By MICHAEL SAMOGALA, RN, CRRN, CBIS
Traumatic Brain Injury is a major cause of death and disability in the United States contributing to about 30 percent of all injury related deaths. In light of the recent and continuing focus regarding brain injury, as well as the specialized care and post-acute rehabilitation that may be required, a brief discussion describing an outcome-based neurobehavioral rehabilitation program's components and process may be beneficial to those individuals who have sustained a brain injury, as well as their healthcare providers, case managers, caregivers and/or significant others. Brain injury is often referred to as a "life changing or catastrophic injury" depending on the type of brain injury, the severity and the outcome.
Acquired Brain Injury (ABI) by definition may be traumatic, such as caused by excessive motion or a delivery of force/impact or velocity to the head, or non-traumatic including stroke, hypoxia, post substance abuse, or chemo toxic exposure such as from chemotherapy treatment.
ABI is always an "individual" injury and never exactly the same for any two individuals, as we all utilize our brains in a unique fashion with areas of dominance and various degrees of compensation and or plasticity. ABI may result in short or long term deficits involving cognitive function (problem solving, attention and memory), motor function (extremity weakness, impaired ambulation, coordination and balance), sensation (hearing, vision, smell, impaired perception and touch) and behavior (emotional regulation, depression, anxiety, aggression, impairments in behavioral control, personality changes). The effect and outcome of the ABI may depend on many factors, along with the type and quality of not only the identification and treatment of the injury, but also the type and quality of the post-acute rehabilitation the individual may receive.
Post-acute rehabilitation for an individual with ABI should, in its most simple form, be based on an outcome focused neurorehabilitation process, including a neurobehavioral program which focuses on the patient achieving the maximum possible level of function and independence. The program itself involves the individual and significant others, through a systemic, comprehensive, multidisciplinary assessment in the development of realistic, measurable, functional goals which directly influence each individual's progression towards their maximum potential, leading to successful community re-entry and a sustained successful outcome.
This being stated, the neurobehavioral component of the program must be dynamic as to begin with the pre-admission assessment information, which is confirmed by a medical records review conducted by a licensed Clinical Liaison and a recommendation for admission presented to a specialized brain injury credentialed multi/intradisciplinary team. The team itself should optimally include:
- Rehabilitation Specific Case Managers (Nurses and Social Workers)
- Board Certified Physiatry services (Rehabilitation Specific MD)
- Board Certified Rehabilitation Nurses (CRRN)
- Board Certified Brain Injury Specialist
- Neurology services (Individual or Accessible)
- Board Certified Psychiatry Services
- Neuropsychology Services
- Cognitive, Dysphagia and Speech Therapy (MS, CCC-SLP)
- Registered Clinical Dietician Services
- Neurobehavioral and Behavior Program with supports as needed
- Physical Therapy
- Occupational Therapy/Functional Independence Team
- Licensed Mental Health Counselor (Certified Substance Abuse Counselor) and support - clients and family members
- Client/Family Support Team
Ideally upon admission, a Board-Certified Physiatrist and a Board-Certified Psychiatrist lead the multi/intradisciplinary team members which assess, identify, describe and intervene using a personalized fluid approach to each clients' strengths and barriers relating to their maximum potential for independence and community re-entry. Very often after an ABI, the individual experiences various behaviors that cannot only be socially unacceptable but dangerous to the individual, significant others or the community in general.
The Board-Certified Psychiatrist, Neuropsychologist and Licensed Mental Health Counselor develop ongoing and dynamic behavioral and therapy plans based on assessment criteria, subjective observable behaviors and identifiable triggers and consequences. As indicated, the therapy consists of scheduled individual sessions as well as group interaction under the headings of anxiety and worry, self-help and empowerment.
The Purpose and Intent of the optimal neurobehavioral program is to assist the client in managing their behavior using a structured behavior plan and process that:
- Defines behavior as response to stimuli, observable, perceivable or inert and with a purpose or meaning.
- Respond to the client's behavioral, cognitive and physical needs.
- Presents a positive, consistent therapeutic approach to self-behavior management
- Incorporates medical, nursing and therapy services which are supported by a facility inclusive environment to promote positive behavioral management techniques.
- The behavior plan from initial to full intervention are communicated and consistently available to all significant others, caregivers and staff as appropriate and applicable
- Provides ongoing education and training for the individual and significant others. Program behavioral techniques are taught and reinforced in order to support long-term goals of achieving the most successful and productive discharge outcome.
As community reintegration remains the primary goal for these individuals, a vocational rehabilitation component within the total program structure should encompass both direct and non-direct assessment, evaluation and access to both in-facility and community based vocational experiences.
The most successful programs often accomplish the inclusion of vocational experience criteria utilizing established partnerships with community-based organizations. Such programs with a dual centered focus greatly add to the successful outcome of these individuals, their support system and the community itself.
In addition, community re- integration is promoted with each individual outside of the significant others' realm of participation. This is effectively accomplished by neurobehavioral team members providing the individual with scheduled functional integration activities, incorporating goal oriented multidisciplinary skills and abilities learned and practiced within the general facility program, then utilized within the outside community under supervision as part of an organized therapeutic regimen.
As discharge planning begins on admission, as soon as possible each member of the intra/multidisciplinary neurobehavioral and clinical rehabilitation team will evaluate the individual and assign a period of time when the significant others can spend at least twenty-four hours with the individual learning, observing and assisting the individual to manage any behavioral or functional deficits contributing to a successful sustained discharge outcome.
In summary, the success and final outcome of the individual with an acquired brain injury from a traumatic or non-traumatic source will depend on many factors; one of the most influential being the type and quality of the post-acute rehabilitation program and neurobehavioral program the individual completed.
Michael Samogala RN, CRRN CBIS has been directly involved in providing professional nursing and education services to the healthcare community for over 40 years. Most notably receiving board certification in rehabilitation nursing and as a brain injury specialist, he continues to provide professional credited continuing education programs to multiple professionals across the country, and remains in the position of Director of Corporate Education, NeuLife Neurological Services.
The CARF accredited Brain Injury Specialty Program at NeuLife Post-Acute Rehabilitation (residential or outpatient) offers comprehensive neurorehabilitation services resulting in eighty percent discharge to home or community.