NeuroRehabilitation - Volume 34, issue 4

Authors: Jacobs, Harvey E.

Article Type: Editorial

DOI: 10.3233/NRE-141069

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 597-599, 2014

Authors: Buzan, Randall D. | Kupfer, Jeff | Eastridge, Dixie | Lema-Hincapie, Andres

Article Type: Research Article

Abstract: Introduction: Patients and their families struggle with accepting changes in personality after traumatic brain injury (TBI). A neuroanatomic understanding may assist with this process. Objectives: We briefly review the history of the Western conceptualization of the Self, and discuss how neuroscience and changes in personality wrought by brain injuries modify and enrich our understanding of our selves and our patients. Conclusion: The sense of self, while conflated with the concept of a “soul” in Western thinking, is more rationally considered a construct derived from neurophysiologic structures. The self or personality therefore often changes when the brain …changes. A neuroanatomic perspective can help patients, families, and clinicians accept and cope with the sequellae of TBI. Show more

Keywords: Traumatic brain injury, personality change, philosophy of mind

DOI: 10.3233/NRE-141071

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 601-611, 2014

Authors: Wortzel, Hal S. | Arciniegas, David B.

Article Type: Research Article

Abstract: Introduction: The advent of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is accompanied by substantial changes in the approach taken in this manual to traumatic brain injury (TBI) and its neuropsychiatric sequelae. Objective: This article reviews the issues pertaining to the treatment of TBI in the DSM-5, and changes relative to the outgoing DSM-IV-TR. The primary context for discussion of TBI in the DSM-5 is the section on Neurocognitive Disorders, where a basic framework is provided for the retrospective diagnosis of TBI and characterization of the clinical presentation as a Mild or Major Neurocognitive …Disorder. The distinctions between these conditions rest not on the initial severity of TBI but instead on the severity of posttraumatic cognitive impairments and their effects on everyday function. The text succinctly reviews the epidemiology, phenomenology, and natural history of TBI and highlights the need to consider the differential diagnosis for persistent postconcussive symptoms. Conclusion: The approach taken to the diagnosis of TBI and its neuropsychiatric consequences in the DSM-5 is improved substantially over that of the DSM-IV-TR, and it is likely to improve the evaluations of persons with TBI by mental health professionals. However, challenges borne of this approach are likely to be revealed as it is implemented in everyday practice and will guide the development of this section of DSM-5.1. Show more

Keywords: Traumatic brain injury, cognition disorders, DSM-5

DOI: 10.3233/NRE-141086

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 613-623, 2014

Authors: Webb, Nadia E. | Little, Brittany | Loupee-Wilson, Stephanie | Power, Elizabeth M.

Article Type: Research Article

Abstract: Introduction: Traumatic Brain Injury (TBI) initiates a cascade of neuromodulatory damage that blurs the distinctions between physical and psychological medicine. Monitoring endocrine function through labs is not part of the medical care algorithm for treatment of TBI, but the clinical symptoms are easily misidentified as they include: depression, fatigue, poor concentration, irritability and a decline in overall cognitive functioning. The reciprocal flow of change between neuroendocrine health and psychosocial health is well established within the field of neuroscience, social psychology, endocrinology and behavioral neurology, but has not translated into patient care. Objectives: This paper outlines common neuroendocrine disruptions …secondary to TBI and their clinical implications for treating mental health professionals. Conclusion: Wider adoption of the consensus guidelines on the detection and monitoring of endocrine abnormalities post-TBI may diminish the severity of functional impairment and improve quality of life. Show more

Keywords: HPA axis, psychoneuroimmunology, TBI, endocrine, social isolation, anterior pituitary, hypopituitarism, brain injury, PTSD, neuroendocrine injury, neurorehabilitation

DOI: 10.3233/NRE-141074

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 625-636, 2014

Authors: McQueen, Ryan | O'Shanick, Gregory J.

Article Type: Research Article

Abstract: Background: While acute rehabilitation following neurotrauma has evolved over the past 30 years to include the common use of pharmacologic agents to promote synaptogenesis and improve recovery potential, little guidance exists for a similar strategy in the post-acute or community re-entry phases of injury. Drawing upon the existing scientific literature, models of pharmacologic intervention in promoting stability in other disease states and the authors' collective clinical experience, this article provides a potential structure by which to implement methods to create a stable physiologic platform to facilitate behavioral intervention. Objectives: This article reviews basic foundations for physiologic optimization, pharmacologic …strategies for facilitation, and dyscompliance after neurotrauma. Methods: Literature review, case analysis, clinical experience. Results: Guidelines for facilitation of behavioral intervention with physiologic stabilization and with pharmacologic agents are presented with clinical rationale for their utilization. Conclusions: Improving physiologic readiness for behavioral intervention in the post-acute and community re-entry phases following neurotrauma has potential to improve both the efficiency and durability of these efforts. Show more

Keywords: Neurotrauma, pharmacology, interventions, behavioral facilitation, post-acute, community re-entry

DOI: 10.3233/NRE-141070

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 637-643, 2014

Authors: Lequerica, Anthony | Krch, Denise

Article Type: Research Article

Abstract: Introduction: With the general population in the United States becoming increasingly diverse, it is important for rehabilitation professionals to develop the capacity to provide culturally sensitive treatment. This is especially relevant when working with minority populations who have a higher risk for brain injury and poorer rehabilitation outcomes. Objectives: This article presents a number of clinical vignettes to illustrate how cultural factors can influence behavior in patients recovering from brain injury, as well as rehabilitation staff. The main objectives are to raise awareness among clinicians and stimulate research ideas by highlighting some real world examples of situations where …a specialized, patient-centered approach needs to consider factors of cultural diversity. Conclusion: Because one's own world view impacts the way we see the world and interpret behavior, it is important to understand one's own ethnocentrism when dealing with a diverse population of patients with brain injury where behavioral sequelae are often expected. Being able to see behavior after brain injury with an open mind and taking into account cultural and contextual factors is an important step in developing culturally competent rehabilitation practices. Show more

Keywords: Culture, diversity, rehabilitation, brain injury

DOI: 10.3233/NRE-141079

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 645-653, 2014

Authors: Karol, Robert L.

Article Type: Research Article

Abstract: Introduction: Neurorehabilitation requires a team effort. Over time the nature of teams has evolved from single discipline work through multi-disciplinary and inter-disciplinary teams to trans-disciplinary teams. However, there are inconsistencies in the literature and clinical practice as to the structure and function of these team models. Each model engenders advantages over its predecessor and unless the models are well understood clinicians may labor in a model that is less efficacious than the most transcendent model. Objectives: To define and examine the models of single discipline care, multi-disciplinary teams, inter-disciplinary teams, and trans-disciplinary teams and to review in depth …trans-disciplinary teams as the most advanced team model. This paper will also consider professional roles and integration across disciplines as well as the crucial topics of staff selection, attendance in rounds and the nature of rounds, staff physical plant assignments, and leadership responsibilities. Leadership responsibilities that will be addressed include scope of practice and role release, peer pressure, and culture change issues. Conclusions: The trans-disciplinary model is the gold standard for teams in neurorehabilitation because they entail more integrated service delivery than do other teams. Trans-disciplinary teams also represent a more persons-centered approach. To initiate a trans-disciplinary model, team members must have excellent communication and shared decision making including persons with brain injury. Leadership must address staff selection, scope of practice and role-release. Otherwise, the model will fail due to peer pressure and institutional or program cultural variables. Show more

Keywords: Team models, rehabilitation teams, multidisciplinary, interdisciplinary, transdisciplinary, role release, scope of practice, culture change

DOI: 10.3233/NRE-141080

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 655-669, 2014

Authors: Huckshorn, Kevin Ann | LeBel, Janice | Jacobs, Harvey E.

Article Type: Research Article

Abstract: Introduction: Seclusion, restraint (S/R) and coercive practices are used across human service populations, settings, with people of all ages. Their use has been increasingly scrutinized by the public, federal government and the media. Alternatives, interventions, and organizational approaches to these forms of containment are now emerging and advancing practice. Aim/purpose: This article provides an overview of the work conducted to reduce the use of coercion restraint, seclusion and other invasive practices in behavioral health settings that often include the defacto admission of persons with Acquired Brain Injury (ABI). The article also examines treatment culture factors that can exacerbate …behavior dysfunction and how to moderate such challenges to prevent the use of S/R procedures among people with ABI. Conclusion: Seclusion and restraint can be avoided and greatly reduced in settings serving people with ABI. When S/R use is recognized as an inadequate organizational response to harmful behavior that maintains patterns of aggression or harm, leadership-driven core strategies can be implemented to disrupt the behavioral sequence. The Six Core Strategies© provide a prevention based framework to anticipate challenge, intervene early, and analyze the factors that contribute to maintaining the cycle of violence if S/R is used. Show more

Keywords: Restraint, seclusion, coercion, acquired brain injury, mental health, treatment, trauma

DOI: 10.3233/NRE-141073

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 671-680, 2014

Authors: Jackson, Howard F. | Hague, Gemma | Daniels, Leanne | Aguilar Jr., Ralph | Carr, Darren | Kenyon, William

Article Type: Research Article

Abstract: Introduction: The importance of structure in post-acute brain injury rehabilitation is repeatedly mentioned in clinical practice. However, there has been little exploration of the key elements of structure that promote greater levels of functioning and emotional/behavioural stability and how these elements are optimally integrated within the infrastructure of a rehabilitation service. Objectives: The nature of structure and why it is helpful is explored initially. Thereafter, the processes involved in transition from externally supported structure to the client ‘self-structuring’ are described. The infrastructure for facilitating these transitional processes are considered in terms of the design of services for systemic …neurorehabilitation encompassing environmental factors (e.g. living environments, vocational and recreational options, step-up services and social milieus), therapeutic alliances (rehabilitation professionals, family, friends), organisational structures (service delivery, rehabilitation coaching, transdisciplinary teams) and rehabilitation philosophies and practice. Conclusion: It is concluded that the process of supporting individuals to transition from the ‘structure’ of the environment and other people towards self-structuring skills is a critical process in rehabilitation. This is reliant upon a comprehensive and robust organisational infrastructure that can successfully and flexibly integrate the core elements of structure across a transitional pathway towards increased independence and self-structuring. Show more

DOI: 10.3233/NRE-141082

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 681-694, 2014

Authors: Jackson, Howard F. | Tunstall, Victoria | Hague, Gemma | Daniels, Leanne | Crompton, Stacey | Taplin, Kimberly

Article Type: Research Article

Abstract: Background: Jackson et al. (this edition) argue that structure is an important component in reducing the handicaps caused by cognitive impairments following acquired brain injury and that post-acute neuropsychological brain injury rehabilitation programmes should not only endeavour to provide structure but also aim to develop self-structuring. However, at present there is no standardized device for assessing self-structuring. Objective: To provide preliminary analysis of the psychometric properties of the Behavioural Assessment of Self-Structuring (BASS) staff rating scale (a 26 item informant five point rating scale based on the degree of support client requires to achieve self-structuring item). …Methods: BASS data was utilised for clients attending residential rehabilitation. Reliability (inter-rarer and intra-rater), validity (construct, concurrent and discriminate) and sensitivity to change were investigated. Results: Initial results indicate that the BASS has reasonably good reliability, good construct validity (via principal components analysis), good discriminant validity, and good concurrent validity correlating well with a number of other outcome measures (HoNOS; NPDS, Supervision Rating Scale, MPAI, FIM and FAM). The BASS did not correlate well with the NPCNA. Finally, the BASS was shown to demonstrate sensitivity to change. Conclusions: Although some caution is required in drawing firm conclusions at the present time and further exploration of the psychometric properties of the BASS is required, initial results are encouraging for the use of the BASS in assessing rehabilitation progress. These findings are discussed in terms of the value of the concept of self-structuring to the rehabilitation process for individuals with neuropsychological impairments consequent on acquired brain injury. Show more

DOI: 10.3233/NRE-141087

Citation: NeuroRehabilitation, vol. 34, no. 4, pp. 695-708, 2014