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.
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.
