Rehabilitation services are aimed at maximising recovery following trauma, and effectively managing the distinctly different challenges that often confront people with traumatic brain injury (TBI) and their families or carers during the stages of recovery, rehabilitation, and social integration.
An essential component of contextualised intervention is the direct and purposeful consideration of the broader context in which the person with TBI functions.
A critical aspect in the evolution of specialised TBI rehabilitation has been the expansion of the physical rehabilitation focus to include cognitive, behaviour, and community elements into models of care.
Causes
Traumatic
- Assaults
- Falls
- Gunshot wounds
- Motor vehicle accidents
- Sport injuries
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Disorders of consciousness
- Persistent post-concussive symptoms
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
- Definition of acquired brain injury (ABI)
- Determine the severity of the TBI
- Different types of acquired/non-traumatic brain injuries and their pathophysiology
- Epidemiology of TBI in Australia and Aotearoa New Zealand, including:
- aetiology, e.g. assault, falls and motor vehicle accident (MVA)
- definition of TBI
- Factors that might affect the trajectory of disability and recovery after TBI
- Pathophysiology of TBI, including:
- diffuse axonal injury
- focal injury
- primary brain damage
- secondary brain damage
- Penetrating and closed TBI
- Post-traumatic amnesia, including:
- clinical management
- methods of measurement
- significance regarding rehabilitation management and outcome
- Spectrum of brain injury populations based on age, severity and aetiology
- Understand the outcomes of ABI versus TBI
The mechanisms of functional recovery
- Theories and physiological changes related to neuroplasticity
- Understanding the underlying physiology and mechanisms of recovery after a TBI:
- resolution of acute factors:
- cerebral oedema
- focal haematoma
- hypoxia
- raised intracranial pressure
Investigations
- Measures of cognitive, behavioural, and affective disturbance, including:
- bedside measures
- comprehensive neuropsychological measures
- research measures
- Measures of impairment, disability, and activity limitation or participation restriction following TBI
- Neurological assessment and monitoring tools:
- Glasgow Coma Scale score
- Ranchos Los Amigos scale
- Neuropsychological evaluation, including Choice Reaction Time, Simple and Wechsler Scales
- Physical examination
- Specific post-traumatic amnesia tools, e.g. Westmead Post-Traumatic Amnesia Scale (WPTAS)
Examinations
- CT scan
- EEG
- MRI
- PET scan
- Single photon emission computed tomography (SPECT)
Acute management
- Common surgical interventions, including decompressive craniectomy (DECRA)
- Methods of acute monitoring in emergency, intensive care, and acute neurosurgical care
- Post-traumatic amnesia
- Role of diagnostic investigations in management and prognosis
- Role of pharmacotherapy, including prophylactic anticonvulsant medication
- Role of rehabilitation physician in intensive care unit/acute neurosurgical unit
Chronic/Long term management
- Autonomic nervous system dysfunction (dysautonomia)
- Chronic behaviour confusion
- Hormone dysfunction
- Vestibular dysfunction
- Vision problems
Community re-integration
- Cognitive retraining exercises
- Driving
- Education on adjustment for patients and families or carers
- Environmental adaptation
- Hobbies or other leisure activities
- Memory compensation techniques
- Re-learning social skills
- Return to work options
- Training and assisting in the development of compensatory techniques for instrumental activities of daily living
Complications of brain injuries – diagnosis and management
- Aspiration pneumonia
- Associated neuroendocrine disorders
- Autonomic dysfunction syndrome, including paroxysmal sympathetic hyperactivity
- Behavioural disturbance
- Contractures
- Fatigue and sleep disorders – altered sleep
- Headache
- Heterotopic ossification
- Hypertonicity and movement disorders
- Pain syndrome – neuropathic pain and central pain syndromes
- Post-traumatic hydrocephalus and ventriculoperitoneal (VP) shunting
- Pressure areas
- Psychiatric disorders, e.g. alcohol and drug issues, mood disorder and post-traumatic stress disorder, psychosis, suicidality
- Seizures and epilepsy
- Syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH)/diabetes insipidus/pituitary dysfunction
- Venous thromboembolism
- Visual disturbances
Disorders of consciousness
- Clinical presentations
- Common issues:
- bowel and bladder function
- maintenance of skin, muscle length, and joint range
- swallowing and nutrition
- tracheostomy care
- Ethical and legal issues pertaining to medical care and life support
- Strategies to manage common issues
Documentation requirements
Dysfunction – diagnosis and management
- Activity limitations and participation:
- community reintegration
- domestic/community ADLs
- driving
- dysregulation
- effects on family system
- mobility
- practical issues pertaining to:
- accommodation
- attendant care
- community support services
- compensation schemes and their impact on patient rehabilitation
- guardianship and financial management
- role of transitional services
- prescription of orthotics and walking aids
- recreational and avocational activities
- self-care
- social and relationship changes, and sexuality
- vocational or study
- Behaviour:
- disinhibition, impulsivity
- egocentricity/self-centredness
- impaired frustration tolerance, anger, agitation, and aggression
- pharmacological and non-pharmacological management strategies
- Cognitive and communication:
- arousal
- assessment of capacity and associated legal requirements
- attention
- executive function
- indications of and how to interpret a neuropsychology report
- language and communication
- learning
- memory
- perception, praxis
- Physical:
- acquired movement disorders
- balance and gait, vestibular dysfunction
- bowel and bladder function
- contracture prevention and management strategies
- cranial nerve lesions, including sensory deficits
- pressure area prevention and management strategies
- sensory impairment, including anosmia and hearing changes
- sleep management
- spasticity
- swallowing and nutrition
- weakness, incoordination, spasticity, contractures
Psychosocial aspects
- Communication disorders
- Family functioning and adjustment
- Psychiatric and psychological disorders, including mood changes, emotional disturbances, and other associated psychiatric disorders
- Substance and alcohol misuse
Rehabilitation potential
- Injury factors – location and severity of injury, other significant injuries
- Post-injury factors – duration of coma and post-traumatic amnesia, hypotension, hypoxia, raised intracranial pressure
- Pre-injury factors – age, drug and alcohol use, intellectual function, psychosocial status
