Acquired Brain Injury (ABI) Research Paper
An acquired brain injury (ABI), whether it occurs due to trauma or other reasons, is a permanent and life altering condition. An infinite combination of brain areas may be affected, with results that are mild, moderate, or severe. Individuals may be impacted cognitively, emotionally, physically and socially, and require extensive rehabilitation. They face a loss of autonomy and independence, are at risk of becoming socially isolated, may have difficulty learning new skills, and can pose a safety risk. Their world has been turned upside down, and improving their sense of self and purpose in this world, is an important therapeutic goal. The Therapeutic Recreation Specialist is an important member of the treatment team who works with the individual to improve their cognitive and physical functioning. They support the individual in engaging socially with others, in gaining a sense of mastery that leads to self-worth, and ultimately impact factors that relate to quality of life and integration in the community.
The etiology, symptoms and characteristics of ABI, as well as the resulting implications to a person’s health and wellness, will be presented. The value of therapeutic recreation associated with these implications will follow.
Description and Etiology
An acquired brain injury is a postnatal injury to the brain (Toronto Acquired Brain Injury Network, [TABIN], 2010). Specifically, it must not be related to a congenital disorder, or developmental disability, including Cerebral Palsy, Autism, Down syndrome, Spina Bifida and Muscular Dystrophy. Additionally, it must not be caused by a disease process which causes progressive brain damage as seen in Alzheimer’s Disease, Dementia, Pick’s Disease, Amyotrophic Lateral Sclerosis, Muscular Sclerosis, Parkinson’s Disease and Huntington’s Disease (TABIN, 2010).
The causes of ABI are many. Trauma caused by a motor vehicle accident, fall, physical assault, or sports injury may result in irreversible damage to the brain (Carter, Van Andel, & Robb, 2003). Brain damage may also occur for non-traumatic reasons due to a medical problem, or non-progressive disease process including anoxia, aneurysm, brain tumours, encephalitis, meningitis, and stroke (TABIN, 2010).
It’s difficult to determine the precise statistics on the incidence of ABI. The Brain Injury Association of Canada, a relatively young organization, is currently working to generate this information. They estimate that ABI affects thousands of Canadians each year, the majority of whom are young adults, with men having double the incidence of women (The Brain Injury Association of Canada, 2004). In the United States, The Centre for Neuro Skills, a world leader in the treatment of ABI, states that risk is highest in young adults fifteen to twenty four years of age, with an elevated risk also seen in adolescent populations, and people over the age of seventy five (2009).
Symptoms and Characteristics
Symptoms and characteristics of ABI are very individual, and vary based on the area of the brain which has sustained damage and the degree of the injury (Carter et al., 2003). A neurologic examination may reveal a variety, or only a few, cognitive and behavioural deficits (Gelber & Callahan, 2004).
Injury to the brain will clearly have an effect on cognitive functioning. Acutely, individuals have an altered level of consciousness including confusion, disorientation and anterograde amnesia, the duration of which is related to injury severity. Problems with attention and concentration include a slowing of cognitive functioning and distractibility. Impairments may be evident in both short and long-term memory, resulting in a diminished ability to carry over information from day to day. Individuals may demonstrate impaired mathematical ability, and difficulty with spatial orientation and perceptual tasks. Disorders of body image may result in neglect of one side of the body, contralateral to the brain injury. Problems with speech and language are evident when the dominant brain hemisphere is damaged and include difficulty with spoken and written languages, and language processing. This may result in aphasia, echolalia, stuttering, impaired articulation known as dysarthria, slow and slurred speech known as choreoathetosis, and problems understanding abstract language (Gelber & Callahan, 2004).
Neurological damage also impacts functioning in the emotional domain. Changes in personality and affect are common, as is an instability of mood. The individual may be mentally rigid, emotionally disinhibited, egocentric, impatient, and irritable. Difficulty controlling anger is a problem, and some individuals are aggressive. A flat affect with apathy and a lack of initiative can interfere with therapy. Delirium is possible with occurrences of hallucinations and delusions in some individuals (Gelber & Callahan, 2004).
While there may be no covert signs of damage to the head, a variety of physical impairments may be detected. Hearing loss may occur with associated vertigo and problems with balance and coordination. Olfactory sensory loss can happen as can loss of vision, with possible accompanying diplopia, eye deviation, nystagmus, and an inability to track moving objects. Weakness and loss of sensation in the face and neck can impair breathing, chewing and swallowing, increase the risk of aspiration and make articulation of speech difficult. Other sensory deficits can occur in the detection of touch, pain, and temperature, as well as the kinesthetic sense of joint position in space. An examination of motor functioning reveals generalized muscle atrophy, spasticity and rigidity of muscle tone, and contractures. Hemiparesis or tetraparesis can limit postural control, and movement. A variety of abnormal movements may be detected including tremors, prolonged muscle contractions known as dystonia, stereotyped movements known as dyskinesia, slow, writhing, spasmodic movements of the face or limbs known as choreoathetosis, and a violent flinging of the proximal upper extremity known as ballismus. Coordination can be altered with intention tremor, a slowness of all voluntary movements and speech known as bradykinesia, impaired ability to produce coordinated movements known as ataxia, and difficulty gauging distance and speed of movement. Difficulty with fine and gross motor movements is common, and either hyperactive or hypoactive reflexes may be evident. These combined motor and sensory deficits can make ambulation difficult, and many individuals are wheelchair users. In those individuals who are able to walk, gait deviation is likely, and assistive devices may be used (Gelber & Callahan, 2004).
The final domain to be discussed is the social domain. Individuals with an ABI may lack impulse control, frequently lose their temper, or display other behaviours that would have been out of character for them before their injury. A lack of sexual control or an impairment in social judgement can be disruptive to others around them (Gelber & Callahan, 2004).
Implications
The repercussions of an ABI will vary based on whether the damage is mild, moderate, or severe. Due to medical advances, there are certainly more people who are surviving to live with severe injury. For these individuals, the impact on the outcome of their life can be profound.
All individuals with ABI face the risk of becoming socially isolated. Family members may have difficulty adjusting to changes in their loved one’s personality (Andrews, Gerhart, & Hosack, 2004). Socially inappropriate behaviours can result in the loss of some relationships and difficulty forming new friendships. Functional impairments that limit an individual’s ability to communicate and interact with others compounds this issue (Andrews et al., 2004).
Loss of autonomy and independence is a major challenge. Assistance with personal care and activities of daily living such as grooming, dressing, feeding, and toileting may be required. The individual may have limited mobility and require a wheelchair for ambulation, or another assistive device. They may be unable to manage their own finances, and lack the ability to participate in basic community activities such as shopping. Communication skills are a prerequisite to independent living in the community (Andrews et al., 2004), and important for indicating personal choices and preferences.
A major barrier to rehabilitation can be impaired learning abilities. The ability to concentrate and remember information is necessary for learning. Therapy can be very difficult when there is little carry over of information from day to day (Andrews et al., 2004).
An individual with an ABI may also be a safety risk for a variety of reasons. Those with poor spatial awareness may be at risk of wandering and becoming lost. A person with one-sided neglect may inadvertently injure themselves. For example, they could wheel themselves into a door frame they don’t see. Their wheelchair could also pinch their hand or run over their foot due to lack of awareness. An inability to detect and localize pain can also cause injury, and increases the risk of the development of pressure ulcerations (Andrews et al., 2004).
Perhaps more important than any other factor, is the impact of ABI on a person’s sense of self. Productivity is typically associated with work and employment settings. A person with an ABI may have a variety of personal limitations, which when combined with societal barriers make return to work an unrealistic goal. Self-concept around life roles and productivity can be damaged, leading to a sense of hopelessness and a loss of purpose in the world (Andrews et al., 2004).
An autoethnographical account of the experiences of one woman with an ABI, Suzanne Lawson, adds life to the implications of impairment. She states, “What to do with the rest of one’s life following a head injury. It is humiliating to be victim to the judgements of young professionals who are secure that they know how another should live, should work, what tires them, what is difficult, what is dangerous. I feel that I am rendered totally impotent. Decisions are made by others – I am incidental”. (Lawson, Delamere, & Hutchinson, 2008, p. 243) Her words speak to the post-injury needs for self-direction, choice, and resumption of purposeful activities based on personal preferences. All health care practitioners should be aware of these needs and keep them in mind in the delivery of client-centred care.
Therapeutic Recreation Practices
Given the implications of the possible symptoms and characteristics experienced with an ABI, an extensive rehabilitation process is warranted. A multidisciplinary approach will best serve the patient, with The Therapeutic Recreation Specialist as a member of that team.
The recreation therapist may play a key role in improving cognitive functioning. Confusion and disorientation may be decreased by engaging the individual in simple activities with low functional demands. These activities may assist in improving attention span, selective attention, recognition of things and events, and the ability to discriminate between figures and ground in images (Andrews et al., 2004).
Therapeutic recreation services may also improve physical functioning, when leisure activities involving physical activity and exercise are encouraged. Recreation activities can be more motivating and enjoyable for the individual, than exercise for its own sake. Improvements in strength, endurance, flexibility and balance can be observed. Secondary complications of ABI may also be reduced including contractures, bladder complications, pressure ulcerations, cardiovascular disease, osteoporosis and obesity. These activities also provide real-world applications for physical therapy goals and skills (Andrews et al., 2004).
A 1989 report by Dordel found that “8 – 20 hours of exercise, physical activity, or sport per week were needed for 10 weeks to 7 months to produce significant” functioning improvement in individuals with head injuries (Mobily & MacNeil, 2002, p. 231). In 1993 Kunstler and Sokoloff found that “intensive TR using corrective exercises, adaptive sports (e.g., adapted swimming, walking, weight training), games and crafts, community reorientation, and leisure counselling translated into dramatic gains (Mobily & MacNeil, 2002, p. 231).
One type of physical activity that has proposed benefits for people with ABI is Tai Chi Qigong. One pilot study compared ten participants with ABI who participated in a Tai Chi Qigong program, with ten participants who engaged in non-exercise based social and leisure activities. The exercise group showed positive changes in mood and self-esteem. Improvements in balance, coordination and flexibility were proposed, but no perceived changes in physical functioning were reported between the two groups. The sample size in this study was small so the results can not be considered conclusive; however, its authors encourage further study of this intervention with this population. The use of Tai Chi Qigong with other populations has shown both physical and psychological benefits. Improvements in mood and self-esteem are particularly important for individuals with TBI in supporting readjustment and social integration in the community (Blake & Batson, 2009).
In facilitating readjustment, participation in leisure activities is also important for the purposes of preventing isolation. Leisure activities encourage the individual to socialize and interact with others in socially appropriate ways. They are an important tool in preventing withdrawal and in preparing the individual for future community integration. They can also be used to involve family members in the rehabilitation process. There may be fear, confusion, and misunderstandings by family members about their loved one’s abilities and limitations. Involving the family in leisure activities during rehabilitation helps them learn how to successfully engage in realistic activities together. It creates a supportive environment for learning, and creates the potential for activities to continue in community settings (Andrews et al., 2004).
Leisure can also be a large contributor to mental health and quality of life. It has been reported that the mental health of adults is highly influenced by their satisfaction with leisure activities, often even more so than their satisfaction with work of even overall health. Other reported benefits from participation in recreation activities, include decreases in tension, anxiety and stress, and improvements in temperament, coping and energy levels (Andrews et al., 2004).
Stumbo and Bloom suggest that the use of games and activities that place emphasis on cognitive processing capabilities provide cognitive gains. Games should be adapted and simplified to promote mastery. Greater cognitive demands are gradually increased to the client’s tolerance level. The three treatment goals are improving problem-solving ability, improving memory skills and increasing attention span (Mobily & MacNeil, 2002).
Therapeutic recreation also improves mental health by impacting self-image. A positive self-image is developed as an individual feels a sense of mastery in performing a leisure activity successfully. Mastery helps the individual develop of sense of their life as productive and meaningful. This is especially important when there has been a loss of previous life roles. Movement away from productivity associated with typical employment creates a broader concept of productiveness and purposefulness. A satisfying life can be viewed as one involving may components including avocational activities such as leisure, productive relationships with family and friends, community service, and continued learning. As the individual masters old activities, that may now be difficult, they can gain a sense of being able to control stress in their life, and can develop a more positive attitude towards their body and even their disability. Mastery in leisure also generalizes to other life areas, and establishes skills the individual will use for the rest of their life (Andrews et al., 2004).
Conclusion
Injury to the brain has complex and multi-faceted effects on the individual. Each person is unique with symptoms and characteristics that can range for mild to profound, based on the location and extent of the injury. As yet, medical science is unable to repair neurological damage, and disability is lifelong. For this reason, the Therapeutic Recreation Specialist plays an important role in the life of an individual who has acquired a brain injury. They work to improving cognitive and physical functioning by engaging the individual in motivating and enjoyable activities. They assist the individual in developing social skills, building health relationships and engaging with the community. They also focus on determinants of mental health which relate to an individuals quality of life. Facilitating the development of mastery in leisure activities promotes health self-esteem and a sense of meaningfulness and purpose in life.
References
Andrews, S., Gerhart, K. & Hosack, K. (2004). Therapeutic Recreation in Traumatic Brain Injury Rehabilitation. In M. J. Ashley (Ed.), Traumatic brain injury: Rehabilitative treatment and case management (2nd ed.), (pp. 539-557). Boca Raton, FL: CRC Press LLC.
Blake, H. & Batson, M. (2009). Exercise intervention in brain injury: A pilot randomized study of Tai Chi Qigong. Clinical Rehabilitation, 23, 589-598.
Carter, M. J., Van Andel, G. E. & Robb, G. M. (2003). Therapeutic recreation: A practical approach (3rd ed.). Long Grove, IL: Waveland Press.
Mobily, K. & MacNeil, R. (2002). Therapeutic recreation and the nature of disabilities. State College, PA: Venture Publishing, Inc.
The Brain Injury Association of Canada. (2004). What is brain injury? Retrieved from http://biac-aclc.ca/en
The Centre for Neuro Skills. (2009). Epidemiology of traumatic brain injury. Retrieved from http://www.neuroskills.com
Gelber, D. A. & Callahan, C. D. (2004). The neurologic examination of the patient with traumatic brain injury. In M. J. Ashley (Ed.), Traumatic brain injury: Rehabilitative treatment and case management (2nd ed.), (pp. 3-26). Boca Raton, FL: CRC Press LLC.
Lawson, S., Delamere, F. M. & Hutchinson, S. L. (2008). A personal narrative of involvement in post-traumatic brain injury rehabilitation: What can we learn for therapeutic recreation practice? Therapeutic Recreation Journal, 42 (4). 236-250.
Toronto Acquired Brain Injury Network. (2010). Resources for professionals: Definition of acquired brain injury. Retrieved from http://www. abinetwork.ca/definition.htm
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