The Role of Specialized Brain Injury Units in the Rehabilitation Process

Billie Schultz and Allen W. Brown

BACKGROUND: LONGITUDINAL CARE

A. Consensus exists for providing a continuum of care to individuals and their families/significant others after moderate-severe traumatic brain injury (TBI), from acute hospitalization to outpatient clinical care and community-based services.

B. Ideally, inpatient rehabilitation brings into focus the comprehensive rehabilitation plan of care initiated by rehabilitation consultation and services provided during acute hospitalization, medical and surgical treatment, and stabilization.

C. Inpatient brain injury rehabilitation provides comprehensive medical rehabilitation services as individuals emerge from trauma-induced alterations of consciousness and families/significant others begin adjusting to these changing circumstances.

D. As the link between acute medical care and community-based services, specialized inpatient brain injury rehabilitation units are a crucial source of clinical data, to define baseline injury severity, monitor progress, measure outcome and satisfaction, and to use for benchmarking and practice improvement [1].

E. Evidence exists showing that early rehabilitation intervention during the acute care stay can improve outcomes including rehabilitation length of stay [2,3].

PRACTICE MODELS

Centralized Brain Injury Units

A. Geographically smaller countries with nationalized health care, and states in the United States with single urban medical centers and large rural populations, often have trauma systems that direct individuals who experience catastrophic and polytraumatic injuries to designated accredited trauma centers for definitive care with treatment directed by consensus guidelines [4].

B. Regional brain injury rehabilitation hospital care driven by a team-based model and treatment guidelines has been shown to be associated with better outcomes after severe TBI when compared to historical controls [5].

C. A model of care which provides acute and rehabilitation services in a single location from admission to the acute hospital through discharge after rehabilitation is uncommon in the United States, and not as developed in Europe for TBI as it is for stroke [6].

D. Whether care is provided in a rehabilitation hospital or a rehabilitation unit within an acute care hospital, effective communication between provider teams by handoff at care transitions is crucial to maintain continuity and minimize safety risks [7].

Brain Injury Services in Rehabilitation Units

A. Most brain rehabilitation units in the United States exist either within acute hospitals or as freestanding rehabilitation hospitals.

B. Clinical services: Consensus exists about what clinical services should be provided during inpatient rehabilitation for TBI [8].

1. Rehabilitation services should be customized to individual needs and refined with clinical change.

2. Services should be comprehensive and interdisciplinary.

3. Cognitive and behavioral assessment should be included.

4. Evaluation of and treatment for substance abuse should be a component of these rehabilitation programs.

5. Persons with TBI, and their families/significant others should be involved in the rehabilitation process. Families and significant others should also be supported through the rehabilitation process.

6. The use of medications for behavioral management and cognitive enhancement should be carefully considered.

7. Specialized programming is necessary for individuals in pediatric and geriatric populations with TBI.

C. Admission guidelines: Many rehabilitation units use admission guidelines as set forth by the Centers for Medicare and Medicaid Services, although these guidelines may not apply to individuals not covered by government-funded health care.

1. An individual should be able and willing to actively participate in an intensive rehabilitation program (recommended intensity and duration: 3 hours of daily therapy services, 5 out of each 7 days with the exception of carefully selected cases for which 15 hours of therapy over the course of a single week may be an appropriate alternative) and should be expected to make measurable improvement in functional capacity or adaptation to impairments within a reasonable period of time.

2. Rehabilitation services should be ordered and coordinated by a rehabilitation physician with specialized training and experience in rehabilitation services and be administered by an interdisciplinary team.

3. Specialized rehabilitation physician and nursing care is needed.

4. Rehabilitation care should be provided by qualified personnel in rehabilitation nursing, physical therapy, occupational therapy, speech-language pathology, social services, psychological services, and prosthetic and orthotic services.

5. Appropriate care cannot be provided in a less intensive medical setting, such as in a skilled care environment.

D. Rehabilitation treatment for individuals in coma or a minimally conscious state

1. Rehabilitation care for individuals who remain in coma or who are minimally conscious after reaching medical stability is provided in specialized hospital-based rehabilitation settings, long-term acute care facilities, or in a skilled care environment.

2. Treatment approaches are generally grouped into three types: sensory stimulation, physical management, and neuromodulation [9].

3. Variations in determining level of consciousness, small sample sizes, and poor study design have limited the application of existing research to develop clinical assessment and treatment guidelines.

4. Effectiveness of treatment is monitored using common outcome tools [10].

5. Many interventions have shown some positive effects on increasing arousal, but more methodologically rigorous study has been recommended [11]. However, the use of amantadine has been shown to accelerate the rate of functional recovery in individuals who experienced trauma-related disorders of consciousness when compared to placebo [12].

E. Rehabilitation after TBI and polytrauma in the military (see also Chapters 64 and 65)

1. The Polytrauma System of Care is an integrated system of specialized care created by the Department of Veterans Affairs to manage patients with brain injury throughout all aspects of the rehabilitative process [13].

2. It serves veterans and active duty service members who have TBI and polytrauma injuries through regional centers around the United States. Through the system, polytrauma is defined as “two or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability” [13].

3. Clinical trials in these centers have shown differential positive effects in subpopulations for cognitive and functional treatment approaches [14].

4. To further advance research, the Department of Veterans Affairs polytrauma system of care has partnered with the National Institute on Disability and Rehabilitation research to establish a longitudinal data system similar to the TBI model system national database in the civilian world [15].

BRAIN INJURY TREATMENT EFFECTIVENESS

A. In an evidence-based review of randomized controlled trials, quasi-randomized and quasi-experimental designs—comparing multidisciplinary rehabilitation with either routinely available local services or lower levels of intervention; or trials comparing an intervention in different settings or at different levels of intensity—it was found that [16]:

1. For moderate to severe injury, there was “strong evidence” of benefit from formal intervention

2. For patients with moderate to severe TBI already in rehabilitation, there was “strong evidence” that more intensive programs are associated with earlier functional gains

3. There was “limited evidence” that specialized inpatient brain injury rehabilitation units may provide additional functional gains

B. In an assimilation of randomized controlled trials in the literature and a review of TBI rehabilitation trials chosen based on evaluation of research quality irrespective of study design, it was found that [17]:

1. Early intensive rehabilitation is recommended

2. Specialized brain injury programs are recommended for individuals with complex needs

3. Vocational programs are recommended for individuals with this potential

C. Further research is needed, and priorities have been defined, to further characterize the roles of cognitive rehabilitation and vocational programs [18].

BRAIN INJURY REHABILITATION DATABASES

A. A national consortium of 16 academic rehabilitation research centers, the Traumatic Brain Injury Model System Centers (funded by the National Institute on Disability, Independent Living and Rehabilitation Research) have contributed data about individuals admitted to specialized brain injury inpatient rehabilitation units to a common database since 1989.

1. Data from acute care and inpatient rehabilitation are submitted, and outcome data are collected from subjects at 1, 2, and 5 years after injury and every 5 years thereafter.

2. This database is used for longitudinal analysis of data from people with TBI and supports research toward developing evidence-based TBI rehabilitation interventions [19].

B. Other proprietary data sources (such as eRehabData.com and the Uniform Data System for Medical Rehabilitation) allow inpatient brain injury rehabilitation programs to monitor clinical metrics and outcomes for benchmarking and to support practice improvement [20].

C. To develop more consistency in research, the National Institutes of Health (NIH) has developed recommendations for collection of standardized outcomes and demographics [21].

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