Traumatic brain injury (TBI) results in complex physical, behavioural, and cognitive changes. There is evidence that interprofessional care, early and timely rehabilitation services, and goal-oriented rehabilitation within an integrated and continuous care pathway can improve outcomes. The person with TBI should be involved in their rehabilitation plan, as there is evidence that high-level engagement in goal setting by the person with TBI results in a greater number of goals being maintained at follow-up (two months).
Due to the complexity and chronicity of TBI, an interprofessional team and an integrated care pathway are essential. Furthermore, case coordination at each phase of the continuum of care is necessary to ensure that the person’s goals are met, adequate communication between professionals occurs, and the transition back to the community is facilitated.
Challenging behaviours, including addictive behaviours, may become a significant problem post TBI. It is thus necessary to ensure rehabilitation professionals are adequately trained in managing challenging behaviours and people with complex issues such as substance use disorders. Concurrent treatment and co-treatment models should be considered for persons with complex issues who require specialized treatment in multiple domains to optimize gains and promote successful transition from rehabilitation into the community.
Healthcare organizations should ensure mechanisms and protocols are in place to facilitate the transition between acute care and rehabilitation. Referral to rehabilitation from acute care should occur quickly to improve outcomes post traumatic brain injury (TBI). Adherence to integrated care pathways requires early engagement from an interprofessional team, as well as persons with lived experience and their caregivers, to ensure a reasonable and comprehensive approach. An example of an evidence-based system-level clinical pathway for persons after moderate to severe TBI can be found on the Neurotrauma Care Pathways website.
Interprofessional rehabilitation teams require sufficient staffing to provide daily therapy, perform case coordination tasks, allow for the management of comorbid conditions and brain injury sequalae, and ensure service quality. Additional resources are necessary to provide culturally sensitive and person-centred care. Data collection mechanisms should be in place to evaluate the characteristics of populations served and the effectiveness of rehabilitation services. The inpatient rehabilitation environment requires adequate tools to facilitate recovery, minimize falls, decrease boredom, allow for cognitive stimulation, and improve safety monitoring, particularly for persons with behavioural issues and agitation (e.g., wander bracelets for patients, secured access doors that limit exit for confused patients while allowing others to move in and out as their status improves).
Mechanisms for collaboration with mental health/substance use services or training for rehabilitation professionals should also be in place.
The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially.
Clinical Tools:
Patient and Family Resources:
Other Resources:
To be Developed Locally:
Due to the unique challenges and complexity of cognitive behavioural changes associated with traumatic brain injury (TBI), it is suggested that all rehabilitation programs should include the same key components. Components include interprofessional care and early and timely specialized rehabilitation services, standardized protocol for managing challenging/addictive behaviours and cross-training healthcare providers, as well as providing goal-oriented rehabilitation within an integrated and continuous care pathway.
The Neurotrauma Care Pathway Project developed an evidence-based ideal care pathway for moderate-severe TBI outlining a person’s transition through each care system e.g. pre-acute, acute care, rehabilitation, and community services. The development process involved extensive consultation with key partners, including persons with lived experience, and thorough review of current research evidence (e.g., Evidence-Based Review of Moderate to Severe ABI (ERABI) and this Guideline) to identify essential building blocks of care across the lifelong pathway of care. See here for the moderate-severe TBI care pathway model.
Collaborations Across Interprofessional Team
It is apparent that effective rehabilitation service requires an interprofessional team, which includes nursing care, physician monitoring, psychologist and social work intervention, physiotherapists, occupational therapists, and speech language pathologists, among other things (Cifu et al., 2003). Semlyen et al. (1998) compared two distinct TBI inpatient rehabilitation strategies. One group of patients received a coordinated, interprofessional regional rehabilitation service, and another received a local, single discipline approach. The interprofessional rehabilitation group made significant gains up to 6 months according to the functional independence measure, and up to 24 months according to the Barthel Index and Newcastle Independence Assessment Form, whereas the single discipline approach group made significant gains only up to 12 weeks post injury. The authors did note that the interprofessional approach site had more access to resources so this may have confounded the findings. Coordination of the interprofessional team should include selecting a cohesive patient-focused model of rehabilitation. Functionally based streamed models of rehabilitation should be considered based on the specific functional deficits of the person with TBI, for example neurocognitive versus neurophysical (Cullen, 2013). Additionally, it is suggested the interprofessional team should ensure that all symptom management is linked to functionally based outcome measures, such that the effectiveness of interventions may be determined (Gerber et al., 2021).
See ERABI Module 3 for additional information on interprofessional rehabilitation teams.
Early and Timely Rehab
No matter the composition of the rehabilitation team, it has long been identified that early onset of therapeutic interventions for those who have sustained a TBI is beneficial. Several studies have shown that introducing a rehabilitation program during the acute phase assists in the overall recovery of individuals with a TBI (Heinemann AW, 1990). A review by Cope (1995) concluded that those who receive early intervention do in fact have better outcomes than those who do not, specifically inpatient rehabilitation initiated within 35 days post injury is associated with improved patient outcomes (Cope & Hall 1982). Further, León-Carrión et al. (2013) reported that patients who received neurorehabilitation earlier demonstrated better global functioning at discharge than patients who began treatment at a later point. Lastly, length of stay was also positively impacted, with those admitted sooner requiring fewer days in rehabilitation (Kunik et al., 2006; Wagner et al., 2003). It is however important to note that inpatient rehabilitation is still found to be beneficial more than 12 months post-injury, thus rehabilitation should still be considered at later injury stages (Tuel et al., 1992).
See ERABI Module 3 for additional information on timely access to rehabilitation.
Goal-Oriented Rehab
Once a patient is admitted rehabilitation should be goal oriented. When examining involvement in goal setting in neurorehabilitation, Webb and Glueckauf (1994) found that patients who had greater involvement in goal-setting maintained their improvements at study follow-up; contrarily, those with low involvement in their goal setting showed a decline in the number of goals attained. Additionally, many studies have examined the effects of goal training or cognitive training (Boman et al., 2004; Chen et al., 2011{Novakovic-Agopian, 2011 #26; Laatsch et al., 1999; Novakovic-Agopian et al., 2011; Sohlberg et al., 2000). Levine et al. (2000) completed an RCT comparing patients using goal management training strategies to a control group exposed to only motor skills training. The treatment group improved on paper and pencil everyday tasks as well as meal preparation, which the authors used as an example of a task heavily reliant on self-regulation. Novakovic-Agonian et al. (2011), found similar results in an RCT crossover where participants were assigned to receive goal-training followed by education or the reverse. The goal training first group saw a significant improvement in sustained attention compared to the education-first group, additionally the goal training first group maintained their gains over 10 weeks.
See ERABI module 13 for more evidence on group goal management training.
Several studies have specifically evaluated the effects of group goal management training. An RCT published in 2011 demonstrated that goal management training is beneficial for executive functions (Chen et al., 2011). In this study, both groups significantly improved in attention-directed goal completion, showing similar results to Novakovic-Agonian et al. (2011). Another RCT evaluated group goal attainment interventions compared to educational interventions (Ownsworth et al., 2008). This study found that all individuals who received goal attainment interventions significantly improved over time on measures of executive functioning, regardless of group assignment at 3-month follow-up based on self-ratings, and relative’s ratings (Ownsworth et al., 2008).
Lastly, assistive technologies may be helpful for improving goal completion post-TBI. Gracey et al. (2017) found in an RCT that reminder text messages sent through the patient’s smart phone, whether alone or in combination with goal management training, improves goal completion.
See ERABI Module 3 and ERABI module 13 for additional information on goal-oriented rehabilitation.
Integrated and Continuous Pathway
Generally, after a TBI, patients follow a typical trajectory or pathway of care: pre-hospital care, acute care – which may include an Emergency Department visit, neurosurgical intervention and/or Intensive Care Unit (ICU) management as necessary, inpatient rehabilitation, and then they are discharged to the community with varying levels of support (Khan et al., 2002). Across settings, this pathway may include cognitive and behavioural rehabilitation programs, community living opportunities, rehabilitation services in the home, care management, and prevention initiatives (Zygun et al., 2005). Transitions between sectors are the most problematic areas in the continuum therefore it is crucial that continuity and accessibility of services is maintained to allow patients the greatest opportunities for rehabilitation and recovery post TBI. Regional differences in resource availability need to be taken into consideration, along with patient demographics, so that the correct pathway decisions can be made.
See here for injury specific care pathway models.
Overall, there is significant heterogeneity in the care received by individuals with TBI and the direct comparison of different health systems is difficult. No matter what health care system is assessed, budgetary concerns play a role in the accessibility of care. As a result, difficult decisions need to be made regarding resource allocation. Despite financial concerns, Khan et al. (2002) provide encouraging news regarding decreases in LOS and fiscal savings brought on by an integrated TBI system in Canada. The authors state that care needs to be taken to ensure that savings do not arise from sacrifices in quality of care but rather from the improvement of systematic inefficiencies. Moreover, Andelic et al. (2014) report that a continuous chain of treatment and interventions worked out to be more cost-effective than the ‘broken chain’ format of rehabilitation with patients receiving inconsistent interventions. Thus, patients transitioning smoothly through the continuum of care not only benefit in terms of functional and cognitive gains, but approximately $6,075.5 USD per patient was saved (Andelic et al., 2014). Finally, Harradine et al. (2004) note that co-ordination of regional facilities resulted in an equal availability of resources despite geographic challenges in New South Wales, Australia.
Challenging Behaviours
Challenging behaviours, including addictive behaviours, may become a significant problem post-TBI. It is necessary to ensure rehabilitation professionals are adequately trained in managing challenging behaviours.
Challenging behaviour following TBI occurs with a relatively high frequency (25-50%), which often includes anger, agitation, aggression, and non-adherence to treatment. The emergence of these behaviours likely arises from injury to the frontal lobes, which results in disinhibited behaviour and a lack of recognition for the consequences of one’s own actions (Kim, 2002). Individuals found to have poor social functioning often engage in a variety of aggressive or agitated behaviours including refusing participation, hitting, kicking, throwing objects, verbal abuse, and self-harm (McNett et al., 2012; Rao et al., 2009). Typically, behavioural management techniques and pharmacological interventions are used to alleviate these challenges with varying degrees of success.
Following acquired brain injury (TBI), individuals may suffer from mood disorders such as major depression and various anxiety disorders. These mental health issues are associated with worsening of other TBI sequela and poorer outcomes (Bedard et al., 2003; Berthier et al., 2001; Jorge, 2005). Among 361 individuals with severe TBI, Silver et al. (2001) found that the most prevalent issues were major substance abuse or dependence (34%) and depression (11.1%); these findings are similar to previous reports by other researchers (Deb et al., 1999; Hibbard et al., 1998; van Reekum et al., 1996). Thus, in order to ensure there is continuity in patient care and to provide optimal management of individuals with TBI, collaboration with appropriate services should be made (e.g., mental health services, addiction/substance use services, etc.).
See ERABI Module 8 for more evidence on mental health post-TBI; specifics on depression and addiction can be found in section 8.5 and section 8.1, respectively.
In terms of addictive behaviours (alcohol, narcotics use and/or gambling) TBI, various studies have looked at the incidence of these behaviours and have found that 30 to 60% of individuals who sustain a TBI have a substance use disorder (Jorge & Starkstein, 2005). Rates of pre-injury substance abuse in those who have sustained a TBI are high. Substance use disorders and TBI are most common in young males and substance intoxication is a leading contributor to accident-related injury (Kraus et al., 1989; Ponsford et al., 2018). Studies differ in the criteria used to determine if an individual has an issue with addiction, dependence, or abuse. Studies that only include subjects with a positive Blood Alcohol Concentration (BAC) at the time of admission will report an inflated incidence compared to patient-reported substance use disorders. Additionally, prevalence rates are variable between populations. Rates of pre-injury alcohol abuse in Australian and North American populations have been recorded at 20-40%, whereas rates in Finland are reported at 8%, which likely reflects cultural differences in alcohol consumption (Alway et al., 2016; Gould et al., 2011; Hibbard et al., 1998; Koponen et al., 2002). Studies suggest that alcohol and substance use decline within the first year of injury (Bombardier et al., 2003; Jorge, 2005; Kelly et al., 1997; Ponsford et al., 2007), but those who returned to drinking two years post-injury are likely to consume more than before the injury (Bombardier et al., 2002; Ponsford et al., 2007). In fact, individuals who abused alcohol pre-injury were ten times more likely to demonstrate problematic alcohol use post injury (Bombardier et al., 2003). Moreover, the correlation between mood disorders and substance abuse has also been shown to be quite strong both before and after injury (Jorge, 2005).
Specialized and Cross-Training of Healthcare Professionals
Cross training community program staff and health care professionals is an important element of managing complex TBI patients. Training should be specialized to TBI to ensure adequate recognition and understanding of TBI and the associated symptoms. Becker et al. (1993), completed a nationwide survey of program directors from acute, subacute, or post-acute programs finding that over three-fourths of the programs currently use paraprofessional staff (e.g., OT Asst, PT Asst), with subacute programs reporting the most use of paraprofessionals. Most respondents endorsed specialized TBI training for professionals and even more so for paraprofessional staff. Many were willing to pay staff to engage in training curriculum content. Areas of importance were treatment of cognitive deficits, behaviour modification techniques, and family and psychosocial issues. In a single-blind randomized trial, ten paid carers were randomly selected from a post-acute residential rehabilitation program and allocated to either a training or control group. Training comprised a 17-hour program (across 8 weeks) with conversational interactions (i.e. structured and casual) between paid carers and people with TBI videotaped pre-training, post-training and at 6-month follow-up: Trained paid carers were more able to acknowledge and reveal the competence of people with TBI. Conversations were perceived as more appropriate, interesting and rewarding compared to the control group. Improvements were confined to the structured conversation and were maintained for 6 months (Behn et al., 2012).
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Every individual with a moderate or severe traumatic brain injury (TBI) who experiences brain injury related impairments/functional changes (physical and/or psychological functioning) should receive timely specialized interprofessional rehabilitation services.
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NOTE: Post-traumatic amnesia/confusion is not a contraindication to initiating rehabilitation (Trevena-Peters et al., 2018).
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To facilitate a person's transition from acute care to a rehabilitation setting, integrated care pathways, referral criteria, and transition protocols should be in place. This will assist in the management of commonly encountered problems associated with traumatic brain injury, such as timely access to services, access to specialist services, health systems data transfer, follow-up etc.
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Rehabilitation programs should have clearly stated admission criteria, which include medically documented TBI with symptoms and impairments appropriate for rehabilitation, medical stability, and ongoing improvement since the initial diagnosis.
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The assessment and planning of rehabilitation should be undertaken through a coordinated, interprofessional team and follow a patient-focused approach responding to the needs and choices of the person with TBI as they evolve over time, and/or as they are determined by the family/caretaker of the person with TBI where the person is determined incompetent.
See Section G. Capacity and Consent on how to determine competency.
NOTE: Functionally based streamed models of rehabilitation should be considered based on the specific functional deficits of the person with TBI ex. neurocognitive vs. neurophysical (Cullen et al., 2013)
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The traumatic brain injury rehabilitation team should optimally consist of a speech-language pathologist, occupational therapist, physiotherapist/kinesiologist, audiologist, social worker, neuropsychologist (and psychometrist where applicable), psychologist (with expertise in behaviour therapy), nurse, physiatrist/specialist in physical medicine and rehabilitation, rehabilitation support personnel, recreational therapist, registered dietician/nutritionist, optometrist, pharmacist and others based on cultural considerations.
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Persons with TBI who require rehabilitation should have case coordination at each phase of the continuum of care. Case coordination may be completed by a single appointed individual or multiple members of the interprofessional rehabilitation team who have clinical experience and specialized training in a TBI-related field.
NOTE: The roles of case coordination include:
NOTE: The absence of a case coordinator should not delay the start of services and support.
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The inpatient rehabilitation environment should be conducive to the person with TBI and their recovery. Strategies should be in place to promote recovery, maintain safety, and allow for privacy. Strategies should include the use of single rooms (where available), a quiet environment, familiar routines, areas for activity to reduce boredom, equipment to reduce falls, and safety monitoring systems.
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The rehabilitation plan should be goal-oriented. Early in the course of rehabilitation, there should be a high degree of involvement from the person with TBI, their family/caregivers, and the rehabilitation team members in goal setting so that goal-monitoring can occur throughout the rehabilitation program. Goals should be revised as needed throughout rehabilitation.
NOTE: Goal Management Training for persons with TBI may be an essential aspect of ensuring the good function of a goal-oriented rehabilitation plan. Reminder text messages sent to patients have also shown to improve goal completion (Gracey et al., 2017).
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Throughout the course of rehabilitation, the person with TBI should be encouraged and supported to safely engage in activities on their own, allowing them to capitalize on the skills and strategies provided during formal rehabilitation sessions. This includes, but is not limited to, tasks of therapeutic value targeting deficits through meaningful activities that can be carried into the community when the person with TBI has been discharged from formal rehabilitation.
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In order to support the continuous quality improvement of their services, inpatient and community-based TBI rehabilitation programs should monitor the population they serve by collecting and analyzing data pertaining to their clinical and socio-demographic profile. These should include but are not limited to:
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In order to support the continuous quality improvement of their services, TBI rehabilitation programs should monitor key performance and outcome indicators including but not limited to:
NOTE: Outcome indicators should be informed by validated/standardized measures for use within the TBI population.
NOTE: Symptom management should be linked to functionally based outcome measures (Gerber et al., 2021).
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Rehabilitation services and programs should establish collaboration with mental health services and programs in order to develop optimal coping strategies for persons living with comorbid traumatic brain injury (TBI) and mental health related challenges and/or official mental illness diagnoses.
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The collaborative approaches should involve cross-training and education for professionals of mental health care services and other community organizations and agencies involved in the care of persons with TBI on the recognition and understanding of TBI and the associated symptoms.
See Section F for more information on Brain Injury Education and Awareness.
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Rehabilitation services and programs should establish collaboration with addiction/substance use services and programs in order to develop optimal management strategies for persons with comorbid TBI and addiction/substance use.
Mechanisms to ensure continuity between the services should be established. This may include having professionals with expertise in addiction/SUD participate as members of the interprofessional rehabilitation team.
For more information see Section S. Substance Use Disorders.
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The collaborative approaches should involve cross-training and education for professionals of addiction/ substance use services on the recognition and understanding of TBI and the associated symptoms.
See Section F for more information on Brain Injury Education and Awareness.
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Rehabilitation professionals working with persons with TBI should be trained in behavioural and affective disorders, and evidence-based interventions specific to TBI in order to apply consistent neurobehavioural change strategies.
For more information see Section R. Neurobehavior and Mental Health
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