Traumatic Brain Injury and Inpatient Medical Rehabilitation

Welcome to Medical Rehab Matters. In this episode we'll be talking about traumatic brain injury or TBI. Traumatic brain injury is a leading cause of death and disability among children and young adults in the U.S. Each year an estimated 1.5 million Americans sustain a TBI. 230 people are hospital eyes and 80 to 90,000 people experience the onset of long-term disability. I'm Patricia Sullivan, Director of Communications for the American Medical Rehabilitation Providers Association and co-host of this episode. With me is Dr. Robert Krueg, immediate past chair of the AMRPA Board and Vice President of Medical Affairs for the Mary Free Bed Rehabilitation Hospital Advisory Group. Our guest today are Dr. Brent Maisel, the executive vice president for Medical Affairs with the Center for Neuroskills and a clinical professor of neurology at the University of Texans Medical Branch in Galveston. Dr. Maisel is a board member of the North American Brain Injury Society and the Brain Injury Association of America where he serves as the National Medical Director. Our other guest is Gary Seal, Regional Director of Clinical Services at the Center for Neuroskills Houston and a researcher and psychologist specializing in brain injury, stroke, substance misuse, and he is a panel member on the BIA's TBI Guidelines Project. Welcome to both of you. Thank you for joining us this morning. We could just sort of set the table. The enormity of the problem with traumatic brain injury, I think there's been a growing recognition over the last decade or so with regard to the prevalence of brain injury and we all tend to think of the traumatic accident, whether it's a motor vehicle accident or something like that, but I think there's been a growing recognition with regard to whether it's repetitive, smaller types of injuries, something like a child heading a soccer ball repetitively that have led to changes in how kids practice or certainly the the National Football League and some of the dramatic instances of former players who have suffered injuries that have led to personality changes and even suicide or other behaviors that are uncharacteristic of them. So I just wanted to set that sort of the preview or table so to speak as we go into the guidelines and how they impact some of those things. I can address that part, Gary, you can certainly address the guidelines. The brain injury is an enormous problem and it's interesting when I got started in brain injury about 30 years ago. It was really an unrecognized issue. Most people, most physicians really had no idea of what an enormous problem this is and something good usually comes out as something bad and the good that has come out of the wars in the east and the NFL is that people now recognize what a significant issue brain injury really is. In the United States, depending on how you define disability, there are about 4 million people who are living with a disability due to brain injury or million people. It is an incredible epidemiologic problem and it just gets worse. The other thing that the public is not aware of and we're gradually educating the healthcare professional on this is that the brain injury is not an event. It is not like a broken bone. You can't just take the brain, put it at rest for two, three months like you would put a broken bone, give it a little therapy and then everything is going to be fine. The brain is far more complex than that and people with brain injuries go on to have multiple multiple kinds of medical issues not necessarily related to the brain itself. We see all sorts of medical issues, endocrine issues, musculoskeletal issues, GI issues, urine issues, dermatologic issues. The brain injury is the beginning of a disease process and we need to recognize that and we need to need to understand that you just don't put the patient in the hospital for a couple weeks after a brain injury and then say good luck. It's not going to work that way. You don't just take a five-year-old and say here go to school for six months and then everything's going to be fine and you educate yourself. You need to train the brain, you need to retrain the brain and you need to keep a wary eye on all the medical issue and the public is starting to become aware of this. Again, especially now that chronic traumatic and cephalopathy from the football players, people are paying far more attention to it, especially the parents who have kids who are playing soccer in football. It's an enormous problem and the medical community needs to get their arms around. And the funding sources as well. The TBI Guidelines project is a multi-year project funded by various sources and it's chaired by Wayne Gordon. There are 50 panelists from across the United States and they're serving on five separate panels. There's a behavioral panel, a medical panel, cognitive panel, functional panel and then there's a participation vocational reentry panel. And the panel to date has reviewed over 20,000 abstracts and we're now rating the evidence and we'll begin drafting guidelines. The medical panel is probably furthest along in terms of scoring and extracting information and developing guidelines but more to come on this very soon. There's a lot of good evidence out there regarding treatment for brain injury. Again, as Dr. Michelle mentioned, with access to care, proper treatment, people can and do have high quality lives after brain injury. But we need to make sure that people are being treated with evidence-based interventions in a timely fashion. So these guidelines will provide evidence-based techniques to help people recover and then read over the community. I think it's so timely that we're doing this important work because as you all are aware, the access to care and the type of care that patients with brain injury receive really tends to fluctuate depending on what region of the country you're in, what hospital you're in, who your case manager or caregiver is, and what your own personal knowledge is and how far you tend to advocate for yourself in many instances. So I think having guidelines that sort of we can all agree to and adhere to will be really helpful in ensuring that patients have the best positive outcomes possible. So I'm going to guess that depending on the extent of the injury and several other factors, it's going to influence which kind of post-cute care facility a patient is sent to or should be sent to. Can you talk about that a little? Sure, so I'll take a stab at it. Obviously injury severity ranges, there's a range of types of injuries and comorbidities if you will. About 80% traumatic brain injuries are mild in nature, meaning the person either is unconscious for repair to time or has an authoritative consciousness and may not require a comprehensive lengthy inpatient state that may be able to be treated on an outpatient basis. And then there are those that suffer severe injuries with numerous medical complications or the pediatric injuries, other co-occurring conditions that Dr. Millele has already mentioned. And those individuals may require a residential treatment for several months to make a good recovery. So depending on the nature and severity of the injury, there are treatment options that range from an outpatient or day neuro program all the way to comprehensive residential treatment. It's a continuum and you know not everybody has to go through the entire continuum. Some people just be go to the acute care hospital and that's all they need. Some will need inpatient rehabilitation programs. Some people that's not enough but they don't need the intensive medical environment of an inpatient rehabilitation hospital so they go to a post-secute program. And sometimes they just need outpatient relative to that or sometimes they just they they can't live independently. They're they're not safe. They have too many medical issues and then they have to be in a residential environment. And then hopefully transition to outpatient and hopefully transition to the normal life. Now something you mentioned a few moments ago when you talked about all the different potential body systems that could be affected by a brain injury. I think what that really speaks to is the importance of having a clinical team that truly understands brain injury. So a lot of the complications can potentially be avoided or manage much more effectively if it's done proactively versus reactable. For instance if somebody has spasticity right which is a lack of control of muscle activity that can lead to posturing or the inability for a patient to be able to coordinate their movements effectively. That's not understood and managed correctly. The patient can develop contractures or reduce range of motion so that even if they have strength in an extremity, it's going to impact their function. And if a clinical team, the physical therapist, occupational therapist, the treating physician understands those things and treats them proactively, you're going to have a much better outcome. Oh, absolutely. It is a team effort. It is not the doctor alone. I'm a neurologist. I used to be a private practice before I got involved in brain injuries and began running a brain injury treatment program. And I will tell you, it took me about five years before I became comfortable with all the nuances of brain injury medicine. It is very complex and I really learned that this is a team effort. Everybody's got to put in their piece. And the physician is one piece of that puzzle, but it's way too complex for one person to do alone. It takes the team and that's why comprehensive therapy is so important. I agree. There's a lot of good evidence that comprehensive treatment team comprise of not only a physician, but a case manager, physical therapist, occupational therapist, speech language pathologist, psychologist or counselor, and then whatever specialties are needed. Neuro-optimology, inter-chronology, all of those, again, under the direction of a case manager, can provide that very specialized care that individuals need. And to your previous point, being proactive, again, can prevent additional injury or disability from infections, from other things that can result from not addressing a problem upfront. I think, too, this may be a good segue into access to care and people being aware of their insurance policies. And when what their policies cover, we oftentimes particularly at the post-acute level run into complications, people accessing care because of the limitations of their policy. So it's very important that people read and understand their policy. Rehabilitation is not always a current benefit and rehabilitation for the duration that's necessary to bring about a good outcome. There may be limitations to that. So it's very important that people understand their insurance policy and the limitations and advocate for proper care. Yeah, I mean, I couldn't agree more. And I think if you or a family member or a friend should be, unfortunately, to suffer a brain injury or they are in an acute hospital setting, you really want to make sure that they're bringing the rehabilitation team to evaluate that patient. So that usually involves the physical therapist, the occupational therapist, the speech language pathologist, the rehabilitation physician, the neurologist. And a surgical procedure was involved, obviously, the neurosurgeon was involved as well. You would think that that happens regularly, but again, it is somewhat inconsistent, which is why we need guidelines. All you have to do is bring it up to the case manager to the attending physician and that can set the process forward. Yeah, I think as Dr. Maisel mentioned, there is a continuum of care that's developed over the last 30 to 40 years for brain injury. And again, it starts pre-hospital when the helicopter lands or the ambulance arrives at the scene. The person is taken to a level one trauma center where they get their emergency room care neurosurgery, those kinds of lifesaving activities. Then they move into intensive care and most are medically stable. They'll move into hospital-based acute rehabilitation. And from there, if they need more, they'll go on to post-acute rehabilitation and then maybe even on the long-term care if necessary. The brain injury Association of America funded a study. It's been a while back. But their findings indicated that fewer than 10 percent of people actually have access to that continuum of care that I just described. So people are being moved out of the continuum or moved into substitute services, a nursing home, if you will, or discharged home with home health care, for example. And again, there are plenty of studies to show that that's not a good way to treat a patient with a moderate-to-submarine injury. And I think that's such a critically important point because as we all know, there's many patients who are initially, they may have been in a coma or there's a scale of cognitive and level of arousal impairment, the ranchos los amigos scale, and patients can be quite low level and extremely confused and incapable of following commands initially. And I've seen those very people make unbelievable recoveries to the point where they go back to their pre-injury jobs, everything from executives to neurosurgeons. I have seen go through that process. So I can't emphasize enough how important it is to ensure that you access the right level of care. You can't predict. I gave up trying to figure out who was going to do well and who wasn't going to do well a long, long, long time ago. You know, there's an expression that the patient has to be their best advocate. They're the ones that have to push for the very best care. And obviously, with the significant brain injury, the patient can advocate. So the families have to advocate and they have to push and they have to be demanding. Lightly so, but they still have to be demanding so that their loved one gets the very best care. And they need to ask the case manager, ask the doctor, if this was your brother, if this was your mother, what would you be doing in this situation? Where would you be sending him or her? And it makes the decision making process so much easier. When I see patients, I tell them, if you were my brother, if you were my sister, this is what I would do. And that's what the families have to demand of the decision makers. What is best for my loved one? What would you do if this was your love? And then you're probably going to get what is very best for you. And to that point, I think patients and their caregivers and loved ones should be aware that there are different certifications that sort of speak to the quality and expertise of different programs. I think the gold standard would be car for accreditation. And you should look for that when you're evaluating different programs to see if a program is a rehab hospital or rehab unit is car for accredited overall and many have car for accreditation specific to brain injury as well. And then once you discharge to them, I don't know if you either of you could speak to your experience with day treatment programs. And I think it's very important that there's a continuum of care and that the patients aren't lost to follow up once discharged. Well, if a patient can go home and be successful, that's wonderful. And in that situation, depending on the geography, having access to a comprehensive rehabilitation program, brain injury rehabilitation program is great because then the therapist can interact with the family and what's not working at home because ultimately that's what's important is what's going on at home. So this would allow for that opportunity. What often happens is they're going to a physical therapy, freestanding physical therapist. And they're wonderful, but you need more than just that for brain injury. You need to have a comprehensive program where the therapists are talking to each other and interacting with the family. And that those therapists also, again, have a neuro background. It's one thing to go to an outpatient clinic where the physical therapist, it may be a very good physical therapist, but has more of an ortho background versus a neuro background. And so again, it's very important in terms of not only is a program car for credited, but their therapy team is experienced in brain injury treatment, brain injury medicine. And a couple of you have said, "Carfe, could somebody spell out what carfe is?" Carfe is the commission for the accreditation of rehabilitation facilities. It is for outpatient programs what J.Co is for inpatient hospital based rehabilitation. I appreciate that you've already brought up the importance of the family, especially, I think, with brain injuries, as the family's being the advocates because if you're that injured, you may not be able to advocate for yourself. I think in addition to advocacy, equality, brain injury program is also going to spend some resources and some time training the family, right? So toward the end of the patient's stay, the family will be brought in and will be taught transfer techniques or we talk how to modify diets or manage behavior or set the environment to promote independence using cognitive rehabilitation strategies. For example, a memory aid note book or some external system for memory. All of those things, the family must learn all those things in order to maintain the outcome, make the outcome durable that the treatment team has has helped produce. And then again, as I already mentioned, follow up is important as well. The program needs to follow up with the patient. And again, if there's a problem and resources can be can be brought to bear and and interventions occur early, then it can reduce re-hospitalization and further disability. Can you just comment on the role of a neuropsychologist and you know, we've alluded to some of the potential behaviors and cognitive issues and what both a behavioral program and/or medication interventions can mean in terms of improvement in these patients? Many programs will have a neuropsychologist either as a staff person or as a consultant. And oftentimes neuropsychologists will conduct a comprehensive neuropsychological assessment, examining everything from tension and memory to some speed of information processing personality, sensation and perception, as well as doing a pretty thorough medical and psychosocial history to try to determine what the patient's behavior and cognition is, is free injury and what's their post injury. The neuropsychologist can also report these brain behavior relationships to the treatment team and help guide the development. Relative to the medications, it's always difficult. There is a medicine for problem with the joints that's approved for people with brain injuries. But aside from that, maybe there's another one, but generally speaking, what we have to do when we treat individuals with brain injuries is borrow from other fields. And we have to be always keeping up with our journals because we have to borrow medications from psychiatry or neurology or or neurosurgery or internal medicine that will help with the patients. It can make a difference. And one of the questions that family should always ask when trying to find the next step in terms of their loved ones' path to recovery is what's the experience of the physician? What's the knowledge of the physician who is going to be ordering those medications? Because it's very, very difficult. And I never cease to be amazed by the positive effect of some of the medications they may have. As I said earlier, it took me about five years before I really became comfortable treating brain injuries because it is so complex. You know, medications, let's say if you borrow a psychiatric medication, those medications were not designed for people who've had brain injuries, who's wiring, if you will, has now become disruptive. And so it's very difficult to anticipate the results. And so you need a physician who's experienced, physiatrists have a fellowship in brain injury. They do an extra year so they can do some certified. There is now a certification for neurologist, physiatrists and psychiatrists as a subspecialty in brain injury medicine. So that's what the individuals need to look for because it is a field unto itself. Yeah, I would just add to that, we just ended right the longest sustained conflict/war in our history in Afghanistan. And I think if we want to look for any kind of silver lining, which is hard to do, something like this with our brave men and women who have gone above and beyond for so many years, it is what we've learned about brain injury and the National Intrepid Center, which is part of Walter Reed, is an incredible outpatient facility. And I believe they have like an 85 or 90% success rate in getting brain injured soldiers or military folks back to active duty. So they've proven that there are amazing techniques and interventions that can really help. It's just a matter of getting access to that type of care. And like so many other things, things that have been pioneered in military facilities or for military personnel, makes its way into the general population. And we're seeing that in our facilities today. And on that note, I would encourage families to look beyond the geographical issues when deciding where the next step is for their loved one. Certainly it's more convenient to have them really close to home and there's some really positive aspects to it. But you have to weigh that against where is the best facility. You want to send your kid to the best college. And so you have to weigh that. It's not just being close to home. You want the most experienced team because this is going to be it. This is probably going to be your last chance on the road to recovery. So find a facility that you think is the best. I think that many patients and family members are justifiably concerned about having their loved one in a facility during the pandemic. But I think we've come a long way in terms of infection control and other mitigation processes and obviously vaccination that makes healthcare facilities extremely safe to be in at this time. And I wouldn't want folks to avoid getting the care that they so desperately need out of a fear of the pandemic. I would say that I know that at center for neuro skills, we have gone to exceptional links to make sure that the majority of our staff receive vaccinations. I think right now we're in the mid 80 85% or more of our staff have been fully vaccinated. We've got cleaning protocols for equipment, you know, sort of public areas, frequent hand washing, frequent testing. Certainly, I know that people are wanting to get out and about. But the treatment facility is going to be a much safer place to be than home depot. And we're a lot more people are bumping in each other and they may or may not be that today. They may or may not be masked. And so I think to put to ease any fear of exposure, most healthcare facilities are going to be a safe place to be. And it is urgent because again, we know from research that some of this recovery is time dependent. And we can get quicker. We can get people into particularly post acute care, the better the outcome. People still make great recoveries, even years post injury, but research shows that the trajectory of the recovery is much better if we can get people into comprehensive, first year of injury. So the timing of this is critical and people should, again, should feel feel good about bringing their loved ones to a healthcare facility, even during this time of COVID. We're coming up on the end of our time together and I wanted to ask all three of you if you had anything that you haven't covered that you wanted to add. I would just like to say one thing to the families and the patients, brain injury rehabilitation is forever. It is for your entire life and you have to approach it that way. Every day you need to do something to make yourself better. Never stop. Never plateau. Keep on pushing forward because you'll get better. All stated. This episode is brought to you by Merstereputics, part of the Merst Group, a privately held family-owned company. Merstereputics is committed to improving the lives of patients who suffer from movement disorders, spasticity, and neurological conditions. Focusing on advancing neuro-modulator technology, Merstereputics offers Xiamen, a uniquely purified therapy that's FDA approved for six therapeutic indications in the United States. Please note that Xiamen has a boxed warning and could result in potentially serious life-threatening side effects. Visit xiamen.com for important safety information and full prescribing information, including a boxed warning. Thanks for listening to Medical Rehab Matters, a podcast by the American Medical Rehabilitation Providers Association. AMRPA would like to thank podcast sponsor Merstereputics for its support, as well as their Golden Platinum Association sponsors. Our platinum sponsors are Bioness, Casa Collina Hospital and Centers for Healthcare, and Select Medical. Our Gold Sponsors are JFK Johnson Rehabilitation Institute, MAS Rehab, and the Center for Improvement and Healthcare Quality. You can learn more about Medical Rehabilitation at AMRPA.org.