Volume 7 Issue 1 January, 2017
Consultation Liaison Psychiatry Focus: Physical Medicine and Rehabilitation
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality and is becoming a public health concern in India. TBI often results in chronic disability. It adversely impacts cognitive and behavioral functioning and hence results in vocational impairment. TBI can cause a plethora of cognitive impairments. Attention, memory, and disturbances in executive functioning are the most commonly encountered neurocognitive deficits with adverse impact on interpersonal and communication skills. These deficits significantly impair activities of daily living (ADL), employment, social relationships, recreation, and active participation in the community and hence result in disability and distress.
TBI is classified as mild, moderate, and severe depending on the level of consciousness, duration of coma and posttraumatic amnesia (PTA). In moderate to severe TBI, cognition appears to be markedly impaired around 1-month post injury or shortly after resolution of PTA. Cognitive impairments persisting even after 3 months were found to be associated with higher frequency of disability. In moderate to severe TBI, cognitive recovery does not return to baseline even after 2 years of injury. However, cognitive recovery is rapid in patients with mild TBI, returning almost to “normal baseline functioning” within 3 months.
The goal of cognitive rehabilitation following TBI is to enhance the persons’ ability to process and interpret information and to improve the person’s ability to perform mental functions. Cognitive rehabilitation is best suited for well-motivated and functionally independent persons with mild to moderate impairments. Cognitive rehabilitation is a multidisciplinary approach which includes physician, neuropsychologists, speech language pathologists, occupational therapists, physical therapist, and social workers. Cognitive rehabilitation consists of diverse interventions tailored to individual needs. Cognitive rehabilitation therapy is divided into two components: restorative and compensatory approach. The restorative approach aims at reinforcing, strengthening, or restoring the impaired skills. It includes the repeated exercise of standardized cognitive tests of increasing difficulty, targeting specific cognitive domains (e.g., selective attention, memory for new information). Compensatory approach teaches ways of bypassing or compensating for the impaired function. Assistive technologies, calendars, electronic memory devices, alarms, or
reminders are used as compensatory techniques. Pharmacotherapy based on catecholaminergic and cholinergic augmentation is a useful adjunct in cognitive rehabilitation.
TBI persons who undergo comprehensive holistic neuropsychological rehabilitation achieve greater improvements in community functioning compared to those who received conventional rehabilitation. Comprehensive holistic rehabilitation programme (CHRP) includes individual and group therapies, psychotherapy, psychoeducation, and family therapy. This holistic neuropsychological intervention stresses on metacognitive and emotional regulation techniques that facilitate skill transfer and generalization, behavioral and affective regulation, and community integration.
Dept. of Physical Medicine and Rehabilitation, AIIMS Bhubaneswar
