World Head Injury Awareness Day : 20 March 2010

The KwaZulu-Natal Department of Health is observing the World Head Injury awareness Day on the 20 March 2010

Introduction

According to the annual mid-year estimates from Statistics South Africa (July 2009) the South Africa's population was 49.3 million. The 2001 census estimated disability prevalence in South Africa to be 5% of the total population

An estimate of 89 000 cases of new traumatic brain injuries are reported annually in South Africa.

The Department of Neurosurgery in Durban ,South Africa which was initially based at Wentworth Hospital from 1980 to the end of November 2002 , which is currently based at Inkosi Albert Luthuli Central Hospital as from December 2002, the Department of Neurosurgery has seen from 1983 to 2006 a total admission of 43626 of which 18207 were trauma related .

What is brain injury?

Brain Injury Group (BIG) defines an acquired brain-injury as an acute injury /impairment of normal brain function that causes altered cognitive functioning. The brain injury could open or closed (Traumatic Brain Injury; Neurological -stroke).

What are the causes of Head Injury?

The three most common causes of a head injury are: Motor vehicle, bicycle, or vehicle-pedestrian mishaps (more than 50%); Falls (approximately 25%) and violence (nearly 20%)

What are the risk factors of Head of Injury?

Age: Individuals between the ages of 15 and 40 years as well as individuals at extremes of age, less than 5 years and greater than 75 years
Sex: Head injury occurs twice as often in men as in women.
Other risk factors include: Alcohol and drug Abuse; Wars and violence; Contact and extreme sports; Driving at high speeds and without seatbelts; Driving motor cycles without helmets and construction work

What are the common Complications and Challenges?

Seizures
Some people who have had a traumatic brain injury will experience at least one seizure during the first week after the injury. This doesn't appear to increase their chances of developing epilepsy. However, the chance of epilepsy does increase if there are major structural injuries to the brain.

Infections
Skull fractures or penetrating wounds can tear the membranes (meninges) that surround the brain, letting in bacteria. Infection of these membranes (meningitis) can be especially dangerous because of its potential to spread to the rest of the nervous system.

Nerve damage
Injuries to the base of the skull can damage cranial nerves, which may result in: Paralysis of facial muscles; Damage to the nerves responsible for eye movements, which can cause double vision and damage to the nerves that provide sense of smell.

Post Traumatic Hydrocephalus
Inability of the brain to absorb cerebrospinal fluid resulting in increased amount in the brain causing high pressures.

Cognitive disabilities
Most people who have had a significant brain injury will experience some problems in their cognitive skills, which may include: Thinking, reasoning, problem solving, information processing, memory, speed of mental processing, judgment, attention, multi-tasking.
The most common of these impairments is short-term memory loss. That means the injured person recalls information from before the head trauma, but has to struggle to learn new information after the head trauma.

Language difficulties
Communication problems are common. Some people who have had brain injuries have problems with spoken and written language, while others have problems deciphering nonverbal signals. In some cases, poor cognitive skills may disrupt the ability to succinctly organize thoughts and ideas.

Personality changes
Brain injuries typically interfere with impulse control, so inappropriate behaviour is often present during recovery and rehabilitation. Patients may be more irritable, anxious or depressed. These unstable emotions and impaired social skills may pose the greatest coping challenge for many families.

Sensory problem
Problems involving senses may include: A persistent ringing in the ears; Difficulty recognizing objects; Impaired hand-eye coordination, which can make one appear clumsy; Blind spots or double vision; and a bitter taste or a bad smell.

Post-concussion syndrome
Post-concussion syndrome is a complex disorder in which concussion symptoms such as headaches and dizziness manifest. These symptoms can last for weeks and sometimes months after the impact that caused the concussion.

Psychosocial problems
Emotional problems e.g. depression, insomnia and lack of interest in daily activities and work may be experienced by patients with head injury.

Alzheimer's or Parkinson's disease
A traumatic brain injury appears to increase the risk of eventually developing Alzheimer's disease and, to a lesser degree, Parkinson's disease. The higher the frequency and severity of the injuries, the greater the risk.

Coma and Death
A person who is unconscious and unresponsive is in a coma. A coma may also lead to a vegetative state or death.

How do you prevent Head Injury?

Head injury prevention methods include:

Always wear a seat belt in a motor vehicle
Use an appropriate child safety seat or a booster
Never drive under the influence of alcohol or drugs
Always wear a helmet when on a bicycle, motorcycle, scooter and other open unrestrained vehicles
Wear a helmet when participating in contact sports
Wear a helmet when horseback riding

Fall Prevention Methods:

Use the rails on stairways
Provide adequate lighting, especially on stairs for people with poor vision or who have difficulty walking
Place bars on windows to prevent children from falling
Sit on safe stools
Do not place obstacles in walking pathways

Gun Safety:

Keep guns locked in a cabinet
Store guns unloaded
Store ammunition apart from guns

How do you manage head injury patient at home?

Once the patient has been discharged from the inpatient rehabilitation treatment unit, the outpatient phase of care begins and goals often will shift from assisting the person to achieve independence in basic routines of daily living to assessing and treating broader psychosocial issues associated with long-term adjustment and community re-integration.

Patients will often have problems in the areas of general cognition, social cognition/awareness, behaviour and emotional regulation that present significant challenges, in terms of being able to resume expected social roles. Often these problems are complicated by adjustment issues that emerge as the person becomes more aware of their residual deficits and faces the challenges of coming to terms with the long-term effects of the injury.
Family members may benefit from psychotherapy and social support services. Support for caregivers becomes particularly important during the outpatient phase of care when behavioural and cognitive problems may complicate and impair the relationships that patients have with those around them. Major challenges occur in sustaining these relationships, particular in the context of marriage, when the impact of the injury significantly alters the relationship in such a way that the resumption of an adult-level interactive relationship may be deeply undermined.
Caretakers of traumatically brain injured patients can often feel a great deal of emotional stress, which can reduce the quality of care. Respite care such as supported living and residential holidays, supported days out doing activities like walking, cycling and climbing offers relief for them and a new area of brain stimulation for the patient. When dealing with caretakers, providers of respite care need to be sensitive and reassuring; some caretakers may have feelings of guilt or inadequacy.

What are the support programmes for head injury patient?

Head injury patient will be cared for by a team of professionals who specialize in the care of trauma victims through rehabilitation.

Their goals are to:

Stabilize the medical and rehabilitation issues related to brain injury and the other injuries.
Prevent secondary complications. Complications could include pressure sores, pneumonia and contractures.
Restore lost functional abilities. Functional changes could include limited ability to move, use the bathroom, talk, eat and think.
The staff will also provide adaptive devices or strategies to enhance functional independence.
The staff will begin to analyze with the family and the patient what changes might be required when the person goes home.
Each day, the patient will participate in therapy. Initially, the patient may require staff assistance for even the simplest activities: brushing teeth, getting out of bed and eating. The patient also may require staff for safety because there is a risk of falling, eloping (trying to get out of the hospital to go home) or getting hurt. The patient may be confused and forgetful.

The Rehabilitation Team:

1) The Physiatrist/ Medical Officer: is the team leader in the rehabilitation program. Physiatrists treat a wide range of problems, including the changes after brain injury. The physiatrist will assess and prescribe the treatment and direct the team.

2)The Neuropsychologist: is a key member of the rehabilitation team. The neuropsychologist will assess the patient's changes in thinking and behaviour. Changes could include:

Poor memory
Poor attention and concentration
Poor decision-making
Impulsivity
Disorientation
Language and communication abilities
Inability to speak
Inability to understand when spoken to
Many patients are unaware of the changes in the brain and how those changes affect their daily lives. A patient may not understand what has happened and may be distraught by being away from home. Through education and counselling, the neuropsychologist can help assure the patient and the patient's family.

3)The Rehabilitation Nurse: Assists patients with brain injury and chronic illness in attaining maximum optimal health, and adapting to an altered lifestyle. The Rehabilitation Nurse provides care for the patient in the nursing unit. The focus of nursing care is on:

Health maintenance
Nutrition
Potential for aspiration
Impaired skin integrity
Bowel and bladder incontinence
Impaired physical mobility
Impaired or limited ability to take care of self
Ineffective airway
Sleep pattern disturbance
Chronic pain
Impaired cognition
Impaired verbal communication and comprehension
Sexual dysfunction

4) The Physiotherapist: works with people with orthopaedic problems, such as low back pain, knee injuries or pain reduction. With traumatic brain injury, the Physio's job is to minimize or overcome paralyzing effects related to the brain injury. Physiotherapists are experts in the examination and treatment of musculoskeletal and neuromuscular problems that affect the abilities to move and function in daily life.

Physiotherapists help with transfers to and from the bed when a patient cannot walk alone. They train a person to begin to walk and move more normally. Physios will assess and or treat patients for: balance, posture, strength, need for a wheelchair, brace or cane, quality of movement, spontaneous movement, coordination of movement, increased sensation of sensory-motor activities and pain management

5) The Occupational Therapist (OT): assesses functions and potential complications related to the movement of upper extremities, daily living skills, cognition, vision and perception. OTS helps determine, with the patient, the best ways to perform daily living skills including showering, dressing and personal hygiene. The OT will identify equipment for eating, dressing and bathing.

The OT also will look at skills to prepare the patient for a return to the home. These skills include: activities of daily living including bathing, dressing, cooking, grocery shopping, banking, budgeting and others. OTs also assists a patient with readiness for returning to work by assessing prevocational and vocational skills.

6) Head Injury Support group
Help patient to feel that they are not alone and to share their experiences with others.

7 ) Social Worker
Social workers are skilled in helping families receive the practical help that is needed. They can provide information about benefits, accommodation and transport and information on disability grant if needed. The social worker is also an experienced counsellor, and is there to talk to about emotions and feelings.

8) Speech and Language Therapist
Speech and language therapists aim to help patients communicate more effectively using both the spoken and written word. They may provide structured exercises and activities aimed at improving speech and language skills, or may work with other staff and relatives to improve all-round communication. The speech therapist will also have experience of communication aids.

Conclusion

Head injury is a devastating condition that causes major psychosocial complications and requires a multidisciplinary approach for treatment to be effective.

For more information on head injury, you can contact Dr. Basil Enicker at the Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital tel. 031 240 1133, email basileni@ialch.co.za or the Disability and Rehabilitation Programme on tel. 033 846 7247 or email Daniel.simbeye@kznhealth.gov.za

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