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Driver S, Douglas M, Reynolds M, McShan E, Swank C, Dubiel R. A narrative review of biopsychosocial factors which impact overweight and obesity for individuals with acquired brain injury. Brain Inj 2021; 35:1075-1085. [PMID: 34324396 DOI: 10.1080/02699052.2021.1953596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary Objective: To discuss the biopsychosocial factors that affect being overweight or obese after acquired brain injury (ABI)Research Design: Narrative reviewMethods and Procedures: Based on the biopsychosocial model, we discuss the unique injury-specific factors that can affect bring overweight or obese among individuals with ABI including: (1) biological, (2) psychological and (3) social/ecological factors.Main Outcomes and Results: Injury-specific factors that impact being overweight or obese following ABI include endocrine dysfunction, pain, bowel and bladder incontinence, balance problems and motor impairment, medications, sleep quality and fatigue, alcohol and tobacco use, psychological disorders and symptoms, cognitive changes, social support, isolation, participation, transportation, independence, and knowledge. These factors may also compound general factors impacting weight management, making it difficult for individuals with ABI to maintain a healthy lifestyle.Conclusions: It is important to recognize the biopsychosocial factors that impact weight-loss and lifestyle change after ABI so that interventions can be tailored to meet individuals' unique needs. Empirical research is needed to better understand how biopsychosocial factors interact and impact overweight/ obesity after ABI.
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Affiliation(s)
- Simon Driver
- Physical Medicine and Rehabilitation, Baylor Scott and White Institute for Rehabilitation, Dallas, Texas, United States of America
| | - Megan Douglas
- Rehabilitation Research Department, Baylor Scott and White Research Institute, Dallas, Texas
| | - Megan Reynolds
- Physical Medicine and Rehabilitation, Baylor Scott and White Institute for Rehabilitation, Dallas, Texas, United States of America
| | - Evan McShan
- Physical Medicine and Rehabilitation, Baylor Scott and White Institute for Rehabilitation, Dallas, Texas, United States of America
| | - Chad Swank
- Physical Medicine and Rehabilitation, Baylor Scott and White Institute for Rehabilitation, Dallas, Texas, United States of America
| | - Randi Dubiel
- Physical Medicine and Rehabilitation, Baylor Scott and White Institute for Rehabilitation, Dallas, Texas, United States of America
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Vital signs fluctuations and their relationship with pain in the brain-injured adult critically ill - A repeated-measures descriptive-correlational study. Intensive Crit Care Nurs 2019; 55:102743. [PMID: 31677850 DOI: 10.1016/j.iccn.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the use of vital signs for pain detection in brain-injured patients in the intensive care unit. DESIGN A repeated-measures descriptive-correlational study. SETTING Two neurological intensive care units in Montréal, Canada. A total of 101 brain-injured patients were included. MAIN OUTCOME MEASURES This study examined the fluctuations in systolic and diastolic blood pressure, heart and respiratory rates, and oxygen saturation in brain-injured critically ill patients before, during, and 15 minutes after turning and soft touch using a data collection computer. When possible, patients' pain self-reports were obtained using a 0-10 Faces Pain Thermometer. RESULTS The heart and respiratory rates were higher during turning than soft touch and higher during the procedure compared to prior (p < 0.05), but their fluctuation was modest. The systolic blood pressure increased during both turning and soft touch by 2 mmHg, but was 26.6 mmHg higher for those who reported pain versus no pain (Mann-Whitney = 25.00, p = 0.008, n = 28). A moderate correlation was observed between the systolic blood pressure (Spearman's rho = 0.617, p = 0.004, n = 24) and self-reported pain intensity during turning. No significant effects were observed for diastolic blood pressure and oxygen saturation. CONCLUSION Only increases in systolic blood pressure were positively associated with pain in this sample and replication studies with larger samples is needed.
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Nazari R, Pahlevan Sharif S, Allen KA, Sharif Nia H, Yee BL, Yaghoobzadeh A. Behavioral Pain Indicators in Patients with Traumatic Brain Injury Admitted to an Intensive Care Unit. J Caring Sci 2018; 7:197-203. [PMID: 30607360 PMCID: PMC6311629 DOI: 10.15171/jcs.2018.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 06/12/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction: A consistent approach to pain assessment for patients admitted to intensive care unit (ICU) is a major difficulty for health practitioners due to some patients' inability, to express their pain verbally. This study aimed to assess pain behaviors (PBs) in traumatic brain injury (TBI) patients at different levels of consciousness. Methods: This study used a repeated-measure, within-subject design with 35 patients admitted to an ICU. The data were collected through observations of nociceptive and non-nociceptive procedures, which were recorded through a 47-item behavior-rating checklist. The analyses were performed by SPSS ver.13 software. Results: The most frequently observed PBs during nociceptive procedures were facial expression levator contractions (65.7%), sudden eye openings (34.3%), frowning (31.4%), lip changes (31.4%), clear movement of extremities (57.1%), neck stiffness (42.9%), sighing (31.4%), and moaning (31.4%). The number of PBs exhibited by participants during nociceptive procedures was significantly higher than those observed before and 15 minutes after the procedures. Also, the number of exhibited PBs in patients during nociceptive procedures was significantly greater than that of exhibited PBs during the non-nociceptive procedure. The results showed a significant difference between different levels of consciousness and also between the numbers of exhibited PBs in participants with different levels of traumatic brain injury severity. Conclusion: The present study showed that most of the behaviors that have been observed during painful stimulation in patients with traumatic brain injury included facial expressions, sudden eye opening, frowning, lip changes, clear movements of extremities, neck stiffness, and sighing or moaning.
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Affiliation(s)
- Roghieh Nazari
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran
University of Medical Sciences, Sari, Iran
| | - Saeed Pahlevan Sharif
- Department, Taylor’s Business School, Taylor’s University Malaysia, Subang Jaya,
Malaysia
| | - Kelly A Allen
- Melbourne Graduate School of Education, University of Melbourne, Melbourne,
Australia
| | - Hamid Sharif Nia
- Department of Nursing, Amol Faculty of Nursing and Midwifery, Mazandaran
University of Medical Sciences, Sari, Iran
| | - Bit-Lian Yee
- Department of Nursing, Open University Malaysia, Kuala Lumpur, Malaysia
| | - Ameneh Yaghoobzadeh
- Department of Geriatric Nursing, School of Nursing and Midwifery, Tehran
University of Medical Sciences, Tehran, Iran
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Balba NM, Elliott JE, Weymann KB, Opel RA, Duke JW, Oken BS, Morasco BJ, Heinricher MM, Lim MM. Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder. J Clin Sleep Med 2018; 14:1865-1878. [PMID: 30373686 DOI: 10.5664/jcsm.7482] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Veterans are at an increased risk for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), both of which are associated with sleep disturbances and increased pain. Furthermore, sleep disturbances and pain are reciprocally related such that each can exacerbate the other. Although both TBI and PTSD are independently linked to sleep disturbances and pain, it remains unclear whether Veterans with comorbid TBI+PTSD show worse sleep disturbances and pain compared to those with only TBI or PTSD. We hypothesized that sleep and pain would be worse in Veterans with comorbid TBI+PTSD compared to Veterans with only TBI or PTSD. METHODS Veterans (n = 639) from the VA Portland Health Care System completed overnight polysomnography and self-report questionnaires. Primary outcome variables were self-reported sleep disturbances and current pain intensity. Participants were categorized into four trauma-exposure groups: (1) neither: without TBI or PTSD (n = 383); (2) TBI: only TBI (n = 67); (3) PTSD: only PTSD (n = 126); and (4) TBI+PTSD: TBI and PTSD (n = 63). RESULTS The PTSD and TBI+PTSD groups reported worse sleep compared to the TBI and neither groups. The TBI+PTSD group reported the greatest pain intensity compared to the other groups. CONCLUSIONS These data suggest sleep and pain are worst in Veterans with TBI and PTSD, and that sleep is similarly impaired in Veterans with PTSD despite not having as much pain. Thus, although this is a complex relationship, these data suggest PTSD may be driving sleep disturbances, and the added effect of TBI in the comorbid group may be driving pain in this population.
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Affiliation(s)
- Nadir M Balba
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon
| | - Jonathan E Elliott
- VA Portland Health Care System, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Kris B Weymann
- VA Portland Health Care System, Portland, Oregon.,School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Ryan A Opel
- VA Portland Health Care System, Portland, Oregon
| | - Joseph W Duke
- Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona
| | - Barry S Oken
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health and Sciences University, Portland, Oregon
| | - Mary M Heinricher
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurological Surgery; Oregon Health and Science University, Portland, Oregon
| | - Miranda M Lim
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, Oregon
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Vining RD, Salsbury SA, Cooley WC, Gosselin D, Corber L, Goertz CM. Patients receiving chiropractic care in a neurorehabilitation hospital: a descriptive study. J Multidiscip Healthc 2018; 11:223-231. [PMID: 29760552 PMCID: PMC5937508 DOI: 10.2147/jmdh.s159618] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objectives Individuals rehabilitating from complex neurological injury require a multidisciplinary approach, which typically does not include chiropractic care. This study describes inpatients receiving multidisciplinary rehabilitation including chiropractic care for brain injury, spinal cord injury (SCI), stroke, and other complex neurological conditions. Design Chiropractic services were integrated into Crotched Mountain Specialty Hospital (CMSH) through this project. Patient characteristics and chiropractic care data were collected to describe those receiving care and the interventions during the first 15 months when chiropractic services were available. Setting CMSH, a 62-bed subacute multidisciplinary rehabilitation, skilled nursing facility located in Greenfield, New Hampshire, USA. Results Patient mean (SD) age (n=27) was 42.8 (13) years, ranging from 20 to 64 years. Males (n=18, 67%) and those of white race/ethnicity (n=23, 85%) comprised the majority. Brain injury (n=20) was the most common admitting condition caused by trauma (n=9), hemorrhage (n=7), infarction (n=2), and general anoxia (n=2). Three patients were admitted for cervical SCI, 1 for ankylosing spondylitis, 1 for traumatic polyarthropathy, and 2 for respiratory failure with encephalopathy. Other common comorbid diagnoses potentially complicating the treatment and recovery process included myospasm (n=13), depression (n=11), anxiety (n=10), dysphagia (n=8), substance abuse (n=8), and candidiasis (n=7). Chiropractic procedures employed, by visit (n=641), included manual myofascial therapies (93%), mechanical percussion (83%), manual muscle stretching (75%), and thrust manipulation (65%) to address patients with spinal-related pain (n=15, 54%), joint or regional stiffness (n= 14, 50%), and extremity pain (n=13, 46%). Care often required adapting to participant limitations or conditions. Such adaptations not commonly encountered in outpatient settings where chiropractic care is usually delivered included the need for lift assistance, wheelchair dependence, contractures, impaired speech, quadriplegia/paraplegia, and the presence of feeding tubes and urinary catheters. Conclusion Patients suffered significant functional limitations and comorbidity resulting in modifications to the typical delivery of chiropractic care. Chiropractic services focused on relieving musculoskeletal pain and stiffness.
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Affiliation(s)
- Robert D Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA
| | - Stacie A Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA
| | - W Carl Cooley
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - Lance Corber
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA
| | - Christine M Goertz
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA
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Analytis P, McKay A, Hamilton M, Williams G, Warren N, Ponsford J. Physical activity: perceptions of people with severe traumatic brain injury living in the community. Brain Inj 2017; 32:209-217. [DOI: 10.1080/02699052.2017.1395479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Penelope Analytis
- Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Heathcare, Melbourne, Australia
| | - Adam McKay
- Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Heathcare, Melbourne, Australia
| | - Megan Hamilton
- Physiotherapy Dept., Epworth Healthcare, Melbourne, Australia
| | - Gavin Williams
- Physiotherapy Dept., Epworth Healthcare, Melbourne, Australia
- Physiotherapy Dept., The University of Melbourne, Melbourne, Australia
| | - Narelle Warren
- School of Social Sciences, Monash University, Melbourne, Australia
| | - Jennie Ponsford
- Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Heathcare, Melbourne, Australia
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An exploratory study of the bilateral bispectral index for pain detection in traumatic-brain-injured patients with altered level of consciousness. J Neurosci Nurs 2016; 47:166-77. [PMID: 25943998 DOI: 10.1097/jnn.0000000000000137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Many patients with a traumatic brain injury (TBI) cannot communicate because of altered level of consciousness. Although observation of pain behaviors (e.g., frowning) is recommended for pain assessment in nonverbal populations, they are attenuated and sometimes even suppressed in patients with TBI receiving high doses of sedatives. This study explored the potential utility of the bilateral bispectral index system (BIS) for pain detection in critically ill adults with TBI and altered level of consciousness. METHODS Using a repeated measure within-subject design, participants (N = 25) were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: (a) noninvasive blood pressure (nonnociceptive) and (b) turning (nociceptive). At each assessment, BIS indexes (0-100) of the right (R) and left (L) hemispheres and pain behaviors were documented. RESULTS Compared with baseline, significant median increases (p ≤ .05) in BIS-R (+4.93%) and BIS-L (+8.43%) and in the frequency of pain behaviors (+3.00) were observed during turning but not noninvasive blood pressure. Interestingly, increases in BIS-R were more pronounced in participants with left-sided TBI (+17.23%, p = .021) than those with right-sided TBI (+3.01%). BIS-R fluctuations in participants with left-sided TBI were also positively correlated (r(s) = .986, p ≤ .001) with the frequency of pain behaviors observed during turning. CONCLUSIONS Overall, only increases in BIS-R were correlated with participants' pain behaviors and in those with left-sided TBI exclusively. Although further research is needed, our findings support the potential use of the bilateral BIS for pain detection in nonverbal patients with TBI who cannot behaviorally respond to pain, but only when they have a left-sided injury.
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Hamilton M, Williams G, Bryant A, Clark R, Spelman T. Which factors influence the activity levels of individuals with traumatic brain injury when they are first discharged home from hospital? Brain Inj 2015; 29:1572-80. [DOI: 10.3109/02699052.2015.1075145] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Arbour C, Gélinas C. Behavioral and physiologic indicators of pain in nonverbal patients with a traumatic brain injury: an integrative review. Pain Manag Nurs 2012; 15:506-18. [PMID: 24882028 DOI: 10.1016/j.pmn.2012.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Revised: 02/24/2012] [Accepted: 03/06/2012] [Indexed: 11/16/2022]
Abstract
The use of behavioral and physiologic indicators is recommended for pain assessment in nonverbal patients. Traumatic brain injuries (TBI) can lead to neurologic changes and affect the way patients respond to pain. As such, commonly used indicators of pain may not apply to TBI patients. This study aimed to review the literature about behavioral/physiologic indicators of pain in nonverbal TBI patients. An integrative review method was used. Medline (from 1948 to June 2011), Cinahl, and Cochrane databases were searched using any combination of the terms brain injury, behavioral indicators, behavioral scale, physiologic indicators, pain, pain assessment, and pain measurement. All articles reporting expert opinion or original data about the validity of behavioral and/or physiologic indicators of pain in TBI patients were considered. For each article included, the quality of findings/clinical recommendations was graded independently by two raters using SORT taxonomy. Eight papers were reviewed. Overall, TBI patients seemed to present a wider range of behavioral reactions to pain than other adult populations. In addition to the commonly observed grimace, agitation, and increased muscle tension, 14%-72% of TBI patients showed raising eyebrows, opening eyes, weeping eyes, and absence of muscle tension when exposed to pain. Those atypical reactions appeared to be present only in the acute phase of TBIs recovery. Similarly to other populations, vital signs were identified as potential indicators of pain in TBI patients. Further research studying TBI patients and considering changes in level of consciousness, location/severity of brain injury, and administration of analgesic/sedative is needed. Until then, nurses should follow the current clinical recommendations.
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Affiliation(s)
- Caroline Arbour
- School of Nursing, McGill University, Montreal, Quebec, Canada.
| | - Céline Gélinas
- School of Nursing, McGill University, Montreal, Quebec, Canada
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Le Q, Gélinas C, Arbour C, Rodrigue N. Description of behaviors in nonverbal critically ill patients with a traumatic brain injury when exposed to common procedures in the intensive care unit: a pilot study. Pain Manag Nurs 2012; 14:e251-e261. [PMID: 24315278 DOI: 10.1016/j.pmn.2012.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 02/19/2012] [Indexed: 11/17/2022]
Abstract
Behavioral indicators are strongly recommended for pain assessment in nonverbal patients. Although pain-related behaviors have been studied in critically ill patients, those with a traumatic brain injury (TBI) have been either excluded or underrepresented. Because these patients also likely experience pain, research is urgently needed to generate knowledge in this field. This pilot study aimed to explore pain-related behaviors of critically ill TBI patients when exposed to common procedures in the intensive care unit (ICU), using video recording at the bedside and a newly developed coding system. Ten TBI patients hospitalized in the ICU participated. A 44-item behavioral checklist created from existing tools was used as a coding system to identify behaviors before, during, and 20 minutes after a nociceptive procedure (turning) and a nonnociceptive procedure (noninvasive blood pressure [NIBP]). Patients were video recorded to check for interrater agreement between two trained observers. TBI patients exhibited more behaviors during turning than at rest or during NIBP (p < .001). The following behaviors were observed during turning: levator contraction (n = 7), frowning (n = 5), opening eyes (n = 5), weeping eyes (n = 5), raising eyebrows (n = 5), activating the ventilator alarms (n = 7), and muscle tension (n = 5). No change in behaviors was noted during NIBP. After educational training and using videos, the average percentage of agreement for observed behaviors between two trained research assistants was 96%. Pain in critically ill TBI patients can be detrimental to health and recovery. ICU clinicians should be aware of pain-related behaviors to enable better detection and treatment in this highly vulnerable group.
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Affiliation(s)
- Quynh Le
- School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Céline Gélinas
- School of Nursing, McGill University, Montreal, Quebec, Canada; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Quebec Interuniversity Nursing Intervention Research Group, Montreal, Quebec, Canada.
| | - Caroline Arbour
- School of Nursing, McGill University, Montreal, Quebec, Canada; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Quebec Interuniversity Nursing Intervention Research Group, Montreal, Quebec, Canada
| | - Nathalie Rodrigue
- McGill University Health Centre-Montreal General Hospital, Montreal, Quebec, Canada
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Riechers RG, Ruff RL. Rehabilitation in the patient with mild traumatic brain injury. Continuum (Minneap Minn) 2010; 16:128-49. [PMID: 22810717 DOI: 10.1212/01.con.0000391456.60793.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Traumatic brain injury (TBI) has garnered increased public attention in the past several years because of high-profile athletes with possible long-term effects of their injuries as well as large numbers of returning combat veterans injured by blast explosions. Most of these injuries are mild in nature and require no specific surgical treatment but may benefit from brief rehabilitation interventions. To appropriately rehabilitate patients with mild traumatic brain injury (mTBI), one must fully understand its clinical course and the factors that accelerate or delay recovery. Education is the centerpiece of mTBI treatment and should be included in the rehabilitation plan. When devising the rehabilitation plan, the neurologist should take into account the goals of the patient and establish a reasonable time frame for treatment paralleling the expected recovery course. Cognitive and vestibular functions are commonly affected after mTBI and are particularly responsive to rehabilitation interventions. Vocational rehabilitation and community reentry planning are aspects of the global rehabilitation plan that should not be neglected. Combat-injured veterans with mTBI present unique challenges to the rehabilitation team, and assessment of these patients often needs to include assessment of psychological function.
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