttoning shirts
|
Finger dexterity
|
Most effective on 3 patients with decreased motor dexterity, to increasing the difficulty
to small buttons over a period of 4–5 wk.
|
|
f.
|
Individual counseling
|
Individual and family
|
Insight oriented psychotherapy
|
Improving insight into their thoughts, feelings and behaviors
|
Given to all the 18 patients and their family members.
|
In addition, cognitive behavior therapy (CBT), rational emotive behavior therapy (REBT),
alleviating focal signs, relearning, relaxation therapy, assertiveness training, anger
management, and vocational and individual counseling that were patient specific.
The eclectic NR ([Tables 1], [2]) varied from 2 to 18 months for each patient. These ranged from 8 to 41 sessions
between different categories of patients. Each session lasted for 1 hour (i.e., 45
minutes for NR session + 15 minutes for compiling the information). The rehabilitation
followed the flooring and ceiling principles of rehabilitation.[22]
[23]
Table 2
Eclectic neuropsychological rehabilitation strategies given for individualized problems
(part B)
|
Type of therapy
|
Task
|
Function targeted
|
No. of patients
|
|
Cognitive behavior therapy
|
Anxiety charting, automatic thoughts questioning, reattribution
|
Dysfunctional emotions, maladaptive behaviors, anxiety, depression, overgeneralizations
|
5
|
|
Rational emotive behavior therapy
|
Rationalization, comprehensive, active-directive approach
|
Irrational thoughts, self-defeating thinking, emoting and behaving
|
8
|
|
Relaxation therapy
|
1. Coloring techniques, shading with colors
2. Jacobson's progressive muscle relaxation technique
|
1. Aggression, irritability, response inhibition
2. Insomnia, hypertension and anxiety, somatic complaints, postconcussive syndrome
|
19
|
|
Relearning
|
Relearning via charts for getting dressed, bathing, brushing teeth, combing hair,
toilet training
|
Skills reacquisition, self-independence
|
5
|
|
Assertiveness training
|
Broken record, fogging, negative inquiry, negative assertion
|
Docility, aggressiveness
|
2
|
|
Social skills training
|
Development of social skills, assertiveness, problem solving
|
Interpersonal skills, effective communication
|
3
|
|
Anger management
|
Jacobson's progressive muscle relaxation, cognitive restructuring, improving communication
|
Emotional, behavioral, and cognitive effects of anger
|
3
|
|
Vocational counseling and guidance
|
Active listening, career talks
|
Facilitating return to work
|
14
|
Neuropsychological Rehabilitation following an Eclectic Approach included
Neuropsychological Rehabilitation following an Eclectic Approach included
Aiding in Basic and Functional Skills Training
Patients after ABI start having problems in their everyday functioning, as their everyday
schedules and time-bound tasks get disrupted. With the help of activity scheduling,
all the patients were aided in basic functional skill training. The patients were
also asked to maintain a daily and weekly chart with things-to-do on the basis of
importance, which they were supposed to bring back every week for a weekly follow-up
of NR. The same was followed by NR/cognitive retraining. This included NR of attention,
memory, executive functioning, perceptuomotor—speed, motor dexterity, and individual
counseling ([Table 1]).
Besides this, individualized psychological rehabilitation was given depending on the
reported problems ([Table 2]). The same was individualized because of heterogeneity of reported problem. Moreover,
the total duration of NR varied between weeks, depending on the performance of each
person. A brief description of the rehabilitation strategies given to the patients
is given in [Table 2].
Cognitive Behavior Therapy
Five patients with dysfunctional emotions, maladaptive behaviors, and cognitive processes
were given cognitive behavior therapy (CBT) through several goal-oriented, explicit
systematic procedures. Most patients had symptoms of depression and anxiety, for which
anxiety charting was done for patients where the automatic thoughts were questioned
and alternative thoughts were given with reattribution of the situation. The patient's
generalizing, overgeneralizing, or jumping to conclusions were directed to an alternative
view to decrease the actual anxiety and depressive thoughts. The goal was that the
patients should become fully independent with lesser anxiety and depressive tendencies.
Rational Emotive Behavior Therapy (REBT)
Eight patients with irrational (self-defeating, socially defeating, and unhelpful)
thoughts and tendencies were channelized toward more rational thoughts and tendencies
by a comprehensive, active-directive approach for the patients with emotional difficulties
such as self-blame; self-pity; clinical anger; hurt; guilt; shame; depression and
anxiety; and behavior tendencies such as procrastination, overcompulsiveness, avoidance,
addiction and withdrawal by the means of their irrational and self-defeating thinking,
emoting, and behaving.[24]
Relaxation Therapy
Relaxation training was used to reduce the patients' experience of anger and tension.[25] Jacobson's progressive muscle relaxation technique (JPMR) was given to six patients
with insomnia or even hypertension with anxiety. This helped most of the patients
relax and even their somatic complaints decreased. This technique was also beneficial
to ease the PCS symptoms and the patients' somatic complaints.
Thirteen patients with aggressive tendencies and irritability were given coloring
tasks. The patients were given a shape to be colored every day and he/she had to make
sure to color it without getting any color out of the boundary of the design. This
also helped in response inhibition retraining. Personality changes, one of the most
common symptoms of head injury, result in various kinds of disinhibition.[26] Coloring helps in certain functions such as fine motor coordination and self-regulation.
It also helps reduce stress.
Relearning
Martelli et al in 2008 evaluated the importance of skills reacquisition after ABI,
which is a holistic habit retraining model of neurorehabilitation.[27] Five of the eight patients with severe TBI who had “no memory” of everyday activities
such as getting dressed, bathing, brushing teeth, combing hair, toilet training, etc.,
had to be taught again via relearning. Techniques were taught to the patients and
their caregivers so that they could relearn how to manage themselves, ultimately aiding
in self-independence.
Assertiveness Training
This was used for two patients who were either docile or very aggressive. This helped
the patients use assertiveness as a means of “reciprocal inhibition” of anxiety. The
goals included increased awareness of personal rights, differentiation between nonassertiveness
and assertiveness, differentiation between passive–aggressiveness and aggressiveness,
and learning both verbal and nonverbal assertiveness skills.
Social Skills Training
Social skills training programs are implemented with individuals who lack interpersonal
skills and the ability to effectively communicate their desires in a problem situation
or conflict.[28] This is geared toward patients with problems in social interactions and includes
focus on the development of social skills, assertiveness, and problem-solving techniques.
Three patients who had difficulty expressing, low social desirability, or had problems
adjusting that resulted in frustration and maladaptive responses were given this training.
Anger Management
Three patients had anger issues that were resolved through relaxation techniques,
cognitive restructuring, and improving communication strategies. The patients were
encouraged to increase their awareness of emotional, behavioral, and cognitive changes
that occur when they become angry. The participants practiced self-talk methods and
timeouts.
Individual Counseling
All patients in all the NR sessions were given insight-oriented psychotherapy to gain
more awareness and insight into their thoughts, feelings, and behaviors.[29] the counseling also included family counseling.
Vocational Guidance and Counseling
After ABI, almost all patients who were working or were students left their respective
jobs/academic pursuits and became unemployed.
Last evaluation included reassessment of psychosocial functioning of patients using
DAQ[26] to see their overall improvement on psychosocial functioning after extensive and
personalized NR, with the special focus on “neuropsychosocial perspective.”
Results
As it was a prospective study based on OPD-generated data for psychosocial functioning
(with the special focus on “neuropsychosocial perspective,” subjective feelings of
functioning were assessed post-rehabilitation after attaining ceiling and flooring
effect on all the domains. This assessment of improvement and effectiveness of the
NR focused on five domains: social, vocational, personal, cognitive, and family. [Table 3] shows the improvement in the scores on DAQ post-NR. In all the cases, it can be
seen that the level of functioning has improved.
Table 3
Changes (reported improvement) in pre- nd post-NR dysfunction scores
|
Patient
|
Pre-NR DAQ
%
|
Post-NR DAQ
%
|
|
Case 1
|
54.40
|
43.60
|
|
Case 2
|
99.20
|
86.00
|
|
Case 3
|
49.60
|
44.00
|
|
Case 4
|
96.00
|
91.90
|
|
Case 5
|
84.00
|
65.60
|
|
Case 6
|
52.00
|
43.20
|
|
Case 7
|
48.40
|
41.60
|
|
Case 8
|
80.00
|
58.40
|
|
Case 9
|
66.00
|
60.00
|
|
Case 10
|
92.00
|
69.00
|
|
Case 11
|
77.60
|
55.60
|
|
Case 12
|
68.40
|
52.00
|
|
Case 13
|
78.60
|
42.10
|
|
Case 14
|
86.80
|
57.20
|
|
Case 15
|
64.00
|
46.00
|
|
Case 16
|
88.40
|
48.40
|
|
Case 17
|
56.80
|
44.00
|
|
Case 18
|
80.00
|
62.40
|
Abbreviations: DAQ, dysfunction analysis questionnaire; NR, neuropsychological rehabilitation.
Note: Below 40% indicates no dysfunction.
As shown in [Table 3], a significant difference in the DAQ post-NR showed significant difference in all
the five areas of functioning: cognitive, personal, vocational, family, and social.
As given in [Table 4], the overall improvement in psychosocial functioning post eclectic NR in the five
areas – cognitive, personal, vocational, family, and social can be studied.
Table 4
Overall improvement in psychosocial functioning posteclectic NR
|
Tests/domain
|
Pre-NR
n = 18
|
Post-NR
n = 18
|
t Value
|
p Value
(level of significance)
|
|
Mean
|
SD
|
Mean
|
SD
|
|
DAQ—overall
|
73.45
|
16.49
|
56.16
|
14.74
|
7.10
|
0.001[b]
|
|
Cognitive area
|
69.04
|
17.17
|
54.66
|
14.98
|
5.40
|
0.001[b]
|
|
Personal area
|
73.33
|
19.65
|
55.00
|
15.21
|
5.51
|
0.001[b]
|
|
Vocational area
|
80.11
|
15.96
|
60.77
|
17.82
|
6.13
|
0.001[b]
|
|
Family area
|
66.77
|
20.29
|
52.44
|
13.62
|
4.70
|
0.002[a]
|
|
Social area
|
76.94
|
17.05
|
57.88
|
17.32
|
6.17
|
0.001[b]
|
Abbreviations: DAQ, dysfunction analysis questionnaire; NR, neuropsychological rehabilitation;
SD, standard deviation.
a Significance at the 0.005 level.
b Significance at the 0.001 level.
Discussion
NR is recognized as an important factor in aiding the process of picking up life,
as much as possible, as it was before brain injury.[30] Prigatano in 2005 adds that it should “help patients to manage residual neuropsychological
disturbances as they emerge into interpersonal situations.”[24]
NR with patients post-ABI varies according to the nature and severity of the injury,
patient's psychosocial context, clinical setting, and time since injury. Early rehabilitation
optimizes outcome, but rehabilitation at a later stage in recovery can also improve
functions significantly.[2] Two key principles underpin all types of rehabilitations: (1) engaging and maintaining
the patient (and family) involvement with the rehabilitation services by the provision
of an emotionally supportive environment and relationships within which empathetic
expert help can be easily accessed and (2) increasing the patient's (and his /her
families) understanding of ABI, their strengths and weaknesses, and the means by which
impairments may best be managed.
In this study, 18 individuals after ABI were followed up and given a comprehensive
NR intervention that was personalized per patient, to rehabilitate the patients' functioning
in cognitive, personal, vocational, family, and social areas. They were rehabilitated
by an eclectic approach using cognitive retraining, functioning retraining, psychological
therapies, relaxation training, relearning, anger management training, and counseling.
There has been extensive literature from all over the world, which proves the effectiveness
of cognitive rehabilitation of patient post-ABI in different cognitive domains such
as attention, concentration, and memory.[24]
[29]
[30] Studies have shown that patients make larger gains in functional tasks used in their
rehabilitation (i.e., activity scheduling) and are more likely to continue practicing
these tasks in everyday living; better results during follow-up are obtained.[31] Studies show that a combination of approaches can benefit individuals after TBI.[32] However, there is a need to study additionally better and effective measures of
therapeutic interventions that have been adapted to be used with patients with TBI.[25] It needs to be seen whether the results are sustainable post-NR.[7]
The effectiveness of CBT in individuals after TBI is dependent on his/her present
level of cognitive functioning.[33] CBT adapted for ABI shows enduring benefits for mood and community integration.[34] Additionally, in REBT, self-defeating thoughts and feelings are challenged by the
therapist. Therefore, it has been suggested that a more flexible protocol of REBT
be implemented for these patients, which is less directive and more adjustable.[33] Manchester and Wood in 2001 supported the view that any form of psychotherapy given
to patients after brain injury should be highly structured and repetitive, which increases
the likelihood of procedural learning through which there are greater chances of the
therapy being successful.[25]
Relaxation training is used to reduce one's experience of anger, frustration, and
tension.[25] There is very little literature on the outcomes of the use of relaxation techniques
after ABI, but it has been widely used for various psychological and psychiatric disorders[35]
[36] and neurologic diseases.[37] Denmark and Gemeinhardt advocated that training in social skills by role playing
provides opportunities for repetition and rehearsal of skills, which helps ameliorate
cognitive deficits such as planning and comprehension.[25]
The results show that the pre- and postdysfunction decreased significantly with the
subjective complaints of the patients. Of the 18 patients, 8 of the 14 patients who
had left their vocation due to the injury rejoined their jobs or academic pursuits
at the end of the rehabilitation. Vocational rehabilitation is recommended as a means
of facilitating return to work after TBI.[38] Cognitive retraining is given extensively the world over to patients after ABI.
Eclectic mix of retraining approach at the OPD level was given to the present group
of persons/patients. Various studies have evaluated the effectiveness of such cognitive
rehabilitation in such patients in different cognitive domains such as attention,
concentration, and memory.[39]
[40]
[41]
[42]
With the results, it can be confidently said that the eclectic approach to NR is successful
in decreasing the subjective complaints of the patients, improving the overall functioning
in all five areas of patients: cognitive, personal, vocational, family, and social.
Even the somatic complaints or the PCS symptoms of the patients such as headaches,
dizziness, nausea, sleep disturbances, noise/light sensitivity, and restlessness were
subjectively decreased after NR.
Studies evaluating the effectiveness of NR for patients with ABI are relatively sparse
and frequently suffer from significant methodological constraints. There is some modest
evidence that restorative techniques involving repeated practice of specific tasks
in laboratory settings can be effective for improving some specific attention and
language-based functions.[2] The current evidence also suggests that compensatory strategies are effective in
reducing everyday memory failures, minimizing anxiety, and increasing self-concept
and quality of interpersonal relationships. Behavioral approaches aimed at maximizing
skill acquisition and monitoring, including performance feedback and reinforcements
have also demonstrated their efficacy. These types of rehabilitations generalize best
to everyday life situations.[43]
[44]
Cattelani and colleagues performed a systematic review on treatment efficacy and clinical
effectiveness of a neurobehavioral rehabilitation program for patients with ABI. This
was done to make evidence-based recommendations for trainings such patients. From
63 studies, they found that the most improvement was indicated when comprehensive-holistic
rehabilitation program was used for improving psychological functioning. Other programs
included CBT and applied behavior analysis.[45]
Evans et al in 2003 reported that to cope more effectively with memory issues after
ABI, patients use compensatory strategies such as memory aids, such as diaries, notebooks,
electronic organizers, etc. Moreover, such patients also use environmental adaptations
and aids such as labeling kitchen cupboards.[9] Using a diary has been proven to be more effective if it is paired with self-instructional
training, and it was also related to more frequent use of the dairy over time, which
proved to be more successful as a memory aid.[7] As a large percentage of the population of the country is low literate, it is necessary
to develop memory aids, which are cultural and education free, which can be used in
India.
Other strategies used for rehabilitating memory for patients after ABI are repetitive
tasks with an attempt to increase the recall ability of the patient.[18] Research also shows that ABI patients use an more number of memory aids after their
injury than they did prior to it, and also these aids vary in their degree of effectiveness.[45] While memory training increases the performance at hand, there is little evidence
that the skills translated to improved performance on memory challenges outside the
therapeutic zone.[45] Another strategy used for improving memory is the use of elaboration to improve
encoding.
The principles[16] followed for an eclectic approach to NR in these cases included: They were begun
as early after the injury as was feasible; services were provided in a holistic and
interdisciplinary manner; and the design and implementation of the various therapeutic
regimens emanated from a comprehensive, systematic, and interdisciplinary evaluation
process.
The eclectic approach to NR also included inclusion of immediate family members/caregivers
in the therapy; empowerment of the client to become active participants in their own
therapy (person-centered care approach)[46] communication between the therapists, patient, family members, caregivers, spouses,
etc.; short- and long-term goal setting; psychoeducation; and supportive therapy.
The results show that the rehabilitation program was successful for all the patients
despite the differences in the severity of injury (mild, moderate, or severe TBI,
or hypoxia), the patient-specific complaints/symptoms, individual differences in impairments,
and also differences in the delay after the date of injury the rehabilitation was
started. Supporting our results, a randomized controlled trial of holistic NR was
conducted in a study in 67 adults after TBI. The rehabilitation included intensive
cognitive rehabilitation that emphasized on the integration of cognitive, interpersonal,
and functioning outcomes of these patients. The results showed that a holistic NR
program is effective in self-regulation and cognitive and emotional processes, and
also helps improve the community functioning and quality of life after TBI.[47]
As can be seen from the results, the overall dysfunctional analysis of the patients
pre- and post-rehabilitation has a significant difference that is significant at the
0.001 level (t = 7.10). A significant improvement is seen in all the five areas of functioning:
cognitive, personal, vocational, family, and social. All the patients reported a subjective
improvement in their overall everyday functioning as well.
Limitations and Future Directions
The scores on different neuropsychological tools could not be compared (pre- and post-rehabilitation),
as not all the tools were used on all the patients. Also, the severity of the injury
could not be correlated to the rehabilitation, whether the rehabilitation was more
effective in any one type of TBI or hypoxia over the other. Further analysis of the
role of age could also have given a clearer understanding of whether rehabilitation
proves more effective in younger population or older.
As there were so many techniques used in the NR program, the efficacy of each could
not be quantified. Therefore, the exact effectiveness of each type separately could
not be observed. All the limitations of this study could be incorporated in a future
cohort, where more substantial claims and generalizations can be made. In a future
larger cohort, the importance of spontaneous recovery could be taken into consideration,
where patients in the spontaneous recovery period be compared with those who have
surpassed this phase.
Conclusion
Eclectic approach to NR was successful in decreasing the overall dysfunction of the
patients in all the areas of functioning (cognitive, personal, vocational, family,
and social) in all the patients despite the severity of injury or the time elapsed
after date of injury. Several therapeutic approaches have been used to assist individuals
after brain injury, but more outcome studies are still needed to dictate which therapy
works best, or if using an eclectic therapy is the key. The challenge is to make the
therapy as person centered and individualistic as possible depending on the individual
needs as there is no “gold standard” for treatment for various issues arising following
brain injury.
Future Directions
Plan individualized NR packages as randomized controlled clinical trials, for different
ABI conditions.
