TBI and Acquired Deafness: Neurological Rehabilitation Plan

Introduction

The patient discussed in this case study is a twenty-five-year-old male who suffered head injuries as the result of a roadside bomb explosion in Iraq. Until this injury, he was a healthy young man with a wife, a child, and a career path in the United States Army. The incident not only altered his life plan for himself and his family, but left him physically disabled and facing the post-surgical prospect of neurological rehabilitation. Worsening the situation, the proximity of the explosion was such that he sustained injuries to both ears and is now hearing impaired, with a complete loss of hearing in either ear. His hearing impairment cannot be repaired with cochlear implants, and, in addition to neurological rehabilitation, he must now begin learning a new means of communication without the benefit of hearing.

The patient's traumatic brain injury (TBI) resulted in intra-parenchymal hemorrhaging, followed by a coma. The hemorrhaging was surgically repaired, and he awoke from the coma experiencing the post-surgical effects of fatigue, attentional deficits, and mood swings and frustration stemming from the combined injuries and his inability to hear and communicate (Uzzell, 1996, p. 8).

Magnetic resonance imaging (MRI) indicates that the surgical procedure was successful, and that with time and proper therapy the patient will most likely regain his full range of physical mobility. However, he may suffer some long-term memory loss. His speech is dually impacted by his acquired deafness and by the normal post-surgical effects on his ability to speak. Like his movement, his speech should return with proper rehabilitation, though the level of recovery will inevitably be influenced by his acquired hearing impairment. A plan of rehabilitation and training, as well as an educational plan to teach him sign language, will be implemented, and his progress will be monitored and evaluated over the upcoming months.

Neurological Rehabilitation for TBI

For patients suffering TBI, Anne-Lise Christensen and Barbara P. Uzzell (1994) note that research has shown: "Along with the increase and diversity of procedures, there is a reemphasis on psychological constructs related to ego psychology such as awareness and self-efficacy as relevant modulating variables in facilitating response to treatment" (p. 1). It therefore becomes necessary to understand everything about the patient, and that means that close family support, interaction, and participation in the patient's neurological rehabilitation are essential to recovery and to regaining as much mental capacity and physical functioning as the patient had prior to the TBI.

Treatment combinations for the patient's TBI will draw on contemporary therapies and exercise, combined with appropriately applied pharmacology. Leonard Diller (1994) discusses the progress made in the rehabilitation of patients suffering TBI and summarizes contemporary rehabilitation as follows:

"Progress toward finding the right treatment combinations has advanced along a number of fronts in the past five years. These include developments in identifying behavioral characteristics at both ends of severity in the recovery from traumatic brain injury. At the most severe end is the application of newer assessment devices, and at the opposite end is the clarification of the definition of minor traumatic brain injury. In the middle range there have been two major developments. First, there has been a proliferation of therapeutic modalities to establish competence in functional settings. Among them are the increase of group methods, the applications of the family coach model as a tool, the use of supported employment, and the introduction of computers for orthotic devices or cognitive aids. Second, there has been a large number of reports on varieties of cognitive remediation. These reports are reviewed with regard to the nature of outcomes that are achieved and their experimental designs. Along with the increase and diversity of procedures, there is a reemphasis on psychological constructs related to ego psychology such as awareness and self-efficacy as relevant modulating variables in facilitating response to treatment" (p. 1).

The combination of pharmacology, rehabilitation, and exercise has led to a number of success stories in neurological rehabilitation. The patient's assessment has involved the combined efforts of a team of therapeutic disciplines, including a pharmacologist. Discussing the role of pharmacology in neurological rehabilitation, Donald G. Stein, Marylou M. Glasier, and Stuart W. Hoffman (1994) jointly conclude:

"It has been only within the last ten years that research on treatment for central nervous system (CNS) recovery after injury has become more focused on the complexities involved in promoting recovery from brain injury when the CNS is viewed as an integrated and dynamic system. There have been major advances in research on recovery over the last decade, including new information on the mechanics and genetics of metabolism and chemical activity, including the definition of excitotoxic effects and the discovery that the brain secretes complex proteins, peptides, and hormones that are capable of directly stimulating the repair of damaged neurons or blocking some of the degenerative processes caused by the injury cascade. Many of these agents, plus other nontoxic, naturally occurring substances, are being tested as treatments for brain injury. Further work is needed to determine appropriate combinations of treatments and optimum times of administration with respect to the time course of the CNS disorder. Understanding the mechanisms underlying traumatic brain injury and repair must eventually come from a merging of the findings of neurochemical alterations in the whole brain with data from intensive behavioral testing, which will determine the meaning of these findings. For optimum treatment strategies, we also need testing procedures and definitions used in connection with treatment for brain injury" (p. 17).