Denise Scalercio Ribeiro
Fall 1999

NEURO-REHABILITATION

Every year over 3 million people sustain a traumatic brain injury 
(TBI). It is estimated that per 100,00 people, 14-30 of them will 
die of a brain injury.  This estimate has a wide range, due to the 
vagueness of the cause of death annotated on the death certificate 
(Silver, Yudofsky, Hales, 1994). Patients may experience a variety 
of disabilities including psychological stress, physical 
impairments, personality changes, and difficulties with 
relationships and employment.  However all hope is not loss.  With 
new technology and assessment tools, neuroscientists are working 
to create several procedures, which may restore brain function, 
thereby allowing clients to live normal lives.
	Assessment is a vital aspect of neuropsychology.  One 
essential variable in assessing a patient with a TBI is looking at 
their level of functioning before the injury.  Unfortunately very 
few patients undergo extensive neuropsychological testing prior to 
the brain injury, therefore, it is very difficult to obtain an 
exact comparison.  However there are methods of evaluating the 
pre-injury functioning.  Except when the brain injury has occurred 
in the posterior left-hemisphere, basic vocabulary and reading 
skills tend to be less affected by TBI, (Lovell & Franzen, 1994). 
Reading tests are suppose to estimate the individual's functioning 
prior to the injury, (Wilshire & Kinsella, 1991).
Neuropsychological assessment is necessary in that it guides the 
process of designing a rehabilitation program.  One type of test 
is called the Category Test.  It tests the ability to identify the 
concept or principle that governs a series of geometric, verbal or 
numerical object. This very complex test measures the capability 
of the individual to abstract. In theory, performance on this test 
would predict a person's capacity to organize, plan, and the 
ability to solve complex problems. Individuals with poor scores on 
this test usually suffer from extensive brain dysfunction that 
often has a recent onset or is rapidly progressive in nature.  An 
individual with a brain lesion who scores relatively well usually 
does not have a rapidly progressive condition (Goldstein & 
Ruthven, 1983).
Levin, High, & Goethe developed the Neurobehavioral Rating Scale, 
(1987). This scale is based on a 7 point Likert scale in which the 
rating ranges from not present to severe. The scale measures 
disturbances in behavior, cognition, emotion, thought content and 
language functioning during the long-term recovery from a brain 
injury. They found that the items that assessed conceptual 
disorganization, inaccurate self-appraisal, decreased 
initiative/motivation and poor planning were correlated with the 
severity of injury. Patients with mild TBI demonstrated greater 
somatic concern and anxiety (1987).
Cognitive functioning is an essential component of assessment.  
The Neurobehavioral Cognitive Status Examination (NCSE) developed 
by Kiernan and colleagues can be completed in 5-20 minutes.  This 
test measures the levels of consciousness, attention, orientation, 
language, visuoconstructional skills, memory, calculations and 
abstract reasoning, (Kiernan, Muller, & Langston, 1987; Schwamm, 
Van Dyke, & Kiernan, 1987).
Brain imaging and electrophysiological studies have recently been 
employed as an important diagnostic tool. These noninvasive tools 
provide accurate pictures of patients' brains without the need to 
engage in costly and potentially traumatic exploratory surgery.
The functional magnetic resonance imaging (fMRI) was developed in 
1980. The technique is based on the changes in the magnetic 
properties of atoms.  The MRI scanner is a magnet that measures 
the direct changes in brain tissue, (Martin, 1999).
The positron emission tomography (PET) measures brain function by 
measuring the brain oxygen consumption, blood flow and glucose 
metabolism. In order to measure the glucose metabolism, 
radioactive glucose (2-deoxyglucose is most commonly use) is 
injected to the patient. The radioactive glucose is taken up by 
metabolically active cells, which emit positrons. When positrons 
are emitted and collide with electrons they form gamma rays, which 
are detected, when they exit the person's skull.  The areas that 
are high in metabolic activity produce more gamma rays because 
they take up more glucose. Computers then convert the gamma 
radiation into a 3 dimensional color-coded image on the computer 
screen. The blood flow is measured by injecting radioactively 
labeled water (hydrogen and oxygen 15). When the water decays the 
positrons are emitted. Once the water reaches the brain, the 
neurons increase their blood flow (Martin, 1999). Data suggests 
that the PET is more sensitive than the MRI to detect brain 
abnormalities in TBI patients (Alavi, 1989; Langfitt et al., 1986; 
Ruff et al., 1989).
The electroencephalogram (EEG) reflects the inhibitions and 
excitations of thousands of neurons. It has been useful in 
recognizing posttraumatic seizures of comatose patients. Up to 7% 
of patients with head injuries develop posttraumatic epilepsy 
(Schaffer et al., 1985). 
When a person experiences a TBI, the symptoms seen are generally 
due to two physiological responses, cell death or inhibition.  
When a neuron dies, it can not be regenerated. Several traumatic 
brain injuries result in injury to axons, which lead to complex 
and widespread effects.  When an axon is cut, the two ends close, 
swell and retract from each other. In the area where the trauma 
occurred as the axon and myelin sheath degenerate, the 
macrophages, which is a large cell that ingests microorganisms, 
cells or other foreign particles, absorbs and destroys the axonal 
debris. Glia cells, which are, cell that support, protect and 
nourish neurons of the central nervous system along with 
astrocytes; a form of glia cells form scar tissue. Then one of two 
things happen, either the cell dies or the Nissl bodies 
degenerate. The Nissl bodies are grain like bodies formed in the 
cytoplasm of the cell bodies of neurons and glia cells (Reber, 
1985). The severity is contingent on how close the to the cell 
body the axon was severed and if any connections were restored.  
It has been found that scar tissues do not provide an adequate 
environment for the regenerative sprouts to grow, (Cohen, 1993).
Several different types of symptomologies are associated with TBI. 
Personality changes have been seen as the most significant 
problem, (Livingston et al., 1985; Tomsen et al., 1984; Weddell et 
al., 1980). Patients with frontal lobe dysfunction may exhibit 
Borderline personality traits such as impulsively, lack of 
empathy, lack of a sense of self, and inability to self-monitor. 
The individual may display a retardation of the maturation 
process, so that they seem childish. Individuals may also have a 
"Chameleon" quality, the person assumes behavioral characteristics 
based on the individuals in the immediate environment (O'Shanick & 
O'Shanick, 1994). In 1978, Lezak described several differences in 
personality following a TBI; difficulty in perceiving social 
situation, difficulty with self-control and monitoring, stimulus 
bound, emotional changes, and an incapacity to learn from social 
experiences. Frontal lobe injuries may result in difficulties with 
abstract though and a loss of a sense of humor. This may be due to 
a difficulty to maintain one set of information and perform a 
simultaneous comparison of another set of data (O'Shanick & 
O'Shanick, 1994).
Patients may also experience intellectual changes.  Arousal may 
range from a state of heightened anxiety or impaired arousal. It 
has been found that the later usually mean a poor prognosis 
(Clifton et al., 1981 & Woolf et al., 1987). The lower vigilance 
state are usually related to a reduction in dopaminergic activity 
(Feeney & Sutton, 1988; Lat et al., 1988; Neppl, 1988) or 
increases in cholinergic activity in the central nervous system, 
(Nissen et al., 1987; Rusted & Warburton, 1989). 
Usually TBI is associated with disturbances in concentration. This 
is believed to be due to the damage to the pathways the inhibit 
transmission of afferent impulses (Gualtier & Evans, 1988; 
Gualtier et al., 1989).
Memory usually suffers when a person experiences a TBI. 
Specifically, the impairment in capacity to encode incoming data, 
this capacity resides in the hippocampus.  This may be due to the 
location of the hippocampus, which resides in the anterior 
temporal lobe when upon impact may force tissue into the 
sphenodial ridge (O'Shanick & O'Shanick, 1994).
Language disturbances are observed in 8%-85% of individuals 
following a TBI, (Grohen, 1977). Patients usually experience 
problems with verbal memory, auditory processing, integration and 
synthesis of linguistic information, word retrieval and spelling. 
Individuals may also experience a difficulty in the spontaneity of 
speech (O'Shanick & O'Shanick, 1994).
Emotional difficulties may also plague individuals with TBI. 
Patients may suffer from depression, however it may be difficult 
to distinguish between reactive depression or depression as a 
consequence of TBI.  For example a person with pseudobulbar palsy 
may display spontaneous crying and laughing that is not related to 
the patient's mood. Studying depression in TBI patients is 
important in that cognitive, perceptual and motor deficits may not 
be related to TBI but to depression, (Goldstein & Ruthven, 1983).
Patients with TBI may also develop obsessive compulsive disorder, 
delirium, mood disorders, psychotic disorder, anxiety disorder, 
aggressive disorders, sexual dysfunction and/or auditory and 
visual hallucinations (Silver et al., 1994; Goldstein & Ruthven, 
1983). It is easy to see why patients may have difficulties with 
interpersonal relationships and integrating into a social 
environment.
There are several factors that influence how well a patient will 
recover. The nature of damage is an important factor. For 
instance, the anatomical distribution of the lesion may be 
widespread if the TBI is severe or if the person is suffering from 
a degenerative disease such as Alzheimer's.  Whereas a more 
focused injury such as a localized tumor may cause less damage 
(Miller, 1984). In general the smaller the lesion, the less the 
damage, contingent upon where the lesion is.  For instance lesions 
in the motor system can cause widespread impairment, (Silver et 
al., 1994).
Age is also a very important factor in predicting recovery. 
Effects of comparable lesions in young children are not as drastic 
as those in adults.  Infants are born with a brain that weighs 350 
grams, but the time they reach young adulthood, the brain weighs 
1200-1400 grams due to the proliferation of neurons, 
interconnections, myelination of axons and development of glial 
cells, (Miller, 1984; Martin, 1999). Therefore, if a young child 
receives a brain injury, their natural developmental cycles will 
be able to aid in recovery.
Every day there are more and more treatments for individuals with 
TBI.  In terms of drugs, it has been found that Acetycholine (AcH) 
improves motor function following a TBI in rats, cats, monkeys, 
and humans with Alzheimer's. Dopamine facilities dopamine 
receptors by enhancing recovery after septal, basal ganglia and 
substantia nigra lesions (Cohen, 1993).
The last fifteen years fetal neural transplantation in animals has 
been used in research.  Most extensively used in rats with 
Parkinson disease with varied success. In humans, transplants from 
patient's adrenal cortex are injected in the caudate nucleus. The 
patients reported a significant ability in movement. However due 
to the side effects and complications, the procedure is rare, 
(Olsen, 1990). Transplantation of human fetal substantia nigra 
tissue has been done to a limited degree. Patients report that 
behavioral deficit improved along with performance, (Cohen, 1993).
Another form of treatment is physical therapy. Usually when the 
therapy is mediated by an interdisciplinary team the results are 
most favorable.  An interdisciplinary team usually consists of a 
psychiatrist, neuropsychologist, speech pathologist and so forth. 
In that a TBI may effect a myriad of functions it is important 
that for the patient to get the best care available that all 
aspects of the dysfunctionality are attended to. Damage to the 
brain is unlike any other damaged organ.  As previously mentioned 
personality and emotional changes are likely to occur resulting in 
difficulty in understanding illness and difficulty to establish 
social relationship (Cohen, 1993).
In conclusion, as research and technology continues to expand and 
explore TBI, it is the hope that more effective treatment and 
stronger assessment tools will be devised. From a humanistic point 
of view, patients with TBI usually suffer from several related 
psychological and social dysfunction, therefore there is a need 
for these people to be recognized as individuals who may be able 
to contribute to society under proper care and supervision.

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Copyright © 1999, Dr. John M. Morgan, All rights reserved - This page last edited 13 - December, 1999
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