Traumatic Brain Injury (TBI) is the third leading cause of death by injury in the United States, with about 550,000 persons hospitalized each year with TBI, and more than 80,000 persons per year developing long-term disability. The majority of persons with TBI are male and less than age 30. Younger age at injury amounts to devastating consequences on social, financial, emotional, and familial development. Since the advancement of earlier in-field care (i.e., “Jaws of life”), and more recent neurosurgical guidelines, people are surviving severe TBI more than ever before. This has implications on rehabilitation of TBI patients given the shear volume of patients and the great variety of problems. The TBI rehabilitation plan begins with establishing the major impairments specific to the injury itself.
General impairments in TBI encompass three main groups: Cognitive, physical, and behavioral. Cognitive deficits are first manifested in problems with communication and comprehension which have profound impact on the rehabilitation plan of care. Typical cognitive issues that affect all aspects of both early and late rehabilitation include memory, concentration, and attention deficits. Diffuse injury, commonly occurring in closed head injuries from acceleration-deceleration mechanism (like a car collision or fall from a high level), classically results in cognitive-related language problems. Cognitive related language problems include difficulty solving problems or learning something new. This is in contrast to the inability to form the words and express oneself (called aphasia). Physical impairments range from arm, legs, and trunk muscular dysfunction to speech and swallowing dysfunction. The behavioral impairments of moderate-to-severe TBI include impulsivity, distractibility, aggression, and agitation as a person with acute TBI recovers.
The patient with moderate-to-severe TBI especially requires a multidisciplinary approach including members of surgery, physiatry (physical medicine and rehabilitation specialists), psychiatry, nursing, physical and occupational therapy (PT, OT), speech and language pathology (SLP), social work, and case management. Due to the enormous complexity of physical, cognitive, and behavioral dysfunctions, in the setting of potential underlying problems such as alcoholism, mental health disorders and / or social challenges, regular communication among trauma team members is paramount to optimizing recovery in both acute care and rehabilitation setting. Admission to the inpatient rehabilitation center is a major step upward with respect to intensity and frequency of rehabilitation; however, it should ideally serve as a continuation of TBI rehabilitation as persons go from “coma to community,” rather than the initiation of rehabilitation.
TBI rehabilitation is incomplete without discussions of prognosis. This is begun in the initial stages of recovery and continues during acute rehabilitation, depending on the individual patient’s course of recovery. Rehabilitation plans with the entire team are carved out on the basis of outcome expectations and goals. All TBI characteristics, including CT and MRI findings, age, Coma scores, other medical problems, and pre-injury psychosocial aspects, play a significant role in realistic predictions of future function.
As with all dramatic functional changes encountered after trauma, family involvement and education cannot be underemphasized as patients proceed through rehabilitation phases. The entire family is “injured” in acute TBI in many complex ways and is modified by premorbid dynamics among members or caregivers. During the continuum of rehabilitation, it is essential that the rehabilitation team direct, educate, and counsel the family. As mentioned, rehabilitation professionals can play a key role as “interventionalists,” guiding patients and families with realistic prognostication, as well as ongoing education as patients recover at various stages during recovery and rehabilitation.
As acute care lengths of stay decreases in the general trauma population, too many TBI survivors are surprisingly not offered specialty TBI rehabilitation units on discharge. For optimal functional recovery, it is imperative that these patients and their families be referred to these specialized units prior to transitioning to skilled nursing facilities and home.
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