Special Report: Closer Look at TBI Treatment

TBI program focuses on cognition, other issues

Program treats many accident, gunshot victims

[Editor’s note: This is the first in a two-part series about traumatic brain injury (TBI) treatment and advances in knowledge and treatment among rehab facilities and providers. In next month’s issue, look for a story highlighting a large rehab center’s state-of-the-art TBI program.]

The 15-year-old traumatic brain injury (TBI) unit at Bacharach Institute for Rehabilitation in Pomona, NJ, has a program that treats patients holistically, training staff to handle the cognitive, emotional, and physical needs of patients.

Many of the unit’s patients were injured by motor vehicle accidents, gunshot wounds, strokes, or aneurysms, among other problems.

"We treat the physical, cognitive, and behavioral aspects of brain injury," says Lisa Rocco, MPT, CBIS, CCCE, clinical education supervisor and physical therapist.

"You can’t treat the body without treating the mind," Rocco says.

With a neuropsychologist serving as director of the program, the holistic approach is a natural for Bacharach, and the rehab institute has added some unique services in an effort to fulfill its mission of treating all of a TBI patient’s rehab needs.

For example, besides having on staff two physicians, therapists, nurses, and a case manager, the brain injury team also includes a nutritionist, a family therapist who is available when needed, and a vocational rehab counselor. Most unusual is the addition of a neuro-optometrist, whose role is to assess how the patient’s brain is interpreting visual information, Rocco says.

"Sometimes after brain injury the person’s visual information is distorted, and this affects function," Rocco explains. "The neuro-optometrist comes in every other week. He’s a great asset to the team."

Typically, the team begins an evaluation of a brain injury patient within 24 hours of admission. The physical therapist is responsible for seeing the patient on the same day of admission. The speech therapist also might see the patient on that first day.

"We meet the family on the first day and try to alleviate some of their fears," Rocco says. "We have such a comprehensive team that everyone is team-oriented with multidisciplinary goals, and they work together."

The team begins to plan the patient’s discharge from Day One of admission, and all disciplines will become involved in meetings with the patient and family. The team’s evaluation might include a visit to the family home to determine whether there are structural barriers to the patient’s recovery of independence, Rocco says.

One strategy that has helped the brain injury team develop such a holistic approach to care is that the staff are taught about cognition problems that may affect patients and their recovery.

"We go over the different cognitive skills, describing how it’s like a foundation for a house," Rocco explains. "First, the patient has to be aroused and have some level of being awake and alert before you can ask the patient to do anything."

Staff are then given tips on helping patients maintain alertness, including choosing the right environment for the therapy or treatment to take place.

Some patients need more stimulation

"If someone is agitated, then we’re not worried about alertness because the patient is in a hyperaroused state," Rocco says. "But if someone is waking up out of a coma and just beginning to respond, then the person needs more stimulation."

In other words, such a patient should not be kept in a dark room that is conducive to sleep. Rather, therapists should transfer the patient to a wheelchair and bring the patient to an area that has more activity, such as a gym with lights and people moving about.

"First, you have to keep them awake, and next have them sustain and pay attention," Rocco says.

If the gym or other public area seems too distracting, then move the patient to a quieter area until the patient is acclimated to the busier setting.

The next step is for therapists to learn functional cognitive activities. For example, a therapist might ask the patient to describe how he or she would visit a family member in the facility. Then the therapist can assist the patient in navigating that route.

Or another cognitive activity might be to take the patient to a staff office where the patient can take drink orders from several employees and then fill those orders.

These types of exercises are important because brain injury patients will recover physical function more quickly than cognitive function, Rocco says.

"Brain injury patients love physical therapy because they can see gains day to day and week to week," Rocco says. "But cognitively, they are not aware of the problems."

This difference is also noticeable in how family and friends react to the person with a brain injury, Rocco notes.

"If you have a catheter in your leg, it’s more concrete and easier to understand than if you have a brain injury," Rocco says. "If there are no scars on your head, people will have a hard time thinking through things, and this can be very dangerous if you don’t have the awareness."

Once a brain injury patient recovers some physical skills, he or she may forget about the brain injury, Rocco says.

"To prevent that, we have central alarms on the beds and wrist band systems where if a patient leaves the unit, there’s an alarm to go off," Rocco says. "If someone is a threat to himself, there are safety measures in place because we have to be one step ahead of patients at all times."

Staff also are taught to integrate functional cognitive activities within traditional physical therapy treatment plans of increasing flexibility, range of motion, strength, and balance.

"The goal is to first work on the patient’s function and then put the patient in a realistic environment," Rocco says. "We create obstacles for distractions, and then move the patient into the hallway where people are going about their business and may not even be aware that a therapist is working with a patient."

Brain injuries aren’t always obvious

People with brain injuries may not walk around in society and interact with people in the most appropriate way, but people outside their family may not realize they have social and cognitive deficits, Rocco explains.

"If you’re a patient and you have a cane, people will move out of your way and give you more space," Rocco says. "But if you’re walking around with a brain injury, people may not know it."

For example, a therapist might take a brain injury patient to a street where the patient will have to visually scan the street from left to right, judge distance, sequence the event, and time the crossing so that he or she will not be hit by a car, Rocco explains. "The patient needs to learn to problem-solve when someone in a car puts a blinker on, or if the patient drops something while crossing and decides whether to stop or continue to the other side."

Showing staff how to teach social skills to brain injury patients is another area that is very different from general rehab.

Therapists may be encouraged to take brain injury patients into public settings, such as a gift shop, and then instruct patients to not touch everything in there, Rocco says.

Finally, brain injury staff are taught how disruptive a patient’s behavior might be to the therapy session. Brain-injured patients sometimes can be physically combative and violent or verbally agitated, and occasionally they can pose a threat to themselves and others, Rocco notes. 

"We try not to use chemical restraints, but sometimes we need to. We don’t use physical restraints," Rocco says.

To prevent violence, a therapist will help an agitated patient avoid obstacles within reach and will not give the person a cane or other assistive device that can be used as a weapon, Rocco adds.

Brain-injury staff are taught how to recognize agitation and potential combativeness in a patient and then how to avoid triggering a violent episode.

"Therapists need to be aware of the environment in which they’re working, so they don’t close themselves off in a corner of a room or nurses station with a patient," Rocco says. "They should approach the patient at a 45-degree angle and keep stimulation low, with one visitor at a time."