Delivering a Holistic Approach to Rehabilitating Motor Skills Following a Frontal Lobe Injury - Essay Example

Key Issues in Neurological Rehabilitation: The challenges of delivering a holistic approach to rehabilitating motor skills following a frontal lobe injury Introduction Brain trauma can bring about significantly unfavourable health injuries and impairment to affected patients. The brain controls majority of our neurological functions and responses; and they help ensure that the organ and system functions are within normal parameters. In instances where frontal lobe injuries are experienced, the rehabilitative processes require various focal points in order to partially and holistically restore normal functioning. This paper shall discuss the challenges of delivering a holistic approach to rehabilitating motor skills following a frontal lobe injury. It will first discuss the impact and pathophysiological elements relating to frontal lobe injuries. Secondly, the rehabilitative process will be presented, followed by a discussion on the challenges faced in frontal lobe problems. Finally, this essay will conclude with possible recommendations for better rehabilitative processes for affected patients. Body Structure, brain The frontal lobe of the brain generally represents a large mass and area (Lux, 2007). It comprises the cerebral system of the brain, which mostly provides a structure for goal-directed activities and behaviour (Badre and D’Esposito, 2009). It is often considered as the part of the brain which manages decision-making and which determines the impact of various actions. As it is found at the anterior part of the brain, it is also vulnerable to various injuries and trauma. After an individual’s frontal lobe is injured, one’s decision making processes may be compromised (Kim, et.al., 2009). Damage to the frontal lobe can also lead to irritability, often manifesting as a change in the mood or the failure to balance or regulate behaviour (Lux, 2007). Injury to the frontal lobe can also cause problems in executive functioning, including anticipation, planning, goal selection, initiation, sequencing, and self-correction (Lezak, 1989). In the case of railroad worker Phineas Gage, his left frontal lobe was injured by a large iron rod and through such injury, he manifested animal propensities; he was irreverent and indulging at times; and he was also impatient and obstinate (MacMillan and Lena, 2010). These qualities were very much in contrast to his personality before he suffered the injury. Patients suffering from damaged frontal lobes often indicate memory loss, with some losses being greater than others (Kane and Engle, 2002). The working memory seems to be affected the most in these injuries with the person’s ability to maintain attention or manage goals being affected (MacMillan, 2000). Risk taking and impulsivity is also increased among individuals with frontal lobe injury. Impulsivity manifests with the patient’s disinhibition and risk taking refers to reward-based elements of the decision-making process (Floden, et.al., 2008). They are therefore more likely to abruptly favour a chance to immediately reward even if the chance of success is very minimal (Floden, et.al., 2008). Increase in risk taking for patients with injured frontal lobes can be directly seen in their gambling activities. Rehabilitation Frontal lobe damage is usually permanent; however, the treatment and rehabilitation will help the patient regain previously lost functions. Through the compensating process for lost skills, the goals of rehabilitation and recovery can be secured (Purves, 2008). The focus for rehabilitation would be on assisting the patient in the regulation of his emotions and on controlling his impulsive and risk-taking behaviour. Mild traumatic frontal brain injury requires special attention especially due to the persistent discrepancy seen between the objective affectations and patient issues or complaints. Various studies have sought to evaluate these patients in relation to outcome. Estimates indicate that about 15% of mild trauma patients experience post-concussive symptoms within the year or more following their injury (Alexander, 1997). Minor neuropsychological problems may not be noticed and may only be more apparent when the individual seeks to return to their routine work demands; however, a link between objective cognitive issues and successful rehabilitation rates has not been clearly established. Patients having better social skills and those with occupations were also more likely to return to work and normal functioning (Ruffolo, et.al., 1999). Dizziness is another problem often seen after frontal lobe injures as well as other traumatic brain injuries. It has been indicated as a major element in higher psychological distress often interfering with return to normal functioning among patients with mild frontal lobe injuries (Chamalian, et.al., 2004). Under conditions where compensation and litigation are significant elements, psychosocial problems, pain as well as depression seem to have a significant role to play, more so than the severity of the injury or the patient’s cognitive status (Mooney, et.al., 2005). Challenges Immediately following the frontal lobe injury, the focus for the patient’s recovery is on survival, preventing complications from the injury, as well as regaining functions and ensuring mobility. The rehabilitation process focuses on these elements of recovery. After in-patient management, the rehabilitation process calls for community-based interventions, usually founded on the medical rehabilitation model (Shames, et.al., 2007). Where the patient has favourable functional recovery, normal activities, including work, may resume without any significant interventions from therapists and rehabilitative professionals. However in cases where gaps in functioning manifest, the patient would likely need professional rehabilitation services, often made possible through professional rehabilitation teams (Shames, et.al., 2007). The kind of services offered for these rehabilitation experts are diverse, and are mostly based on the health system and the location of such system. The general change seen in the WHO’s system of classification, which is the International Classification of Functioning, Disability, and Health (ICF) indicates that returning to work and normal functioning is the main element and goal of rehabilitation (Shames, et.al., 2007). Return to work would help improve their self-esteem and decrease the risk for secondary injury (Wehman, et.al., 2005). In general, rehabilitation professionals involved in the management of these patients seek an improved prognosis for patients (Khan, et.al., 2003). Families and patients seek realistic expectations, and based on these expectations, a plan needs to be secured. Ben-Yishay and Lakin (1989) established that an essential element of rehabilitation which was significantly successful for vocational rehabilitation is securing the patient’s self awareness. Sherer and colleagues (1998) also established a strong connection between self-awareness and return to work outcomes. They discussed that limited self-awareness usually compromised patient motivation for treatment (Shames, et.al., 2007). With higher educational levels, successful rehabilitation and return to work in the first year was also more likely. This is contrary to the severely disabled patients with their previous work no longer available and who must also go through a long process for rehabilitation. Wagner and colleagues (2002) indicate links between the failure of rehabilitation and other premorbid elements, such as psychiatric history, violent injury, alcohol, and drug use. Where rehabilitation services are also available for specific citizens, favourable outcomes can also be expected. Harradine and colleagues (2004) indicated that residency in the urban or rural centres did not affect the outcome for as long as rehabilitation services are equally accessible to patients in either area. Testing sessions which seek to determine neurological functions for affected patients are often carried out in a structured manner, with limited distractions for the patients and sessions carried out for only a few hours (Shames, et.al., 2007). Standard assessment may not be able to determine behavioural or impaired executive functions which may be seen within the environment or workplace as distractions may abound and the patient has to go through different activities for several hours (Stuss and Knight, 2013). Patients may also carry out complicated activities familiar to them. In effect, actual performance may sometimes be better than is predicted through formal test procedures. It is therefore recommended that neuropsychological testing be applied in order to identify gaps and abilities and to indicate circumstances where problems come about (Vuadens, et.al., 2006). Within this context, it is an important resource in handling the rehabilitative process. Psychosocial adjustment affects the prognosis of the patient, and the impact of unemployment on the patient. Franulic, et.al (2004) assessed a group of brain trauma patients with varying severities, with their psychosocial adjustment evaluated through the Neurobehavioral Rating Scale and the Hamilton Anxiety and Depression Rating Scale. Major differences were seen in the employed and unemployed groups. The authors recommended that these tests be used in screening for intensive psychosocial interventions for at risk patients (Franulic, et.al., 2004). Rehabilitation challenges As expected, similar controversies and issues which have been seen in relation to the rehabilitation of frontal lobe injury patients are issues which have already mentioned in the above discussion on vocational rehabilitation (Cicerone, et.al., 2011). The stage of rehabilitation which succeeds inpatient rehabilitation also addresses the specific long-term incident of brain injuries; it is labelled as post-acute brain injury rehabilitation (PABIR). Such stage can be seen in various settings under varying structures and programs. Residential neurobehavioral programs help manage head injury patients experiencing severe behavioural disturbances; they also provide intensive behavioural interventions (Cicerone, et.al., 2011). Outpatient activities often include comprehensive day treatment program; these programs highlight self-awareness, social skills, and coping mechanisms, including independence in daily activities and community reintegration activities (Chesnutt, et.al., 1998). Such community and re-integration programs are usually different in terms of content and length and are founded on the presence of technical experts. Malec and Basford (1996) assessed the different PABIR programs and all of the programs include behavioural and cognitive interventions. CBT highlights the management of internal cognitive structures in order to manage emotional and behavioural responses (Shames, et.al., 2007). Cognitive rehabilitation seeks to manage attention and adopts compensatory activities to manage gaps. These programs also impact on various issues, most of which affect the patient’s motivation to later return to work (Klonoff, et.al., 1999). In a review by Cicerone, et.al., (2009) it was established three important elements and standards relating to the holistic rehabilitation of frontal lobe injury patients. These elements include practice standards, practice guidelines, and practice options. The support for cognitive-linguistic therapies need to be improved based on the studies reviewed by Cicerone, et.al., (2009) especially where patients manifest language deficits following frontal lobe injuries. Evidence from the review also indicates support for the use of gestural or strategy training for apraxia following hemisphere stroke. Much evidence is available supporting clinical recommendations for strategy training for individuals with mild memory gaps following frontal lobe injury. Strategy training is also a major challenge in the management of attention deficits caused by the trauma (Cicerone, et.al., 2009). Due to the complicated rehabilitation process involved in restoring brain functions, injured patients must secure a continuum of care, from acute to the inpatient stage, and lastly to the community phase (Shames, et.al., 2007). This would comprise a holistic program of rehabilitation. Since frontal brain injury impacts on young patients during their active years, it is important for rehabilitation to include activities which can help ensure return to work and normal functioning. Return to work is significant to the social, economic, and psychological recovery of these patients; moreover, their quality of life can also be improved. Trudel and colleagues (2006) discuss how individuals who have experienced frontal lobe injuries need a continuum of care which would cover acute hospitalization and rehabilitation, as well as community reintegration and return of functions as a productive citizen. Such goals are major challenges to meet and in the military, according to Trudel, et.al., (2006) have been difficult to promote where the injuries require medical board discharge. Whether civilian or military however, these frontal brain injury patients who progress well can eventually be reintegrated into the community with the application of holistic techniques of care (Trudel, et.al., 2006). Conclusion As indicated in the discussion above, various demographic elements, injury-related aspects, and environmental elements often compromise a patient’s rehabilitation from frontal lobe injury. Self-awareness and motivation are essential elements which can help ensure successful efforts towards recovery. Rehabilitation must therefore focus on increasing such self-awareness and motivation. Most frontal lobe injury patients may be able to return to work or regain normal functioning if adequate efforts are indicated towards recovery and rehabilitation. Studies indicate favourable results from economic investments in rehabilitation. Additional efforts must also be made towards identifying brain trauma patients who have a risk of not being able to recover normal functions. Efforts must also be directed towards ensuring the coordinated and structured program in managing the unique issues of these patients, including supported-employment programs and community efforts to ensure the availability of these activities. Unfortunately however, the access to these programs is not widespread due to geographic, financial, and technical limitations. Social and cultural elements may also manifest as issues in the patients return to work or normal functioning. The rehabilitation of care workers must also be considered in order to ensure continuity of care for the patients. Laws which help ease the process of return to normal functioning can also help manage the crucial stages of the patient’s recovery. With integrated and systemic effort, improved outcomes and results may be seen; moreover, the quality of the patient’s life may also be improved. References Badre, D. & DEsposito, M. (2009). Is the rostro-caudal axis of the frontal lobe hierarchical? Nature Reviews Neuroscince, 10, 659-669. Ben-Yishay, Y & Lakin, P. (1989). Structured group treatment for brain injury survivors. In D. Ellis & A. Christenson (eds). Neuropsychological treatment after brain injury (pp. 271-295). Boston: Kluwer Academic. Chamaliam L. & Feinstein, A. (2004). Outcome after mild to moderate TBI: The role of dizziness. Arch Phys Med Rehabil, 85, 1662-1666. Cicerone, K., Langenbahn, D., Braden, C. & Malec, J. (2011). Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008. Arch Phys Med Rehabil, 92, 520-532. Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., and Kneipp, S., (2005). Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Archives of physical medicine and rehabilitation, 86(8), 1681-1692. Floden, D., Alexander, M.P., Kubu, C.S., Katz, D., & Stuss, D.T. (2008). Impulsivity and risk- taking behavior in focal frontal lobe lesions. Neuropsychologia, 46, 213-223. Franulic, A., Carbonell, C. & Sepulveda, I. (2004). Psychosocial adjustment and employment outcome 2, 5 and 10 years after TBI. Brain Inj., 18(2), 119-29. Gil, M., Cohen, M., Korn, C., & Groswasser, Z. (1996). Vocational outcome of aphasic patients following severe TBI. Brain Inj, 10, 39-45. Gollaher, K., High, W., & Sherer, M. (1998). Prediction of employment outcome one to three years following TBI. Brain Inj, 12, 255-263. Greenspan, A., Wrigley, J., & Kresnow, M. (1996). Factors influencing failure to return to work due to traumatic brain injury. Brain Inj, 10(3), 207-218. Greenwald, B., Burnett, D., & Miller, M. (2003). Congenital and acquired brain injury: Epidemiology and pathophysiology. Arch Phys Med Rehabil, 84(1), 3-7. Harradine, P., Winstanley, J. & Tate, R. (2004). Return to productive activity after TBI: Relationship with measures of disability, handicap and community integration. Arch Phys Med Rehabil, 181, 130-134. Kane, M.J. & Engle, R.W. (2002). The role of prefontal cortex in working-memory capacity, executive attention, and general fluid intelligence: An individual-differences perspective. Psychonomic Bulletin & Review, 9(4), 637-671. Keren, O., Cohen, M., Lazar-Zwacker, I., & Gorswasser, Z. (2001). Tracheotomy in severe TBI patients: Sequelae and relation to vocational outcome. Brain Inj, 15, 531-536. Keyser-Marcus, L., Bricout, J., Wehman, P., Campbell, L. & Cifu, D. (2002). Acute predictors of return to employment after traumatic brain injury: A longitudinal follow-up. Arch Phys Med Rehabil, 83, 635-641. Khan, F., Baguley, I. & Cameron, I. (2003). Rehabilitation after traumatic brain injury. Med J Aust, 178 (6), 290-295. Klonoff, P., Watt, L., Dawson, L., Henderson, S., Gehrels, J. & Wethe, J. (2006). Psychosocial outcomes 1-7 years after comprehensive milieu-oriented neurorehabilitation: The role of pre-injury status. Brain Inj, 20(6), 601-612. Lezak M.D. (1989). Assessment of psychosocial dysfunction resulting from head trauma. In: Lezak MD (ed). Assessment of the behavioral consequences of head trauma (pp. 113-143). New York (NY): A. R. Liss. Lux, W.E. (2007). A neuropsychiatric perspective on traumatic brain injury. Journal of Rehabilitation Research & Development, 44(7), 951-962. Macmillan, M. (1986). A wonderful journey through skull and brains: The travels of Mr. Gages tamping iron. Brain and Cognition 5 (1), 67–107. Malec, J. & Basford, J. (1996). Postacute brain injury rehabilitation. Arch Phys Med Rehabil, 77(2), 198-207. Mooney, G., Speed, J., & Sheppard, S. (2005). Factors related to recovery after mild traumatic brain injury. Brain Inj, 19(12), 975-987. Ponsford, J., Olver, J., Curran, C. & Ng, K. (1995). Prediction of employment status 2 years after traumatic brain injury. Brain Inj, 9(1), 11-20. Purves, D. (2008). Neuroscience. Sunderland, MA: Sinauer Associates, Inc. Ruffolo, C., Freidland, J., Dawson, D., Colantonio, A., & Lindsay, P. (1998). Mild TBI from motor vehicle accidents: Factors associated with return to work. Arch Phys Med Rehabil, 80, 392-398. Shames, J., Treger, I., Ring, H. & Giaquinto, S. (2007). Return to work following traumatic brain injury: Trends and challenges. Disability and Rehabilitation, 29(17), 1387-1395. Sherer, M., Bergloff, P., Levin, E., High, W., Oden, K., & Nick, T. (1998). Impaired awareness and employment outcome after traumatic brain injury. J. Head Trauma Rehabil, 13, 52-61. Stuss, D. & Knight, R. (2012). Principles of frontal lobe function. London: Oxford University Press. Trudel, T. M., Nidiffer, F. D., & Barth, J. T. (2007). Community-integrated brain injury rehabilitation: Treatment models and challenges for civilian, military, and veteran populations. Journal of Rehabilitation Research and Development, 44(7), 1007. Vuadens, P., Arnold, P., & Belmann, A. (2006). Return to work after TBI: A difficult challenge. In C. Gobelet, F. Franchignoni (eds). Vocational rehabilitation (pp. 143-163). Paris: Springer. Wagner, A., Hammond, F., Sasser, H., & Wiercisiewski, D. (2002). Return to productive activity after TBI: Relationship with measures of disability, handicap, and community integration. Arch Phys Med Rehabil. 83, 108-114. Walker, W., Marwitz, J., Kreutzer, J., Hart, T., & Novack, T. (1996). Occupational categories and return to work after traumatic brain injury: A multicenter study. Arch Phys Med Rehabil, 87, 1576-1582. Wehman, P., Targett, P., West, M. & Kregel, J. (2005). Production work and employment for persons with traumatic brain injury: What have we learned. J Head Trauma Rehabil, 20(2), 115-127. Wright, J. (2000). The Glasgow Coma Scale. The Center for Outcome Measurement in Brain Injury. Retrieved from http://www.tbims.org/combi/gos. Wright, J. (2006). The Disability Rating Scale. The Center for Outcome Measurement in Brain Injury. Retrieved from http://www.tbims.org/combi/drs. Read More