Question: My 41 year-old husband is 10 months, post-severe TBI from a first aneurysm. Reportedly, he has reached a plateau and has stopped physical therapy. He was transferred to long-term care three weeks ago. I have argued that he should at the least have a therapist give range of motion exercises. He is receiving occupational therapy and speech therapy twice a week. Since his transfer, he is less lethargic and very responsive. How can I fight to have his physical therapy restored? He currently is taking Amantadine (150 milligrams twice daily for seven months). I read about a drug called Donepezil but cannot find any information on it. I read it is similar to Amantadine. Can you please advise me on this drug? Finally, I was told six months ago that he reached a “plateau.” He now speaks, writes, has incredible strength in both arms, eats regular food and his emotions are coming around—laughing and crying. Isn't this considered progress? I don't know if I am more angry, frustrated or disappointed. I appreciate your time and thank you in advance. I hope you can help me.
Answer: Brain Injury Source, Ask the Doctor
By Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CIME
BK Smithtown, NY
There is much information that you have not provided regarding the type and severity of aneurysm that your husband sustained. Typically, aneurysms are graded based upon whether they are saccular (also referred to as berry aneurysms) or non-saccular. This categorization is further divided into subtypes. It generally is thought that aneurysms-whether present at birth or developing de novo in adulthood-generally continue to grow with age, reaching a "critical size" beyond which hemorrhage becomes increasingly probable. There is some controversy over what "critical size" exactly means, in terms of measurements, but it probably is somewhere between five to 10 millimeters in diameter.
Clinical findings in survivors of aneurysmal rupture vary depending on the origin, location and severity of the hemorrhage. Clinical grading of hemorrhage, specifically, subarachnoid hemorrhage is based on the Hunt & Hess scale (which grades from I to V). Grade I implies that the bleed produces no symptoms or only mild headache. At the other extreme, grade V is defined as deep coma with extensor posturing. Depending upon severity and location, as well as static imaging findings, outcomes may be quite disparate across different individuals with aneurysms and associated rupture.
I certainly have seen people with acquired brain injuries (ABIs) continue to make improvements well beyond 12 months-post injury, although the more traditional recovery projectory more commonly parallels that of stroke recovery. [Author's Note: Your husband did not sustain a TBI.] I always think it is important to make a distinction between neurologic recovery plateau and functional recovery plateau (i.e., people reach a level at which no further neurologic recovery may be evident but continue to make functional improvements due to the fact that they are learning new ways to adapt to their disability, either self taught or through appropriately administered therapy). Without knowing all the medications your husband is taking, it would be remiss of me-both clinically and ethically-to make specific recommendations having not reviewed his chart in detail and/or examined him.
I would note, however, that Amantadine typically is considered to be a dopamine agonist drug, although it probably has a number of other actions neurochemically. Amantadine is a "good" drug overall and relatively simple to use. Occasionally, Amantadine can induce seizures in persons following ABI, who are otherwise at risk for epilepsy, because of the drug's propensity for lowering seizure threshold. As I probably have had about five cases of this over my career, I do not share to cause any "paranoia" about the risk procedures, but simply to inform.
Amantadine can work nicely in individuals who have problems with initiation, as can more traditional psychostimulants such Methylphenidate (Ritalin). Donepezil is a drug currently approved by the FDA only for treatment of Alzheimer's-associated dementia. There are newer drugs on the market such as Rivastigmine-again only FDA approved for Alzheimer's disease- that may offer better clinical results relative to cognitive enhancement in persons with ABI, although their use would be considered "off-label."
If your husband is not being followed by a qualified neurorehabilitationist - either physiatrist or neurologist - I think this would be the first step in assuring that he is receiving appropriate care. Additionally, you may want to make sure you understand the limitations of your current health care policy as it relates to specifics regarding indications for therapy. If you are correct, and I have no reason to doubt that you are, regarding your husband's ongoing progress, then he obviously has not plateaued from a neurological or functional standpoint. There are multiple pharmacologic methods that can be used to address some of the problems that you are noting in your husband, including lethargy and fatigue, as well as, potentially inappropriate emotions. There are certainly also rehabilitative strategies including behavioral therapy to help with some of these issues.
I am sorry that I cannot offer more specifics, as the details of this case are not available to me. Certainly, the emotions you are experiencing of anger, frustration and disappointment all are quite normal for a family member at this age of a loved one's recovery. You did not mention whether you are in counseling but I certainly think this would be helpful. Additionally, making sure that you have contact with local support groups and brain injury advocacy organization might assist you in better understanding your husband's condition and advocating for needed services.
Nathan Zasler, MD, FAAPM&R, FAADEP, CIME, DAAPM
Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM, CIME, is an internationally respected specialist in brain injury care and rehabilitation. Dr. Zasler is medical director of the Concussion Care Centre of Virginia, Ltd. and is involved with several brain injury rehabilitation programs in the Richmond, Virginia area, including Tree of Life, LLC, a living assistance program for persons with ABI. Dr. Zasler has lectured and written extensively on neurologic issues with over 500 lectures and publications, including two edited textbooks. Dr. Zasler is a member of numerous editorial boards and is editor-in-chief of the international scientific publication Neurorehabilitation: An Interdisciplinary Journal. He is active in numerous national and international organizations including serving on the Board of Governors of the International Brain Injury Association (IBIA). He is also grant reviewer for several federal agencies and serves on the Advisory Board for the Department of Head Injury Program. His main areas of interest include low-level neurologic states after brain injury, post-concussive disorders and neuromedical issues in acquired brain injury.