Treatments for Complications in TBI Patients

Professional Treatment for Behavioral/Emotional Issues

Behavioral/emotional difficulties following a TBI may be best addressed by combining interventions by healthcare professionals with strategies used by the person with TBI and their family, friends, and coworkers. Physicians and Rehabilitation Psychologists/Neuropsychologists are two types of healthcare professionalS who can offer valuable interventions.

Physicians  Significant behavioral/emotional difficulties may respond to medications in combination with behavior-based interventions and strategies. Medications may be prescribed by physiatrists and/or psychiatrists to reduce agitation/anger, depression, emotional lability.

Rehabilitation Psychologists/Neuropsychologists  These providers are able to assess cognitive and behavioral functioning and offer therapy services to persons with TBI and other affected individuals such as family members. Goals of therapy can include:

• Identification of specific strategies to manage behavioral changes from TBI
• Anger management
• Impulse control strategies
• Emotional liability
• Reduced motivation/apathy
• Help with psychological adjustment to changes in functioning caused by the TBI
• Address lowered self-esteem secondary to TBI-related difficulties
• Provide specific strategies for managing depressed mood, anxiety
• Assistance with adjustment to changes in family roles that can occur after a TBI (e.g., if parent with TBI now requires help from the child in doing daily activities).

Management Strategies for Behavioral/Emotional Issues

Treatment from healthcare professionals plays an vital role in helping address behavioral/emotional issues in persons with TBI, whether they are having minor or substantial effects on the individual’s functioning. In situations where the affected person’s emotional distress is high (e.g., there are concerns about potential for self-harm), professional help should be sought immediately.

Many treatment strategies can be used by the person with TBI and those interacting with him/her which have positive effects on behavioral/emotional functioning. Below are some specific strategies that can be used to address common behavioral/emotional difficulties following TBI. As with all strategies for changing human behavior, patience, consistency, and repetition in the use of these strategies are needed to obtain the best results.

Anger/ Frustration

• Strategies for Others
  • When the individual is angry, talk in a soothing manner.
  • Acknowledge the individual’s frustrations and help with problem-solving if possible.
  • Try to distract the individual and help divert his/her attention to something else if he/she is too upset to problem-solve effectively.
  • Serve as a role model for the individual by using effective anger management strategies.
  • Be patient in the moment and persistent over time in helping the individual manage his/her anger.
  • Avoid trying to reason with the individual when he/she is at peak anger levels.
  • Avoid criticizing the individual if his/her strategies for managing anger don’t work at first.
• Strategies for the Person with TBI
  • Practice anger-management strategies before anger occurs.
  • Learn to identify early signs of anger.
  • Learn to identify situations (“triggers”) that can lead to anger.
  • Avoid triggers if possible, or learn and use anger-management strategies in those situations.
  • Get help from family, friends, and others in efforts to learn and use anger-management strategies.
  • Seek to include regular activity, hobbies, and other sources of enjoyment in one’s life.

Emotional Distress

• Strategies for Others
  • If the individual appears down, ask about his/her mood in an accepting, non-judgmental manner (acknowledging that it is OK to feel distressed).
  • Try to help the individual identify source of distress (e.g., is it related to transient issue, or does it reflect ongoing distress about situation, etc.).
  • If the distress is related to specific issue, encourage and help the individual to problem-solve regarding how to address the issue.
  • Alternatively, try to distract the individual if the issue is not one that can be readily addressed.
  • If distress is related to a general sense of loss since the TBI, consider the following strategies:
    • Acknowledge the individual’s sense of loss as a result of changes following the TBI.
    • Provide honest but supportive feedback regarding changes observed (e.g., don’t deny difficulties, but also be sure to highlight ongoing strengths).
    • Support the individual’s efforts to develop new ideas about him/herself and what he/she may be able to do.
    • Help to identify new goals (both short-term and long-term) and think of ways to achieve these goals.
  • Ensure that the individual has opportunities for positive experiences. This may include:
    • Spending time in settings the individual enjoys (e.g., outside, in nature).
    • Gathering with supportive friends/family.
    • Engaging in activities the individual enjoys (e.g., movies, etc.).
    • Avoid criticizing the individual with statements about differences in his/her behaviors/skills/etc. prior to the TBI.
    • Avoid attempts to minimize or make light of the individual’s distress about perceived changes in self since the TBI.
    • Avoid assuming that the individual is not aware of, and possibly distressed by, changes that others observe.
• Strategies for the Person with TBI
  • Acknowledge and allow self to grieve changes/losses that occurred since the TBI.
  • Accept support/encouragement offered by others.
  • Work to move from focusing on TBI-related difficulties to instead recognizing current strengths and abilities.
  • Enlist the help of trusted family and friends in identifying strengths.
  • Identify new, reasonable goals given strengths and weaknesses.
  • Work with family members, friends, and healthcare providers (rehabilitation psychologist/neuropsychologist ) to develop strategies to achieve these goals.
  • In addition to striving for accomplishment, pursue hobbies and/or other sources of enjoyment.

Emotional Liability

• Strategies for Others
  • Work with the individual with TBI to identify situations that are associated with emotional liability (e.g., frustration, fatigue).
  • Use some basic strategies to de-escalate potentially problematic situations:
    • Recognize early signs of increased emotionality.
    • Use distraction to decrease focus on cause of emotional reaction.
    • Encourage/help the individual take a break from the situation associated with the emotional reaction (e.g., leaving the room and going to a safe, quiet place).
    • When the individual is emotionally liable, maintain an interactional style that is non-confrontational and soothing (e.g., speaking in a calm voice, with non-threatening body language).
    • Acknowledge the individual’s distress and help with problem-solving if possible.
    • During non-emotional times, help the individual identify words that can be used to communicate with others about his/her emotions.
    • Avoid engaging in discussions/arguments with the individual when he/she is experiencing high levels of emotionality.
    • Avoid escalating the individual’s emotions by responding with intense emotions.
    • Avoid attempting to reason with the individual during periods of high emotionality.
• Strategies for the Person with TBI
  • Attend to early signs of emotionality.
  • Be aware of factors that contribute to increased emotionality (e.g., fatigue, pain).
  • Try to minimize exposure to situations that are associated with increased emotionality, particularly when at risk for increased emotionality (e.g., due to fatigue, pain, etc.).
  • Use strategies to cope with high emotionality, including:
  • Using words to express emotions.
  • Removing self from the stress-inducing situation.
  • Using relaxation techniques (can be developed with the aid of psychologist).
  • Enlist the help of trusted family member, friends, healthcare providers in developing strategies to manage emotional responses.

Self-control/Impulsivity/Poor Judgment

• Strategies for Others
  • Be aware of the relationship between TBI-related changes in brain functioning and increased impulsivity.
  • Work with the individual to identify triggers to impulsive behaviors (e.g., increased emotionality, influence of peers).
  • Try to identify environmental changes that may help avoid triggers (e.g., minimize contact with peers having a negative influence).
  • Develop a subtle signal (e.g., a hand gesture) to help the individual remember to stop and think before acting when questionable behaviors are occurring in social contexts and use redirection as needed.
  • When not in social situations, provide the individual with non-judgmental feedback regarding the appropriateness of his/her behaviors/decisions.
  • This may initially be tried while the behaviors are occurring. If the individual responds negatively at that time, follow-up at a later time after his/her behaviors and emotions have stabilized.
  • Balance encouraging independence with helping the individual with TBI recognize his/her limits in decision-making.
  • Talk with the person about “pros” and “cons” for decisions/behaviors. Help him/her to weigh the positive and negative aspects.
  • Serve as a model by making important decisions in a thoughtful manner and including the individual with TBI in the reasoning process.
  • Avoid criticizing the individual for impulsive behaviors without providing constructive ideas about other ways to behave.
  • Avoid comparing the individual’s past and current abilities.
  • Avoid trying to convince the individual to change behaviors when his/her level of emotionality is high (use distraction and wait until the individual is calm before addressing the issue).
• Strategies for the Person with TBI
  • Identify triggers to impulsive behaviors with help of trusted others (e.g., family, friends, healthcare providers).
  • Develop strategies to reduce the likelihood of acting before considering consequences.
  • Have family members/friends give a signal to help with stopping and considering behaviors before acting further.
  • Accept feedback from trusted others (e.g., family, good friends) regarding when it is important to stop and consider behaviors even if it is difficult to recognize the need for this.

Apathy

• Strategies for Others
  • Recognize that apathy may result from changes to the brain associated with TBI.
  • Recognize that apathy can also be a sign of depression.
  • Look for other symptoms of depression (e.g., sadness, appetite/sleep difficulties, feelings of worthlessness).
  • If other signs of depression are present, consider using strategies for coping with Depression (see above) in addition to seeking help from healthcare providers .
  • Use techniques to enhance initiation, including:
  • Work with the individual to develop a set of agreed-upon goals.
  • Develop a schedule of daily activities and check off each activity as it has been completed.
  • Develop a schedule that involves slowly increasing activities and responsibilities over time.
  • Add 1-2 new responsibilities each week, and reward the individual for successfully adding new tasks.
  • Choose activities or other rewards that the individual will receive after completing less interesting tasks.
• Strategies for the Person with TBI
  • Accept help from trusted others (e.g., family, friends) in identifying plans/schedules for activities.
  • Use a timer to provide prompts when a task needs to be done (e.g., a watch alarm can sound when medications need to be taken).
  • Set appropriate goals for activities each day, with the help of trusted others.

ACUTE INPATIENT REHABILITATION

Inpatient rehabilitation is designed to help improve function after a moderate to severe traumatic brain injury (TBI) and is typically provided by a team of people including physicians, nurses and other specialized therapists and medical professionals. Inpatient rehabilitation can be utilized to treat a number of the problems associated with TBIs such as:

• Thinking problems – difficulty with memory, language, concentration, judgment and problem solving.
• Physical problems – loss of coordination, strength, movement, and swallowing.
• Sensory problems – changes in sense of smell, vision, hearing, and tactile touch.
• Emotional problems – mood changes, impulsiveness, irritability.

Eligibility for inpatient rehabilitation

• Individuals will be eligible to receive inpatient rehabilitation if:
  • They have a new TBI that prevents them from returning home to family care;
  • Their medical condition is stable enough to allow participation in therapies (For people relying on Medicare for funding, this means being able to participate in at least 3 hours of therapy per day. Specialized rehabilitation in a nursing facility is an option for those who cannot participate in 3 hours of rehabilitation per day.).
  • They are able to make progress in therapies.
  • They have a social support system that will allow them to return home or to another community care setting after reasonable improvement of function.
  • They have insurance or other ways to cover the cost of treatment.

How inpatient rehabilitation works

• Therapies will be designed to address the individual’s special needs. An individual will receive at least 3 hours of different types of therapy throughout the day, with breaks in between, 5-7 days a week.
• The program will be developed and implemented under the care of a physician who will see the individual at least 3 times a week.
• Most TBI rehabilitation inpatients participate in physical therapy, occupational therapy, and speech therapy. Each of these therapies may be provided in an individual or group format.

• Rehabilitation team
  • Rehabilitation care usually involves a team of highly trained practitioners, often referred to as the “multidisciplinary team.” This team works together every day and shares information about your treatment and recovery. Members of the multidisciplinary team are:
    • Physician: This may be a physiatrist (physician whose specialty is rehabilitation medicine), neurologist or another specialist familiar with TBI rehabilitation. He/she is in charge of the individual’s overall treatment and directs your rehabilitation program. Specifically, he/she will evaluate the individual’s physical abilities, along with their thinking and behavior; prescribe medication as necessary to manage mood, sleep, pain and nutrition; and prescribe tailored therapy orders for physical therapy, occupational therapy, and speech therapy.
    • Rehabilitation Nurse: The rehabilitation nurse works alongside the physician in managing medical problems and preventing complications. The nurse’s duties include assessing a variety of issues, including self-care, bowel and bladder function, sexuality, nutrition, and mobility. The nurse will also help to reinforce the treatments of the other team members and provide education about the brain injury and medications.
    • Psychologist/Neuropsychologist: He/she will assess and treat problems the individual may be experiencing with thinking, memory, mood and behavior. The psychologist/neuropsychologist may also provide counseling and education to the individual’s family members, thus ensuring that they have an understanding of the treatment plan and possible outcomes.
    • Physical therapist: The physical therapist (PT) will develop a program to help improve the individual’s physical function and mobility. The PT’s role is to teach the individual how to be as physically independent, active and as safe as possible within their environment. The PT will seek to accomplish their role through therapeutic exercises and re-education of your muscles and nerves, with the goal of restoring normal function. Specific goals to be accomplished through physical therapy include strengthening the individual’s muscles and improving endurance, walking, and balance.
    • Occupational therapist: Occupational therapists (OT) provide training in activities of daily living to help you become more independent. These activities typically include eating, bathing, grooming, dressing, and transferring to and from your bed, wheelchair, toilet, tub and shower. Depending upon where the individual receives treatment, occupational therapists may also assess thinking skills, such as orientation, memory, attention, concentration, calculation, problem-solving, reasoning and judgment; assess visual problems; help manage more complex activities such as meal preparation/cooking, money management, and getting involved in community activities; and recommend and order appropriate equipment the individual may require before returning home.
    • Speech-language pathology therapist: The speech-language pathology therapist is responsible for the treatment of speech, swallow and communication problems. He/she will help an individual with communication problems such as difficulty understanding what others say or expressing oneself clearly; teach exercises and techniques to improve the ability to speak and express oneself, including exercises designed to strengthen the muscles used in speech/swallowing, and speech drills to improve clarity; assess the individual’s language skills, such as orientation, memory, attention, concentration, calculation, problem-solving, reasoning and judgment; Provide a communication device if the individual requires a breathing tube (tracheotomy); Evaluate swallowing abilities if the individual experiences difficulty swallowing (dysphasia); and if necessary, recommend the types and consistencies of foods and drinks that an individual may safely consume.
    • Recreation therapist: The recreation therapist’s role is to provide the individual with recreational resources and opportunities to improve health and well-being to enable the individual to become reconnected to his or her community. Returning to recreation and/or finding new recreational activities is an important part of recovery.
    • Social worker: The social worker will provide the individual and his/her family with information about community resources and help plan for the individual’s discharge from the hospital. The social worker can assist in helping to determine eligibility for benefits, such as Medicaid and Social Security; make referrals to community resources; and provide ongoing supportive counseling to help the individual adjust to his/her new situation.
    • Nutritionist/Dietitian: The dietitian evaluates the individual’s nutritional status and makes recommendations about proper nutrition and diet. Individuals are often malnourished and underweight after staying in the hospital for an extended period and thus individualized attention to diet and caloric intake assists in recovery. The dietitian will also educate the individual regarding menu selection, proper food consistencies, diet changes, etc., as it fits the individual’s needs.