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implementing holistic approach to rehabilitation in brain injury after cardiac arrest

Introduction

Cardiac arrest is a catastrophic event in which heart stops beating, depriving the amount of oxygen needed in body for survival. Despite of modernization in resuscitation techniques more than 90% people suffer mortality or are left with severe neurological impairments. There are more than 356,000 people suffering with cardiac arrest each year from which 90% leads to fatal consequences as stated in a report by American Heart Association. Apart from severe fatal consequences, one of the major concern is prolong lack of oxygen on brain and the damage which it results. The annual rate of acquired brain injury in Canada is 452 people every year. In 2000, guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care has proposed the term “Cardiopulmonary-cerebral resuscitation” to emphasize brain damage in relation to cardiac arrest.

During an event of cardiac arrest, the person experiences unconsciousness within 20 seconds. At this point due to oxygen insufficiency, brain will not be able to function normally to maintain the other organs to work efficiently. This leads to hypoxic-anoxic injury which affects all the areas of brain. When there is cardiac arrest, cardiopulmonary resuscitation must be started within 2 minutes as research studies suggest that brain damage starts occurring immediately after 3 minutes of heart stop beating. By the span of 9 minutes severe and irreversible changes occur in brain and when extended up to 10 minutes or after that, the chances of survival are low. Recent statistics show that 8 out of 10 people are comatose or in vegetative state and sustain greater extent of brain damage. The most likely brain area being affected are cerebral cortex, hippocampi, the cerebellum and basal ganglia.

The injury cascade which begins with hypoxia and reperfusion can continue for hours to days or months after the initial event. Neurological outcomes among the survivors covers a broad spectrum for recovery ranging from complete recovery to vegetative state or neurological death. Patients who suffer mild degree of ischemic changes demonstrate the reversible clinical features where recovery is rapid and complete. On other hand, patient with severe ischemia suffer with structural damage to specific areas of brain as if they had a stroke. This group suffers coma for at least 12 hours and on arousal shows incomplete recovery but in time leads to independent functioning with some existing neurological deficits or severely disabled and dependent in nursing homes. Those who suffer with more widespread destructive and ischemic changes in brain results in coma for several weeks or in vegetative state or die a neurological death.

The increasing number of people surviving cardiac arrest has put a great burden on estimating the neurological prognosis in patients who are initially comatose and the outcome is unclear. Motor and sensory impairments, cognitive issues, emotional problems and fatigue are the most common problems associated among people who survived cardiac arrest. As this injury is heterogeneous in nature it requires a diverse range of rehabilitation from a variety of healthcare providers from different settings during their course of recovery. They may also require continuing care for many years as the functional outcomes may vary in each individual. Thus, the overall goal of rehabilitation following brain injury is to assist the person achieve its highest functional level and restore the level of independency. The rehabilitation for brain injury is constantly emerging with innovative and diverse approaches to treatment. There must be a continuum of services to support the individual throughout the recovery process which includes the inpatient phase, as well as the community phase.

Rehabilitation promotes the body’s natural healing abilities and brain’s relearning activities. It includes many forms like physical, occupational, speech, and psychiatric as well as social support. Many times rehabilitation is determined by the medical examination the individual report during the event. This often leads to the time when patient care is neglected considering the chances of recovery. But despite of all the reports and existing symptoms, there is evidence that intense rehab can give good functional outcomes. Although it is evident that there is always lack in single approach and rehabilitation for such people must follow a holistic approach.

The holistic approach in rehabilitation emphasizes practioners to view the person as whole and focus on all the needs as well as address all the unique needs of an individual. The purpose of this case report is to explore the rehabilitation of an adult who acquired brain injury, post cardiac arrest. Also, meeting all the requirements of body and treating the person as whole with holistic approach.


Client Characteristics

A 23 year old adult was relaxing at her home with her family post-dinner, where suddenly she started having an episode of cardiac arrest. The family called emergency services who revived her and shifted to the hospital. The patient lost consciousness at the moment and remained in the same state for couple of days. Diagnostic imaging confirmed injury to brain with loss of all the body functions. Tracheostomy tube was placed for her breathing. Her Glasgow coma score upon admitted was 0 and she was in coma for 14 days. Also, she presented level I on Rancho Los Amigos scale and severity of brain injury was classified as severe. She regained her consciousness after 14 days and with her Glasgow coma score at 7. There was no command following or any purposeful movement by her which followed by a vegetative state for 18 days. After 18 days, she started with response to commands and self-awareness with GCS at 13.

After a month in ICU, the patient’s Functional Independent Score was 20 and started with her basic in-patient physiotherapy. Her pre-existing conditions included loss of motor and sensory control to all functions for all functions of body, loss of speech, Cognitive impairments and no bladder or bowel control. Due to all her pre-existing conditions and stable medical condition, hospital protocol dictated that she can enter the out-patient rehabilitation center. Upon reaching local rehabilitation centers by her father they refused for her intake seeing poor prognosis of the condition. Despite of all the rejections, she was approved by one rehabilitation center which decided to give a try on her condition.

During the admission at rehabilitation center, she had developed severe tightness in her legs which was released by surgical intervention. The GCS upon her admission was 15 with Functional Independent Measure at 33. Her physical conditions include no independent sitting or transfers with poor trunk control, no standing or walking possible. Due to tracheostomy, speech was lost with mild cognitive impairments. Upon her stay at the rehabilitation center, they started with strengthening exercise for upper-limb and lower-limb, transfer activities, standing and walking activities on walker with 3 person assistance, occupational therapy for hand movements and speech therapy.

Due to sudden strike of pandemic of Novel Coronavirus in March 2020 all the rehabilitation centers were evacuated which brought her back home. At home, the family continued with the basic protocol of strengthening and transfers as directed by the Physiotherapist for 2 months and shifted her to an out-patient clinic which continued with same plan of care. Later after 4 months, she regained her rehabilitation training at the center for 3 months. Her Functional Independent Measure score was improved to 51. But, again due to severe circumstances of pandemic she was brought back to her home.

Since then, she started taking rehabilitation at our out-patient clinic. At that point, she demonstrated signs of increased tone in her muscles of extremities, restrictive chest expansion with use of accessory muscles for breathing, scoliosis at Thoraco-lumbar level, walking with 3 personal assistance, Standing with maximum assistance, no speech, no control to prehension movements of hands, mild cognitive impairments, no eating or drinking by mouth. However, she was a good candidate for a holistic approach to her rehabilitation.

Intervention

The patient was at Rancho Los Amigos level V, therefore the focus of her rehabilitation was to create a program which covers all her needs including physical, social, cognitive and behavioral. The treatment included restoring her functions with gaining maximum independce in her daily activities with evidence-based protocols. Thus, holistic rehabilitation included components of task-specific training, balance re-training, gait re-education, strength training, respiratory therapy, writing and prehension training, dysphagia training, speech therapy, rational acupuncture for her myoclonic seizures and massage therapy to inhibit tone of spastic muscle and elicit contractions of weak muscles, all in context of functional task where possible.

To achieve maximum outcome of treatment, appropriate learning strategies were incorporated based on patients cognitive abilities. Treatment was begun with having a standard routine using distributed practice. As the patient improved in her cognitive and physical functions, treatment progressed to random practice schedules and complex cognitive tasks. Family attendance and their involvement in rehabilitation was also incorporated during the sessions to better achieve the outcomes. Adaptations were done to avoid fatigue in terms of intensity and lowering frequency during treatment sessions.

Treatment occurred 3 days in a week for 60 minutes which progressed to 5 days in a week for 90 minutes. Apart from these, home-exercise program were given on the other 2 days of week. All the exercise are listed below, however, not all were performed in a single treatment session. Each day, session involved selection of these exercises with varied parameters. It was recommended that patient follows this exercise with her family members on other 2 days of week outside of out-patient rehabilitation clinic.

Balance and Mobility

Treatment started with basic sitting posture and progressed to standing. It also progressed to dynamic exercises after the patient tolerated static postures. The following exercises were included to help patient gain balance,

· Hold posture while sitting on edge of bed or chair for developing good trunk control under close supervision.

· Functional task in sitting involving shoulder flexion and abduction to maintain trunk stability.

· Lower limb and pelvis weight shifting for improvement in sitting trunk balance.

· Weight shifting in standing with variable reach outs, focusing on stability of body.

· Marching with assistance for co-ordination.

· Standing balance on different surfaces to maintain stability.

Strength Training

· Active assisted upper-limb strengthening

· Trunk muscle strengthening

· Isolated knee extension strengthening in supine as well as sitting

· Hip musculature strengthening

· Back extensor strengthening in sitting

· Scapular muscle strengthening

Flexibility Training

· All Upper-limb and lower-limb musculature stretching

· Isolated pectoral muscle stretching

· Neck musculature stretching

Mat Exercise

· Rolling Activities to improve co-ordination

· Kneeling Activities

· Pelvic-femoral dissociation activities

· Crawling activities

· Supine to sit activities

· Sit to stand activities

Gait Training

· Walking activities with walker

· Treadmill Training

Breathing Exercises

Fine and motor skill activities

Writing Activities

Dysphagia Training

· Oral musculature stretching

· Chewing activities

· Pharyngeal muscle strengthening

· Swallowing activities

Acupuncture for myoclonic seizures

Massage therapy for inhibiting spastic muscle and activating weaker muscles

Outcome

4 months rehabilitation in out-patient clinic

There was significant change in Functional independence measure (FIM) score which was 51 and improved to 64. The components of FIM which should drastic improvement were self-care, transfers and locomotion. The Rancho los amigos level improved to level VII which shows that she requires minimal assistance in her activities of daily living than before. Remarkable changes were also observed in physical functions after 4 weeks of holistic rehabilitation which are mentioned below;

· She is now able to perform sit to stand activity independently under supervision.

· Improved weight bearing on both the lower-limbs while doing standing or walking activity.

· Walking with walker is possible independently under supervision with proper weight shifting on verbal cues.

· Increased trunk stability in kneeling activity and able to do transitions on her own.

· Treadmill walking is possible independently with no assistance under supervision at minimal speed.

· Perform her activities of daily living on her own like brushing, grooming, clothing, toileting and bathing on her own with minimal assistance.

· She is able to perform eating and drinking activities independently under supervision.

· Improved writing skills with proper gripping.

· Communication is improved with better speech and pronunciation. However, there is still difficulty with some pronunciations and needs correction.

· Cognitive and memory status is significantly improved.




Discussion

This case report incorporated a holistic approach for rehabilitation to improve functional status of her which was not only limited to physiotherapy treatment. It also involved therapies from different settings like rationale acupuncture, massage, cognitive and behavioral therapy and also the family involvement which enhanced the results. Based on her outcomes holistic approach showed great benefits. Although there are many evidences which suggest that a patient must be treated as a whole rather than just focusing on any individual aspect but its practical implementation is unusual. The possible barriers to this could be due to lack of knowledge or time which should be investigated.

Furthermore, reliance on diagnostic images and results should not be considered an important aspect while planning rehabilitation for such patients. There are many times when the prognosis is poor with severe damage, the patient does not receive the appropriate plan for rehabilitation and results in medical negligence. Similarly with this case, even though not been approved by some rehabilitation centers showed remarkable changes in her functional outcomes. Also, the incorporation of family during rehab plays a vital role. It give encouragement and positive feedback to the patient which in turn leads to good results.

In summary, although the patient showed improvements in general terms, there are some gaps in outcome of certain rehabilitation interventions like rationale acupuncture and massage therapy which should be studied.


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