Brain Surgery Information:

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CHAPTER 20: RECOVERY AND REHABILITATION

General comments on recovery

The road to recovery may be short or it may be a long one. For many, it is successfully traversed. For some, it is not. Others are given no fighting chance from the onset. The recovery period for “elective” treatment in patients with brain conditions is frequently shorter and less complex compared with that for patients undergoing “emergency” treatment.

Brain disorders can take their toll on a patient and his or her family members physically and psychologically. Physically, for a patient undergoing open surgery for a brain condition, there may be wound-related discomfort (Chapter 16) and fatigue. Fatigue, which may be described as feeling “drained” or “generally weak”, can persist for a few months following hospitalization. It will likely resolve with time, but its resolution may be helped by regular napping and by eventually weaning off medications such as those for pain or seizures per the physician’s recommendations. In addition, there may be new physical impairment(s) associated with the condition or its treatment, including problems with balance and coordination, weakness in one or more limbs, difficulty with speech and swallowing, and problems with vision. Many times, such deficits improve with time. They may resolve entirely, or partially. Physical healing may take a few or several months, even a few years, and may need PT. It is possible that a patient with a serious brain condition may permanently require assistance with his or her activities of daily living (ADL), such as dressing, bathing, walking, eating, and so forth. Psychologically, for a patient, there may be problems associated with a depressed mood, emotional or behavioral instability, or slowed or abnormal brain processing referred to as cognitive dysfunction. Cognitive dysfunction may also include impairment of language and memory functions. All of the above may negatively impact on a patient’s sexual functioning and sex drive. These psychological and cognitive problems may take months or a few years to improve and, again, their resolution may be complete or partial.

Family members of severe brain disorder survivors may come across times when they are forced to make very difficult decisions, and deal with circumstances that they may never have imagined before such an event. It is important that they remain strong, persistent, and united through this difficult time. The patient is likely facing a life-altering event, whose recovery frequently requires considerable patience and ongoing love and support, even if the event seems to have changed them physically and/or psychologically. Persons who survive severe brain injury or disease frequently need more help than they were previously used to or more than they may be willing to accept. Such help is critical and should benefit them significantly. It may be in the form of PT, speech therapy, a psychologist or psychiatrist, a home nurse, a temporary stay in a skilled nursing facility, rehabilitation center or a nursing home, more contact and support from family members and friends, more interaction with a priest or church, or an equivalent religious or spiritual person or group. Time and positivity are essential.

Recovery from a brain disorder is influenced by many factors, including the following:

·  Clinical presentation: Perhaps first and foremost is the manner of a brain disorder patient’s presentation. Some patients are neurologically devastated at the time of their presentation to hospital. Others are surprisingly well despite their underlying condition.

·  Experience and resources: Important factors involved in a patient’s recovery are the experience of the physicians and paramedical staff, and the resources of the hospital facility at which the patient is treated. Again, these may not be in a patient’s hands, but when considering elective treatment of a brain disorder, a patient should research the treating doctor or facility’s backgrounds, even by word of mouth and the Internet. For complex brain conditions, having the procedure carried out in a large teaching center is probably in a patient’s best interest. The quality of the hospital’s rehabilitation service is also paramount, because it is that team of doctors and therapists who will optimize recovery once the neurosurgeon has done his or her part.

·  Psyche: Finally, it can hardly be overstated that a patient’s mindset is critical to healing. Part of one’s personal role in recovery means staying focused on healing, being positive, understanding how precious the days and moments of one’s life are, maintaining a healthy and balanced diet, walking and getting as much sunshine as one can, and continuing to meet with family and friends as regularly as possible. Returning to one’s job, whenever possible, is a wonderful milestone to cross.

Will “alternative” therapies help a patient?

Alternative therapies are those that are not “mainstream”, that is, neither surgical nor rehabilitation therapy. Although their definitions are somewhat subjective, today the divide between “mainstream” and “alternative” is narrowing. Alternative therapies include yoga, acupuncture, massage therapy, and hydrotherapy. However, hydrotherapy may be a part of a mainstream PT program. Do they help? Yes, they often help people, including brain disorder patients, in the healing process. Do they help all persons? No, not all, maybe not even most, but they definitely have helped some. Will they help a specific patient? No one can know this till he or she has tried one or more of these. Will they hurt? They are very unlikely to hurt a person in any significant way. One or more of these “alternative” therapies may be of benefit to patients if carried out in a professional and safe way by caring and appropriately trained individuals.

Rehabilitation

Many brain disorder patients will not require formal inpatient or outpatient rehabilitation. However, a significant proportion will. Rehabilitation services are available at most teaching hospitals, usually as part of a Department of PMR. Rehabilitation services represent an umbrella for a multitude of subdisciplines, and the “rehab team” is comprised of several members:

·  Physiatrists: Physicians who have specialized in rehabilitation medicine and who oversee the rehabilitation process for patients admitted to their Service.

·  PTs: Individuals who have special training in activities, both passive and active, that will improve a patient’s coordination, strength and balance. PTs work on specific muscle group movements and exercises, and the patient as a whole. Some also train certain patients in the use of wheel chairs and walkers.

·  Occupational therapists (OTs): Persons who work on activities that are directly relevant to a patient’s ADL, such as bathing, toileting, dressing, navigating around the ward or through rooms in which a home-like environment is simulated, or in and out of a car. Some also train certain patients in the use of wheel chairs and walkers as they apply to navigating in a home environment, and engage patients in games and activities that focus on dexterity and concentration.

·  Speech therapists: Persons who assess an individual’s speech and swallowing function, both at the bedside and in an imaging suite. X-ray techniques are used for the formal assessment of swallowing function, and “dysphagia”, “aspiration”, and “laryngeal penetration” are terms commonly used as markers of swallowing impairment. Speech therapists focus on exercises that are geared towards improving speech and swallowing function which can be impaired particularly by lesions involving the brainstem and lower cranial nerves.

·  Social workers: Individuals who assess the social support networks of a patient and provide information and coordination regarding community support services that may be of direct benefit to certain patients. They assist in finding appropriate placement or disposition for certain patients who are ready to be dismissed from the hospital facility but are not yet ready to transition to a home environment. Placement may in a nursing home or a skilled nursing facility, or an acute rehabilitation facility closer to the patient’s home.

·  Psychologists: Persons trained in addressing the psychological stresses and needs of patients and their significant others. Specifically, they may assist in depression and behavioral counseling, and may provide important recovery strategies for patients with significant memory and cognitive impairment.

·  Rehabilitation nurses: Nursing staff with a special interest in the well being of rehab patients.

·  Rehabilitation admission coordinators: As the title suggests, rehab coordinators act as liaisons between hospital and insurance services and patients in the assessment of suitability for inpatient rehabilitation. Note that many rehab services have specific criteria that must be met for inpatient stay. Such criteria involve determining if a patient is neurologically impaired enough to require inpatient rehab, and if a patient requiring inpatient rehab is awake and interactive enough to meaningfully participate in, for example, a minimum of three hours per day of rehabilitation exercises and activities. Further, the patient’s insurance should allow for inpatient rehabilitation. If the insurer does not permit this, for whatever reason, the request for transfer to the rehab unit can be denied. However, rehabilitation may still be permitted at a unit closer to the patient’s home. Alternatively, special “charitable” funds may be available from the hospital, or the PMR and Neurosurgical Services may negotiate directly with an insurance company through the hospital to see if an appropriate arrangement can be made.

What can a patient expect regarding rehabilitation?

·  “Bedside rehab”: Most patients with severe brain conditions will have bedside rehabilitation. This will typically begin with the assessment of a physiatrist, followed by the direct involvement of PTs, and possibly also OTs and a speech therapist. If a patient is comatose or semi-comatose, rehabilitation services can still be consulted mainly for two reasons: (1) Basic “range of motion” (ROM) exercises, which are commenced early to prevent or minimize loss of muscle bulk and development of joint contractures from disuse; and (2) having a PMR Service on board from an early stage in a critically ill or neurologically impaired patient is helpful for future inpatient rehabilitation planning. It should be noted that some Services may determine that a patient is physically and cognitively sound enough not to require any rehab, but will ask for formal assessment by PTs and OTs to assess the patient from the perspective of personal safety as they transition to home. This is referred to as a “home safety assessment”. For example, can the patient get out of bed to a chair or walk a reasonable distance without falling? Can he or she get into a bath tub, dress independently, navigate around a room steadily, climb stairs, and eat without assistance? These therapists will provide invaluable advice to the patient regarding their home-going needs, including need for bath rails, ankle orthoses, walkers, wheelchairs, and so forth.

·  “Inpatient rehab”: Many brain disorder patients will undergo a period of inpatient rehabilitation. This will most often be at the facility at which they were admitted, but sometimes at a facility closer to their homes, or both. Once the Neurosurgery Service is satisfied that it has carried out everything it can for a patient, for patients who are still significantly neurologically impaired, the consulting PMR Service is requested to take over primary care. Such patients are transferred to the PMR “floor” or “unit” in the hospital. Here, all the team members of the PMR Service can interact with the patient in a closer and more personal manner. In this environment, the patient has direct access to the various rehab programs and resources. The inpatient stay in rehab varies from patient to patient according to their physical, cognitive and psychosocial needs. It is usually a minimum of one week, and may be for several weeks. The exercises and activities involved in the unit include those mentioned above. Dismissal from a rehab facility usually entails a determination that the patient is now strong, mentally sound, and safe enough to transition to the home environment. If not, the patient may be dismissed to another rehab or other type of facility closer to his or her home according to the patient’s needs.

·  “Outpatient rehab”: This is generally for patients who have been through, or are in too good a neurologic condition for, inpatient rehab. Such patients are set up with community PTs, typically closer to their home. Outpatient PT sessions may be as frequent as once daily or as infrequent as once weekly following dismissal. Instructions are usually provided in the dismissal summary or in a specific referral letter from the hospital physiatrist. The duration of outpatient rehab varies from patient to patient. It may be for a few weeks or a few months. The primary doctor should reassess the patient somewhere within 3 months of surgery and at that time make any further recommendations for ongoing PT needs, if any. Many PTs in the community wish to have a written prescription or referral letter or detailed dismissal summary from the primary doctor or hospital Service specifying the duration and type of outpatient PT required.