Traumatic Brain Injury (TBI)

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Chronic Treatment

Disabilities from TBI may last a lifetime, and different interventions may be appropriate even many years later. This is particularly true for survivors of moderate to severe TBI. It is essential for survivors, their families, and caregivers to be involved in designing and implementing the rehabilitation plan.

There are two categories of chronic treatment:

• Community-based rehabilitation and return to work or school, and
• Treatment of long-term consequences of the injury.

Community-based Rehabilitation
Ultimately, rehabilitation must take place in the community rather than the controlled environment of a rehabilitation facility. Some patients do best with individual therapy (speech, occupational, physical) at an outpatient facility or at home. For others, a multidisciplinary, case-managed program works best. Most urban regions in the United States have these programs. This approach utilizes a team of professionals that is usually composed of one or more therapists and social workers, a case manager, and vocational specialist. Case-managed programs are very effective, especially for patients with complex medical and social problems.

Treatment of Consequences of TBI
Patients may have residual symptoms that require skilled management by qualified neurologists, physiatrists, and neuropsychologists.

Common symptoms and their related treatments include:

• Abnormal muscle tone (e.g., spasticity, dystonia) may be treated with physical therapy, oral medication, and minor surgery.
• Chronic pain sometimes requires medication, physical therapy, and psychological techniques.
• Depression, anxiety, and behavioral problems usually are treated with medication and psychotherapy.
• Seizures and headaches may require medication.

The Glasgow Coma Scale is useful for predicting early outcome from a head injury but it is less useful for estimating how a patient eventually will function in daily, independent living.

Many rehabilitation centers use the Ranchos Los Amigos Scale of Cognitive Functioning to follow the recovery of the head injury survivor and to determine when he/she is ready to begin a structured rehabilitation program. The scale is divided into eight stages, from coma to appropriate behavior and cognitive functioning.

Rancho Los Amigos Levels of Cognitive Functioning

I. No response to stimulation
II. Generalized response to stimulation
III. Localized response to stimulation
IV. Confused, agitated behavior
V. Confused, inappropriate, nonagitated behavior
VI. Confused, appropriate behavior
VII. Automatic, appropriate behavior
VIII. Purposeful, appropriate behavior

This scale does not take into account many changes in the patient's cognitive, memory, and motor functions that suggest whether he or she will be able to return to work or school. Assessments by neuropsychologists, speech pathologists, and therapists are needed.

The amount of social support a person receives gradually becomes the most important factor in ensuring the fullest possible recovery. Once the patient plateaus, family, friends, and an experienced treatment team of physicians, therapists, social workers and psychologists must work together to provide critical emotional, physical, medical, and psychological support.

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