VOCATIONAL REHABILITATION FOR INDIVIDUALS WITH ACQUIRED BRAIN INJURY

Introduction

Acquired brain injury is among the leading causes of death and disability in the US. Acquired brain injury is considered to be the most common neurological disorder with debilitating effects. Traumatic brain injury which is a type of acquired brain injury is considered to be eight times more common than AIDS, spinal cord injury, breast cancer and multiple sclerosis combined (CDC, 2014). One estimated incidence of acquired brain injury shows that one out of 500 in the global population is common to occur mostly for children under the age of four, people under 30 and those over 65 years (Bazarian, Cernak, Noble-Haeusslein, Potolicchio, & Temkin, 2009). This means that there are a large number of acquired brain injury survivors worldwide. Acquired brain injury also has adverse impacts on the cognitive, emotional and behavioural wellbeing of the survivors hence the impacts have to be addressed.

A number of approaches have been used to develop an understanding of acquired brain injury. These include psychological theories and models. The traditional neurobiological approach of understanding acquired brain injury should embrace a more complex understanding of social factors proposed in psychology. Psychological approaches to health and acquired brain injury should integrate the multiple factors of injuries and ill-health that characterize even a single diagnosis of acquired brain injury (King, & Tyerman, 2003). This paper discusses acquired brain injury, its types and impacts, and how psychological theory can be applied to working with acquired brain injury clients.

Applying the sociological approach to brain injury

Research shows that psychology plays a critical role in determining health and disease (Aronson, Wilson, & Akert, 2010). Social factors like social support and maintained group membership are related to positive clinical outcomes such as immunity. Social psychology influences various disciplines including cognitive psychology, individual psychology, sociology and language. This makes social psychology intellectually stimulating and practical potential to be applied on the study of various conditions including acquired brain injury which has both social and biological components. 

Another important factor to consider while discussing how the psychological theory can be applied to acquired brain injury is neuropsychology. Neuropsychology refers to the relationship between brain and behaviour and it is strongly influenced by cognitive psychology (Aronson, Wilson, & Akert, 2010). The neuropsychological perspective is important in the identification of deficits. Some patients with closed head injuries can show significant cognitive deficits but have very little evidence of cerebral damage. Neuropsychology can therefore be used to identify the nature and extent of cognitive disturbance that affects a brain injury patient. In order to understand how the psychological theories and models apply to acquired brain injury, it is important to first understand types of acquired brain injury, their effects, outcome and rehabilitation (King, & Tyerman, 2003). 

What is brain injury?

Brain injury refers to any type of injury that causes damage to the brain. It is any type of brain injury that leads to impairment in cognitive, physical, speech or behaviour functioning. Acquired brain injury refers to brain injuries that occur after birth and may result from various conditions including trauma caused by head injury or postsurgical damage, vascular accident like stroke, toxic or metabolic insult, infection, cerebral anoxia, and infection or inflammation. Acquired brain injury refers to any sudden injury that leads to temporary or permanent damage to the brain. Brain injury is unique because every injury and effect is different and recovery occurs through different levels including functional, psychological and neuropsychological. Prognosis and outcome of brain injuries varies and is highly dependent on multiple factors including the location of injury, the level of tissue and physiological damage, aetiology of the injury, and the age of patient when the injury occurs. The age is important because it determines the amount of plasticity available in the brain to compensate for the injury and the amount of cognitive experience that the patient can draw from (Nochi, 1997).  

Types of acquired brain injury

There are different types of acquired brain injury traumatic brain injury, hypoxic/anoxic brain injury, alcohol related brain injury, among others. The most common type of brain injury is traumatic brain injury which is the disruption of the normal brain function as a result of trauma from direct blow to the head, penetration of the brain, or any force that leads to brain movement inside the skull. According to the Centers for Disease Control and Prevention, most traumatic brain injuries result from falls, (40 %), road traffic accidents (20 %), being struck by an object or against and object (18 %), and assault (11 %). In younger children, falls are the most common causes of brain injury (2014). 

The severity of traumatic brain injury is measured is measured through different ways. For instance, it can be measured based on whether there is a loss of consciousness (LOC), and its duration and depth depending on how a patient responds to stimuli. The Glasgow Coma Scale is able to measure the severity of LOC as mild, moderate, or severe. The severity of LOC can also be measured through the length of time that the injured person is alert but not able to take in new information (Bazarian et al. 2009). 

Hypoxic or anoxic brain injury occur when there is reduced oxygen (hypoxic) or a complete lack of oxygen (anoxic) supply to the brain. Hypoxic/anoxic brain injury may result from anoxic anoxia, anaemic anoxia, or stagnant (ischemic) anoxia. Anoxic anoxia occurs when there is no enough oxygen to be absorbed by the body and may occur in high altitude sickness. Anaemic anoxia occurs when there is not enough blood to carry the needed amounts of oxygen to body cells. This may be as a result of acute haemorrhages, carbon monoxide poisoning, obstructive arteries or chronic anaemia. Stagnant (ischemic) anoxia is also known as hypoxic ischemic injury and involves diffuse damage in the cerebral cortex and cerebellum. Reduced oxygen supply to the brain can lead to profound cognitive, emotional and physical impairments which can be permanent or very slow to recover from. As a result, this type of acquired brain injury could have a wide range of impacts throughout the brain compared to traumatic brain injury (King, & Tyerman, 2003). 

Alcohol related brain injury refers to the physical injury caused to the brain as a result of excess alcohol consumption. Alcohol can have a toxic effect on the brain particularly on the central nervous system. This type of damage results in changes in metabolism, heart functioning and supply, and also interference with thiamine absorption. Alcohol is mostly associated with poor nutrition and it could lead to dehydration that may cause wastage of brain cells. Alcohol related brain injury can result in different degrees of brain injury from excess consumption of alcohol depending on amount and pattern of alcohol consumption, nutrition, age and gender. This type of acquired brain injury could be mild, moderate, severe or very severe. Alcohol related brain injury can lead to changes in cognition, difficulties in motor skills, balance and coordination, and various neurological disorders (King, & Tyerman, 2003). 

Effects of acquired brain injury 

Acquired brain injury leads to cognitive deficits that have adverse impacts on emotions and behaviour of patients and also affect their rehabilitation. Acquired brain injury can result in impairments in cognition, motor function, language, sensory processing, and emotional disturbances. Cognitive effects of brain injury affect the way a patient thinks, learns and remembers. Different mental abilities are located in the brain and so acquired brain injury can damage some skills such as memory, speed of thought and processing, understanding, concentration, and solving problems (King, & Tyerman, 2003). Acquired brain injury causes significant levels of disability that result in various long term problems. In the US, approximately 5.3 million people have long term needs for help to perform daily tasks as a result of acquired brain injury. The affected individual end up with communication impairments including reduced ability to understand, speak or use the spoken language. In addition, acquired brain injury leads to disturbances in memory, learning and awareness. Most people with acquired brain injury report more cognitive impairments than physical deficits (Abrams, Barker, Haffey, & Nelson, 1993). 

Traumatic brain injury can result in various neurocognitive developmental impairments and difficulties that subsequently affect behaviour and functioning. Some of these effects include deficits in cognitive, socio-cognitive, cognitive empathy, impulse control, regulation of responses, social or pragmatic communication, and hence the ability to appropriately respond to emotions of other people. The extent of cognitive impairment depends on the volume of brain tissue lost as a result of the injury as well as the region of the brain injured. Severe and moderate traumatic brain injury could lead to long term cognitive defects. Mild traumatic brain injury could lead to lower educational levels, emotional distress, and poor physiological functioning. 

Brain injury could also lead to several neurological disorders six months or more post injury. Most types of traumatic brain injury lead to seizures. According to Bazarian et al. (2009), about 25 per cent of patients with contusions and 50 per cent of patients with penetrating head injuries develop seizures within 24 hours after the injury. However, these immediate seizures are not related to post traumatic seizures that recur at least one week after the first seizure. About 32 to 53 per cent of penetrating traumatic brain injuries results in seizures.

Occupational needs after brain injury

Acquired brain injuries could affect motor, sensory, cognitive and behavioural functioning as seen above. A survivor of acquired brain injury might therefore find it difficult to return to normal day to day activities like going back to work or to school, or engage in other activities that the person enjoyed before the injury. It is also common to find some of the brain patients experience decreased balance and coordination, memory impairments, and difficulties in making decisions. Brain injury could also affect visual and functions, as well as decrease the frustration tolerance of a person (Ponsford, Olver, & Curran, 1995). 

Occupational needs encompass all activities and aspects in a person’s life including employment, education, self-care, home management, feeding habits, leisure and even social participation. All these needs are usually affected by acquired brain damage and this makes life difficult for brain damage survivors.  Return to work or other meaningful occupation is a critical factor in the quality of life after brain injury. Such patients may therefore need the help of other people in relearning and regaining the ability to perform these activities (remediate) or help in determining new ways of engaging in these activities (compensatory strategies). Occupational therapy can therefore be crucial in assisting individuals with brain injury to perform basic activities of daily living (Johnstone, Reid-Arndt, Franklin, & Harper, 2006). 

Recovery of the lost functions and skills from acquired brain injury is mostly incomplete and this puts survivors at risk of social and psychological problems. Effective treatment of brain damage should therefore focus on improving the physical, mental, psychological, emotional and behavioural status of the patient (Abrams, Barker, Haffey, & Nelson, 1993).

Vocational outcome and rehabilitation after brain injury

Vocational outcome and rehabilitation refers to the process through which individuals with permanent or temporary disability following brain injury are enabled to access, return to or remain in employment. Research on vocational outcome after traumatic brain injury shows that mild injury does not decrease the number of full time employment (Tyerman, 2012). However, a modest brain injury could decrease the number of full time employment by 13 % while severe injury leads to a 42 % decrease in the number of full time employment. A follow up study in Glasgow showed that out of 134 people with severe traumatic brain injury, 86 % were employed prior to the injury while only 29% of them were employed in a follow up study 2 to 3 years later (Ponsford, Olver, & Curran, 1995). However, this group of people that remained in employment long after the acquired brain injury had undergone brain injury rehabilitation. Only up to a third of brain injury patients in the UK are able to return to work after rehabilitation and those that are not able to return to work within two years after the injury are very unlikely to return to work afterwards (Tyerman, 2012). 

Positive outcomes have been shown for specialist brain injury vocational programs in the US with up to two thirds of people returning to work after rehabilitation. Vocational rehabilitation programs can have long term benefits for brain injury patients. The rehabilitation programs provide services that promote optimal independence and participation. Brain injury rehabilitation mainly focuses on provision of assistive devices and interventions used to address difficulties in motor skills, sensory function, personal and domestic independence, communication and language skills, cognitive function, behaviour and emotional control (Nochi, 1997).

Psychological theories and approaches can also be used in the rehabilitation of acquired brain injury. Rehabilitation following acquired brain damage centres on enabling people to attain their optimal capacity in terms of psychological, social, vocational, leisure and daily function. Brain injured individuals should receive psychological and neurological evaluations to understand what parts of the brain are affected and at what degree. It is important to integrate the biological with the social in psychological therapy following acquired drain injury (Johnstone, Reid-Arndt, Franklin, & Harper, 2006). 

The psychological model recognizes that the mind is not entirely internal or entirely external but involves reciprocal processes of interaction between both. The individual’s past knowledge, skills, work history and social situation can impact the present functioning of a patient. An important aspect of brain injury rehabilitation is promoting the recovery of cognitive function and reducing cognitive disability. Cognitive rehabilitation involves a program that incorporates therapeutic cognitive activities based on the brain behaviour of a person. Cognitive rehabilitation helps in reinforcing or re-establishing previously learned behaviours or establishing new ways of cognitive activities for the impaired neurological systems (Walsh, Fortune, Gallagher, & Muldoon, 2012).  

A thorough assessment of brain injured individuals should also include emotional and behavioural assessment. This can help in identifying those emotions and behaviours that are maintained by environmental factors and evaluate the functional consequences of organic damage. Several issues must however be highlighted when applying the emotional and behavioural assessment of patients with traumatic head injuries. It is important to identify whether the patient performance problems involve a skill deficit, a function of environmental factors or just organic problems. 

Future research

Psychological theories and models can be employed in understanding acquired brain damage its effects and rehabilitation. Social psychology and neuropsychology can both be used to explain the interaction between biology and society as it concerns acquired brain injury. As much as psychology and neuroscience can be used to explain cognition in terms of intrapersonal processes, it is not fully accepted by modern scholarship. This is because modern scholarship argues that both cross conceptual and methodological levels are necessary to understand cognition. Social identity has being used to predict wellbeing after brain injury. The relationship between severity of brain injury and effects on life satisfaction among patients are explained by the social identities and networks following brain injury. However, more research should be done on how social identity processes affect the clinical outcome of brain injury rehabilitation (Walsh, Fortune, Gallagher, & Muldoon, 2012).  

Conclusion

In conclusion, brain injury is a major cause of death and disability in both children and working adults. Brain injury affects cognitive, emotional and behavioural functions among patients. Addressing these needs is key in promoting individual health and wellbeing of patients. In addition, it helps in meeting occupational needs that are affected by brain injury. Psychological theories and approaches particularly social psychology and neuropsychology can be used in alleviating some of the cognitive, behavioural and emotional effects of brain injury. Psychological theory can therefore be used to understand acquired brain injury and produce an effective rehabilitation program for patients. 

 

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