TBI Rehabilitation
Rehabilitation is an important and critical part of the recovery process for a TBI patient. During the acute stage, moderately to severely injured patients may receive treatment and care in an intensive care unit of a hospital followed by movement to a step-down unit or to a neurosurgical ward. Once medically stable, the patient may be transferred to a subacute unit of the medical center, to a long-term acute care (LTAC) facility, to a rehabilitation inpatient treatment unit contained within the acute trauma center, or to an independent off-site or 'free-standing' rehabilitation hospital. Patients are best managed on an inpatient treatment unit that has a specialty focus in Brain Injury Rehabilitation. Rehabilitation programs may be reviewed and accredited for this type of specialty care by the Commission on Accreditation of Rehabilitation Facilities. 
Decisions regarding when and where an individual should be treated at a particular point during the recovery process are complex and depend on many different factors including the level to which the person can be engaged actively and can participate to some degree in the rehabilitation process. Moderately to severely injured patients may receive specialized rehabilitation treatment that draws on the skills and knowledge of many specialists, involving treatment programs in the areas of physical therapy, occupational therapy, speech/language therapy, physiatry (medical specialist in physical medicine and rehabilitation), psychology, psychiatry, and social work, among others. The services and efforts of this team of healthcare professionals are generally applied to the practical concerns of and the pragmatic problems encountered by the brain injury survivor in their daily life. This treatment program is generally provided through a coordinated and self-organized process in the context of a transdisciplinary model of team healthcare delivery. This model keeps the primary focus on the overarching goal of optimizing patient function and independence through the coordinated application of discipline-specific expertise brought to bear on this issue by individual experts from various specific disciplinary backgrounds.
The overall goal of rehabilitation after a TBI is to improve the patient's ability to function at home and in society in the face of the residual effects of the injury, which may be complex and multifaceted (see Disabilities resulting from TBI section above). Therapists help the patient adapt to disabilities or change the patient's living space and conditions to make everyday activities easier and to accommodate residual impairments. Education and training for identified caregivers who will be involved in assisting the patient after discharge are also critically important components of the rehabilitation program.
Once the patient has been discharged from the inpatient rehabilitation treatment unit, the outpatient phase of care begins and goals often will shift from assisting the person to achieve independence in basic routines of daily living to assessing and treating broader psychosocial issues associated with long-term adjustment and community re-integration. Patients/clients will often have problems in the areas of general cognition, social cognition/awareness, behavior and emotional regulation that present significant challenges, in terms of being able to resume expected social roles. Often these problems are complicated by adjustment issues that emerge as the person becomes more aware of their residual deficits and faces the challenges of coming to terms with the long-term effects of the injury. Other concerns such as posttraumatic stress disorder associated with preserved remembrance of emotionally provocative circumstances of injury, may emerge and complicate the recovery process.
An additional goal of the rehabilitation program is to prevent, wherever possible, but otherwise to diagnose and treat in an efficient and effective manner, any complications (e.g. posttraumatic hydrocephalus, neuro-endocrine deficiencies, adjustment reactions, deep venous thromboembolism, etc.) that may cause additional morbidity and mortality.
Some patients may need medication for psychiatric and physical problems resulting from the TBI, and various medications are available that may lessen or moderate the problematic manifestations of the injury without directly altering the underlying pathology. Great care must be taken in prescribing medications because TBI patients are more susceptible to side effects and may react adversely to some pharmacological agents or may be inordinately sensitive to them, for example, due to a more permeable blood-brain barrier that may result from injury effects.
It is important for the family caregivers to provide assistance and encouragement for the patient by being involved in the rehabilitation program. Family members may also benefit from psychotherapy and social support services. Support for caregivers becomes particularly important during the outpatient phase of care when behavioral and cognitive problems may complicate and impair the relationships that patients have with those around them. Major challenges occur in sustaining these relationships, particularly in the context of marriage, when the impact of the injury significantly alters the relationship in such a way that the resumption of an adult-level interactive relationship may be deeply undermined.
It should be noted that similar principles of rehabilitation for diffuse brain injury can be applied to individuals with brain injury of both traumatic and nontraumatic etiologies. Acquired Brain Injury (ABI) is an all-encompassing term that can be applied to the various etiologies producing global encephalopathies with diffuse and/or multi-focal brain dysfunction that is precipitated during life in a previously fully functional individual. The etiologic processes associated with ABI can be subdivided into those related to trauma and those not directly related to trauma. TBI can therefore be viewed as a particular instance of ABI caused by trauma, and the principles of rehabilitation referred to here for TBI can be readily adapted and applied to individuals with all forms of ABI, independent of specific etiology.
Caretakers of traumatically brain injured patients can often feel a great deal of emotional stress, which can reduce the quality of care. Respite care such as supported living and residential holidays, supported days out doing activities like walking, cycling, kayaking and climbing offers relief for them and a new area of brain stimulation for the patient. When dealing with caretakers, providers of respite care need to be sensitive and reassuring, and should be aware that some caretakers may have feelings of guilt or inadequacy.
As an attorney and husband of a medical malpractice TBI PATIENT, I agree with your observations completely. My wife, Cynthia suffered a traumatic brain injury during a routine operation at George Washington University Medical Center in May 1990. That operation was designed to correct a condition known as hydrocephalus (water on the brain), by inserting a VP shunt in the meninges of her brain, thereby relieving intracranial pressure caused by the hydrocephalus. Unfortunately, a bleed occurred during the operation and went undetected long enough for her brain to begin collapsing in on itself, long enough for her to experience respiratory failure, and long enough for her to suffer permanent neurological damage.
After spending three months in the hospital, Cynthia was transferred by ambulance to Magee Rehabilitation hospital (Magee) in Philadelphia. After three months of intensive therapy at Magee, she was able to walk, with a quad cane, about sixty feet at a time. While she still wore diapers, her feeding tube had been removed, and she was beginning to communicate on an adult level, although with a flat affect to her speech. You can see from the photos on her web site that Cynthia has progressed far beyond this point, and far beyond all doctors' predictions.
Twenty-two months after her release from Magee, Cynthia resumed her master's program at The Johns Hopkins School of Advanced International Studies(SAIS)as a Philip Merrill fellow. She graduated in 1994; and, in 1995, her medical malpractice case was tried before the Superior Court of the District of Columbia.
Wanting to tell her amazing story and, simultaneously, communicate her messages of hope, inspiration and the overall power of family, friends and prayer, Cynthia has written a book - Searching For The Open Door, A Woman's Struggle For Survival After A Traumatic Brain Injury. Cynthia plans to donate ten to twenty percent of book sales to Magee. This is her attempt to "give back" and provide others with the hope and inspiration to put up a good fight. To read a sample chapter of Cynthia's book, go to: http://www.newriverpublications.com/Searching_for_the_Open_Door.html