Traumatic brain injury (TBI) inpatient rehabilitation models should include an interprofessional team with access to specialists and community programs, as well as substance use and mental health services. It is important that the team has regular meetings to discuss patient progress and integrates the patient’s family/caregivers into care meetings to ensure education and coordination.
Inpatient rehabilitation interventions should include the implementation of evidence-based cognitive intervention appropriate to the person with TBI's functional goals, to optimize outcome following TBI. There is evidence that time spent in more complex and advanced therapy activities across disciplines improves outcomes beyond that attained using only basic-level therapy. Evidence also suggests starting advanced therapy early on in rehabilitation.
Individuals with low Functional Independence Measure (FIM) cognitive subscores benefit from intervention targeting advanced communication, cognitive-communication, social communication function, competence, and advanced reading and writing, where there is indication of impairment in these areas.
In order to optimize and maintain outcomes following TBI inpatient rehabilitation, interventions should promote engagement and participation from the person with TBI and family/caregiver. To achieve optimal efficiencies of inpatient rehabilitation, persons with TBI should receive one-on-one therapeutic interventions for a minimum of 3 hours per day, as tolerated. Persons with comorbid conditions should be treated collaboratively by providers with expertise in the relevant disorders to optimize gains and increase efficiency of rehabilitation.
A target length of stay should be established with input from persons with TBI and their families/caregivers as soon as possible after admission to inpatient rehabilitation. The target length of stay should be established based on comparison to individuals with similar functional status, availability of resources and supports in the community, and level of caregiver support and ability, among other personal injury related factors. The established target length of stay should be reviewed regularly with the person with TBI and family/caregivers, taking into consideration goal achievement and progression toward functional independence.
To ensure efficient planning for discharge, the team, the person with TBI, and their family/caregivers should get started as soon after admission as possible with arrangements for equipment, home renovations, and outpatient rehabilitation and attendant care plans for after discharge. Throughout the discharge planning process, collaboration and communication with all those involved is essential, and the wishes of the person with TBI should be prioritized when possible. Referral to community care services and follow-up appointments should be booked prior to discharge. Communication to primary care should include a recommendation to have regular follow up appointments at the initiation of the primary care provider. Among people with lived experience, an abrupt discontinuation of treatment upon discharge has been found to be detrimental to the recovery process.
A process for recording case information and action items in a standardized current written treatment plan that is easily accessed by all service providers and persons part of the circle of care should be established. This should occur at the biweekly interprofessional team conference, and written information should be shared at family/caregiver conferences, likely in both print and digital forms.
Interprofessional teams should use standardized measures and assessment tools, such as the Functional Independence Measure (FIM) or other standardized tools (preferably those validated for use with persons after TBI) to evaluate the effectiveness of rehabilitation interventions, as well as their duration and intensity. Length of stay data should be collected routinely and common functional-progression benchmarks, derived from multiple traumatic brain injury (TBI) rehabilitation programs (e.g., FIM Rehabilitation Practice Groups), should be used to estimate target length of stay alongside patient/caregiver input.
System-level mechanisms that facilitate the transition from rehabilitation to the community and ensure community follow-up are essential. This includes creating a formal comprehensive written discharge plan, discharge report, and outpatient rehabilitation plan; as well as mechanisms to ensure community support-personnel (e.g., personal support workers, rehabilitation support worker, community support worker) and suitable environmental supports are in place. Communication and data transfer between the interprofessional rehabilitation team and the primary care provider of the person with TBI must occur prior to discharge.
Mechanisms to support re-entry into inpatient rehabilitation should also be in place in case of changes to condition caused by age or the development of brain injury sequalae that necessitate further rehabilitation.
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:
Other Resource:
Access to Specialists/Community Programs
Traumatic brain injury (TBI) inpatient rehabilitation models should include a number of aspects including a coordinated interprofessional rehabilitation team that has access to specialists and community programs, specifically substance use and mental health services. When complex issues are identified, such as co-occurring mental health and substance use disorders or complex medical issues, more frequent meetings may be required. See Section A Summary of Evidence for more information/evidence on the importance of this aspect in ensuring a complete and continuous care pathway for persons with TBI.
Integration of Family/Friends/Caregiver in Care Meetings
Another important aspect of inpatient rehabilitation models is ensuring the wellbeing of caregivers and family of the person with TBI. Education and access to information have been found to reduce the perception of caregiver burden. Caregivers regard health information support as a valuable resource, particularly in the early stages of TBI care (Calvete & de Arroyabe, 2012; Liu et al., 2015). When these resources are unavailable or inaccessible, it can negatively impact caregiver mental health. Doyle et al. (2013) revealed that most unmet caregiver needs – resulting in anxiety and depression – revolved around a lack of health information regarding the patient and TBI. Thus, it is important to integrate family and/or caregivers into care meetings to provide them with education and information about resources and strategies that can be used to reduce overall caregiver burden.
See ERABI section 13.5.2 for more evidence on the importance of integrating family/caregivers into care meetings.
Interval Rehabilitation
Interval rehabilitation involves periods of high intensity rehabilitation followed by low-intensity rehabilitation that can take place in either a rehabilitation centre and/or home/community-based care. Based on the complicated and prolonged pathway that TBI recovery can take, an interval rehabilitation program is important to integrate into inpatient rehabilitation models. Interval rehabilitation focuses on individual patient goals and is designed to improve functioning and optimize participation in daily life (Bender et al., 2014). Bender et al. (2014) reported an improvement in FIM scores during early rehabilitation, community care, and inpatient interval rehabilitation, with benefits that lasted up to one and a half years, despite the therapy only lasting six to seven weeks. Bender et al. (2014) also report that patients who entered the interval rehabilitation program demonstrated improvement-rate increases comparable to initial rehabilitation levels, where the greatest gains are said to be made, highlighting the benefit of additional rehabilitation at later stages of recovery. Wales and Bernhardt (2000) utilized a case study of a slow to recover TBI patient to demonstrate importance of model of care for this group. Interval rehabilitation may also be delivered remotely through telerehabilitation (Lauaté et al., 2016).
Attributes of Rehabilitation Interventions that Optimize Patient Outcomes
Attributes of rehabilitation such as the duration, intensity and content of rehabilitation interventions greatly affect patient outcome. A number of studies have evaluated the efficacy of increased intensity of inpatient rehabilitation on patient outcomes and length of stay following brain injury. In a multicenter PCT, Cifu et al. (2003) examined the efficacy of rehabilitation intensity on functional outcomes at discharge. Rehabilitation intensity predicted motor functioning at discharge but not cognitive gain. Cicerone et al. (2004) found that intensive and structured cognitive rehabilitation therapy (group and individual) and standard neurorehabilitation therapy both resulted in improvements on the community integration questionnaire, however, in the more intensive program, participants made greater gains in cognitive functioning. In a RCT by Zhu et al. (2001), patients were randomized into two groups based on rehabilitation intensity. One group received 4 hours per day of therapy, and another received 2 hours per day, with both groups receiving therapy 5 days per week. The authors reported that significantly more patients from the intensive group achieved good outcomes at 2 months as defined by the Glasgow Outcome Scale, however, this effect was not sustained at 3 months as the conventional therapy group caught up. Moreover, there were no differences between groups in the Functional Independence Measure scores. This study suggests that more intensive rehabilitation may provide added benefits in the first two to three months post injury, although as time progresses, those who receive less intensive therapy eventually catch up.
In another longitudinal non-randomized study, Horn et al. (2015) examined associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months post-discharge for patients with TBI. Consecutive patients (N=2130) enrolled between 2008 and 2011, and admitted for inpatient rehabilitation after an index TBI were studied. The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. They concluded that greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups at discharge. At 9 months post-discharge, similar but less pervasive associations were observed for therapy activities. In addition, rehabilitation specifically focusing on cognitive impairment following TBI is important as it has been found to contribute to chronic disability (Cicerone et al., 2004). As cognitive rehabilitation can reduce functional disability and recovery time (Barman et al., 2016), it is imperative that rehabilitation effectively targets cognition to improve independence with daily functioning and social integration. Current cognitive therapies focus on behavioural retraining, self-awareness, or general cognitive function.
See ERABI section 13.1.2 for more evidence on cognitive interventions.
Planned discharge/ transition back to community
See ERABI module 13 for more evidence on community reintegration post TBI.
REFERENCES
Acquired Brain Injury Knowledge Uptake Strategy (ABIKUS) (2007).
Barman, A., Chatterjee, A., & Bhide, R. (2016). Cognitive Impairment and Rehabilitation Strategies After Traumatic Brain Injury. Indian J Psychol Med, 38(3), 172.
Beaulieu, C. L., Peng, J., Hade, E. M., Corrigan, J. D., Seel, R. T., Dijkers, M. P., Hammond, F. M., Horn, S. D., Timpson, M. L., Swan, M., & Bogner, J. (2019). Level of Effort and 3 Hour Rule Compliance. Arch Phys Med Rehabil, 100(10), 1827–1836.
Behn, N., Marshall, J., Togher, L., & Cruice, M. (2019). Feasibility and initial efficacy of project-based treatment for people with ABI. Int J Lang Commun Disord, 54(3), 465–478.
Bender, A., Bauch, S., & Grill, E. (2014). Efficacy of a post-acute interval inpatient neurorehabilitation programme for severe brain injury. Brain Injury, 28(1), 44-50.
Blackerby, W. F. (1990). Intensity of rehabilitation and length of stay. Brain Inj, 4(2), 167-173.
Bogner, J., Hade, E. M., Peng, J., Beaulieu, C. L., Horn, S. D., Corrigan, J. D., Hammond, F. M., Dijkers, M. P., Montgomery, E., Gilchrist, K., Giuffrida, C., Lash, A., & Timpson, M. (2019). Family Involvement in Traumatic Brain Injury Inpatient Rehabilitation: A Propensity Score Analysis of Effects on Outcomes During the First Year After Discharge. Arch Phys Med Rehabil, 100(10), 1801–1809.
Calvete, E., & de Arroyabe, E. L. (2012). Depression and grief in Spanish family caregivers of people with traumatic brain injury: The roles of social support and coping. Brain Inj, 26(6), 834-843.
Cicerone, K. D., Mott, T., Azulay, J., & Friel, J. C. (2004). Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury. Arch Phys Med Rehabil, 85(6), 943-950.
Cifu, D. X., Kreutzer, J. S., Kolakowsky-Hayner, S. A., Marwitz, J. H., & Englander, J. (2003). The relationship between therapy intensity and rehabilitative outcomes after traumatic brain injury: a multicenter analysis. Arch Phys Med Rehabil, 84(10), 1441-1448.
Doyle, S. T., Perrin, P. B., Diaz Sosa, D. M., Espinosa Jove, I. G., Lee, G. K., & Arango-Lasprilla, J. C. (2013). Connecting family needs and TBI caregiver mental health in Mexico City, Mexico. Brain Inj, 27(12), 1441-1449.
Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). https://erabi.ca//.
Hade, E. M., Bogner, J., Corrigan, J. D., Horn, S. D., & Peng, J. (2019). Comparative Effectiveness of Inpatient Rehabilitation Interventions for Traumatic Brain Injury: Introduction. Arch Phys Med Rehabil, 100(10), 1986–1989.
Horn, S. D., Corrigan, J. D., Beaulieu, C. L., Bogner, J., Barrett, R. S., Giuffrida, C. G., . . . Deutscher, D. (2015). Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge. Arch Phys Med Rehabil, 96(8 Suppl), S304-329
Liu, W., Zhu, J., Liu, J., & Guo, Q. (2015). Psychological state and needs of family member caregivers for victims of traumatic brain injury: A cross-sectional descriptive study.
Int J Nurs Sci, 2(3), 231-236.
Luauté, J., Hamonet, J., Pradat-Diehl, P., & SOFMER (2016). Behavioral and affective disorders after brain injury: French guidelines for prevention and community supports. Ann Phys Rehabil Med, 59(1), 68–73.
MacDonald S. (2017). Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury. Brain Inj, 31(13-14), 1760–1780.
New Zealand Guidelines Group (NZGG). (2007).
Okrainec, K., Chaput, A., Rac, V. E., Tomlinson, G., Matelski, J., Robson, M., Troup, A., Krahn, M., & Hahn-Goldberg, S. (2022). Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario Hospitals. PloS One, 17(10).
Seel, R. T., Corrigan, J. D., Dijkers, M. P., Barrett, R. S., Bogner, J., Smout, R. J., Garmoe, W., & Horn, S. D. (2015). Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury. Arch Phys Med Rehabil, 96(8 Suppl), S235–S244.
Spivack, G., Spettell, C. M., Ellis, D. W., & Ross, S. E. (1992). Effects of intensity of treatment and length of stay on rehabilitation outcomes. Brain Inj, 6(5), 419-434.
Timpson, M., Hade, E. M., Beaulieu, C., Horn, S. D., Hammond, F. M., Peng, J., Montgomery, E., Giuffrida, C., Gilchrist, K., Lash, A., Dijkers, M., Corrigan, J. D., & Bogner, J. (2019). Advanced Therapy in Traumatic Brain Injury Inpatient Rehabilitation: Effects on Outcomes During the First Year After Discharge. Arch Phys Med Rehabil, 100(10), 1818–1826.
Tyson, B. T., Pham, M. T., Brown, N. T., & Mayer, T. R. (2012). Patient safety considerations in the rehabilitation of the individual with cognitive impairment. Phys Med and Rehabil Clin N Na, 23(2), 315–334.
Wales, L. R., & Bernhardt, J. A. (2000). A case for slow to recover rehabilitation services following severe acquired brain injury. Aust J Physiother, 46(2), 143-146.
Webb, P. M., & Glueckauf, R. L. (1994). The effects of direct involvement in goal setting on rehabilitation outcome for persons with traumatic brain injuries. Rehabil Psychol, 39(3), 179–188.
Wiseman-Hakes, C., Ryu, H., Lightfoot, D., Kukreja, G., Colantonio, A., & Matheson, F. I. (2020). Examining the efficacy of communication partner training for improving communication interactions and outcomes for individuals with Traumatic Brain Injury: A systematic review. Arch Rehabil Res Clin Transl, 2(1), 100036.
Zhu, X. L., Poon, W. S., Chan, C. H., & Chan, S. H. (2001). Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury? Interim result of a randomized controlled trial. Br J Neurosurg, 15(6), 464-473.
Traumatic brain injury (TBI) rehabilitation teams should have access to specialist professionals and programs to provide consultation services, education, and oversight, especially for individuals with multiple injuries and diagnoses. Examples include expertise in amputee care, musculoskeletal injury, or spinal cord injury. Examples of specialist professionals and services may include neuropsychiatry, audiology, ophthalmology, and/or diagnostic imaging (e.g., MRI and CT).
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NOTE: When complex issues are identified, such as co-occurring mental health and substance use disorders or complex medical issues, more frequent meetings may be required.
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Direct integration of family/caregivers should be encouraged within the rehabilitation process when beneficial to the patient. This may include allowing family/caregivers to attend sessions with the patient as well as hands-on training and education during the session.
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When treating people with TBI who have prolonged recovery with ongoing or new needs, an interval rehabilitation program (e.g., readmission to inpatient and/or outpatient rehabilitation as clinically warranted or as needs arise over time) should be considered and could include virtual/telerehabilitation (Luauté et al., 2016). Ongoing access to treatment should be based on the demonstration of continued measurable functional generalizable and sustainable improvements in response to treatment and not determined by standard admission lengths.
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When the person with TBI presents with a comorbid disorder (e.g., mental health, substance use) community providers with expertise in the relevant disorder should work collaboratively with the interprofessional rehabilitation team to support the person with TBI.
See Module A.2 Coordinating Management of Comorbid Conditions.
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A target length of stay should be established with input from persons with traumatic brain injury (TBI) and their families/caregivers as soon as possible after admission to inpatient rehabilitation. This discussion should include the rehabilitation organization's criteria for discharge in order to increase patient and family knowledge early in the process, to allow time for advanced discharge planning, and to facilitate transition planning. Working towards the agreed-upon target length of stay will support consistency and continuity of care, by allowing time for advanced planning and preparation for discharge.
Suggested tool: Length of Stay (LOS) - Reference table, Ontario data
Suggested tool: Length of Stay (LOS) - Reference table, Quebec data
NOTE: The target length of stay should be established based on comparison to individuals with similar functional status, availability of resources and supports in the community, and level of caregiver support and ability. Other factors such as the Glasgow Coma Score in the first few days after injury, intracranial surgery, the degree of initial disability, the presence of fractures of the upper and lower extremities or pelvis, presence of comorbid disorders, and the person’s age should also be taken into account.
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The established target length of stay for intensive rehabilitation following TBI should be reviewed regularly with the patient and family/caregivers. Discussions should take into consideration goal achievement and progression toward functional independence, assessed using objective outcome measures.
Suggested tool: Length of Stay (LOS) - Reference table, Ontario data
Suggested tool: Length of Stay (LOS) - Reference table, Quebec data
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In order to optimize outcome following TBI, inpatient rehabilitation interventions should include evidence-based cognitive strategies to manage higher-level cognitive functions, as tolerated (e.g., goal management training, problem-solving skills, planning and pacing, working memory, memory, math skills, metacognitive awareness and strategies) starting early in rehabilitation.
NOTE: Research indicates that time spent in more complex and advanced therapy activities across clinical disciplines improves outcomes beyond that attained using only basic-level cognitive therapy.
See Module J for more information on Cognitive Rehabilitation.
REFERENCES:
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In order to optimize outcome following TBI, inpatient rehabilitation interventions for patients with lower Cognitive FIM subscores (scores of ≤10 out of 35) and communication impairments should target advanced communication, cognitive-communication, social communication function (i.e., interventions focused on higher level functions, such as executive functions, that challenge patients in the areas of expression, auditory comprehension, and problem solving), competence (the ability to achieve communication goals in a socially appropriate manner), and advanced reading and writing.
See Module K for Cognitive Communication rehabilitation.
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In order to optimize and maintain outcomes following TBI inpatient rehabilitation, interventions that are challenging and require significant effort on the part of the person with TBI should be promoted (i.e., the clinician should not avoid challenging activities unless it exacerbates problematic behaviour or irritability, and should explore alternate ways to provide the right challenge while considering the person's abilities, cognitive reserve, fatigue, and behaviours). To avoid frustration or misunderstanding on the part of the patient/family, the rationale for providing interventions that are challenging and require significant effort should be clearly, and repeatedly (as needed), communicated.
REFERENCES:
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To achieve optimal efficiencies of inpatient rehabilitation, persons with TBI should receive a minimum of 3 hours per day of therapeutic interventions, as tolerated, with the addition of more hours if appropriate.
See recommendations C2.3-C2.5 as well as Section 2 for specific physical and cognitive therapeutic interventions.
NOTE: Increased rehabilitation intensity, as defined by a greater frequency/length of therapeutic interventions per day has been shown to improve outcomes post TBI.
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In order to optimize and maintain outcomes following TBI inpatient rehabilitation, the person with TBI should be provided with strategies and coached to engage in activities that they can do safely on their own. This should involve integration of skills and strategies learned in formal rehabilitation sessions into everyday activities and interests to facilitate recovery even when they are not participating in a formal rehabilitation intervention.
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The established target length of stay for intensive rehabilitation following TBI should be reviewed regularly with the patient and family/caregivers. Discussions should take into consideration goal achievement and progression toward functional independence, assessed using objective outcome measures.
Suggested tool: Length of Stay (LOS) - Reference table, Ontario data
Suggested tool: Length of Stay (LOS) - Reference table, Quebec data
See recommendations C1.2 and C1.3 regarding engagement of person with TBI and their family/caregivers in the discharge planning process.
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A well-planned transition process from inpatient rehabilitation to the community provides beneficial outcomes and should be an integrated part of treatment programs.
See recommendations C3.3-C3.10 for specific recommendations for the transition process.
NOTE: Take account of the domestic and social environment of the person with TBI, or if they live in residential or sheltered care while planning the process
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A formalized discharge plan, distinct from the rehabilitation plan, should be prepared, discussed with and provided to the person with TBI their family/caregivers and, if available, their community case coordinator or main community-based provider. This plan should be part of the official documents (charting) completed at discharge and transferred to the next group of providers in the continuum of care.
See recommendation C3.10 for more information on discharge reports.
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Persons with TBI should be discharged to the community as soon as appropriate rehabilitative and support services are in place, either through referral or scheduled service/appointments. If rehabilitation supports are not in place at discharge, clinicians should plan for and ensure that individuals are safe within these limitations in the physical, service and support environments.
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The inpatient rehabilitation team should clearly communicate with the primary care provider, persons with TBI and their family/caregivers, and the community-based care coordinator (where available) about any referrals and services/appointments arranged and recommended at discharge.
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When temporary or permanent alterations to the home of the individual with TBI are required, these should be recommended with a reasonable amount of time allowed for installation and completion prior to discharge. However, when the person or their family/caregivers are unable or unwilling to make the necessary renovations or modifications, discharge should not be held up and alternatives should be explored.
NOTE: Temporary home alterations should be selected when the person with TBI's functional status is not stabilized so as to allow for functional gains.
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Individuals with TBI should be transitioned from inpatient rehabilitation to home/community living in a manner that is supportive and may include a graduated transition (e.g., home/community visits, weekend/weekday passes with family during rehabilitation, experiences in transitional living, and IADL evaluations within the home and community environment).
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Preparing individuals with TBI and their family/caregivers, including external supports (e.g., PSWs from Home and Community Care) for community transition should include:
See Section E. Caregivers and Families
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Copies and/or digital access to both the discharge report and the patient care plan should be provided to the person with TBI. With their consent, access should also be provided to the family/caregivers, as well as all professionals relevant to the person’s rehabilitation in the community including the primary care team, local/regional ABI community service providers, social services, and allied health professionals, in a privacy compliant manner.
These reports should include:
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Outpatient rehabilitation treatment plans should be discussed with the person with TBI, their family/caregivers, and health care professionals involved in the transition, however obtaining the person with TBI's agreement with the goals of the treatment plan should be prioritized whenever possible.
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There should be a process among the outpatient interprofessional rehabilitation team/providers for regularly reviewing the progress and status of the person with TBI (i.e., usually at 3 months intervals) and the resources made available to the person with TBI should be revised based on these follow-up assessments. This review should be initiated by the Primary Care Provider and/or the community-based case manager (where presented) and communicated to the Primary Care Provider.
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