The Continuum of Rehabilitation for Persons with Traumatic Brain Injury
Lifetime of Care: Community Integrated Rehabilitation continued...
CIR is also referred to as post-acute brain injury rehabilitation and generally includes a number of approaches that allow for individuals with TBI to benefit from further rehabilitation after medical stability is established and initial acute (in-hospital) rehabilitation is completed. Specific models of CIR include neurobehavioral programs, residential programs, comprehensive holistic (day treatment) programs and more recently, home-based programs. Neurobehavioral CIR programs have historically focused on treatment of mood, behavior and executive function, while ensuring supervision and safety in a residential, non-hospital setting. Such programs focus on psychosocial outcomes with emphasis on application of behavioral principles and development of functional skills. Neurobehavioral CIR programs typically have treatment teams, utilize direct support personnel as therapeutic extenders, and are often led by neuropsychologists or behavior analysts. Residential CIR programs were initially developed for individuals who required extended comprehensive TBI rehabilitation, but needed 24-hour supervision or did not have access to adequate outpatient/day services. The home-like environment and staff support served to facilitate development of skills needed to negotiate everyday life, easing generalization across community environments. Comprehensive holistic day treatment CIR programs provide a milieu-oriented, multimodal approach with a neuropsychological focus. Interventions target awareness, cognitive functions, social skills and vocational preparation through individual, group and family-involved interventions delivered by a treatment team. Home-based CIR involves a highly variable degree of services and supports for the individual with TBI able to reside in a home environment. Typically, such individuals do not require 24-hour supports or supervision. Home-based CIR may include the spectrum of outpatient services commonly accessed through individual treatment providers or clinics, or minimal professional supports. There is usually no identified ‘treatment team’, although collaboration across a number of health and social service systems may be evident. Behavioral approaches using self-monitoring and cueing are employed, as well as models wherein family members or in-home paraprofessionals are engaged as therapeutic change agents. Additionally, Home-based CIR involves participant education and the growing use of adaptive equipment, telephonic or web-based support, and technological devices. These devices will be the topic of a future article.
There are also instances where individuals experience a TBI but do not require inpatient rehabilitation or even an inpatient acute care stay. Most of these individuals are considered to have had a mild TBI and are good candidates for CIR. Mild TBI has been called the “invisible injury” since the majority of individuals present without noticeable physical deficits or obvious cognitive and behavioral issues at first glance. However, upon closer examination, they may have difficulty across cognitive, behavioral, and emotional domains of functioning. Balance deficits and symptoms such as loss of the sense of smell, headaches, nausea, and dizziness may also be seen. Fatigue, mood change and trouble concentrating are common. Often these individuals are able to function independently in the community with minimal support from family or friends, but struggle to resume their former roles as related to work and relationships. Sometimes, cognitive and physical symptoms only emerge after the person with a mild TBI has attempted to return to these former life activities and roles. In many cases, it takes rejection or failure with these former relationships and roles for the person to seek treatment. However, due to the subtlety of their deficits and problems, those with mild TBI may never seek help, struggle to find the right type of help and/or not be able to secure insurance or other funding to cover their specific rehabilitation needs.