Connect with us
  • Elysium

Insight

Neurobehavioural rehab in aggression management after TBI

Changes in personality following TBIs are often more problematic than neurocognitive, functional deficits or even physical disabilities. Dr Grzegorz Grzegorzak, consultant neuropsychiatrist at St Peter’s Hospital, South Wales, explains why taking a neurobehavioural approach to treating TBI can be highly effective.

Published

on

Personality changes are sometimes referred to as neurobehavioural disability (ND), especially when associated with social difficulties.

The concept of ND involves impairments of numerous aspects of functioning including the abilities to self- monitor and self-regulate, to control frustration, anger and aggression, to tolerate delay in gratification, and to self-motivate.

These impairments can lead to a sense of being overwhelmed when facing situations requiring control and management of internal impulses or coping with social situations or tasks.

Impulsivity, disinhibition and aggression all have significant potential to interfere with rehabilitation efforts, jeopardize recovery and become a major obstacle to successful functioning in social roles.

Research estimates the prevalence of aggression in survivors of TBI as being as high as 33.7 per cent.

Addressing aggression as soon as it arises is critical to the individual’s recovery.

Sometimes aggressive behaviour is so intense and frequent that its management takes priority over all other aspects of care and rehabilitation.

Neurobehavioural rehabilitation (NR) was introduced in the late 1970‘s as an attempt to improve functional abilities of TBI patients.

NR stems from recognising that people who survive TBI can still learn new skills to self-regulate and to modify their behaviour.

The basis of NR is embedded in learning theory and thus the success of NR is reliant on the patient’s ability to make use of new information and experiences.

Therefore, NR is only suitable for the post-acute phase of recovery from TBI, and in fact is intended as a medium to long term rehabilitation programme.

​NR interventions are composed of comprehensive and multidisciplinary efforts to create a user-friendly, supportive and encouraging social environment which facilitates therapeutic interactions and activities.

Specific goals and detailed routines are constructed for each patient individually, based on structured collection of data informed by behavioural analysis.

The process of designing and implementing the interventions puts emphasis on personal autonomy.

Clinical formulation is preferred over medical diagnosis. The attitude of the MDT should always be positive, embracing a strong belief in the patient’s ability to achieve their goals, improve and recover.

Carefully managed feedback and positive reinforcement are an essential part of NR.

Consistent interactions with every member of the team are of utmost importance, given that neurobehavioural intervention should not be limited to scheduled activities but in fact incorporated in every interaction.

Over the last forty years the model has been implemented by many neurorehabilitation services worldwide.

Several case studies describing recovery pathways through NR paint a very positive picture, and our own experience at St Peter’s of adopting a neurobehavioural approach has demonstrated it can produce real and measurable outcomes for both our patients andtheir families.

Case Study: Mehmet

On admission to St Peter’s Hospital, Mehmet presented with extreme challenging behaviours including serious assaults on staff, destruction of environment, verbal abuse and shouting.

Mehmet has frontal lobe dysfunction as a result of a head injury he sustained. For the previous 18 months he had been in a general hospital.

At St Peter’s a bespoke positive behaviour support plan and activity plan were developed with Mehmet’s input and reflecting his cultural needs which, under the supervision of his MDT, promoted positive changes to his social interactions, routines and activities.

Over nine months Mehmet’s challenging behaviours reduced significantly and he now enjoys a wide range of activities including regular community visits and has strengthened his relationship with his family.

Dr Grzegorz Grzegorzak is one of the consultant neuropsychiatrists at St Peter’s Hospital a specialist 39-bed Neuropsychiatric facility in Newport, South Wales run by the Ludlow Street Healthcare Group. www.saintpetershospital.co.uk

Continue Reading
Click to comment

Leave a Reply

Your email address will not be published. Required fields are marked *

Brain injury

Has UEFA done enough to protect player safety at Euro 2020?

Published

on

The collapse of Denmark’s Christian Eriksen due to a cardiac arrest during his team’s opening game at Euro 2020 shocked football fans worldwide and raised many questions about player safety. Here, sports disputes lawyer Barrington Atkins examines football authorities’ approach to the safety of players and asks whether UEFA has done enough to protect those competing at Euro 2020

 

Concussion safety was meant to be at the forefront of the Euro 2020 finals. 

All 24 teams committed to following the recommendations of the Union of European Football Associations (UEFA) Concussion Charter, which was a commitment to player welfare and player safety. 

All 24 teams agreed to implement the serious measures recommended by UEFA to provide care for players who experience concussions or have injuries on the pitch. The message of the Charter was clear: if a player is suspected of concussion, they must be removed from the field of play.

UEFA’s focus on concussion follows a growing awareness of the greater risk footballers’ face of neurodegenerative diseases from head injuries. Research commissioned by the Football Association and the Professional Footballers’ Association found that ex-professional footballers are three and a half times more likely to die from dementia than people of the same age range in the general population.

The concussion and fractured skull sustained by Wolves’ Raul Jimenez following a collision with Arsenal’s David Luiz in November 2020 was the final straw that led to the implementation of the concussion substitutes rule in the Premier League. This new rule states that if a player has clear symptoms of concussion or video provides clear evidence of concussion, his team will be permitted to replace him with an additional substitute.

On 21 February 2021, Rob Holding became the first Premier League player to be replaced under the rule. The protection the rule provided to player safety was instantly demonstrated as Holding was confirmed to have concussion the following day.

Despite the proven benefits, UEFA decided against approving the concussion substitutes rule for the Euro 2020 finals. The injuries football fans have witnessed during the European tournament have undoubtedly challenged UEFA’s decision and called into question whether the Concussion Charter is effective enough for player safety.

The first incident occurred when France’s Benjamin Pavard sustained a head injury following a collision with Germany’s Robin Gosens. Pavard received treatment for several minutes before being given the green light to continue playing. Pavard later revealed that he was knocked out for 10 to 15 seconds. Controversially, UEFA confirmed that the correct concussion protocols were followed.

Only six days later, Austria’s Christoph Baumgartner received a blow to the head, went back on the pitch and was then substituted. His coach later admitted that Baumgartner had been experiencing dizziness. 

Russia’s Danila was the third player in the tournament to collapse to the ground following a head injury. He was cleared to play on but was withdrawn at half time. These incidents demonstrate that football authorities need to do more to protect players’ health.

Cardiac conditions too are highly significant here, being the leading cause of death in professional footballers. Data has revealed a prevalence of sudden cardiac death of seven in 100,000 football players.

Quick application of a defibrillator can improve a patient’s survival by 75 per cent. However, when Cameroon’s Marc-Vivien Foé collapsed during the 2003 Confederations Cup in France, it took six minutes before attempts to restart his heart began. The lack of awareness of the need for speedy care contributed to Foé’s death, but the incident spurred football authorities to implement changes to reduce the risk of cardiac arrest on the field.

The English Football Association has now increased screening frequency so that players are tested between the ages of 14 and 25. For incidents where cardiac conditions slip through the net, sporting organisations have pitch-side defibrillators and medical staff trained in CPR to help resuscitate a player if they suffer a cardiac arrest.

Player safety was brought to the forefront on 12 June 2021 when Christian Eriksen experienced a cardiac arrest during Denmark’s game against Finland. Thankfully, football authorities’ understanding of the need for urgent medical attention in cardiac emergencies helped save Eriksen’s life.

The Euro 2020 finals have shown that football authorities need to take further urgent action to protect player welfare and player safety. However, as Christian Erikson’s recovery happily shows, player safety can be achieved when football authorities apply the correct protocols and have appropriate medical equipment in place.

Continue Reading

Insight

Life after lockdown – what comes next?

Published

on

As we prepare to emerge from lockdown in less than two weeks, attention is turning to what the ‘new normal’ will be like. Margreet Wittink at Renovo Care shares some reflections from the pandemic and thoughts on what may lie ahead

 

The 19th of July 2021. More than just any date.

We all have certain dates that are important to us, like birthdays and anniversary dates. However, this year we have been governed by dates set by the government trying to get back to a normal life post-COVID.

We seemed to be going in the right direction but then the Delta variant presented itself. The infection rates started to go up again and continue to rise but with far less hospital admissions. Opinion seems to be divided on whether we need to remain cautious and wait or return to normal life whatever it may bring.  The British Medical Association is calling for caution and is asking for ongoing use of face masks and new ventilation standards.

The 19th of July 2021 will mark the fourth and final stage of lifting lockdown in England. It makes me reflect on the period since March 23 2020 when the first lockdown started.

A birthday present my son didn’t want. Being an essential worker continuing to drive to Hollanden Park Hospital on an empty M25 and A21, seeing a banner thanking those who continued to work which I appreciated so much. Taking staff temperatures which was thought to be needed for just three months but lasted so much longer.

The absolute low of the period? Losing a much loved colleague and being unable to pay the traditional respects. But never losing sight of the most important aspect of our work; keeping our patients at Renovo Care safe.

Will life get back to normal? But what is normal? Hasn’t COVID shown us all that life can change dramatically in a short period of time?

That is something that is all too familiar to our patients who come to Renovo Care for their neurological rehabilitation following stroke, traumatic brain injury, Guillain Barre Syndrome to name a few of the diagnosis we treat.

We know how important family support is to our patients and how difficult it has been for them to be at our hospital without seeing their loved ones regularly in person. The use of Zoom and Microsoft Teams has given us a way to be in touch and being able to share therapy sessions, but it has been a poor substitute.

Recently we have been able to allow family members, who take on a carer role, in again nearer the discharge date to work together to prepare for a smooth transfer from Renovo Care to home. This has made such a difference to them to know what can be expected when their loved one comes home following a major event that changed their life.

Normality. What will it look like? No more face masks or social distancing? Are we ready for it?

I think that staff and patients alike will welcome staff not having to wear masks. When one of our patients left, he actually asked one of the therapists if she could remove her mask for a moment so he could see what she looked like.

Not wearing face masks will allow us all to see facial expressions again which is so important for communicating with each other. Hats off to our speech and language therapists who had to adapt their way of working around the COVID restrictions.

Will our visiting return to the way it used to be? Successful neurorehabilitation requires 24-hour support of all the parties involved which includes family. Being able to get hugs, to be held and to be seen face-to-face by your loved ones when you are working hard to regain your independence is so important to keep the focus on the goals they are trying to achieve.

It will require a transition from staff as we’ve had a dedicated visitors’ areas away from our patient rooms and rehab facilities for such a long time now, that it will be a novelty to have visitors back in these areas again.

The 19th of July 2021; the final stage of England’s COVID lockdown roadmap. The final review will happen on the 12th of July following analysis of the latest data. The Delta variant is on the rise but so are the vaccination numbers. Renovo Care has had a successful vaccination programme for staff and patients.

It looks like it is really happening and here at Renovo Care we will be ready for whatever comes and will make sure that our patient best interests are at the heart of what we do. 

  • Margreet Wittink is head of therapies/ lead occupational therapist, at Renovo Care Group’s Hollanden Park Hospital

Continue Reading

Insight

‘Like bees collaborating in a hive, achievements in rehab should be shared’

Published

on

Achievement in rehabilitation should be shared and celebrated with supporters to help sustain and encourage progress, says Lisa Beaumont, whose own ten-year recovery from stroke continues with the support of family, friends and therapists

 

Rehabilitation works best when it is not undertaken in isolation.

Over the past month, I have been thrilled by the progress that I have made towards my goal to walk without a stick, my posture has improved significantly during lockdown and I have enjoyed walking in the garden in June’s sunshine. 

My progress has reminded me of the saying, “it takes a village to raise a child”. I would like to adapt that expression to become: “it takes a village to deliver successful rehabilitation, many people have important roles to play”.

Just like bees cooperate in a productive hive, it is helpful for the patient to share their achievements with supporters, because their affirmation gives encouragement for renewed progress.

From the outset, I have been very fortunate that I’ve had the support from family, friends and therapists throughout my ten year recovery. 

An important feature of the rehabilitation platform Neuro ProActive is that it makes it easy to share a patient’s progress with  each of the key players in their recovery programme. For me, it looks like this:

My team is my neuro-physiotherapist, Jane Cast (neurorehabkent.com)

My representatives are my carers and sister. It is a bonus that I can keep everyone who is in my support bubble informed about my progress privately, by sharing photos and videos securely within the fully-encrypted platform.

Neuro ProActive is also a key player. Recently named as a Strategic Partner for UKABIF, we are now also part of the Criminal Justice Acquired Brain Injury Interest Group.

Prepared with assistance from Paige Gravenell (neurorehabkent.com)

Continue Reading

Newsletter



Get the NR Times update

Trending