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 > D. Promoting Reintegration and Participation

D. Promoting Reintegration and Participation

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Rehabilitation to support community reintegration for individuals following traumatic brain injury (TBI) should be a coordinated process.  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.  Several factors are associated with poor 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.  Leisure activities should also be facilitated through identifying what is meaningful and productive for the individual.  Increased independence can be facilitated by a return to driving, though assessment and retraining is required to confirm an individual’s ability to safely operate a vehicle.   Assessment and case coordination are important facilitators in vocational rehabilitation. 

Reintegration to community for an individual with moderate to severe TBI is not a linear process.  System planners and clinical leads should recognize that supports and specialized services may be required long-term to ensure continued progress and gains.  Follow-up with individuals and their families/caregivers in the form of appointments or telephone interviews should be made by referring programs to ensure continuity of services.   Outpatient and community-based programs should plan for a new client’s entry into their service in a timely manner through coordination, intake and assessment.  Outpatient programs require sufficient staffing to ensure that skills can be practiced in a realistic and meaningful environment to the individual with TBI.  Rehabilitation programs should build a partnership with peer support organizations within the community (e.g. local brain injury association). Programs should put in place a mechanism allowing for individuals to re-access services, if required, in periods of life transition that demand new skills to be developed.  Rehabilitation teams should establish a mechanism for referral to appropriate physicians to enable assessments for driving capacity to be made. Vocational rehabilitation should be offered to individuals 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.


Indicators examples

  • Average time between referral and admission to outpatient/community-based rehabilitation services.

  • Proportion of individuals with ongoing disability following TBI who have access to a specialized outpatient / community based rehabilitation service.

  • Proportion of individuals with TBI with a documented assessment of daily living and instrumental activities of daily living (ADL/IADL) in the person’s chart.

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 reintegration is challenging. A study by Fleming et al. (2014) found that 47% of participants reported physical barriers and 54% reported service barriers in their attempts to reintegrate into society. Service barriers and physical/structural barriers (Pappadis, 2012), as well as financial strain are associated with poor community reintegration (Nalder et al., 2012).

In terms of outpatient care or community care there are several similarities to inpatient rehabilitation. A multidisciplinary approach is still 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).  However, a longer duration of rehabilitation is suggested but with less intensity to allow patients to integrate back into daily life. Jeyaraj et al. (2013) noted that there is a need to train clinicians who provide community services about how best to assist individuals with acquired brain injury (ABI) and increase the amount of community resources. Cusick (2003) compared individuals enrolled in a Medicaid Waiver Program to those receiving no outpatient Medicaid support. Although patients in the Medicaid waiver program showed higher levels of resource use, as well as improved mental health status and less substance abuse, the control groups scored better on independence based measures (i.e. physical, cognitive, and mobility). Given all the confounding variables that were not controlled for, firm conclusions cannot be drawn from this study; however, such programs seem promising in terms of helping patients with ABI access appropriate services. 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.

Braunling-McMorrow et al. (2010) looked at the benefits of participation in a weekly program that included both behavioural and cognitive therapies that would teach participants to respond to various life events appropriately and allow for greater independence. Those in the neurobehavioural group admitted within the first six months of injury showed greater improvement than those admitted later. The study authors suggest that injury severity may have been a factor, with more severe cases being admitted sooner. As well, for those admitted later, gains had already been made and this may have made the gains in the program appear less significant (Braunling-McMorrow et al., 2010).

At home follow-up for patients with traumatic brain injury (TBI) have 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).

Another study by 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 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.

Bender et al. (2014) evaluated an inpatient interval rehabilitation program compared to an early rehabilitation program. Bender et al. (2014) reported 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 for additional rehabilitation at later stages of recovery. The study found 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).

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.

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” in an attempt 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.

For many individuals in our society, driving represents a significant marker of independence. In the literature, return to driving rates ranged from 36.5% to 75% (Fleming et al., 2014; Hawley, 2001; Leon-Carrion et al., 2005; Liddle et al., 2012; Pietrapiana et al., 2005). Of concern, at admission to rehabilitation, one study found 30.5% of the patients were driving despite not being fit to do so (Leon-Carrion et al., 2005). It is imperative that thorough evaluations are conducted prior to the return to driving. Schanke et al. (2008) found that patients who had sustained a TBI had twice as many accidents post-injury then they did pre-injury. The authors felt this may be the result of a lack of adequate compensation for the patients cognitive deficits post-injury, particularly deficits relating to executive function.

In terms of returning patients back to work or educational settings, 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, as well as knowledge of pre-injury skills, as well as a vocational plan, with continual access to resources (Stergiou-Kita et al., 2011). Malec and Degiorgio (2002) reported that patients in three different rehabilitation pathways, who differed in terms of cognitive functioning and disability, were able to succeed in terms of community-based employment. The study highlights the need for an individualized approach to ensure successful integration into the community. 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). 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 increased health costs, suggesting cost-effectiveness. There is a need for definitive Randomized Controlled Trials (RCT) in this group.

Bell, K. R., Brockway, J. A., Hart, T., Whyte, J., Sherer, M., Fraser, R. T., . . . Dikmen, S. S. (2011). Scheduled telephone intervention for traumatic brain injury: a multicenter randomized controlled trial. Arch Phys Med Rehabil, 92(10), 1552-1560.

Bell, K. R., Temkin, N. R., Esselman, P. C., Doctor, J. N., Bombardier, C. H., Fraser, R. T., . . . Dikmen, S. (2005). The effect of a scheduled telephone intervention on outcome after moderate to severe traumatic brain injury: a randomized trial. Arch Phys Med Rehabil, 86(5), 851-856.

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.

Braunling-McMorrow, D., Dollinger, S. J., Gould, M., Neumann, T., & Heiligenthal, R. (2010). Outcomes of post-acute rehabilitation for persons with brain injury. Brain Inj, 24(7-8), 928-938.

Cusick, A. (2003). Clinical research: A room of one's own. Aust Occup Ther J, 50(1), 44-47.

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

Fleming, J., Braithwaite, H., Gustafsson, L., Griffin, J., Collier, A. M., & Fletcher, S. (2011). Participation in leisure activities during brain injury rehabilitation. Brain Inj, 25(9), 806-818.

Fleming, J., Nalder, E., Alves-Stein, S., & Cornwell, P. (2014). The effect of environmental barriers on community integration for individuals with moderate to severe traumatic brain injury. J Head Trauma Rehabil, 29(2), 125-135.

Hawley, C. A. (2001). Return to driving after head injury. J Neurol Neurosurg Psychiatry, 70(6), 761-766.

Hibbard, M. R., Cantor, J., Charatz, H., Rosenthal, R., Ashman, T., Gundersen, N., . . . Gartner, A. (2002). Peer support in the community: initial findings of a mentoring program for individuals with traumatic brain injury and their families. J Head Trauma Rehabil, 17(2), 112-131.

Jeyaraj, J. A., Clendenning, A., Bellemare-Lapierre, V., Iqbal, S., Lemoine, M. C., Edwards, D., & Korner-Bitensky, N. (2013). Clinicians' perceptions of factors contributing to complexity and intensity of care of outpatients with traumatic brain injury. Brain Inj, 27(12), 1338-1347.

Johnson, K., & Davis, P. K. (1998). A supported relationships intervention to increase the social integration of persons with traumatic brain injuries. Behav Modif, 22(4), 502-528.

Lamontagne, M. E., Poncet, F., Careau, E., Sirois, M. J., & Boucher, N. (2013). Life habits performance of individuals with brain injury in different living environments. Brain Inj, 27(2), 135-144.

Leon-Carrion, J., Dominguez-Morales, M. R., & Martin, J. M. (2005). Driving with cognitive deficits: neurorehabilitation and legal measures are needed for driving again after severe traumatic brain injury. Brain Inj, 19(3), 213-219.

Liddle, J., Fleming, J., McKenna, K., Turpin, M., Whitelaw, P., & Allen, S. (2012). Adjustment to loss of the driving role following traumatic brain injury: a qualitative exploration with key stakeholders. Aust Occup Ther J, 59(1), 79-88.

Malec, J. F., & Degiorgio, L. (2002). Characteristics of successful and unsuccessful completers of 3 postacute brain injury rehabilitation pathways. Arch Phys Med Rehabil, 83(12), 1759-1764.

Martelli, M. F., Zasler, N. D., & Tiernan, P. (2012). Community based rehabilitation: special issues. NeuroRehabilitation, 31(1), 3-18.

Mitchell, E. J., Veitch, C., & Passey, M. (2014). Efficacy of leisure intervention groups in rehabilitation of people with an acquired brain injury. Disabil Rehabil, 36(17), 1474-1482.

Nalder, E., Fleming, J., Foster, M., Cornwell, P., Shields, C., & Khan, A. (2012). Identifying factors associated with perceived success in the transition from hospital to home after brain injury. J Head Trauma Rehabil, 27(2), 143-153.

Pappadis, M. R., Sander, A. M., Leung, P., & Struchen, M. A. (2012). The impact of perceived environmental barriers on community integration in persons with traumatic brain injury. Acta Neuropsychol, 10(3), 385-397.

Pietrapiana, P., Tamietto, M., Torrini, G., Mezzanato, T., Rago, R., & Perino, C. (2005). Role of premorbid factors in predicting safe return to driving after severe TBI. Brain Inj, 19(3), 197-211.

Ponsford, J., Harrington, H., Olver, J., & Roper, M. (2006). Evaluation of a community-based model of rehabilitation following traumatic brain injury. Neuropsychol Rehabil, 16(3), 315-328.

Radford, K., Phillips, J., Drummond, A., Sach, T., Walker, M., Tyerman, A., . . . Jones, T. (2013). Return to work after traumatic brain injury: Cohort comparison and economic evaluation. Brain Injury, 27(5), 507-520.

Schanke, A. K., Rike, P. O., Molmen, A., & Osten, P. E. (2008). Driving behaviour after brain injury: a follow-up of accident rate and driving patterns 6-9 years post-injury. J Rehabil Med, 40(9), 733-736.

Sloan, S., Callaway, L., Winkler, D., McKinley, K., & Ziino, C. (2012). Accommodation Outcomes and Transitions Following Community-Based Intervention for Individuals with Acquired Brain Injury. Brain Impairment, 13(1), 24-43.

Stergiou-Kita, M., Dawson, D. R., & Rappolt, S. G. (2011). An integrated review of the processes and factors relevant to vocational evaluation following traumatic brain injury. J Occup Rehabil, 21(3), 374-394.

Struchen, M. A., Davis, L. C., Bogaards, J. A., Hudler-Hull, T., Clark, A. N., Mazzei, D. M., . . . Caroselli, J. S. (2011). Making connections after brain injury: development and evaluation of a social peer-mentoring program for persons with traumatic brain injury. J Head Trauma Rehabil, 26(1), 4-19.

Thomas, D., & Menz, F. (1996). Functional Assessment of vocational skills and behaviours of persons with brain trauma injuries. Journal of vocational rehabilitation, 7(243-256).

Turner, B., Fleming, J., Cornwell, P., Haines, T., & Ownsworth, T. (2009). Profiling early outcomes during the transition from hospital to home after brain injury. Brain Inj, 23(1), 51-60.

Wise, E. K., Mathews-Dalton, C., Dikmen, S., Temkin, N., Machamer, J., Bell, K., & Powell, J. M. (2010). Impact of traumatic brain injury on participation in leisure activities. Arch Phys Med Rehabil, 91(9), 1357-1362.

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P Priority F Fundamental New Level of evidence A B C

D 1.1 P B

All individuals with traumatic brain injury (TBI) discharged from a specialized TBI rehabilitation program (inpatient, outpatient, residential) should have access, if needed, to scheduled telephone follow-up contact with a professional skilled in motivational interviewing, goal setting, providing reassurance and problem-solving support.

(Adapted from NZGG 2007, 9.1, p. 130)

D 1.2 C

Postdischarge long-term services (e.g., counselling, provision of information, etc.) should be available, if needed, for the person with traumatic brain injury and his/her family/caregivers, to enable and sustain optimal societal participation while supporting personal choice and facilitating adjustment.

(Adapted from NZGG 2007, 9.2, p. 132)

P Priority F Fundamental New Level of evidence A B C

D 2.1 F C

Individuals with ongoing disability after traumatic brain injury should have timely access to specialized outpatient or community-based rehabilitation to facilitate continued progress and successful community reintegration.

(Adapted from NZGG 2007, 6.6, p. 116)

D 2.2 P icon B

A peer-supported relationship model of intervention within a community-based program should be available to individuals with traumatic brain injury in order to promote social integration, coping and psychological functioning.

(INESSS-ONF, 2015)


- ERABI Module 13 - Community Reintegration, 13.2.3

Please note that ERABI concludes that peer-mentoring is actually not effective based on the literature. 

D 2.3 icon C

Access to interval care (re-entry to care or intensification of services) should be allowed so that individuals with traumatic brain injury can access treatment as their impairments, ability and participation goals change or new challenges/transitions create a renewed need for services.

(INESSS-ONF, 2015)

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.


- Bender et al. (2014)

P Priority F Fundamental New Level of evidence A B C

D 3.1 P icon C

All individuals with traumatic brain injury should be assessed for their level of independence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

(INESSS-ONF, 2015) 

D 3.2 C

All daily living tasks should be practised in the most realistic and appropriate environment for the person with traumatic brain injury, with the opportunity to practise skills in natural settings outside therapy sessions.

(Adapted from NZGG 2007, 6.2, p. 106)

D 3.3 P B

An individualized life skills training protocol should be developed for each person with traumatic brain injury, to assist them in dealing effectively with the demands and challenges of everyday life. Depending on the needs of the person and his/her impairment profile, life skills training may focus on social skills, activities of daily living / instrumental activities of daily living (ADLs/IADLs), interpersonal skills, job skills, problem-solving skills, decision-making skills, self-advocacy skills, behavioural self-regulation skills, etc.

(Adapted from AOTA 2009, p. 83) 

D 3.4 C

As appropriate, environmental cues should be included in the person with traumatic brain injury’s treatment plan for activities of daily living and instrumental activities of daily living (ADLs/IADLs).

(Adapted from AOTA 2009, p. 83)

D 3.5 C

Compensatory training, individualized environmental adaptation as well as remediation training should be provided to the person with traumatic brain injury, either simultaneously or sequentially, as appropriate.

(Adapted from AOTA 2009, p. 82)

P Priority F Fundamental New Level of evidence A B C

D 4.1 C

All individuals with traumatic brain injury should be assessed by a rehabilitation professional or team regarding leisure activities. Assessments should include identification of:

  • Their pre-injury level of participation in leisure/meaningful activities

  • The barriers or compounding problems which inhibit their engagement in such activities

(Adapted from NZGG 2007, 6.6, p. 116)

D 4.2 P B

Individuals with traumatic brain injury with difficulty undertaking leisure/meaningful activities of their choice should be offered a goal-directed community-based program aimed at increasing participation in leisure/meaningful and social activities.

(Adapted from ABIKUS 2007, G97, p. 32)

P Priority F Fundamental New Level of evidence A B C

D 5.1 C

A physician/health care professional with experience in traumatic brain injury should assess individuals who wish to drive, in accordance with local legislation and in liaison with the interdisciplinary rehabilitation team.

(Adapted from ABIKUS 2007, G90, p. 31)

D 5.2 C

If the capacity of the person with traumatic brain injury to drive is unclear, a comprehensive assessment of capacity to drive should be undertaken at an approved driving assessment centre or service or by professionals qualified to conduct such an evaluation.

(Adapted from ABIKUS 2007, G92, p. 31)

D 5.3 P C

If during assessment or treatment of a person with traumatic brain injury (TBI), the interdisciplinary rehabilitation team determines that the person’s ability to drive safely may be affected, then they should:

  • Provide clear guidance to treating health professionals, the person and family/caregivers about any concerns about driving, and reinforce the need for disclosure and assessment in the event that return to driving is sought later post-injury

  • Provide the person with information about the law and driving after TBI

  • If applicable, advise the person and/or their advocate that they are obliged by law to inform the relevant government body that the person has suffered a neurological or other impairment and to provide the relevant information on its effects

(Adapted from ABIKUS 2007, G91, p. 31)

P Priority F Fundamental New Level of evidence A B C

D 6.1 P C

Individuals with traumatic brain injury should be assessed for the need for vocational rehabilitation to assist their return to work or to school, or for entering the workforce for those not previously employed and should include:

  • Comprehensive pre-injury history (including educational and work history)

  • Current capacities of the person, in particular at the cognitive, psychological and physical levels

  • Current social status

  • Evaluation of the person’s vocational and/or educational needs

  • Identification of difficulties which are likely to limit the prospects of a successful return to work or to school and appropriate interventions to minimize them

  • Direct liaison with employers (including occupational health services when available) or education providers (teachers, services for disabled students, etc.), to discuss needs and the appropriate action in advance of any return

  • Evaluation of environmental factors, workplace and psychosocial aspects including social environment and work culture

  • Verbal and written advice about their return, including arrangements for review and follow-up

(Adapted from NZGG 2007, 6.4, p. 110, ABIKUS 2007, G93, p. 32 and Stergiou-Kita 2011, 2, p.15–16)

D 6.2 icon C

Vocational rehabilitation interventions should be offered to individuals with traumatic brain injury 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, and on-site training.

(INESSS-ONF, 2015)


- Radford et al. (2013)

D 6.3 P C

Standard vocational rehabilitation interventions offered to individuals with traumatic brain injury, such as cognitive training and behaviour modification, should be monitored for effectiveness, and supported employment should be provided for those who wish to return to work and for whom the standard interventions are insufficiently effective.

(Adapted from NZGG 2007, 6.4, p. 110)

D 6.4 C

Supported employment offered to individuals with traumatic brain injury (TBI) who wish to return to work should include these fundamental aspects:

  • Job placement, including:

    - Matching job needs to abilities and potential

    - Facilitating communication between the person, the employer and caregivers

    - Arranging travel/training

  • Job site training and advocacy including:

    - Training

    - Proactive assessment of potential problems in the job environment

    - Designing solutions in cooperation with the person with TBI, caregivers and employers

    - Ongoing assessment of the person’s work performance

  • Job retention and follow-up including:

    - Monitoring of progress to anticipate problems and intervene proactively when necessary

(Adapted from NZGG 2007, 6.4, p. 111)

D 6.5 B

An assessment of the requirements of the occupation/job the person with traumatic brain injury is considering entering or re-entering (i.e., job analysis) should be conducted prior to job reintegration. This should include the identification and/or assessment of the following elements:

Occupation/job title/category/classification; occupation/job description; complexity and variety of tasks associated with the occupation/job demands.

(Adapted from Stergiou-Kita 2011, 5, p.27)

D 6.6 icon B

Upon completion of the vocational evaluation process following traumatic brain injury (TBI), the evaluator should draw conclusions based on the analysis of findings from all assessments completed and data gathered. The evaluator should relate conclusions back to the original evaluation purpose/question(s) to make recommendations for work re-entry, return to work or future vocational planning through verbal and/or written report to the person with TBI being evaluated and relevant stakeholders, as per the consents established.

(INESSS-ONF, 2015)

D 6.7 P icon B

Gradual work trial for individuals with traumatic brain injury should include a start date, an indication of how to increase hours and days, limitations and restrictions, as well as recommended accommodations.

(INESSS-ONF, 2015)

D 6.8 icon C

If unable to engage in paid employment, individuals with traumatic brain injury should be assisted to explore other avenues for productivity that promote community integration (e.g., volunteer work with TBI- and non-TBI-specific organizations).

(INESSS-ONF, 2015)

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