TBI units need special staff skills, programs

Have you heard of neuro-optometry?

Traumatic brain injury (TBI) affects patients’ lives in so many different physical, cognitive, and behavioral ways that often a rehab team will include some nontraditional members and some unusual approaches to treatment.

At Kessler Institute for Rehabilitation in West Orange, NJ, the TBI program includes wheelchair, brace, and spasticity clinics, as well as an outpatient cognitive therapy program, among other components of its comprehensive approach, says Jonathan Fellus, MD, neurologist and director of Brain Injury Services for Kessler Institute. Fellus also is a clinical assistant professor at New Jersey Medical School in Newark.

Brain-injured patients generally are medically stabilized in the acute care hospital, and then are admitted to the special care unit, where therapy may be provided in smaller, less-distracting, one-on-one sessions that are designed to help patients who have limited ability to maintain attention and endurance. Then they are moved to the progressive care unit, a more complex and social environment where they will gain awareness, insight, and judgment, Fellus says.

After they are discharged from the inpatient brain injury unit, the patient may go home or begin outpatient therapy, or he or she could be referred to a day hospital to receive outpatient therapies several times a week. But once the TBI staff determine a patient is ready, the patient will be referred to the outpatient cognitive therapy program.

A typical week in the cognitive therapy program will include daily attendance from 10 a.m. to 3 p.m. with a full day of individual and group therapy, some neuropsychological counseling, and eventually sessions with a vocational counselor.

"They may do work trials within the building with the maintenance or kitchen staff," Fellus says. "We’ve even had a couple of doctors as patients who as part of their cognitive therapy were sent to work with the physicians here, and they’d go on rounds and have cases to discuss."

The goal of the cognitive program is to keep patients under one roof three to five times a week for four to 16 weeks, Fellus notes.

Patients progress from level one, which is basic, to level two, which is mainstream, to level three, which is when they return only for tuning up their new skills or to receive ongoing counseling while returning to work or school, Fellus says.

"We’re dealing here with a very heterogeneous group of people, from the laborer to the white-collar professional, and we can’t address all of their needs in a group session," Fellus says. "Because the outpatient cognitive program is primarily run by a neuropsychologist, there is a great deal of individualized behavioral modification going on."

One unique member of the TBI team is a rehabilitative neuro-optometrist who works with therapists in helping to realign visual information the patient sees by placing a prism lens over the patient’s existing lens or fitting a patient’s glasses with a prism lens, says Fellus.

Common visual problems that occur after a brain injury are blurred vision, perception and balance difficulties, and headaches and attention deficits that occur as a result of vision changes.

The neuro-optometrist and occupational therapist will work together to devise an exercise regimen that incorporates visual vestibular integration, which is how the eyes feed the balance mechanism and interact there, Fellus says.

"We have at least three different systems that help us keep our balance, including the inner ear balance that is always being matched with what our eyes are seeing and that is matched with our body’s position in space," Fellus explains. "There’s a complex interaction between the three systems, and neuro-optometry is good at helping to coordinate them."

Typically, at Kessler Institute, the occupational therapist will do a brief vision screening test and then let the patient’s physician know when a referral to the neuro-optometrist is indicated.

Another unusual TBI team member is a nurse case manager with TBI experience who is dedicated to obtaining insurance clearance for the TBI cognitive program.

Because each payer has its own complex set of rules, a great deal of staff time is required to explain the program and obtain funding, Fellus says.

"You have to be creative in moving benefits around," Fellus says. "If someone has unlimited physical therapy coverage but not a scratch on the body, then trying to get the insurance company to move that money to cover cognitive treatment is a worthy challenge."

So far, the nurse case manager has been successful in the role, and the dedicated staff hours have paid dividends for the patient and program alike, Fellus adds.

Need More Information?
  • Jonathan Fellus, MD, Director of Brain Injury Services, Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ 07052. Telephone: (973) 414-4776.