Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 1: Components of the Optimal TBI Rehabilitation System > C. Subacute Rehabilitation

C. Subacute Rehabilitation

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Inpatient rehabilitation teams require many types of professionals and it is important that the team have regular meetings to discuss patient progress. Some of these meetings should be with the patient and his/her family to provide education and coordination.

There is evidence that more cognitively impaired individuals with traumatic brain injury (TBI) require rehabilitation that includes cognitively effortful activities and time in specific activities which increases prediction of better outcomes beyond that attained using only basic level therapy. Those individuals (e.g. low cognitive Functional Independence Measure (FIM) sub score) benefit from more time spent in advanced expression tasks and advanced reading and writing. 

Teams should be aware of the need to intervene differently for those with impaired awareness of disability and behavioural difficulties, such as disinhibition. Teams should have the expertise to identify when impairments of awareness or behavioural difficulties may be interfering with participation in rehabilitation, and have the capacity to create a rehabilitation plan that specifically addresses this. Behavioural disturbance is a common outcome of TBI, and teams should have access to appropriate expertise and safety measures to manage individuals with impulsivity, poor awareness of disability, and behavioural disinhibition.

To ensure efficient planning for discharge, the team, the patient and his/her family should get started with arrangements for equipment, home renovations, and rehabilitation and attendant care plans for after discharge. Throughout the discharge planning process, collaboration and communication with all involved is essential.

A process for setting and recording patient goals in a standardized written treatment plan should be established.

Teams should use standardized measures such as the FIM or other tools to evaluate their patients and collect length of stay data routinely.

Common benchmarks derived from multiple brain injury rehabilitation programs should be used to estimate target length of stay (e.g.  FIM Rehabilitation Practice Groups). Rehabilitation staff should receive training in patient and family education principles.  Family conferences should routinely include provision of written information for family and caregivers.  Rehabilitation team members should receive specialized training in behavioural assessment.

 

Indicators examples

  • Proportion of individuals with TBI for whom a target length of stay was recorded in the medical chart within 7 days following admission to the rehabilitation program.

  • Proportion of individuals with TBI for whom at least one objective in the rehabilitation plan specifically targets advanced cognitive functions, including:

    • Problem solving

    • Mathematical skills

    • Memory

  •  Proportion of individuals with TBI receiving a minimum of 3 hours/day of therapeutic interventions with focus on cognitive tasks during inpatient rehabilitation stay.

  • Proportion of discharge reports sent to the treating general practitioners.

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.

Cifu et al. (2003) examined the efficacy of rehabilitation intensity and functional gain in relation to the hospital LOS in a multicentre, prospective controlled trial. Rehabilitation intensity was found to predict motor functioning at discharge (p<0.001) but not cognitive gain (p<0.05). However, both cognitive and motor abilities at admission were significant predictors of LOS (p<0.01). LOS was significantly decreased (31%) for both acute care and coma groups with increased intensity (Blackerby, 1990). Further, Spivack et al. (1992) conducted a study looking at the combined effects of rehabilitation intensity and inpatient rehabilitation LOS.  In their comparison of patients who had a long LOS and received low-intensity or high-intensity rehabilitation, the latter group fared better on the Rancho Los Amigos Scale at discharge.

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, 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.

REFERENCES
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.

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.

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.

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.

Wales, L. R., & Bernhardt, J. A. (2000). A case for slow to recover rehabilitation services following severe acquired brain injury. Australian Journal of Physiotherapy, 46(2), 143-146.

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C1. TBI Inpatient Rehabilitation Models

P Priority F Fundamental New Level of evidence A B C
C 1.1 C

Traumatic brain injury rehabilitation teams should have access to specialist professionals to provide consultation services, education and oversight, especially for individuals with multiple injuries and diagnoses (examples include expertise in amputee care or spinal cord injury).

(Adapted from NZGG 2007, 5, p. 80)

C 1.2 C

Interdisciplinary team conferences should occur regularly (at least every two weeks) during the inpatient rehabilitation of individuals with traumatic brain injury.

(INESSS-ONF, 2015)

C 1.3 C

Family conferences with members of the interdisciplinary team should be offered regularly during the inpatient rehabilitation of individuals with traumatic brain injury.

(INESSS-ONF, 2015)

C 1.4 C

When treating individuals with traumatic brain injury who have prolonged recovery, an interval rehabilitation program (e.g., inpatient rehabilitation at different points in time) should be considered. Access to treatment should not be temporally limited but should be dependent on the person’s potential for measurable functional gain.

(INESSS-ONF, 2015)

REFERENCES:

- Bender et al. (2014)

- Wales and Bernhardt (2000)

C2. Duration, Intensity and Other Attributes

P Priority F Fundamental New Level of evidence A B C
C 2.1 P C

A target length of stay should be established as soon as possible after admission to inpatient rehabilitation, to ensure consistency of care following traumatic brain injury and to facilitate discharge planning and community integration.

 

Suggested tool: Length of Stay (LOS) - Reference table, Ontario data

Suggested tool: Length of Stay (LOS) - Reference table, Quebec data

(INESSS-ONF, 2015)

Note: The target length of stay should be established based on individuals with similar functional status and availability of resources in the community, and take into account 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, and the person’s age.

C 2.2 C

Target length of stay for intensive rehabilitation following traumatic brain injury should be reviewed regularly while taking into consideration achievement of goals and progression toward functional independence.

 

Suggested tool: Length of Stay (LOS) - Reference table, Ontario data

Suggested tool: Length of Stay (LOS) - Reference table, Quebec data

(INESSS-ONF, 2015)

C 2.3 P B

In order to optimize outcome following traumatic brain injury, inpatient rehabilitation interventions should target advanced cognitive functions, e.g., problem-solving, math skills and memory, where patient capacity permits.

(INESSS-ONF, 2015)

Note: Research indicates that effort in advanced therapy and time in specific activities improves outcome beyond that attained using only basic level therapy.

REFERENCE:

- Horn et al. (2015)

C 2.4 P B

In order to optimize outcome following traumatic brain injury, inpatient rehabilitation interventions should promote significant involvement of and effort by the person with TBI.

(INESSS-ONF, 2015)

REFERENCES:

- Horn et al. (2015)

- Seel et al. (2015)

C 2.5 B

In order to optimize outcome following traumatic brain injury, inpatient rehabilitation interventions for patients with lower FIM cognitive subscores should target advanced expression tasks and advanced reading and writing, where there is indication of impairment in these areas.

(INESSS-ONF, 2015)

REFERENCE:

- Horn et al. (2015)

C 2.6 P C

To achieve optimal efficiencies of inpatient rehabilitation, individuals with traumatic brain injury should receive a minimum of 3 hours per day of therapeutic interventions, ensuring focus on cognitive tasks as recommended in C2.3, C2.4 and C2.5.

(INESSS-ONF, 2015)

C3. Planning Discharge to the Community

P Priority F Fundamental New Level of evidence A B C
C 3.1 P C

A potential discharge date should be established early in the course of rehabilitation and reviewed regularly as the person’s presentation changes to guide the rehabilitation process and prepare the person with traumatic brain injury and his/her family for discharge.

 

Suggested tool: Length of Stay (LOS) - Reference table, Ontario data

Suggested tool: Length of Stay (LOS) - Reference table, Quebec data

(INESSS-ONF, 2015)

C 3.2 P C

Planned discharge from inpatient rehabilitation to home for individuals with traumatic brain injury (TBI) provides beneficial outcomes and should:

  • Be an integrated part of treatment programs

  • Involve the person with TBI and caregivers, primary care team, social services and allied health professionals, as appropriate

  • Take account of the domestic and social environment of the person with TBI, or if he/she lives in residential or sheltered care

(Adapted from SIGN 2013, 2.3 and 10.4.2)

C 3.3 C

Individuals with traumatic brain injury may be transferred back to the community, when appropriate specialized rehabilitation and needs support can be continued in that environment without delay.

(Adapted from ABIKUS 2007, G83, p. 30)

C 3.4 C

A formalized discharge plan, distinct from the rehabilitation plan, should be prepared, discussed with the person with traumatic brain injury, his/her family/caregivers and, if available, the community case coordinator, and be part of the official documents (charting) completed at discharge that are transmitted to the next providers in the continuum of care.

(INESSS-ONF, 2015)

C 3.5 C

Outpatient rehabilitation treatment plans should be agreed to jointly by the person with traumatic brain injury and family/caregivers, and health care professionals involved in the transition.

(Adapted from ABIKUS 2007, G85, p. 30)

C 3.6 C

There should be a process for regularly reviewing how the outpatient rehabilitation treatment plan of the person with traumatic brain injury progresses (i.e., usually at 3–6 months postdischarge and repeated thereafter).

(INESSS-ONF, 2015)

C 3.7 C

Essential alterations to the home of the person with traumatic brain injury should be recommended, with a reasonable amount of time allowed for installation and completion prior to discharge. However, when the person or his/her family are unable or unwilling to make the planned renovations or modifications, discharge should not be held up and alternatives should be sought.

(INESSS-ONF, 2015)

C 3.8 C

Individuals with traumatic brain injury should be transitioned from inpatient rehabilitation to home on a supported, gradual basis (e.g., home visits, weekend/weekday passes with family, and experiences in transitional living).

(INESSS-ONF, 2015)

C 3.9 C

Preparing individuals with traumatic brain injury (TBI) and family/caregivers for community transition should include:

  • Training of family/caregivers in the use of equipment and the management of the individual in order to ensure his or her safety in the home environment

  • Educating individuals with TBI and family/caregivers about relevant formal and informal resources, including voluntary services and self-help groups, and how to access them.

(Adapted from ABIKUS 2007, G84, p. 30)

C 3.10 P C

Copies of both the discharge report and the patient care plan should be provided to the person with traumatic brain injury, and, with his or her consent, to the family/caregivers, as well as all professionals relevant to the person’s rehabilitation in the community, especially the general practitioner.

These reports should include:

  • Electronic health records summary or report detailing the clinical history, examination and any imaging

  • The results of all recent assessments

  • A summary of progress made and/or reasons for discharge/transfer

  • Recommendations for future interventions and follow-up

(Adapted from ABIKUS, 2007, G87, p. 30)

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