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 > A. Key Components of TBI Rehabilitation

A. Key Components of TBI Rehabilitation

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Traumatic brain injury results in complex physical, emotional and cognitive changes. There is solid evidence that rehabilitation can improve outcomes. There is also evidence that earlier rehabilitation will result in better outcomes than delayed.  However, because of complexity, a large interdisciplinary team is required. Furthermore, each individual has unique needs; therefore, a case coordinator can coordinate an individual’s rehabilitation program to ensure that the person’s goals are met and to facilitate transition back into normal living. Because of the emotional changes, a quiet environment may reduce the incidence of challenging behaviours.

There is a need for coordination between acute care and rehabilitation teams. Processes for referral to rehabilitation need to respond quickly. Development of clinical pathways requires clinician engagement to ensure a reasonable approach.  Traumatic brain injury rehabilitation teams require adequate staffing to provide daily therapy. This usually requires an environment with features such as 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.

Indicators examples

  • Proportion of individuals with TBI who required and received rehabilitation services within two working days of the transfer from acute care.

  • Average time between trauma and start of rehabilitation interventions.

  • Presence of written rehabilitation admission criteria for individuals with TBI which include all four fundamental elements:

  1. A traumatic brain injury diagnosis;

  2. Medical stability;

  3. The ability to improve through the rehabilitation process;

  4. The ability to learn and engage in rehabilitation.

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:

  • Clearly defined admission criteria – including clear definition of what is a medically stable and rehab ready condition

Several studies have shown early rehabilitation to be beneficial in an individual’s overall recovery from TBI (Cope, 1995; Heinemann, 1990; Kunik et al., 2006; León-Carrión et al., 2013; Mackay et al., 1992). 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. Length of stay was also positively impacted, with those admitted sooner requiring fewer days in rehabilitation (Kunik et al., 2006; Wagner et al., 2003).

Integrated care pathways and protocols should be in place during rehabilitation transition. 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 have reduced costs as well (Andelic et al., 2014). In a cohort study, Harradine et al. (2004) noted that co-ordination of regional facilities resulted in an equitable availability of resources despite geographic challenges in New South Wales, Australia. A series of interviews with case managers and brain injury staff revealed that a comprehensive rehabilitation case management approach provided a consistent and continuous transition through the rehabilitation continuum (Kennedy et al., 2012). Similarly, Talbot et al. (2014) conducted interviews with patients and focus groups with clinicians, and reported that a new Collaborative Care model resulted in improved continuity of care and communication among clinicians and patients. The increased communication allowed clinicians to better monitor and facilitate patient progress.

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.

Addictive behaviours (alcohol and narcotics abuse and gambling) have been shown to be a serious problem for some individuals both pre and post ABI. Various studies have looked at the incidence of these behaviours and have found that 30 to 60% of individuals who sustain an ABI have a dependence issues (Jorge & Starkstein, 2005). Many individuals relapse post injury, often within the first or second year. In order to ensure there is continuity in patient care and to provide optimal management of individuals with TBI, collaboration with appropriate services should also be made (e.g., mental health services, addition/substance abuse services, etc.). To optimize these collaborations, cross-training and education of all professionals involved is necessary so that issues specific to TBI are recognized and understood.  Regional differences in resource availability need to be taken into consideration along with patient demographics so that pathway decisions can be made. Therefore, rehabilitation programs should collect and analyze data regarding the population serviced to allow for proper evaluation.

Challenging behaviour following a brain injury occurs with a relatively high frequency (25-50%). Challenging behaviour can include, but is not limited to, the following: non-compliance with treatment, anger, agitation, verbal and/or physical aggression and depression. The emergence of these behaviours likely arises from injury to the frontal lobes and more specifically the orbitofrontal areas resulting in disinhibited behaviour and lack of recognition of the consequences of one’s behaviour. Typically behavioural management techniques and pharmacological interventions are used to minimize and/or alleviate these challenges with varying degrees of success (McDonald et al., 2008).

Program Staff and health care professionnal  training is an important element of managing complex TBI patients. 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 programme and allocated to either a training or control group. Training comprised a 17-hour programme (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-months 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).

Andelic, N., Ye, J., Tornas, S., Roe, C., Lu, J., Bautz-Holter, E., Mogner, T., Sigurdardottir, S., Schanke, A. K.. Aas, E.. (2014). Cost-effectiveness analysis of an early-initiated, continuous chain of rehabilitation after severe traumatic brain injury. J Neurotrauma, 31(14), 1313-1320.

Becker, H., Harrelt, W. T., & Keller, L. (1993). A survey of professional and paraprofessional training needs for traumatic brain injury rehabilitation. J Head Trauma Rehabil, 8(1), 88-101.

Behn, N., Togher, L., Power, E., & Heard, R. (2012). Evaluating communication training for paid carers of people with traumatic brain injury. Brain Inj, 26(13-14), 1702-1715.

Cope, D. N. (1995). The effectiveness of traumatic brain injury rehabilitation: a review. Brain Inj, 9(7), 649-670.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). http://www.abiebr.com/.  

Harradine, P. G., Winstanley, J. B., Tate, R., Cameron, I. D., Baguley, I. J., & Harris, R. D. (2004). Severe traumatic brain injury in New South Wales: comparable outcomes for rural and urban residents. Med J Aust, 181(3), 130-134.

Heinemann, A. W., Sahgal, V., Cichowski, K., Tuel, S. M., Betts, H. B. . (1990). Functional outcome following traumatic brain injury rehabilitation. J Neurol Rehabil, 4, 27-37.

Jorge, R. E., & Starkstein, S. E. (2005). Pathophysiologic aspects of major depression following traumatic brain injury. J Head Trauma Rehabil, 20(6), 475-487.

Kennedy, N., Barnes, J., Rose, A., & Veitch, C. (2012). Clinicians' expectations and early experiences of a new comprehensive rehabilitation case management model in a specialist brain injury rehabilitation unit. Brain Impairment, 13(1), 62-71.

Kunik, C. L., Flowers, L., & Kazanjian, T. (2006). Time to rehabilitation admission and associated outcomes for patients with traumatic brain injury. Arch Phys Med Rehabil, 87(12), 1590-1596.

León-Carrión, J., MacHuca-Murga, F., Solís-Marcos, I., León-Domínguez, U., & Domínguez-Morales, M. D. R. (2013). The sooner patients begin neurorehabilitation, the better their functional outcome. Brain Injury, 27(10), 1119-1123.

Mackay, L., Bernstein, B., Chapman, P., Morgan, A., & Milazzo, L. (1992). Early intervention in severe head injury: long-term benefits of a formalized program. Arch Phys Med Rehabil, 73(7), 635-641.

McDonald, S., Tate, R., Togher, L., Bornhofen, C., Long, E., Gertler, P., & Bowen, R. (2008). Social skills treatment for people with severe, chronic acquired brain injuries: a multicenter trial. Arch Phys Med Rehabil, 89(9), 1648-1659.

Talbot, L. R., Levesque, A., & Trottier, J. (2014). Process of implementing collaborative care and its impacts on the provision of care and rehabilitation services to patients with a moderate or severe traumatic brain injury. J Multidiscip Healthc, 7, 313-320.

Wagner, A. K., Fabio, T., Zafonte, R. D., Goldberg, G., Marion, D. W., & Peitzman, A. B. (2003). Physical medicine and rehabilitation consultation: relationships with acute functional outcome, length of stay, and discharge planning after traumatic brain injury. Am J Phys Med Rehabil, 82(7), 526-536.

Webb, P. M., & Glueckauf, R. L. (1994). The effects of direct involvement in goal setting on rehabilitation outcome for persons with traumatic brain injuries. Rehabilitation Psychology, 39(3), 179-188.

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P Priority F Fundamental New Level of evidence A B C

A.1.1 F C

Every individual with traumatic brain injury should have timely, specialized interdisciplinary rehabilitation services.

(Adapted from ABIKUS 2007, G2, p. 16)

A 1.2 P icon B

Rehabilitation interventions should be initiated as soon as the condition of the person with traumatic brain injury allows.

(INESSS-ONF, 2015)


- ERABI Module 3- Efficacy and Models of Care Following an Acquired Brain Injury

- Leon-Carrion et al. (2013)

- Wagner et al. (2003)

A 1.3 F icon C

Rehabilitation programs should have clearly stated admission criteria, which include a traumatic brain injury diagnosis, medical stability, the ability to improve through the rehabilitation process, the ability to learn and engage in rehabilitation and sufficient tolerance for therapy duration.

(INESSS-ONF, 2015)

A 1.4 F C

The assessment and planning of rehabilitation should be undertaken through a coordinated, interdisciplinary team and follow a patient-focused approach responding to the needs and choices of individuals with traumatic brain injury as they evolve over time.

(Adapted from NZGG 2007, 4.4, p. 76 and ABIKUS 2007, G1, p. 16)

A 1.5 F icon C

The traumatic brain injury rehabilitation team should optimally consist of a speech-language pathologist, occupational therapist, physiotherapist, social worker, neuropsychologist (and psychometrist), psychologist (with expertise in behaviour therapy), nurse, physician and/or physiatrist, rehabilitation support personnel, nutritionist, therapeutic recreationist and pharmacist.

(INESSS-ONF, 2015)

Note: Specific membership should be based on the individual’s developing needs as determined by initial and ongoing assessments and goal setting with the individual and family.

A 1.6 P B

Individuals with traumatic brain injury (TBI) who require rehabilitation should have a case or clinical coordinator appointed at each phase of the continuum of care.

(Adapted from NZGG 2007,, p. 75)

Note: The case coordinator should have clinical experience and specialized training in a TBI-related field, and should assume the following roles:

  • Oversee the planning and delivery of rehabilitation

  • Coordinate the interdisciplinary team, avoiding duplication of tasks or interventions

  • Advocate for the needs of the individual with TBI and their caregivers

  • Plan and coordinate the transition between phases in the continuum of care, providing continuity and good communication between various care providers

  • Be the key point of contact for the person with TBI, his/her family, the interdisciplinary team, and other resources

A 1.7 F C

Integrated care pathways and protocols should be in place to facilitate a person’s transition from an acute care to a rehabilitation setting and to assist in the management of commonly encountered problems associated with traumatic brain injury.

(Adapted from ABIKUS 2007, G5, p. 16)

A 1.8 icon C

The rehabilitation environment should be conducive to the person with traumatic brain injury and his or her recovery. Strategies should be in place to promote privacy and sleep hygiene such as the use of single rooms (where available), a quiet environment, and familiar routines.

(INESSS-ONF, 2015)

A 1.9 F icon B

The rehabilitation plan should be goal-oriented. There should be a high degree of involvement of the person with traumatic brain injury (TBI), their family/caregivers and the rehabilitation team members in goal setting early in the course of rehabilitation, so that they can be monitored throughout the rehabilitation program.

(INESSS-ONF, 2015)

Note: High-level involvement in goal setting by the person with TBI results in a greater number of goals being maintained at follow-up (two months).


- Webb (1994)

A 1.10 F icon C

In order to support the continuous quality improvement of their services, traumatic brain injury (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:

  • Volume of referrals

  • Age

  • Sex/gender

  • Race

  • Etiology of TBI

  • Severity of TBI

  • Glasgow Coma Scale

  • Duration of post-traumatic amnesia

  • Others

(INESSS-ONF, 2015)

A 1.11 F icon C

In order to support the continuous quality improvement of their services, traumatic brain injury rehabilitation programs should monitor key aspects of their processes and efficiency, including but not limited to:

  • Injury onset days to start of rehabilitation

  • Length of stay in rehabilitation

  • Intensity of services

  • Measures of functional change progression (ex. FIM, FAM, DRS, MPAI4, CRS-R)

  • Discharge disposition (return to home, level of services required, etc.)

  • School/work orientation on discharge

  • Satisfaction and quality of life

(INESSS-ONF, 2015)

P Priority F Fundamental New Level of evidence A B C

A 2.1 P C

Collaboration and continuity mechanisms should be established with mental health services and programs in order to develop optimal management strategies for individuals with comorbid traumatic brain injury (TBI) and mental health issues.

The collaboration mechanisms should involve cross-training and education for professionals of mental health care services on the recognition and understanding of issues particular to individuals with TBI.

(Adapted from NZGG 2007, 14.4, p. 172) 

For more information see Section R. Neurobehaviour and Mental Health

A 2.2 P C

Collaboration and continuity mechanisms should be established with addiction / substance use services and programs in order to develop optimal management strategies for individuals with comorbid traumatic brain injury (TBI) and addiction / substance use issues.

The collaboration mechanisms should involve cross-training and education for addiction / substance use service professionals on the recognition and understanding of issues particular to individuals with TBI.

(Adapted from NZGG 2007, 14.3, p. 170)

For more information see Section S. Substance Use Disorders.

A 2.3 P icon B

Health care professionals working with individuals having sustained a traumatic brain injury (TBI) should be trained in behaviour disorders specific to TBI in order to apply consistent neurobehavioural change strategies.

(INESSS-ONF, 2015)


- ABIKUS (2007), G20, p.19
- Behn et al. (2012)
- Becker et al. (1993)

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