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Traumatic brain injury occurring with spinal cord injury: significance for rehabilitation

Journal of Rehabilitation, April-June, 1993 by Mary Alice Povolny, Steven P. Kaplan

Research indicates that traumatic brain injury (TBI) often occurs with traumatic spinal cord injury (SCI). However, the literature strongly suggests that TBI frequently remains undiagnosed in the presence of an SCI; a situation that may account for some rehabilitation failure and unusual affective stance seen in SCI individuals. Rehabilitation programming with people who incur SCI is intensive, and includes relearning daily living skills (ADLs), and communication and vocational skills; efforts requiring the injured person to adequately attend to and process information. Cognitive and emotional sequelae of TBI can adversely effect learning and skills acquisition and, therefore, must be assessed early in the rehabilitation process. We review literature concerning concomitance of TBI and SCI, and, we present specific instruments to assess the presence of TBI in motorically restricted individuals. Finally, we present factors which complicate the assessment of TBI in the SCI population, and provide implications for rehabilitation assessment and intervention procedures.

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Current trends in comprehensive spinal cord injury (SCI) management are toward early initiation of rehabilitation, often beginning immediately after injury (Woodbury & Redd, 1987). Rehabilitation of people with SCI is an intensive process that includes training in daily living skills, mobility, communication capabilities, and in psychosocial adaption to disability. In addition to the personnel intensity of therapy that is involved in the rehabilitation process, the financial cost of care is staggering. The National Spinal Cord Injury Data Statistical Center Annual Report (1990) cited the initial hospitalization and rehabilitation period (injury to home) for clients admitted to model systems from 1986 through 1990. The mean period for clients with incomplete paraplegia was 76.8 days; 84.4 days were average for persons with complete paraplegia, eighty-eight days were required for clients with incomplete quadriplegia, and 124.4 days were needed for people with complete quadriplegia. The mean total cost in 1990 dollars for the initial hospitalization and rehabilitation periods for clients reported on for 1987 through 1989 was $103,718 (Spinal Cord Injury, 1990).

A traumatic brain injury (TBI) concomitant with SCI can complicate and compromise rehabilitation efforts due in part to the deficits associated with brain injury. Cognitive impairments, including limitations in higher order executive functions, judgment, memory and functional language are common sequelae of TBI (Lezak 1987). Psychosocial effects associated with TBI may include egocentricity, denial, lability, disinhibition, agitation, depression, impulsivity and lethargy; symptoms which often mislabel people as lazy and uncooperative (Fraser, McMahon, & Voganthaler, 1988). Psychoemotional problems from TBI, in connection with the massive difficulties posed by SCI will make rehabilitation efforts even more challenging than usual. Successful rehabilitation is certainly possible when TBI and SCI occur together; if potential problems are properly assessed, identified, and integrated into treatment planning, chances are enhanced for achieving optimal rehabilitation outcomes.

Incidence

Demographics

Striking similarities are evident between the TBI and SCI populations in demographic profile as well as injury circumstances. The incidence of TBI is higher for males than for females (by more than 2:1) with over 50% of the population being between the ages of 15 and 24 (Jennett & Teasdale, 1981). Similarly, over 80% of all reported SCI cases occur to men (Buchanan, 1987) and over half the population is between 15 and 30, with the most common age being 18 years. Both populations most frequently incur injury from motor vehicle accidents (50% in both cases), falls (21% in both cases), and from mishaps occurring during sports activities (Buchanan & Nawoczenski, 1987; NIHF, 1985). The similar demographic and incidence profiles of people with TBI and SCI may indicate a correspondence between the two disabilities, and posits a higher than expected co-occurrence rate of these injuries. In a literature review, Morris, Roth and Davidoff (1986) reported an average 50% concomitance rate of TBI with SCI.

Empirical Research

Several studies have been conducted to determine the frequency of TBI co-occurring with SCI. Researchers have indeed found evidence of the commonplace nature of this phenomenon. Richards, Brown, Hagglund, Bua and Reeder (1988) administered a comprehensive neuropsychologic test battery to 150 persons with SCI shortly after they were injured. Richards et al. (1988) hypothesized that if TBI co-occurs with SCI, retesting at regular intervals would reveal improvement over time as some TBI effects abate. They found significant improvements in neuropsychological function across time in a pattern consistent with recovery from nonsevere brain injuries. According to this study, clinicians should be aware, especially early in the rehabilitation process, that their clients with SCI may also have TBI, and, therefore should be serially tested.

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Traumatic brain injury occurring with spinal cord injury: significance for rehabilitation

Journal of Rehabilitation, April-June, 1993 by Mary Alice Povolny, Steven P. Kaplan

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