Neurorehabilitation Approach for Patients with Large Volume Brain Compromise
A multipronged approach to neurorehabilitation that includes both domain-specific (e.g., attention, memory, executive function) and global strategies (e.g., physical activity and exercise) is strongly recommended for patients with large volume brain compromise to optimize functional recovery and quality of life. 1
Initial Assessment and Planning
Comprehensive Cognitive Assessment
- Use validated assessment tools to determine cognitive rehabilitation needs 1
- Evaluate specific domains:
- Visuo-perceptual function
- Learning abilities
- Awareness/insight into changes
- Attention
- Memory
- Executive function
Functional Assessment
- Evaluate impact on Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) 1:
- Basic ADLs: Bathing, dressing, feeding, toileting, mobility/transfers
- IADLs: Driving, community mobility, shopping, medication management, financial decisions, home safety
Treatment Plan Development
- Engage patients, caregivers, and families in developing a goal-oriented rehabilitation plan 1
- Consider prognosis for recovery/decline and impact of comorbidities (fatigue, pain, depression, anxiety) 1
- Regularly review and adapt the plan as cognitive status changes 1
Rehabilitation Approach by Setting
Acute Phase
- Begin neurorehabilitation as soon as clinical stability is achieved 2
- For patients with cerebellar infarcts or other conditions at risk of deterioration:
Inpatient Rehabilitation
- Recommended for patients with more severe deficits in acute phase 2
- Provide high-intensity therapy: at least 45-60 minutes of each specific needed therapy daily 2
- Implement coordinated multidisciplinary team approach 2
Transition to Outpatient Care
- Transition as soon as clinical situation allows while maintaining treatment intensity 2
- Ensure continuity of care between settings 1
Domain-Specific Interventions
Cognitive Rehabilitation
- Implement both compensatory and remedial approaches 1
- Target specific domains:
- Attention training
- Memory strategies
- Executive function exercises
- Visuo-perceptual training
Physical Rehabilitation
- Physical therapy for:
- Pain management
- Range of motion
- Strengthening
- Functional mobility 1
- Occupational therapy for:
- Activities of daily living
- Adaptive equipment needs 1
Communication Rehabilitation
- Speech-language pathology for:
- Communication deficits
- Swallowing disorders
- Hearing loss management 1
Psychological Support
- Psychological interventions for:
- Anxiety and depression
- Adjustment to disability
- Body image issues
- Behavioral changes 1
- Cognitive behavioral therapy for persistent mood disorders 1
Environmental Modifications
- Modify social and physical environments to optimize function 1
- Embed structure and routine to support cognitive function 1
- Consider assistive technologies to enhance independence 1
Virtual Reality Applications
- Virtual reality can provide:
- Enhanced ecological validity
- Controlled assessment and treatment environments
- Individualized task complexity
- Repeated practice of functional tasks 1
- VR systems should be developed through co-design with patients and therapists 1
Long-term Management
Duration of Treatment
- Base duration on treatment response and potential for further improvement 2
- Provide follow-up services after discharge to maintain benefits and detect complications 2
Addressing Persistent Symptoms
- Implement interdisciplinary coordinated rehabilitation for persistent symptoms 1
- Provide vocational assessment and counseling for those unable to resume previous work duties 1
Family and Caregiver Support
- Educate and train caregivers to enhance engagement and reduce burden 1
- Involve family in rehabilitation planning and implementation 1
Special Considerations
Brain Abscess Patients
- Refer to specialized neurorehabilitation to manage long-term sequelae and help patients regain functional capacity 1
- Be attentive to signs of affective disorders (increased use of anxiolytics and antidepressants) 1
- Provide counseling about returning to work and maintaining family/social relationships 1
Traumatic Brain Injury
- Be aware of typical medical complications:
- Paroxysmal sympathetic hyperactivity
- Post-traumatic hydrocephalus
- Post-traumatic neuroendocrine dysfunctions 4
- Address psychological support needs, which are often underaddressed 5
Monitoring and Outcome Measurement
- Regularly assess progress using standardized outcome measures
- Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available 1
- Adjust treatment based on neuromonitoring data and cerebral autoregulation status 1
The evidence strongly supports a comprehensive, individualized approach to neurorehabilitation for patients with large volume brain compromise. While the quality of evidence varies, the Canadian Stroke Best Practice Recommendations provide strong recommendations for multipronged rehabilitation approaches that address both domain-specific and global strategies 1. Early initiation of rehabilitation, high treatment intensity, and coordinated multidisciplinary care are key principles that should guide treatment planning and implementation.