From our Physiotherapy Unit we work on the prevention, cure and palliation of various musculoskeletal disorders of the nervous and respiratory system caused by various injuries, in order to achieve the highest degree of functional capacity and possible independence for the patient.

We have professionals specializing in neurological physiotherapy, as well as respiratory and orthopaedic physiotherapy. These use the Bobath Concept, the Perfetti Method and tools such as dry needling and Kinesio Taping for neurological disorders, as well as the different techniques for respiratory physiotherapy in order to improve respiratory function; and manual therapy and electrotherapy techniques for musculoskeletal injuries.

ROLE OF THE PSYCHIATRIST IN NEUROREHABILITATION

The patient with a brain injury presents syndromes that combine cognitive disorders (memory, language, reasoning, attention, etc.) with emotional and behavioural disorders. In fact, it is very rare that they only suffer from motor impairment (inability to walk, paralysis, etc.). Our obligation is to describe in detail these changes in the assessment of patients. That is why the information provided by their families and people who know them well is essential since on occasions certain changes could go unnoticed in a medical interview. On the other hand, in order to understand the cognitive situation we have with the invaluable help of the assessment of the neuropsychologist. And for the diagnosis and treatment of these disorders we have the presence of the psychiatrist. But not a consultant psychiatrist that examines the patient on only one occasion and where if considered appropriate, a treatment treatment is indicated, what we have is a “bedside” psychiatrist.  This person is with the patient day-to-day, which is essential to understanding the patient and their progress. Another function of the psychiatrist can be the modular, the interaction of the interdisciplinary team with families. People can feel support and harmony from simple active, empathetic listening.

People with brain damage may have changes in mood and emotional lability, with a tendency to cry or laugh for no apparent reason. Quite often depression can occur, which should be treated pharmacologically, because otherwise it may stall the overall progression of the patient. In fact, if there is no improvement in a patient, without the justification of organic cause or elapsed time, the presence of depression should be suspected. Disinhibition, lack of self-control or “slow-down” is also frequent, which can lead patients to say anything that they think, without considering whether it is appropriate or not, or to an action, without anticipating the consequences of what they are doing, with impulse prevailing over respect for social standards. Anger, irritability, or even aggressiveness may occur. But also the opposite is the case, with the occurrence of apathy. On other occasions, a degree of impatience, immaturity, puerility or egocentric behaviours may dominate, with the patient, in general, lacking empathy. They want something and they want it immediately, with no capacity to wait. The way of being of the person concerned, their personality, can change after brain damage. This may result in exacerbation and exaggeration from the previous characteristics of the patient, in their way of being, even to the point of radical or extreme change that makes the familiar say things such as “I have a stranger at home”, “I don’t recognize him”.

In many cases, psychopharmacology can be useful to treat certain impairments that may arise. For example, it may be helpful in insomnia, emotional lability or depression. In fact, a high percentage of patients benefit from the psychopharmacological treatments. The specialist psychiatrist in brain damage will know the medications that can cause iatrogenic complications in patients suffering from brain damage and which, therefore, should not be used. The specialist psychiatrist will also indicate, if considered appropriate, and once the family and patient have been informed, whether to use certain techniques such as Transcranial Magnetic Stimulation.

Psychiatry tries to understand the psychological suffering of the individual, and how it spreads to the family, therefore the interrelationship between them and the brain damage is necessary and unavoidable.

Therefore, upon admission the psychiatrist will perform a psychopathological examination on the patient and will undertake a psychopathological interview with the family. Hence, extract enough data to be able to relay the situation and mode of action to the team. On occasions, an indication of physical containment will be necessary (due to not being aware of disease and the existence of risk to one’s person or third parties, aggressiveness, etc.). To have a real understanding of the cognitive and affective-behavioural situation, it is essential, in addition to the data provided by neuropsychology, to observe the patient outside of the office, the way they act and interact with different people in everyday situations and in different spaces. Their condition is transferred to the team during clinical sessions, and depending on these sessions, and in accordance with the therapists, the objectives are planned and treatment is indicated, where considered appropriate.

Throughout the time that the patient is undergoing neurorehabilitation therapy they will be reviewed daily. A sketch is made of their mental state and behaviour, their oscillations or changes, and in line with this the appropriate action is taken. According to their progress, the objectives to be achieved are jointly re-established with the rest of the interdisciplinary team. The family is essential in this process and they continue to provide information on these matters.

When it gets close to hospital discharge, a report will be drafted in which the cognitive-behavioural and emotional situation will be outlined, as well as the improvements achieved and current status, along with drug treatment, if required, all of which will be reported to the family.

The figure of the social worker in the field of health and brain damage is relatively new. It came about due to the latent needs of patients; not only to rehabilitate the psychological or motor aspect but also the social aspect.

The first moments of brain damage for the family are very difficult to manage, because they prioritize the state of the patient over what will happen next, the social worker dedicated to Acquired Brain Injury deals with the subacute phase in which the patient and the family are highly involved in rehabilitation. Rehabilitation of all damaged aspects in which all professionals are involved in a multidisciplinary manner in coordination to achieve substantial improvement.

The figure of the social worker focuses on:

Initial phase:

–          Reception of cases to assess the family social structure, the support that the patient receives and the financial resources available to them.

–          Advice on the resources and support that they can manage (Law on dependency, disability, work incapacity, etc.).

During treatment:

–          Link between families and medical staff and professionals from the clinic to achieve better communication and understanding between them.

–          Advice on technical aids necessary for each patient based on economic resources.

–          Find resources upon discharge and perform coordination with social services in the area, and social work of the referral hospital.

–          Attention to families, guiding and helping them to face the new social situation.

Upon hospital discharge:

–         Support for families at the return-home phase,

–          Prevent over-burdening the family, accompanying them in solving social problems generated during the recovery process.

–          Advice on normalization and rehabilitation of the daily life of the family nucleus.

PETITION TO INTERVENE

Initially, the intervention by the Neuropsychologist may be requested for the purpose of evaluation, assessment and diagnosis of higher psychological functions and affective-behavioural condition, in order to understand the problem with the patient, as well as its cause and implications.

More specifically, the purpose of the assessment may be aimed at the detection and localization of brain lesions, in cases such as low-severity brain disorders, the beginning of degenerative processes, minimal brain dysfunction, etc.

The differential diagnosis may also be an objective of neuropsychological assessment, i.e. discriminating whether changes that the patient presents have an organic base, or conversely are functional, such as the differential diagnosis of depression/dementia.

Moreover, the evaluation process can be directed towards the study and detection of simulation in the judicial proceedings, in which there may doubt over the veracity of the disorder and/or exaggeration of possible symptoms.

In the same judiciary scope, the valuation may go to the completion of forensic neuropsychological appraisals, whose purpose is to objectify and determine, with the highest degree of accuracy, possible difficulties and their implications for the life of the person. That is to say, the consequences associated with neurological disorders, in their bio-psycho-social and labour dimension, are measured.

Regarding the work sphere, the assessment of psychological functions after brain injury is performed in order to consider possible reintegration into the workplace.

Furthermore, with regard to the child population, the study may be directed to more specific issues such as the progress of mental retardation and assessment of special educational needs.

WHAT DOES THE NEUROPSYCHOLOGIST EVALUATE AND ASSESS?

Basically we can divide the field of study of the neuropsychologist into two: higher psychological functions and the effects, emotions and behaviour.

Higher psychological functions are those cognitive abilities that allow us to face, effectively and efficiently, the demands of everyday life to which we are exposed through people throughout our lives, and thus we can distinguish the following:

–       Orientation: this covers 4 dimensions. Personal, in which the most essential and close information to the person is sought (name, age, date of birth, marital status, etc.). Temporal, in which the time parameters are valued (day of the week, day of the month, month and year). Spacial, the degree of knowledge that the person has on your location is looked at (place where they are located, city, etc.). Situational, explores the degree of knowledge that the person has about their present situation (what’s happened, where, and why is the person in the hospital, etc.).

–       Attention: This is the basic mechanism underlying all cognitive processes that enables the person to focus on any proposed activity, without losing the its progress, allowing them to be kept immersed for a period in a given activity (studying, driving, reading a book, watching television, following a conversation, performing a routine domestic or household task, etc.).

–       Hemi-spacial neglect: This is the difficulty to address and respond to stimuli within a hemispacial and hemibody area, contralateral to the lesion.

–       The speed of information processing and execution: The speed with which our brain processes information and can issue a response. Any activity that we carry out requires an adequate speed in order to function effectively. After a brain injury, the brain slows down, needing more time to perform any activity (talking, answering, thinking, writing, etc.).

–       Language: This is the faculty that allows us to communicate with each other, and can be considered as an expressive or comprehensive mode, by allowing us to understand the messages conveyed and in turn allowing us to issue our own messages. That is, it is the basis of personal relationships and social communication. Also, language is a tool for intellectual activity (thinking, memorizing, representing reality, etc.) and for the organization and regulation of mental processes (planning, scheduling, etc.). Language can be impaired in different ways, each forming a characteristic syndrome (aphasia).

–       Reading and writing are special forms of comprehensive and expressive language.  Therefore, people with language impairment (aphasia) will have difficulty expressing or understanding written instructions and messages. We can also assess changes in reading and writing independently and without language impairment (dyslexia and agraphia).

–       Arithmetic skill is the ability to identify and understand numeric values and perform arithmetic operations (money management, accounts and problems.). This can also be affected as part of language disorders, but impairments may also occur independently (acalculia).

–       Memory is one of the most important fields of neuropsychological investigation. The type of problem will vary depending on the brain structures affected. Some people have generalized impairments, others more specific to retaining verbal information (names, text, etc.), as well as impairments in retaining visual information (images, video, physical spaces, etc.), other examples include problems with immediate information (repeating a phone number), or the ability to retain the temporal order of events, etc. Memory is largely what makes us different as people. “We are what our memory is”, from the moment we are born we accumulate experiences and memories, and when they disappear through injury, we erase all of our personal history. Difficulties can be rendered visible in daily life, presenting problems in retaining information managed by the person, directly or indirectly, (what he has done the previous day, who he has called on the phone, conversations, movies, reading newspapers and books, and can even lead to repetition due to having forgotten that the subject has already been mentioned, etc.), as well as prospective memory (what to do tomorrow, what to buy, what food do I have to make today, etc.). Similarly, memory problems may lead to the inability to recognize familiar faces and people (you can mistake the wife and children for strangers), or the immediate area in which we live (become disoriented and lost in a familiar place).

–       Executive functions are evaluated rigorously in neuropsychological investigation, constituting the cognitive capacities involved in the initiation, planning, programming, controlling and regulation of all cognitive processes and behaviour. Allow the proper handling of the information that we receive, which allows us to understand and efficiently integrate with the demands of daily life, acting in a planned and programmed manner, anticipating the consequences of our behaviour (preparing food, household activities, shopping, etc.).

–       The superior visual functions will be needed to handle all the information, in visual form, that we see daily; we distinguish between the following three groups:

–       Visuoperceptual functions:

o    Problems in visual analysis and synthesis (discriminating the differences between similar images, inferring an image from an element).

o    Problems in recognizing objects and pictures (visual agnosia), where the patient does not know what a particular and known object or drawing is.

o    Difficulties in facial recognition (the patient does not recognize faces, even those with whom they are closest).

–       Visuospacial functions:

o    Problems locating a given point in space and tracking it with the eye.

o    Problems appreciating the distance from a given a point in space.

o    Difficulty recognizing the same image or object in a different position.

o    Problems or topographical orientation (people becoming spatially disoriented and may even become lost).

o    Hemi-spacial visual neglect (difficulty responding to stimulation from one side of a spacial area, either the right or the left).

–       Visuoconstructive functions:

o   Problems assembling or joining (doing puzzles, building figures with parts, etc.).

o    Problems copying or drawing.

–       The motor functions are explored through the study of motor skills, handedness, left/right orientation, motor coordination and performing movements and gestures (praxis) with hands (complex) and the mouth and face (orofacial).

–       Perception and reproduction of rhythmic structures consists of the imitation and production of sequences and rhythms, the impairment of which is closely related to disorders such as dyslexia or aphasia.

–       Examination of higher cutaneous and kinesthetic functions is necessary for studying skin, muscle and joint sensations. These are of great importance in examining the brain areas that receive such information, valuing also touch, discrimination and tactile sensitivity.

–       IQ or Intellectual Quotient (IQ), is a means of intelligence scales, by which we can obtain the general intellectual performance of the individual, as a global measure of cognitive functionality.

From an emotional-behavioural point of view, the following problems are treated:

– Apathy, indifference and demotivation.

– Lack of initiative and not completing activities.

– Impulsiveness.

– Lack of awareness of disease and deficits (anosognosia).

– Confabulation (memory gaps that the patient fills with fantasy and that have a behavioural impact).

– Irritability and aggressiveness.

– Inappropriate sexual conduct.

– Disinhibition.

– Depersonalization (feeling of being separated from one’s body and mental processes).

– Derealization (feeling that one’s surroundings are not real and are strange, like a dream).

– Childish and immature attitude.

– Egocentrism.

– Emotional lability (rapid mood changes).

– Difficulty with emotional expression (aprosodia).

– Difficulty controlling and regulating behaviour.

– Deficits in social skills.

– Suspiciousness or paranoid ideation.

– Changes in thought content (delusions, overvalued, obsessive).

– Changes in the course of thought (concretism, stiffness, prolix thought, tirelessness).

– Perceptual changes (hallucinations).

– Mood disorders.

From the psychopathological point of view disorders that may or may not be associated with brain injury are measured:

– Anxiety disorders.

▪ Specific phobias.

▪ Social phobia.

▪ Agoraphobia.

▪ Panic disorder.

▪ Obsessive compulsive disorders.

▪ Post traumatic stress disorder.

▪ Generalized anxiety.

– Sexual dysfunctions.

▪ Hypoactive sexual desire.

▪ Sexual aversion disorder.

▪ Erection disorder in men and arousal disorder in women.

▪ Ejaculation disorder.

▪ Female orgasmic disorder.

▪ Problems and couple therapy.

– Somatoform disorders.

▪ Hypochondria.

▪ Body dysmorphic disorder.

– Mood disorder.

▪ Depression.

▪ Bipolar disorders.

– Factitious disorder (intentional production or feigning of symptoms).

– Personality disorders.

Specifically assessed in the child population:

– Encephalopathy and cerebral palsy.

– Disorders of cognitive function.

▪ Learning disabilities (reading, writing and arithmetic).

▪ Mental deficiency.

– Language disorder.

– Disorders of communication and social interaction.

– Motor conduct disorder.

▪ Laterality problems.

▪ Dysgraphia.

▪ Dyspraxia.

▪ Psychomotor instability.

– Behavioural disorders.

▪ Oppositional, defiant, hostile and aggressive behaviour.

▪ Phobias and fears.

▪ Obsessive behaviours and rituals.

▪ Hysterical behaviour.

▪ Attention deficit disorder with hyperactivity.

– Affective disorders.

▪ Depression.

▪ Anguish and anxiety.

– Bladder/bowel control problems.

RETURNING THE INFORMATION:

Once the assessment has been completed, it is necessary to relay the results by means of two procedures:

–       Making a written report.

–       Verbal information to the family and/or the patient.

SETTING GOALS AND THE DEVELOPMENT OF THE INTERVENTION PROGRAMME

Subsequently, the general objectives are established, and the specific initial targets and intervention programme are drafted:

–       Psychological and neuropsychological objectives.

–       Specific cognitive objectives to be developed during Occupational Therapy.

INTERVENTION 

The next step is intervention, rehabilitation and carrying out the appropriate neuropsychological and psychological treatments, using the wide range of psychotherapeutic techniques and procedures available to adults, adolescents and children.

Establishment of guidelines for the management of the patient by the hospital staff and by the family (behaviour modification programmes, as well as programmes to address aggressiveness, severe memory problems, etc.).

FOLLOW-UP

–          Monitoring of cognitive behavioural progress during the therapeutic process.

–          Restructuring of the initial objectives.

–          Drafting of clinical reports on a quarterly basis.

–          Provision of periodic information to the family.

–          Coordination and supervision of occupational therapy.

DISCHARGE

Drafting of clinical reports on treated patients upon discharge, which reflects, in detail, what the psychological or neuropsychological situation is at the point of discharge, as well as establishing certain guidelines.

The main objective of the neurologist is to optimize the medical, neurological and behavioural state of the patient.

When the patient is admitted, the neurologist is responsible for initially assess the patient, their background and current situation:

1. Initial assessment of the patient: Through the neurological examination the site of the injury can be determined in order to help direct the most appropriate treatment.  It also identifies the physical , neurological, cognitive and behavioural defects that impair the functional recovery of the patient as well as their ability to perform specific tasks.
2. Personal history: The neurologist must know the diseases prior to admission, i.e., medical comorbidities that must be treated. Specifically, hypertension, dyslipidemia, diabetes and heart problems.
3. Assessment of the current situation of the patient with the aim of preventing complications arising as a result of medication, previous diseases and the brain damage. For example, seizures infections (respiratory and urinary), dehydration, fainting, etc.

On admission the pharmacological treatment is monitored and controlled, both neurological and medical. If necessary, diagnostic tests that help in the diagnosis  (analytical, neuroimaging and neurophysiological) or the opinion of a second specialist are sought when associated pathologies so require.

Each week, the neurorehabilitation team meets in a clinical session to discuss the neurorehabilitation objectives of each patient and the progress and obstacles to achieving these goals (for example: pain, depression, spasticity, extrapyramidal effects, cardiovascular instability or breathing).

At the time of hospital discharge, the neurologist assesses the patient’s medical progress and neurological sequelae in order to issue a medical report together with the neurorehabilitation team.