Feature Article: Rehabilitation Intervention for an Individual with Spinal Cord/Brain Injury and Visual Impairment
John W. DenBoer, MA and Sigmund Hough, PhD, ABPP
Abstract
This case study explored the challenge of using verbal feedback with an individual following simultaneous with spinal cord injury and traumatic brain injury (SCI/TBI) with visual impairment. A man in his late 20’s received a severe open head injury and T5 ASIA B ischemic spinal cord injury secondary to a motorcycle accident in which he was not wearing a protective helmet. Neuropsychological testing revealed moderate-to-severe deficits in the area of delayed memory, with particular problems in acquisition and maintenance of new information. The individual demonstrated difficulty in making functional rehabilitation progress related to visual and memory decrements. At the conclusion of inpatient rehabilitation, he demonstrated the capacity to make functional rehabilitation gains through the use of consistent verbal cues and reinforcement.
Keywords: brain injury, rehabilitation, spinal cord injury, visual impairment
Introduction
Spinal cord injury is a destructive event that often results in significant physical and emotional changes and life-long adjustment. Although the etiology of SCI is varied, the primary causes include motor-vehicle accidents, falls, sports-related injuries, and violence (e.g., Elovic & Kirschblum, 1999). Given that these events are also the major causes of traumatic brain injury (TBI), it should not be a surprise that a growing body of research has begun to examine the complex association between TBI and SCI. Although estimates vary, it is thought that between 20% and 50% of patients with cervical SCI have experienced some degree of TBI (Cook, 2003). Although the literature pertaining to the management of either TBI or SCI is quite large, empirical investigations examining dual-diagnosis SCI/TBI are relatively lacking.
There are 10,000 hospital admissions for SCI in the United States each year. In contrast, there are more than 250,000 TBI-related hospital admissions (Elovic & Kirschblum, 1999). The majority of SCIs occur in young people, with approximately 55% of traumatic SCIs sustained by individuals between the ages of 16 and 30. Similarly, the highest incidence rate reported for people with TBI occurs in those between the ages of 15 and 24 (Elovic et al.). TBI is considered primary when the individual’s brain injury is more severe in actual physical damage and resulting brain-behavior impairment, where SCI is the primary focus due to pervasive paralysis and physical impairment. It is far more common for patients with SCI to have concomitant TBI, with the incidence rate ranging from 24% to 50%, than for those with primary identified TBI to also have SCI, with estimates for this problem ranging from 1.2% to 6% (Elovic et al.).
Arzaga, Shaw, and Vasile (2003) have highlighted the complexity of dual-diagnosis SCI/TBI, noting that many brain injuries tend to be undetected, or, if detected, their importance minimized, particularly during the emergent and acute phases of rehabilitation. According to the researchers, treatment providers may begin to notice that the SCI individual has a brain injury when they begin to demonstrate problems with resistance or cannot carry out functional activities appropriate to their level of SCI. In general, the researcher’s findings show that cognitive deficits can greatly complicate the ability of a person with SCI to learn compensatory strategies for dealing with the physical limitations imposed by their SCI.
In terms of etiology, dual-diagnosis TBI and cervical SCI are primarily due to high-velocity mechanisms of injury, with the severity of TBI or initial Glasgow Coma Scale (GCS) scores offering less utility as predictor variables. Additionally, individuals undergoing blunt trauma in high-velocity mechanism incidents appear to be at particular risk for extradural supportive soft tissue cerebrospinal injuries (Albrecht, Malik, Kingsley, & Hart, 2003). The range of causes of SCI/TBI has not been fully examined; more research is needed in this area.
Neurocognitive differences have been found between persons with SCI and non-SCI individuals. Specifically, Tran, Boord, Middleton, and Craig (2004) found that individuals with SCI, compared to able-bodied controls, demonstrated consistently reduced brain wave activity as measured by peak amplitude and magnitude, with these differences found to be larger in the parietal and occipital regions of the brain. According to the researchers, individuals sustaining SCI had consistently lower frequencies than controls without SCI. A notable additional finding was that a subgroup of SCI participants with tetraplegia displayed significantly reduced brain activity compared to the paraplegic subgroup and able-bodied controls.
Co-occurring TBI has been found to impair the functional outcome of persons with SCI. Macciocchi, Bowman, Coker, Apple, & Persons (2004) found that SCI patients with dual-diagnosis TBI demonstrated significantly lower Cognitive FIM scores at admission and discharge from rehabilitation compared to persons with SCI alone. The researchers also found that individuals with dual-diagnosis SCI/TBI achieved a significantly lower Motor FIM change than persons with SCI. In contrast, GCS scores or the presence of intracranial lesions were not successful predictors of functional outcome in the dual-diagnosis group. These results underscore the notion that while brain injury appears to limit the functional gains made by SCI patients, a non-linear relationship appears to exist between brain injury severity and functional change.
These findings have important implications for rehabilitation, as there may be significant disruption of traditional rehabilitation treatment, goals, and outcome when TBI and SCI occur together (Riker & Regan, 1999). Due to the psychological and neuropsychological features of concomitant SCI/TBI, interdisciplinary rehabilitation teams are required to adjust rehabilitation approaches and modify treatment expectations for the SCI/TBI individual. This case study explored the unique challenge of using verbal feedback with an individual following dual-diagnosis SCI/TBI and visual impairment.
Case Background
A male in his late 20’s received a SCI/TBI secondary to a motorcycle accident in which he was not wearing a helmet. He sustained a T5 ASIA B ischemic spinal cord injury and severe open head injury. Length of coma was approximately 12 weeks. His medical records revealed that he experienced legal blindness in both eyes as a result of ischemic optic neuropathy caused by significant blood loss associated with his accident.
This individual presented to an urban Veterans Affairs Medical Center SCI inpatient unit for rehabilitation in preparation for an intensive blind rehabilitation program. Psychology received a formal consult to evaluate his cognitive status in preparation for this program. Specifically, he was transferred to this program for an upgrade of his activities of daily living (ADL’s), bed-to-wheelchair transfers, and bowel and bladder management.
The man presented with a complex symptom constellation. From a cognitive standpoint, he showed persistent delayed memory loss with subsequent problems in rehabilitative skill acquisition. Central to these problems was the significant difficulty he experienced remembering details. Although he had a limited daily schedule, he would easily forget his appointments if a nursing aide did not remind him of them. When residing in an assisted living environment, he was noted to forget appointments quite frequently.
His pronounced memory problems greatly impacted his progress in physical rehabilitation activities, as he would consistently forget what he had accomplished the previous day and what he was scheduled to do during the present day, as well as failing to recall his future therapeutic goals. He also reported increased forgetting for detail. In general, his functional rehabilitation difficulties appeared to be related to his difficulty in acquiring and retaining new information. Psychology was consulted to help develop a plan to improve this individual’s participation in rehabilitation activities.
Method
Study Design
This case study was AB in nature, with A = the baseline period prior to verbal feedback and B = verbal feedback. Verbal feedback was defined as detailed professional information given to the patient related to his rehabilitation progress. Verbal feedback was also provided through the use of a Voice Cue™ device (see below). Dependent variables included functional rehabilitation gains as measured in a variety of areas, psychological health, and cognitive performance.
Neuropsychological Evaluation
Neuropsychological testing was conducted over the course of two, two-hour testing sessions, with the evaluation taking place approximately four weeks into the individual’s ten-week inpatient stay. A brief cognitive screen administered during the first testing session revealed severe impairments in the area of immediate memory for words presented in auditory fashion, although the individual performed within normal limits on the rest of the cognitive domains assessed during the first testing period. The individual’s performance during the second testing session revealed average to above-average verbal intelligence. Abstraction capabilities appeared average. Similarly, he was able to complete arithmetic problems with accuracy. Working memory appeared to be above-average. Consistent with findings obtained during the first test period, he displayed moderate deficits in the area of delayed memory for auditory information. A notable finding on testing was that the patient appeared to experience significant problems recalling information after periods of distraction. Given the results of testing, combined with his presentation, the individual received a diagnosis of post-concussion syndrome. These results were consistent with findings from a previous neuropsychological evaluation the individual underwent approximately two years prior.
Individual and Team Recommendations
Based on the results of neuropsychological evaluation, the following recommendations were offered. It is important to note that these recommendations pertained not only to the individual, but also to the interdisciplinary SCI treatment team.
1. Given that the individual appears to be able to learn information effectively (although he cannot retain this information well), he should be encouraged to develop creative strategies for information retention, including using his mini tape recorder to replay important information.
2. Although the individual is of above-average intelligence, he appears to retain information presented in a simple manner much better than detailed data. When interacting with him, rehabilitation staff should attempt to present information to him in as straightforward a manner as possible.
3. The individual will continue to benefit from information presented in different sensory modalities. If possible, important information regarding his goals should be presented in both tactile and verbal forms.
4. A structured daily schedule with clear goals and expectancies may benefit the individual greatly in his rehabilitation efforts. This schedule should be communicated by nursing staff to the patient at the start of each day so he is able to plan his activities accordingly.
5. In an effort to improve the individual’s ability to cope with his loss of vision, he is encouraged to seek assistance from the Vision Clinic, affiliated with VA Boston Healthcare System.
6. The individual is also encouraged to continue to meet with an occupational therapist to assist him in bed-to-wheelchair transfers and other independence-promoting exercises.
All SCI interdisciplinary team members worked intensively with the individual beginning with his admission to the inpatient unit. Members of the treatment team included physicians, social workers, occupational therapists, physical therapists, and psychologists. A speech and language pathologist was also an important member of the treatment team since this professional worked with the patient to increase his facility with the Voice Cue™ device.
Cognitive Rehabilitation
Psychology met with this individual over the course of 12 individual psychotherapy sessions, conducted over the span of approximately 1.5 months. Psychotherapy incorporated divergent techniques, mainly derived from the cognitive rehabilitation literature. In an attempt to improve the individual’s sustained attention and concentration, visual imagery was used. In addition to the cognitive rehabilitation aspect of psychotherapy, other areas of treatment focus included increasing the individual’s willingness to advocate for his current and future medical and emotional needs, and to process his feelings regarding his childhood and current estrangement from his family.
In addition to working individually with the person, psychology consulted with the SCI inpatient interdisciplinary team, asking staff to provide the man with clear and constant expectations regarding his progress in all rehabilitation modalities. This communication was particularly necessary in the area of physical, occupational, and kineseotherapy, given that the individual experienced the majority of his problems in these areas. Psychology also worked with him to develop techniques for coping with his poor memory, including brainstorming ways to retain more information over a longer period of time.
These techniques included using a Voice Cue™ device that was clipped to the patient’s shirt and used to record verbal instructions, programmed to replay these instructions at preset times throughout the day. These instructions ranged from “brush your teeth” and “take your medication” to reminders of how much weight the patient lifted or how many exercises he did during a certain day. As detailed in the results section, this device was found to significantly improve the patient’s functional rehabilitation gains.
Along with the use of the Voice Cue™ device, information was also presented in a straightforward manner and in both tactile and verbal modalities, which appeared to benefit the individual. Examples of tactile presentation included the therapist guiding the patient’s hands around the various Voice Cue™ buttons in addition to the work of physical and occupational therapy staff in helping the patient maneuver his body to successful transfer positions. Additionally, a structured daily schedule with goals and expectancies was used, with this information posted on the individual’s walls and communicated to him throughout the day. All of these techniques appeared to be helpful in improving his participation in rehabilitation activities.
Results
At the conclusion of an eight-week rehabilitation period, the individual was able to demonstrate capacity to make functional rehabilitation gains via consistent verbal cues. Functional gains were demonstrated across a variety of treatment domains, including physical and occupational therapy, speech and language, and mental health. In the area of physical and occupational therapy the patient demonstrated significantly faster times in conducting bed-to-wheelchair and wheelchair-to-bed transfers. He was also observed to perform this activity in a more focused manner. In the area of speech and language, at the conclusion of rehabilitation the patient demonstrated significant greater facility in using his Voice Cue™ device. With the aid of this device, he was also able to complete his activities of daily living with greater proficiency.
The patient demonstrated notable progress in the areas of emotional and cognitive functioning. Notably, his Global Assessment of Functioning (GAF), a brief general measure of psychological well-being, improved from an admission rating of 60 to 75 at the time of discharge. Additionally, his Cognitive FIM score increased significantly throughout the course of treatment.
At the conclusion of cognitive rehabilitation the individual actively endorsed pursuing the following goals: 1) listening to books on tape, 2) participating in increased arts and crafts activities, 3) working with clay (sculpting) and doing oil painting, 4) using a computer to do book reports, and 5) participating in increased occupational therapy, physical therapy, and kinesoeotherapy.
Despite the patient’s improvement across a variety of areas, he experienced significantly greater problems achieving functional gains in rehabilitation when compared with other SCI inpatients who had not sustained a traumatic brain injury. He also experienced significantly greater difficulty achieving functional gains in comparison to dual-diagnosis SCI/TBI patients without visual impairment.
Discussion
The use of verbal feedback with a person with SCI/TBI and visual impairment proved to be quite challenging, but through interdisciplinary team communication and efficient staff interventions, the individual was able to demonstrate notable functional gains, ultimately improving his functional independence and personally-defined quality of life.
The difficulty that the individual experienced in achieving functional gains in the current study are consistent with aforementioned findings by Macciocchi et al. (2004) who found that persons with dual-diagnosis SCI/TBI achieved smaller functional gains during rehabilitation when compared to peers with SCI. Corroborating findings from Macciocchi et al., it appeared that while the individual in the present study was limited by both his brain injury severity and visual impairment, the relationship between the impact of these constructs did not form a direct linear relationship with the person’s functional limitations.
In terms of visual rehabilitation services, the VA Boston VIST team may have been of service to this patient, although it is important to note that traditional education materials and groups in SCI or TBI programs will need to adapt their training procedure and materials to individuals with dual diagnosis. This can be done by targeting residual strengths in the emotion, physical, and cognitive areas. Similarly, environmental modification, a clear and consistent daily schedule of therapy, limiting distractions and competing stimuli, and prioritizing activities and providing rest breaks may also be of benefit.
Future research may focus on the importance of patients’ attributional style and self-definition of their SCI. Findings from Crewe (1996) suggest that individuals who demonstrate better adjustment to SCI are those that redefine their values and increase their awareness and appreciation across a variety of life activities and abilities. Additionally, Hammell (2004) suggests that quality of life among community-dwelling individuals with high spinal cord injury can be improved through a reorientation of life values and goals. Future studies in this area may also focus on using assessment measures for vision rehabilitation (Babcock-Parziale & Williams, 2006).
In summary, effective intervention with this patient did not solely include cognitive rehabilitation, but targeted emotional intervention as well. Although more progress is left to be made, this unique treatment mixture proved to be effective in successfully treating the challenging combination of the patient’s SCI, TBI, and visual impairment.
References
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John W. DenBoer, MA, is Clinical Fellow in Psychology, Harvard University School of Medicine, Teaching Fellow in Psychiatry, Boston University School of Medicine, and Psychology Intern at the Spinal Cord Injury and Neuropsychology Services, VA Boston Healthcare System
Sigmund Hough, PhD, ABPP, is Assistant Professor, Harvard University Medical School; Adjunct Assistant Professor, Boston University School of Medicine, and Clinical Neuropsychologist at the Spinal Cord Injury Service, VA Boston Healthcare System.