Maximizing Brain Injury Recovery: Integrating Critical Care and Early Rehabilitation.

Maximizing Brain Injury Recovery: Integrating Critical Care and Early Rehabilitation Mackay LE, Chapman PE, Morgan AS. Gaithersburg, MD 20878, Aspen Publishers Inc, 1997, hardcover, 621 pp, illus, $79.

This book is a collaborative effort among the authors--a speech pathologist, a physical therapist, and a physician-with the help of 10 additional contributors. The book provides guidelines for implementing rehabilitation strategies for patients with brain injuries, including when they are treated in critical care settings. The book provides information that serves as a foundation for understanding critical care. It also contains a review of the pathology and pathophysiology of brain injury and many examples of how various team members interact to maximize functional outcome in the acute setting.

The introductory chapter reviews the epidemiology of brain injury, summarizes primary prevention strategies, and provides a concise description of the regional trauma system network in the United States. The chapter includes a discussion of how this network of trauma centers influences outcome. (An appendix summarizes the essential and desirable characteristics of the 4 levels of trauma care.) Also, as part of the introduction, chapter 2 highlights team-focused intervention in critical care.

The next section of the book reviews the neuroanatomy of the brain (cellular level, gross anatomy, and cortical organization), blood supply, the physiology and pathophysiology of brain injury, cranial nerve function and common injuries, and maxillofacial injuries. This review of the basic knowledge of the brain seems out of place with the flow of the rest of the book, because it truly provides basic information that is very familiar to many practicing therapists. However, the summary of common injuries to cranial nerves and maxillofacial injury is a welcome, concise resource that describes the deficits that might be encountered after traumatic brain injury. The chapter also briefly summarizes the treatment options for deficits.

The text reviews medical management in the acute setting in several fashions. It concisely summarizes the use of information from emergency medical... services and from various forms of monitoring technology in the intensive care unit. Precautions for equipment commonly encountered in the intensive care unit are provided in chart format. The text describes the management of associated injuries and complications. A separate chapter outlines metabolic responses to brain injury with specific guidelines for nutritional management. Pharmacologic management is well summarized with a description of the role of neurotransmitters throughout recovery and categorical descriptions of medications that facilitate or retard recovery. Common medical conditions that occur after brain injury (eg, agitation, seizure, autonomic disturbances, spasticity) are then described, accompanied by a brief description of the appropriate pharmacologic agents for each condition. The chapters reviewing medical management are easily understood and provide foundations for further reading.

In keeping with the book's focus on team intervention, a series of chapters summarize the contribution of specific disciplines to critical care and early rehabilitation efforts. Physical therapy, occupational therapy, respiratory management, nutrition, speech and language pathology, and audiology as well as crisis intervention for the family are each addressed in a separate chapter. The physical therapy chapter summarizes this discipline's approach in a stepwise manner from the first observation of the patient through intervention. The focus of treatment is range-of-motion maintenance, positioning, and monitoring of consciousness. Helpful clinical tips are included for optimizing positioning and for reducing abnormal postures. Physical therapist evaluation is described in a traditional format using Ranchos Los Amigos Scale of Cognitive Functioning (RLASCF) levels as a guide. No mention is made of standardized tools that may be appropriate for use by the physical therapist in this setting. Occupational therapy and speech and language pathology chapters follow a similar format, resulting in some redundant summaries of the equipment issues in the intensive care unit, behavioral observation, RLASCF levels, and family interaction. Interestingly, the chapter on occupational therapy was written by the physical therapist author.

The chapters describing respiratory management, nutrition, and audiology provide very specific, detailed information about the specialized contribution that the discipline or area makes to the process. The crisis intervention chapter contains an excellent summary of information that is useful to all disciplines when encountering families in the acute setting. A final chapter discusses secondary prevention, future medical advances in brain injury and possible areas of research, benefits of rehabilitation, and transitions from critical care to other settings. This chapter summarizes the authors' hope that studies of early rehabilitation in critical care will validate the improvement of functional outcomes as a result of early intervention.

This text is an excellent resource for students who are encountering brain injury in the critical care environment for the first time or for a range of practitioners in critical care facilities. The reader gains an appreciation of the role of various disciplines in managing patients with a brain injury who are critically ill. Although the title of the book describes a focus on early rehabilitation, the chapters describing individual disciplines seem to be largely impairment oriented. Length of stay and acuity of medical issues certainly limit the ability to focus on function in this population; however, early rehabilitation efforts need to include functional assessment and functional training to a degree that is feasible.

The organization and flow of the book could be improved, because some chapters appear to be out of sequence. Although the book has an index, it is incomplete. For instance, the RLASCF, mentioned several times throughout the book in very detailed and useful tables, is not listed. The value of a good index to find information about a particular topic cannot be underestimated.

Karen McCulloch, PT, NCS University of North Carolina at Chapel Hill Chapel Hill, NC

Ms McCulloch is Clinical Assistant Professor in the physical therapy program and specializes in intervention for patients with brain injury.