Inpatient Rehabilitation Following Traumatic Brain Injury

In the United States, acute rehabilitation units or inpatient rehabilitation facilities (IRFs) provide a unique level of care distinct from long-term acute care and subacute, postacute residential, or skilled nursing facilities. IRFs often provide physiatry-coordinated interdisciplinary team–based care with a minimum of 15 hours per week of intensive therapy to acutely ill individuals. IRFs discharge people to the community nearly twice as often as skilled nursing facilities, keeping rehospitalization rates at less than one-third those of skilled nursing facilities.¹ IRFs are associated with decreased mortality and better long-term outcomes, including reintegration into the community.²

Three general neurorehabilitation principles historically have been recognized: 1) reversal of diaschisis, 2) behavioral compensation, and 3) neural plasticity. Inpatient rehabilitation optimizes behaviorally driven neuroplasticity by means of repetitive task-specific training techniques.³ Addressing medical, physical, cognitive, and emotional symptoms with aims to maximize function, minimize complications, and prepare individuals and their families for discharge to the community are common goals addressed during IRF admission. IRF team members may include physical medicine and rehabilitation physicians or neurologists, nurses, physical and occupational therapists, speech-language pathologists, neuropsychologists or psychologists, case managers or social workers, and recreational, music, or art therapists. Many of these professionals may have subspecialty certification and training. Individuals with various manifestations after acquired brain injury may be appropriate for IRFs, including patients with agitation or disorders of consciousness. Practice guidelines related to disorders of consciousness⁴ recommend settings staffed by multidisciplinary rehabilitation teams with specialized training, which resembles IRFs. Brain injury units in IRFs tend to be locked units to protect and safeguard patients with agitation. Posttraumatic agitation, a form of hyperactive delirium, presents during the transient anterograde amnesia phase and is prolonged by administration of neuroleptics and benzodiazepines.⁵ Traumatic injuries to the brain may result in concomitant multiple fractures and additional sequela associated with trauma. Patients with orthopedic restrictions also are commonly served in the IRF setting.

Medical Complications

As awareness and participation in physical examination improve, occult fractures and nerve injuries may come to light. However, the overlay of neurobehavioral and neurocognitive issues may confound symptom detection and treatment of various symptoms and internal sensations, such as pain, dysuria, and hunger. People in the IRF setting may experience ongoing complications and comorbidities affecting almost every organ system (Table 1). Some of these conditions, such as atelectasis, pressure ulcers, deep vein thrombosis, constipation, and hypercalcemia, can be consequences of immobility. Other complications are unique to individuals with neurotrauma, including cerebral salt wasting, paroxysmal sympathetic hyperactivity, spasticity, and heterotopic ossification.

Hypertonicity can progress to contractures. Range of motion exercises, passive and dynamic splinting, medications, chemodenervation, neurolysis, and intrathecal baclofen pumps are all possible treatments. A hard end stop in the range of motion may signify heterotopic ossification. A triple-phase bone scan may detect heterotopic ossification in the earliest phase and expand treatment options, such as nonsteroidal anti-inflammatory drugs and bisphosphonates to slow progression. Serial imaging and orthopedic evaluation may become necessary, and the risk of progression and development of other medical complications can continue after discharge.

Paroxysmal sympathetic hyperactivity, or neurostorming, presents with episodic hypertension, tachycardia, tachypnea, diaphoresis, and posturing. Medications to treat paroxysmal sympathetic hyperactivity usually are started in the intensive care unit (ICU) but may require adjustment during inpatient rehabilitation to optimize functionality. Some of these medications can be sedating and may impair cognition and later behaviors.

Fall and reinjury prevention is an important rehabilitation nursing goal. Some strategies include ensuring call notification systems are within reach and ensuring use of nonskid socks, handrails, and durable medical equipment. Using restraints to address behavior that may result in injury to the patient or others may be medically necessary. If indicated, the least restrictive modality should be used to decrease the risk of worsening delirium. Monitoring sleep-wake cycles is crucial because poor sleep quality has been linked to longer inpatient stays.⁶ Sleep medications, when used in an inpatient rehabilitation setting, may normalize sleep–wake cycles, positively affecting cognition and behavior.

Pain is handled differently in the rehabilitation setting than in ICU setting. Whereas patients may have received continuous infusions of opioids for treatment of pain in the ICU, in inpatient rehabilitation, the aim is to mimic medication use in a home setting. Patients may be unable to express pain, making nonverbal behavioral pain assessments and scheduled pain medication administration necessary. Because of the increased risk of opioid addiction and accidental overdose in individuals with brain injuries, efforts to wean opiates and use multimodal pain treatments must be undertaken.

Individuals with traumatic brain injury (TBI) or orthopedic injuries may require more calories than their activity level may predict. The authors recommend 20 to 30 calories/kg/day. Patients on NPO status because of dysphagia must receive enteral feeding by means of gastrostomy or gastrojejunostomy tubes. With guidance from speech-language pathologists, oral feeds may be resumed, and enteral feeding may be weaned. Patients who cannot express their wants and needs are susceptible to dehydration and hypoglycemia. Enteral feeds may result in loose stools and, in turn, electrolyte losses.

Treatment Approach

Pharmacologic and nonpharmacologic interventions need further study, but certain medications, environmental modification, and behavioral strategies are a mainstay in IRF.⁷

Pharmacologic Approach

In the IRF setting, the medication list can be modified, formulations changed, drug toxicity monitored, and medications reconciled against the prehospitalization medication list. An important priority in inpatient rehabilitation is to optimize cognitive function. Medications used to treat neuropsychiatric symptoms after TBI are used off-label as evidence for their use is emerging.⁸

The symptoms guide the treatment plan. Various clinical symptoms seen frequently in the IRF setting after an acquired brain injury include depressed mood, apathy, insomnia, fatigue, agitation, impaired cognition, pain, and abnormal movements. Medications to optimize cognition commonly have dopaminergic, (nor)adrenergic, serotonergic, histaminergic, cholinergic, or NMDA antagonist activity. Amantadine is used frequently in the brain injury unit to optimize cognition. Psychostimulants such as methylphenidate can boost the frontal networks and improve initiation, processing speed, attention, and disinhibition. Selective serotonin reuptake inhibitors such as fluoxetine can help with arousal and irritability. Deprescribing medications with the potential to impair cognitive or motor function or neuroplasticity, such as benzodiazepines, first-generation antipsychotics, and anticholinergics, is often an important first step. General principles in developing a medication regimen are listed in Table 2.⁹

Behavioral Approach

Neurobehavioral excesses may result from injury to the prefrontal circuitry responsible for inhibition, initiation, and learning and may be worsened by environmental or psychological stimulation. Predictive routines—including opening the blinds during the daytime and turning off television screens and lights at night, avoiding provocations, providing cognitive support by reducing requirements for information processing and environmental distractions as well as frequent orientation, and using memory aids—may help.¹⁰ The use of bright light therapy is being studied but photophobia and the risk of overstimulation may limit its use. It is important to provide opportunities for a person to control aspects of their day, such as choices of activities and timing of completion. Activities, routines, and support assisting self-regulation are favored over extrinsic motivators. A neuropsychologist or rehabilitation psychologist can be invaluable to the rehabilitation team, patient, and family. Engagement of family members in the rehabilitation process is critical to optimize the transition of care to home or another setting.^11,12

Neurologic and Neurosurgical Complications

Several complications can hinder functional progress. Seizures are seen frequently in the rehabilitation unit. They are a recognized complication of and worsen functional outcomes after TBI.¹³ Posttraumatic epilepsy, which affects up to 30% of adults who experience TBI, most commonly occurs in the first 3 years following the injury.¹⁴

If recovery is not progressing as expected, hydrocephalus should be considered. Posttraumatic hydrocephalus can contribute to behavioral changes, regression, or therapeutic progress stagnation.¹⁵ Subtle symptoms of hydrocephalus include abulia, emotional lability, perseveration, mutism, apraxia, or change in bladder or bowel function.¹⁶ Other symptoms include headache, nausea, agitation, increased spasticity, and seizures.¹⁵ Decompressive hemicraniectomy and traumatic subarachnoid hemorrhage are risk factors for the development of posttraumatic hydrocephalus.¹⁷

Decompressive hemicraniectomy improves survival following severe brain injury, cerebral edema, and intractable intracranial hypertension. After decompressive hemicraniectomy, patients frequently can participate in an intensive rehabilitation program. Early cranioplasty also has been shown to improve functional outcomes and decrease the risk of posttraumatic hydrocephalus.¹⁸ People with or without a ventriculoperitoneal shunt after undergoing decompressive hemicraniectomy are at risk for trephined or sinking skin flap syndrome¹⁹ (Figure 1). When this occurs, after cerebral edema has subsided, atmospheric pressure contributes to a contralateral midline shift and herniation. Hallmarks of the syndrome include a headache and functional and cognitive decline with postural changes.²⁰ These patients may present similarly to patients with hydrocephalus.

Prognostication and Planning

Inpatient rehabilitation is only one portion of the recovery process. Most individuals require ongoing multidisciplinary care in the outpatient setting to continue medication management and therapies. Katz et al¹¹ have shown that even among people who presented with disorders of consciousness, nearly 50% achieve independent living in 1 year, and 22% return to work or school 2 years postinjury. Errors in prognostication abound for individuals with disorders of consciousness, and approximately 40% of clinical assessments in people with disorders of consciousness lead to misdiagnoses.¹² Assignment of surrogate decision-makers, applications for appropriate insurance benefits, and life care planning are important aspects of case management services. Inpatient rehabilitation is only one setting for the recovery process. Many people require close follow-up by physiatrists and other specialists in the outpatient setting to continue medication management.

Conclusion

Care of the person with TBI in a rehabilitation setting requires a multidisciplinary approach. Discharge planning needs may be complex, and safety and extensive family training and education on recovery after brain injury are of utmost importance. Systemic barriers exist in the treatment and rehabilitation of individuals who experience a brain injury. Because of tighter regulatory oversight and changes to the payment system, access for people with TBI to IRF²¹ and lengths of stay are decreasing in the United States. Systematic biases also limit IRF care for adult Hispanic or Black individuals with TBI regardless of insurance coverage.²² The potential for meaningful recovery often is underestimated. Despite these challenges, rehabilitation opportunities should be available to all people with brain injuries.