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8. Physical rehabilitation of brain-damaged patients
138
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
Our task is to make use of the visual and auditory stimuli he experiences on his return to consciousness to retrain him by stimulating his perceptual abilities. To do this, we present him with objects in several bright colours, of different textures, of different shapes and sizes, in two dimensions or three, in order first to assess and then to improve his perception. Without adequate perception his judgement of the world around him, his orientation in space, his ability to read and write by recognizing the symbols will be seriously impaired; writing will be particularly important if his injury has affected his powers of speech so that it may carry the risk that he will remain for the rest of his life unable to communicate with others. This is a difficult task for both patient and therapist and it demands time, concentration, and endless patience and perseverance if re-education in the complex skills of everyday living is to be achieved. The victim of head injury is in the unfortunate position of having lost not one skill but a combination of many, and the greater the severity of the injury the less will be his potential for relearning. In addition, if he has come from a culturally deprived environment, he will be further handicapped and will experience even greater difficulty in relearning. Nevertheless, experience shows thai future behaviour is dependent on the relearning of the skills of perception. The problems set by short attention-span, easy distractability and variable performances lead to frustration, which can be overcome by short frequent periods of treatment. Unfortunately, this is often impossible in present conditions, and this lack of adequate treatment can lead to bizarre behaviour, which, if allowed to continue
Injury Oct. 1969
can reach alarming proportions when the patient, leaves the sheltered environment of the hospital and does not have active and gainful employment. The establishment of the head injury workshop has done much to fill this potentially dangerous gap and has proved that a return to full employment is possible for many patients, but the workshop is insufficiently staffed and inadequately equipped and supplied with appropriate work to meet all the needs. The younger patients, I have observed, are not adequately catered for as regards either work or recreational facilities and their developing minds and bodies have insufficient outlets to allow them to reach social adjustment and emotional and mental maturity. Their normal desires to become one of a group, to associate with the opposite sex, which can be difficult to satisfy because of their injuries, tend to lead to problem behaviour, which can effect their entire family. I am convinced that if these normal drives were directed towards a satisfying goal from the time of admission to hospital and were continued, many patients would be able to hold their own w i t h their peer groups on almost equal terms and would thus retain self-respect. However, personal conviction, even when based on experience, is not enough. Therefore, I venture to suggest that the possibilities of education by formal, technical, and industrial training schemes appropriate to the pace of these patients should be investigated and the results of the research should be made available to a centre for head injury patients so as to supplement neurological and psychological investigations and the findings of therapists of all disciplines.
Requests for repriats shouM be addressed to :--Miss A. Savage, Birmingham Accident Hospital, Bath Row, Birmingham 15.
8. PHYSICAL REHABILITATION OF BRAIN-DAMAGED PATIENTS J. V. T H A C K E R A Y , M.S.R.G. THE physical problems of re-education of braindamaged patients are two-fold : - 1. The actual physical problems that brain damage brings: spasticity, lack of co-ordination, loss of positional sense, epileptic fits, and muscular weakness from prolonged bed-rest.
2. The actual handling of these patients. The patient may be too heavy or too difficult to be helped by one therapist, or may physically resist any form of treatment. Any method that cuts down the lifting, holding, or direct assistance by the therapist shauld be
Volume I Number 2
REHABILITATION AFTER SEVERE HEAD INJURIES
adopted. Therapists can tire almost as quickly as the patient if they have to hold and assist the patient both physically and mentally. Firstly, a method of communication with the patient must be established. All treatment will fail if the patient does not receive and understand in some way what is happening and what is required of him. A common mistake is to think that if patients do not reply to questions, or make an attempt to speak, they do not understand. Direct, clear, intelligent speech from this kind of patient is often the last thing to return, and may never return, but the patient can still have a clear understanding of what is being asked of him. At the end of the unconscious period, attempts are constantly made to get the patient to obey simple commands. This is the point where rapport with the patient is built up and a method of communication arrived at. To help overcome the second problem, the use of apparatus of a suitable kind must be encouraged. A sling frame is most useful instead of a pool. In a supporting frame the patient can be shown how and where to move a limb; the therapist is free to move the limb, name the movement, repeat it as required, and the patient is quite safe. Callipers and splints to support weak or spastic limbs should be made. The patient should be made cle/trly to understand that these are really only temporary aids and are being used only for this phase of treatment and that he will ' grow ' out of them as his strength and balance improve. The order of progress for the first part of the programme is lying, kneeling, sitting, standing, with re-education in walking as part of every treatment session. A bed is a poor place to treat an uncoordinated spastic patient. A number of rubber mats on the gymnasium floor is far better at a quiet part of the day. The patient knows he cannot fall if he is at ground level, and the therapist has only to use skill and the minimum of assistance to aid the patient's movements, no matter how big the patient or severe his handicap. Sitting up, with or without assistance; turning to a prone position; large range movements of both arms and legs can be encouraged or assisted as required. The rebuilding and retraining of weak or uncoordinated muscle groups should be started at this stage. Simple crawling on all fours is a usefulway of rebuilding and retraining coarse movements of the shoulders, hips, and trunk. Relaxation techniques can also be used. Kneeling is a halfway stage to standing, and a great deal of the fear of falling can be removed
139
if the patient can cope with ball games in this position. Sitting on a gymnasium stool or chair with the back removed is far better for postural retraining than a wheelchair. The patients usually use the back of a wheelchair as a fixed point to work from, instead of their own trunk muscles. (The patient probably spends many hours a day sitting in a chair.) Just to sit unaided on a stool requires concentration as well as co-ordination. Throwing a ball from a stool is a good test of progress in co-ordination, concentration, and balance. Standing should be aided in every way. A method we have tried with success is to fasten the patient to the wall-bars with a broad leather belt for increasing lengths of time, and to exercise or throw and catch a ball whilst fastened to the wall-bars. A fact to bear in mind, if the patient has made a slow recovery and has been in a bed and chair existence for a long time, is that standing can be an uncomfortable and even an unnerving experience. Standing should be attempted, if only for a short period, at every treatment session, even for a patient who may at first seem to be still unconscious. When the patient can walk without the aid of a therapist the order of treatment is changed from standing to sitting, to lying on the mats. The patient learns to sit down, then rise up, and move off unassisted. The final stage is when the patient gets up from the floor, to stand and then walk away. Severe head injury patients require individual treatment. We have tried group treatments and failed because the individual requirements of each patient are so different. In the final stages, however, we have mixed one patient into a normal class, i.e., hand class for patients with mild spasticity of the upper limb, foot class for patients with a balance problem. This works very well in practice. Passive movements: it is my increasing opinion that passive movements are contra-indicated in spastic joints and muscles. For paralysed muscles, yes; for spastic ones, no. As the patient recovers the spasm usually gets less, as dexterity increases joint stiffness goes, much as in any other injured joint or muscle groups. Passive movements can lead to the ruin of a joint by new bone formation. The fixed spastic joint requires the surgeon's attention and carefully made plaster-of-Paris splints, not passive stretching. A final word for the therapist with a longstanding severe head injury patient to treal~ is that it is highly probable that it is the therapist who requires the support and encouragement as much as the patient.
Requests for reprints shouM be addressed to:--J. V. Thackeray, Rehabilitation Department, Birmingham Accident Hospital, Bath Row, Birmingham 15.
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
Our task is to make use of the visual and auditory stimuli he experiences on his return to consciousness to retrain him by stimulating his perceptual abilities. To do this, we present him with objects in several bright colours, of different textures, of different shapes and sizes, in two dimensions or three, in order first to assess and then to improve his perception. Without adequate perception his judgement of the world around him, his orientation in space, his ability to read and write by recognizing the symbols will be seriously impaired; writing will be particularly important if his injury has affected his powers of speech so that it may carry the risk that he will remain for the rest of his life unable to communicate with others. This is a difficult task for both patient and therapist and it demands time, concentration, and endless patience and perseverance if re-education in the complex skills of everyday living is to be achieved. The victim of head injury is in the unfortunate position of having lost not one skill but a combination of many, and the greater the severity of the injury the less will be his potential for relearning. In addition, if he has come from a culturally deprived environment, he will be further handicapped and will experience even greater difficulty in relearning. Nevertheless, experience shows thai future behaviour is dependent on the relearning of the skills of perception. The problems set by short attention-span, easy distractability and variable performances lead to frustration, which can be overcome by short frequent periods of treatment. Unfortunately, this is often impossible in present conditions, and this lack of adequate treatment can lead to bizarre behaviour, which, if allowed to continue
Injury Oct. 1969
can reach alarming proportions when the patient, leaves the sheltered environment of the hospital and does not have active and gainful employment. The establishment of the head injury workshop has done much to fill this potentially dangerous gap and has proved that a return to full employment is possible for many patients, but the workshop is insufficiently staffed and inadequately equipped and supplied with appropriate work to meet all the needs. The younger patients, I have observed, are not adequately catered for as regards either work or recreational facilities and their developing minds and bodies have insufficient outlets to allow them to reach social adjustment and emotional and mental maturity. Their normal desires to become one of a group, to associate with the opposite sex, which can be difficult to satisfy because of their injuries, tend to lead to problem behaviour, which can effect their entire family. I am convinced that if these normal drives were directed towards a satisfying goal from the time of admission to hospital and were continued, many patients would be able to hold their own w i t h their peer groups on almost equal terms and would thus retain self-respect. However, personal conviction, even when based on experience, is not enough. Therefore, I venture to suggest that the possibilities of education by formal, technical, and industrial training schemes appropriate to the pace of these patients should be investigated and the results of the research should be made available to a centre for head injury patients so as to supplement neurological and psychological investigations and the findings of therapists of all disciplines.
Requests for repriats shouM be addressed to :--Miss A. Savage, Birmingham Accident Hospital, Bath Row, Birmingham 15.
8. PHYSICAL REHABILITATION OF BRAIN-DAMAGED PATIENTS J. V. T H A C K E R A Y , M.S.R.G. THE physical problems of re-education of braindamaged patients are two-fold : - 1. The actual physical problems that brain damage brings: spasticity, lack of co-ordination, loss of positional sense, epileptic fits, and muscular weakness from prolonged bed-rest.
2. The actual handling of these patients. The patient may be too heavy or too difficult to be helped by one therapist, or may physically resist any form of treatment. Any method that cuts down the lifting, holding, or direct assistance by the therapist shauld be
Volume I Number 2
REHABILITATION AFTER SEVERE HEAD INJURIES
adopted. Therapists can tire almost as quickly as the patient if they have to hold and assist the patient both physically and mentally. Firstly, a method of communication with the patient must be established. All treatment will fail if the patient does not receive and understand in some way what is happening and what is required of him. A common mistake is to think that if patients do not reply to questions, or make an attempt to speak, they do not understand. Direct, clear, intelligent speech from this kind of patient is often the last thing to return, and may never return, but the patient can still have a clear understanding of what is being asked of him. At the end of the unconscious period, attempts are constantly made to get the patient to obey simple commands. This is the point where rapport with the patient is built up and a method of communication arrived at. To help overcome the second problem, the use of apparatus of a suitable kind must be encouraged. A sling frame is most useful instead of a pool. In a supporting frame the patient can be shown how and where to move a limb; the therapist is free to move the limb, name the movement, repeat it as required, and the patient is quite safe. Callipers and splints to support weak or spastic limbs should be made. The patient should be made cle/trly to understand that these are really only temporary aids and are being used only for this phase of treatment and that he will ' grow ' out of them as his strength and balance improve. The order of progress for the first part of the programme is lying, kneeling, sitting, standing, with re-education in walking as part of every treatment session. A bed is a poor place to treat an uncoordinated spastic patient. A number of rubber mats on the gymnasium floor is far better at a quiet part of the day. The patient knows he cannot fall if he is at ground level, and the therapist has only to use skill and the minimum of assistance to aid the patient's movements, no matter how big the patient or severe his handicap. Sitting up, with or without assistance; turning to a prone position; large range movements of both arms and legs can be encouraged or assisted as required. The rebuilding and retraining of weak or uncoordinated muscle groups should be started at this stage. Simple crawling on all fours is a usefulway of rebuilding and retraining coarse movements of the shoulders, hips, and trunk. Relaxation techniques can also be used. Kneeling is a halfway stage to standing, and a great deal of the fear of falling can be removed
139
if the patient can cope with ball games in this position. Sitting on a gymnasium stool or chair with the back removed is far better for postural retraining than a wheelchair. The patients usually use the back of a wheelchair as a fixed point to work from, instead of their own trunk muscles. (The patient probably spends many hours a day sitting in a chair.) Just to sit unaided on a stool requires concentration as well as co-ordination. Throwing a ball from a stool is a good test of progress in co-ordination, concentration, and balance. Standing should be aided in every way. A method we have tried with success is to fasten the patient to the wall-bars with a broad leather belt for increasing lengths of time, and to exercise or throw and catch a ball whilst fastened to the wall-bars. A fact to bear in mind, if the patient has made a slow recovery and has been in a bed and chair existence for a long time, is that standing can be an uncomfortable and even an unnerving experience. Standing should be attempted, if only for a short period, at every treatment session, even for a patient who may at first seem to be still unconscious. When the patient can walk without the aid of a therapist the order of treatment is changed from standing to sitting, to lying on the mats. The patient learns to sit down, then rise up, and move off unassisted. The final stage is when the patient gets up from the floor, to stand and then walk away. Severe head injury patients require individual treatment. We have tried group treatments and failed because the individual requirements of each patient are so different. In the final stages, however, we have mixed one patient into a normal class, i.e., hand class for patients with mild spasticity of the upper limb, foot class for patients with a balance problem. This works very well in practice. Passive movements: it is my increasing opinion that passive movements are contra-indicated in spastic joints and muscles. For paralysed muscles, yes; for spastic ones, no. As the patient recovers the spasm usually gets less, as dexterity increases joint stiffness goes, much as in any other injured joint or muscle groups. Passive movements can lead to the ruin of a joint by new bone formation. The fixed spastic joint requires the surgeon's attention and carefully made plaster-of-Paris splints, not passive stretching. A final word for the therapist with a longstanding severe head injury patient to treal~ is that it is highly probable that it is the therapist who requires the support and encouragement as much as the patient.
Requests for reprints shouM be addressed to:--J. V. Thackeray, Rehabilitation Department, Birmingham Accident Hospital, Bath Row, Birmingham 15.