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The Continuum of Rehabilitation for Persons with Traumatic Brain Injury

By Brian Im, MD
WebMD Feature from “Exceptional Parent” Magazine

According to the Centers for Disease Control and Prevention, a traumatic brain injury (TBI) occurs when an impact to the head results in disruption of brain functioning. While post-TBI physical impairments can hinder functional independence, the behavioral, cognitive, emotional, psychosocial, and personality changes associated with TBI frequently lead to even greater problems. Comprehensive evaluation and treatment are the foundation to optimizing outcome after TBI, as the complex functions affected, in interaction with the cultural, social, and personality backgrounds of each individual, demonstrate the need for unique approaches to intervention.

Traumatic brain injuries are categorized along a continuum of severity: severe, moderate, and mild injury—with the majority of injuries falling into the mild range. Although there are multiple factors and different grading systems used to classify these injuries, most use similar criteria. Many times, individuals with more severe injuries have more severe deficits, more residual long-term impairments, and a longer recovery course. Those with milder TBIs may have subtle problems that are never properly diagnosed. These categorizations are usually made early on in the course of injury and do not always correlate with the speed or extent of recovery from a TBI.

The continuum of rehabilitation for persons with traumatic brain injury is broadly segmented into three stages that follow the initial acute medical intervention. These three stages are: Inpatient, Community Integration, and Lifetime of Care. Although they reflect a general progression in rehabilitation, a person with traumatic brain injury does not necessarily proceed through these stages in exact order. Each person’s rehabilitation process is unique to his or her circumstances.

Initial Intervention

Typically, individuals identified as having experienced a TBI are seen in an emergency department and, along with a clinical exam, may undergo immediate neuro-radiological examination such as head computerized tomographic (CT) scan or magnetic resonance imaging (MRI), to assess signs of brain trauma (bleeding within the skull or brain known as intracranial hemorrhaging, increased pressure on the brain, or bruising of the brain known as contusions). Individuals with identified brain pathology are typically admitted to the hospital intensive care unit for close observation and needed medical interventions. If the pressure on the brain becomes severe enough, surgical intervention to relieve this pressure becomes necessary. In less severe cases, the patient may be treated with medications to prevent medical complications associated with brain trauma and monitored.

There can also be lack of conclusive physical evidence of the injury on standard imaging such as CT and MRI scans, especially in mild TBI, since microscopic damage after TBI is often not visible on standard neuroradiological assessment tools. In mild TBI, physical symptoms may also resolve quickly or never develop despite cognitive and behavioral problems existing, thus the need for comprehensive evaluation including clinical history, neurologic and mental status exam, and neuropsychological testing. However, these assessment tools are rarely utilized in the emergency or acute care setting, and the person with mild TBI is often not diagnosed and sent home. Even in the scenario of severe TBI, the life threatening medical issues (such as the hemorrhaging or increased pressure on the brain mentioned above) and/or trauma to other areas of the body, may minimize or obscure diagnosis and treatment of non-physical aspects of TBI. Although efforts are being made to inform physicians and the public of the spectrum of TBI symptoms, more awareness is still needed since it is impossible to appropriately treat TBI if the TBI is not recognized.

 

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