Challenges in Treating Acquired Brain Injury

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According to the Brain Injury Association of America, an acquired brain injury (ABI) is “an injury to the brain that occurs after birth and is not hereditary, congenital, degenerative, or caused by birth trauma.”¹ Each year in the United States, approximately 3.5 million ABIs occur due to trauma (2.5 million), vascular events, or stroke (800,000), and infections, toxic exposure, or other causes (200,000).^2,3 The consequences of ABI are numerous and can include cognitive, physical, emotional, and behavioral difficulties. These consequences can persist for weeks or months or can become permanent.⁴ At present, approximately 6 million Americans live with a disability due to a traumatic brain injury (TBI); another 4 million live with a permanent disability due to stroke. Given that the brain is the most complex organ in the human body, that individual differences exist regarding the effects of brain injury, and gaps persist in the treatment continuum, challenges arise in treating individuals with ABI.

No 2 Brain Injuries Are Alike

No 2 brain injuries are the same because the effects of brain injury depend on a variety of variables, including the type or cause of brain injury (ie, trauma, stroke, anoxic encephalopathy, etc), location of the injury, and severity of the injury.⁵ Individual characteristics such as age, gender, education, vocational history, psychiatric and substance abuse history also play a role.⁶ Finally, life experiences, culture, and other personal factors influence the expression of impairment and effort expended in rehabilitation, which may impact long-term outcomes. Therefore, when treating ABI, professionals must individualize treatment and tailor interventions to the unique needs of the individual.

Brain Injury as a Chronic Health Condition

Brain injury was previously viewed as an event, but is now considered a chronic health condition.^7,8 The Centers for Medicare and Medicaid Services recently recognized brain injury as a chronic health condition and included it in the list of special needs plans effective for the 2025 plan year. For many individuals, a brain injury can be both disease causative and disease accelerative. Individuals with brain injury are at a higher risk for developing epilepsy, endocrine disorders, sleep disorders, metabolic syndrome, psychiatric disorders, and infections due to compromised immune response. Comorbidities that accompany brain injury can complicate rehabilitation and require specialized medical management, often for the long term. Guidelines exist for the medical management of brain injury through the continuum of care and focus on preventing secondary complications, early multidisciplinary rehabilitation, and community-based postacute rehabilitation to restore functional abilities and promote community reintegration.^9,10

Neuropsychiatric Disorders

Neuropsychiatric disorders regularly occur following brain injury and are often diagnosed within the first year postinjury.^10,11 The most commonly diagnosed DSM-5 disorders include mood, anxiety, and substance use disorders (SUDs).^12,13 While a preinjury diagnosis of psychiatric disorder is a strong predictor of postinjury disorders, a significant percentage of individuals with brain injury are diagnosed with new onset of a neuropsychiatric disorder.^10-13 With brain injury and cooccurring neuropsychiatric disorders, it is sometimes difficult to determine if presenting symptoms are the direct result of injury to the brain, or an appropriate situational reaction to the injury.¹⁴

Many of the symptoms frequently reported following brain injury, such as irritability, fatigue, sleep problems, decreased initiation, and attentional difficulties, may or may not be associated with a neuropsychiatric disorder such as depression.^15,16 For this reason, a thorough assessment is necessary to differentiate whether symptoms are due to the brain injury, a preexisting condition, psychosocial consequences stemming from injury, or a combination of factors.^16,17 Arciniegas et al recommend that assessment include a thorough developmental, psychiatric, and medication history, along with a current mental status and neurological examination.¹⁶ Neuropsychiatric symptoms can be quantified using standardized scales and inventories, and should be evaluated in the context of the patient’s premorbid history and current circumstances. Given that a large number of patients present with a mood disorder postinjury, mood stabilization should be a treatment priority.¹⁷ When medications are prescribed, Arciniegas recommends a conservative approach because patients with TBI may be particularly sensitive and susceptible to medication adverse effects.¹⁶ Frequent monitoring is recommended for effectiveness, adverse effects, and drug interactions. Avoid medications with sedative properties. When possible, psychotherapy should accompany a medication regimen when treating neuropsychiatric disorders postinjury.¹⁶

At Risk Substance Use

The relationship between risky substance use and ABI is well documented. Studies indicate that between one-third to one-half of individuals diagnosed with TBI were intoxicated at the time of injury.^18-19 Chronic at-risk alcohol use is associated with the development of hypertension, diabetes, coagulopathies, and heart arrhythmias, all of which are risk factors for stroke.²⁰ Prescription opioids and illicit drugs have also been linked to ABI due to the depressive effects of opioids on the respiratory system resulting in anoxic brain injury.²¹ Illicit stimulant drug use (ie, methamphetamine, cocaine, etc) can elevate heart rate and blood pressure to dangerous levels, and is associated with hemorrhagic stroke.^22-23 Given that substantial numbers of individuals with ABI engaged in risky substance use preinjury, and a large percentage return to risky levels of alcohol consumption and/or drug use within the first 1-2 years after injury, it is important for rehabilitation practitioners to understand the relationship between substance use and ABI.²⁴ Treatment practices include motivational interviewing techniques to enhance readiness to change, screening and brief interventions (ie, counseling, education, and referral) to reduce future alcohol use.^25,26 Additionally, skill-based interventions such as education and cognitive behavioral therapy techniques assist individuals with brain injury and cooccurring substance misuse to improve coping skills, manage anger and frustration, and improve self-monitoring/self-management. Finally, pharmacological interventions involve the use ofUSFood and Drug Administration approved medications such as disulfiram (Antabuse), naltrexone, and acamprosate, for treatment of alcohol use.²⁷ Unfortunately, treatment for cooccurring brain injury and substance misuse remains fragmented and poorly coordinated. Corrigan has proposed a 4-quadrant model to describe where individuals with cooccurring TBI and SUD could receive treatment, the types of treatment that are best for those settings, as well as strategies to adapt treatment for individuals with cognitive impairment.^28,29

Access to Treatment and Rehabilitation

A comprehensive continuum of care has evolved over the past few decades for the specialized treatment of ABI.³⁰ The components of this continuum of care include emergency and prehospital activities (ie, first responder and EMS activities), acute neurosurgical and medical care in a trauma or intensive care environment, comprehensive in-patient rehabilitation in a hospital setting, and community-based postacute rehabilitation and long-term care. The overarching goals of this continuum include promoting medical stability and the prevention of secondary complications; increasing functional capacities through remediation and compensation, use of adaptive equipment, and environmental modifications; and improving abilities to engage in meaningful activities and participate in important societal roles to promote community integration.

The rational approach to rehabilitation is adapting and individualizing treatment to the identified impairments at each component of the continuum and preparing the individual for progression to the next component. Unfortunately, only a small percentage of individuals with ABI have access to the full continuum of care due to geographic location, low referral rates from in-patient rehabilitation facilities, and lack of funding for some aspects of care.³¹ Access to care could be improved by better coordinating transitions between components of the continuum, including information and data exchanges and an identified navigator to lead the rehabilitation process across time.³² Access to care can also be improved by ensuring funding for care across the entire continuum, positively impacting long-term outcomes, promoting community integration, and likely saving money over the life of the patient. Presently, most commercial insurance plans fund activities in the early components of the continuum (ie, trauma and in-patient, hospital-based rehabilitation), but do not always cover postacute rehabilitation or long-term care. Advocacy and changes in public policy are needed.

Gaps in Knowledge

While much is known regarding the diagnosis and treatment of ABI, significant gaps exist. Researchers, physicians, and rehabilitation professionals agree that improvement in rehabilitation outcomes following ABI could be achieved by addressing these gaps.³² For example, a better understanding of factors that affect outcomes would improve early prediction of a patient’s recovery trajectory, allowing for better identification and use of necessary resources. Diagnosis, prognosis, and monitoring could be improved by using available tools and developing new tools, such as blood biomarkers, and easier access to enhanced imaging such as PET, fMRI, and diffusion tensor imaging. Decreasing variability in the care patients receive by promoting use of evidenced based guidelines and best clinical practices and closing gaps regarding effectiveness of rehabilitation interventions across clinical disciplines such as occupational therapy, speech language pathology, physical therapy, and neuropsychology would also improve patient outcomes following ABI.

Dr Seale is the Regional Director of Clinical Services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a psychological associate with independent practice. He is a certified brain injury specialist trainer and holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.

References

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