Rehabilitation to support community reintegration for individuals following traumatic brain injury (TBI) should be a coordinated process, including supports addressing a diverse range of needs, often for extended periods of time. Timely access to specialized outpatient or community-based rehabilitation has shown to be beneficial. It has also been shown that gains can be made over longer periods of time, highlighting the value of rehabilitation at later stages of recovery, involving re-entry into inpatient rehabilitation from the community, or re-accessing outpatient services.
Several factors are associated with poor community reintegration, and efforts should be taken to mitigate these. Approaches to promote reintegration and participation can reduce isolation, provide opportunities to develop and practice new skills, and optimize the individual’s performance in tasks of daily living. Daily living tasks have more benefit when practiced in realistic/naturalistic environments, which also allows appropriate environmental supports to be prescribed. Leisure activities should be facilitated through identifying what is meaningful and productive for the individual. Participation in these activities should be reassessed at follow-up appointments as leisure education programs may be required. Additionally, at home follow-up for patients with TBI has proven benefits.
Increased independence can be facilitated by a return to driving, though, professional assessment and retraining is required to confirm the person with TBI’s ability to safely operate a vehicle. Additionally, assessment and case coordination are important facilitators for vocational/educational rehabilitation.
For an individual with moderate to severe traumatic brain injury (TBI), reintegration into the community is not a linear process. System planners and clinical leads should recognize that support and specialized services may be required long-term to ensure continued progress and gains as well as maintenance to independence.
Follow-up with the person with TBI and their family/caregivers, in the form of appointments or telephone interviews, should be completed by the referring inpatient program to ensure continuity of services. The primary care and community care providers should also be involved in providing and ensuring follow-up appointments.
Outpatient and community-based programs should plan for a new client’s entry into their service in a timely manner through coordination with the inpatient program and/or the primary care provider of the person with TBI. Outpatient programs require sufficient staffing to ensure that compensatory skills can be practised in a realistic and meaningful environment for the individual with TBI, as well as allow for adequate assessment and management of reintegration to all desired life roles. Rehabilitation programs should build a partnership with peer support/mentoring organizations within the community (e.g., local brain injury association) and should educate the person with TBI and their family/caregivers on the community supports available to them. Outpatient programs should put in place mechanisms that allow individuals to re-access services during periods of life transition that demand new skills to be developed. This may include re-accessing acute care, specialist care, and/or inpatient rehabilitation.
Rehabilitation teams should establish referral mechanisms to appropriate physicians to enable assessments for driving capacity and facilitate return to driving if feasible. Vocational/educational rehabilitation should be offered to individuals with TBI who require support and training to assist their return to work, school, and/or volunteering, or for entering the workforce for those not previously employed.
Indicators examples
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 Resource:
Community Rehabilitation
Reintegration into usual roles in the community is the ultimate goal of traumatic brain injury (TBI) rehabilitation. Community reintegration post TBI is multifaceted and can therefore be a challenging hurdle to overcome for both patients and their caregivers. The transition back into the community from acute care or post-acute rehabilitation requires diverse support, often for extended periods of time. Rehabilitation interventions primarily focus on restoring independence
There are several different approaches to community rehabilitation. Three studies used a variety of approaches with the Community Integration Questionnaire as an outcome measure and found that transitional living compared to community-based rehabilitation, attending a brain injury drop in centre compared to not attending, and community-based intensive life skill training, improved outcomes (social integration and productivity subscales) on the questionnaire (Hopman et al., 2012; McLean et al., 2012; Wheeler et al., 2007). Occupational therapy and early-onset continuous rehabilitation were also found to improve independent living skills and ADLs in individuals with TBI (Dawson et al., 2013; Lippert-Gruner et al., 2002; Trombly et al., 1998).
In terms of outpatient and community care, there are several similarities to inpatient rehabilitation. An interprofessional approach is favourable for outpatient services, and timely rehabilitation is imperative as patients are often sent home too early and referred to outpatient services too late (Jeyaraj et al., 2013; Poncet et al., 2018).
A number of studies have assessed the effectiveness of different types of outpatient rehabilitation programs. Ponsford et al. (2006) compared outpatients treated in the community to those who returned to the hospital for outpatient care. The findings indicate that patients who received hospital-based outpatient care were significantly less dependent on support from close others, more independent in mobility, displayed fewer inappropriate social behaviours, and had less difficulty with motor speech and following conversations than those receiving community-based rehabilitation. No significant differences were shown in terms of employment outcomes. Additionally, Cusick et al. (2003) evaluated whether services provided through Colorado’s Medicaid Program improved psychosocial outcomes and reported that individuals receiving outpatient services had significantly reduced mental health problems compared to those who did not. However, there were no significant differences between groups in terms of satisfaction with life.
Jeyaraj et al. (2013) noted that there is thus a need to train clinicians who provide community services about how best to assist individuals with acquired brain injury (TBI) and increase the amount of community resources. In terms of services, it is important to highlight the findings of Turner et al. (2009) that showed stress and depression significantly increased over time after rehabilitation. Although the focus is often on functional status, it is crucial that the psychological wellbeing of individuals with brain injury is remembered during this transitional phase.
See ERABI module 13 for more evidence on community rehabilitation post ABI.
Post-Discharge Follow Up and Support
At home follow-up for patients with traumatic brain injury (TBI) has proven benefits. Bell et al. (2005) found that scheduled telephone counselling and education was beneficial in comparison to usual outpatient care. Those who received the intervention were significantly better, at 1-year follow up, in terms of functional status and quality of well-being. However, these findings were not replicated in a later study (Bell et al., 2011). Matching individuals with community participants or mentors has been shown to be a simple yet effective strategy in improving perceived levels of social support (Hibbard et al., 2002; Johnson & Davis, 1998; Struchen et al., 2011).
The facilitators and barriers to successful peer-support should be noted; knowledge awareness and communication of mentor/mentee role, logistics of participating, readiness and motivation of the person with TBI to participate, a need for clear expectations, and matching mentee and mentor, all affect the success of peer support (Lau et al., 2021).
See ERABI module 13 for more evidence on the effectiveness of peer mentorship in improving TBI outcomes.
Rehabilitation to Enhance Daily Living skills
As suggested in the following cohort studies, daily living tasks show improvements when practiced in a realistic setting. Lamontagne et al. (2013) reported that individuals living in a structured institutionalized setting experienced greater difficulty, with social role-related life habits being performed more easily by patients living in group homes or with foster families. Similar findings were reported by Sloan et al. (2012) in that patients living in a disability-specific setting required higher levels of support than those in home-like settings. The authors argue that due to time-constraints, caregivers may provide more assistance than is needed, thus reducing the patients’ autonomy and independence.
Patients should have adequate environmental supports and compensatory training within their home environment to appropriately rehabilitate daily living tasks.
See ERABI module 18 for more information on environmental supports.
Leisure and Recreation Rehab
Brain injury negatively affects participation in leisure activities (Fleming et al., 2011; Wise et al., 2010). Therapeutic recreational activities and leisure education can improve participation. Mitchell et al. (2014) studied 12 adults with brain injury admitted to a week-long residential leisure intervention program called “Pushing the Boundaries” to trial leisure intervention through groups. The program included leisure awareness, leisure resources, social interaction skills and leisure activity skills finding improvements in leisure satisfaction, self-esteem and QOL following the program. Carbonneau et al. (2011) found similar results in a smaller leisure education program trial.
Activity participation should be continuously reassessed following TBI, especially after disruptions to the person’s habits and routines have been observed. Additionally, the intensity of such programs should not be so high that it interferes with a patient's ability to perform day-to-day responsibilities (Goverover et al., 2022).
Driving
Losing the ability to drive is one of the most challenging consequences of an TBI, since the ability (or inability) to drive is often seen as a key determinant of an individual’s level of social engagement and general independence (Lane & Benoit, 2011). Individuals with a TBI often return to driving in an effort to feel independent, even if they are not fit to do so (Leon-Carrion et al., 2005; Liddle et al., 2011, 2012). One study found 30.5% of the patients were driving despite not being fit to do so (Leon-Carrion et al., 2005). Driving a motor vehicle requires good function across multiple domains which may have been affected by the injury, including perception, cognition, communication, and coordination. In particular, driving depends on functional vision, rapid reliable responses, attentiveness despite distractions, and quick decision making. Individuals with an TBI may have difficulty driving due to deficits in monitoring simultaneous inputs (Formisano et al., 2005; Masson et al., 2013; Ortoleva et al., 2012) and anticipating dangerous situations (van Zomeren et al., 1987). Adjusting to post-injury abilities can also be an issue among returning drivers, as some individuals are less likely to modify their driving style and behaviour following TBI, particularly younger male drivers (Labbe et al., 2014). All of these factors contribute to the increased likelihood that individuals with an TBI will be involved in more accidents than the general population (Bivona et al., 2012; Formisano et al., 2005), reinforcing the need for effective driver rehabilitation therapies. It is thus imperative that thorough evaluations are conducted prior to the return to driving.
Vocational/Educational Rehab
Vocational success has significant implications for life satisfaction following TBI. Decreased life satisfaction has been associated with unemployment as well as passive and uninvolved lifestyles (Melamed et al., 1992). Brain injury can deprive individuals from participating in gainful and challenging employment and achieving social and financial stability. Both depression and anxiety are more common among individuals who are unable to return to work or who cannot find work post TBI (McCrimmon & Oddy, 2006; Ponsford & Spitz, 2015).
Vocational reintegration can be facilitated through the case coordination model whereby the patient collaborates with a case coordinator who assesses the services needed and makes appropriate referrals on the patient’s behalf (Martelli et al., 2012). This is further discussed by Thomas and Menz (1996) who suggest the process should involve an assessment of functional skills, knowledge of pre-injury skills, as well as a vocational plan, with continual access to resources (Stergiou-Kita et al., 2011).
Radford et al. (2013) evaluated a TBI specialist vocational rehabilitation (VR) intervention in those with TBI requiring > 48 hours acute hospitalization in a non-randomized trial. The primary outcome was return to work at follow-up by postal questionnaire at 3-, 6- and 12-months post-hospital discharge. At 12 months, 15% more TBI-VR participants (27% more with moderate/severe TBI) were working than Usual Care (27/36, 75% vs. 27/45, 60%). Mean TBI-VR health costs per person (consultant, GP, therapy, medication) were only £75 greater at 1 year. People with moderate/severe TBI benefitted most. This positive trend was achieved without greatly increasing health costs, suggesting cost-effectiveness. There is a need for definitive Randomized Controlled Trials (RCT) in this group.
General inpatient or outpatient rehabilitation programs may also be effective for improving employment outcomes. In a recent study by Perumparaichallai et al. (2020), 89% of participants reported engaging in competitive employment, structured volunteer work, or education at up to 30 years after receiving milieu-oriented neurorehabilitation with programs in inpatient and community settings. Trexler et al. (2016) reported that access to a multidisciplinary team led to an increase in employment and independence compared to standard outpatient care. In addition, Walker et al. (2006) found that 39% of individuals were employed at 1-year post injury following inpatient rehabilitation. Though there is less research on general multidisciplinary rehabilitation programs, it seems that they also have a positive effect on employability post TBI. It is important to note that factors such as level of education, race/ethnicity, age at application, pre-employment status, supplemental government income, comorbid depression, etc., are all significantly associated with an employment outcome.
There is support for brief intervention formats for individuals in the chronic post-injury phase (Ownsworth et al, 2008). The intensity of therapy and the resources and interventions offered must match the individual’s needs, severity of injury, and goals, among other factors (Malec & Degiorgio, 2002).
The vocational rehabilitation intervention process may include: one key clinician to coordinate the process, choosing assessments based on pre-injury work demands, emphasize the importance of core work skills, and considering the most appropriate service for the referral at the conclusion of rehabilitation (O-Keefe et al., 2021). Additionally, vocational rehabilitation interventions may be virtual and remote in nature and practitioners should remain cognizant of facilitators and barriers to successful remote rehabilitation (Kettlewell et al., 2021). Specific education/vocation-focused mentoring programs within the community or vocational/educational environment should be offered to persons with TBI in an attempt to improve employment and education rates Lastly, compensatory cognitive training has been found to improve return to work in persons with TBI as well as shown to be cost-effective (Fure et al., 2021).
See ERABI section 3.4 and section 13.3 for more evidence on vocational rehabilitation and productivity post ABI.
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All persons with traumatic brain injury (TBI) discharged from a specialized TBI rehabilitation program (inpatient, outpatient, residential) should have access to scheduled telephone, virtual or in person follow-up contact with a professional trained in working with persons after brain injury. It is preferable that this professional have skills in promotion of self-management skills, motivational interviewing, and goal setting, in order to adequately provide reassurance and problem-solving support.
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In addition to referrals to community-based services (public or private/third-party funded) and/or scheduled follow-up arrangements, the discharging rehab team should provide the person with TBI and/or their family/caregivers with written information on how to contact/access community brain injury supports and services (e.g., ABI Navigator, provincial and local brain injury associations) and other community support services, as well as how to access crisis services if needed.
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Persons with ongoing disability after TBI should have timely (e.g., within the first six months of injury access to specialized outpatient or community-based rehabilitation to facilitate continued progress and successful community reintegration.
NOTE: Community rehabilitation programs that focus on managing and compensating for TBI symptom have been found to augment independent functioning and societal participation.
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A community-based, age-appropriate peer support program should be available to individuals with TBI and their family members in order to promote social integration, coping, and psychological functioning.
NOTE: The facilitators and barriers to successful peer- support should be noted; knowledge awareness and communication of mentor/mentee role, logistics of participating, readiness and motivation of the person with TBI to participate, a need for clear expectations, and matching mentee and mentor, all affect the success of peer support.
REFERENCES:
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Access to interval care (e.g., re-admission to inpatient and/or outpatient rehabilitation as clinically warranted or as needs arise over time) should be allowed so that persons with TBI can access needed treatment as their impairments, ability, and participation goals change in relation to aging, or new challenges/transitions create a renewed need for services.
NOTE: Access to interval care should be primarily determined by the person’s needs, goals, and the potential benefit of services, rather than the time since injury or history of previous treatment.
NOTE: It is important to recognize that inpatient rehabilitation has been found to benefit patient outcomes into the chronic stage of TBI (more than 12 months post-injury).
REFERENCES:
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All persons with traumatic brain injury (TBI) should be re- assessed for their level of independence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Privacy-compliant observation-based assessments should be done in the environment in which they will be regularly performing their ADLs and IADLs. Where appropriate, consider the use of virtual therapy/telemedicine tools which can facilitate assessment when clinicians and individuals cannot be co-located.
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All ADLs and IADLs should be practiced and the level of independence assessed in the most realistic and appropriate environment for the person with TBI, with the opportunity to practice skills in the environments where they will be performing their daily tasks.
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An individualized life skills training protocol should be developed for each person with TBI, to assist them in dealing effectively with the demands and challenges of everyday life. Depending on the needs of the person and their impairment profile, life skills training may focus on social communication and communication, activities of daily living/instrumental activities of daily living, energy management strategies, interpersonal skills, job skills, self-regulation strategies, problem-solving skills, decision-making skills, self-advocacy strategies, self-care and mindfulness, etc.
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As appropriate, environmental supports (bathroom modifications, accessible transportation, anti-glare screens, scheduling tools/technology) should be included in the person with TBI’s treatment plan for activities of daily living and instrumental activities of daily living (ADLs/IADLs).
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Training for the person with TBI and their family/caregivers in compensation strategies and/or how to adapt their individualized environmental contexts (e.g., technology, equipment, and cuing) to optimize independence should be a part of a transdisciplinary program of intervention. These interventions should be designed to be used in the settings that are most relevant to the person with TBI, and geared toward the achievement of the client's goals, their interests, their needs, and available resources. Care should be taken to introduce interventions in a manner that maximizes the client's ability to benefit from the intervention.
Last Updated February 2023
All persons with traumatic brain injury (TBI) should be assessed by a rehabilitation professional or team regarding leisure activities. Assessments should include identification of:
NOTE: Activity participation should be continuously reassessed following TBI, especially after disruptions to the persons habits and routines have been observed.
Last Updated February 2023
Persons with TBI who have difficulty undertaking leisure/meaningful activities of their choice should be offered a goal-directed community-based leisure education program aimed at increasing participation in leisure/meaningful and social activities.
Last Updated February 2023
Barriers to engaging in leisure activities should be reduced by use of assistive technologies (such as social-assistive tech, persuasive assistive tech, personalized assistive tech, and planning assistive tech).
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Last Updated February 2023
Guided exercise programs that incorporate aerobic activity, strengthening, and functional balance should be offered to persons with TBI upon medical clearance, in consultation with their physician or physical therapist. These could be home-based, provided virtually/through telerehab, or in the community. Depending on the person with TBI, offers for exercise programs should be made multiple times throughout the continuum of care.
NOTE: The intensity of such programs should not be so high that it interferes with a patient's ability to perform day-to-day responsibilities.
Last Updated February 2023
A physician/health care professional (e.g., Occupational Therapist) with experience in traumatic brain injury (TBI) should assess all individuals with moderate to severe TBI who wish to drive, in accordance with local legislation and in liaison with the interprofessional rehabilitation team.
Last Updated February 2023
For persons with moderate to severe TBI who wish to drive, a comprehensive assessment of ability to drive should be undertaken at an approved driving assessment centre or service - or by professionals qualified to conduct such an evaluation.
NOTE: Whether or not this is legislated will depend on the jurisdiction. This is legislated in Quebec through SAAQ however is not legislated in Ontario.
Last Updated February 2023
If during assessment or treatment of a person with TBI, the interprofessional rehabilitation team determines that the person’s ability to drive safely may be affected, then they should:
Last Updated February 2023
Persons with traumatic brain injury (TBI) should be assessed during inpatient care by a qualified professional for the need for vocational rehabilitation to assist their return to work or school, and for those not previously employed, assist them in entering the workforce. This assessment should include:
NOTE: Persons performing assessment should be aware that factors such as level of education, race/ethnicity, age at application, pre-employment status, supplemental government income, comorbid depression, etc., are all significantly associated with an employment outcome.
Last Updated February 2023
Vocational rehabilitation interventions should be offered to persons with TBI who require support and training to assist their return to work or to school, or for entering the workforce for those not previously employed. Vocational rehabilitation should include: cognitive, communicative, physical and behavioural strategies, work simulation activities, employer education, and on-site training. Interventions should include training and education about the specific needs of persons with TBI for people who are naturally present in the educational or vocational environment of the person with TBI.
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Last Updated February 2023
Standard vocational rehabilitation interventions offered to persons with TBI, such as cognitive training, compensatory strategy training, and behaviour modification, should be monitored for effectiveness. Supported employment (e.g., vocational assessment, job "hardening", job search skills etc.) should be provided for those who wish to return to work and for whom the standard rehab interventions are insufficiently effective. Refer to 6.4 for more information on supported employment.
Last Updated February 2023
Supported employment offered to persons with TBI who wish to return to work should include these fundamental aspects:
Last Updated February 2023
An assessment of the requirements of the occupation/job the person with TBI is considering entering or re-entering (i.e., job analysis) should be conducted prior to job reintegration by a caregiver or practitioner who is familiar with the capabilities of the person with TBI. To ensure workplace retention, this assessment should include the identification of the following elements and workplace factors: Occupation/job title/category/classification; occupation/job description; complexity and variety of tasks associated with the occupation/job demands.
NOTE: There is some evidence that specific workplace factors can affect workplace retention for persons with TBI more than others.
Last Updated February 2023
Upon completion of the vocational evaluation process, the evaluator should provide practical, specific, and actionable recommendations to help the person with TBI determine their readiness for return to work as well as to obtain, resume, or sustain, paid employment, educational pursuits, and/or volunteer work. Recommendations can be made through verbal and written report to both the person with TBI being evaluated, and any relevant stakeholders (for example, employers, school counsellors, educators, family members, care partners) as per the consents established.
Last Updated February 2023
Gradual work trial for persons with TBI should include a start date, an indication of how to increase hours and days, limitations and restrictions, as well as recommended accommodations.
Last Updated February 2023
If unable to engage in paid employment, persons with TBI should be assisted to explore other avenues for productivity that promote community integration (e.g., volunteer work with TBI- and non-TBI-specific organizations). Volunteer work may also be viewed as training prior to return to work as well as a strategy to improve life satisfaction and overall psychological wellbeing in persons with TBI.
Last Updated February 2023