Managing Traumatic Brain Injury Rehabilitation

Before beginning TBI rehabilitation, confirm:

Required clinical questions:

• What is the injury mechanism and severity classification (mild, moderate, severe)?
• What was the initial GCS score and lowest GCS in the first 24 hours?
• What is the neuroimaging finding (CT/MRI: contusions, hemorrhage, DAI, edema)?
• What is the duration of loss of consciousness and current RLAS level?
• Is the patient still in post-traumatic amnesia (PTA)?
• Are there associated injuries (fractures, spinal injury, facial/ocular injuries, polytrauma)?

Required documents:

• Emergency department and neurosurgical records
• Neuroimaging reports (CT head, MRI brain if available)
• GCS documentation from scene, ED, and serial in acute care
• Current medication list (anticonvulsants, antispasmodics, neuromodulators, sedatives)
• Pre-injury history: occupation, education, substance use, psychiatric history, prior TBI
• Rehabilitation physician evaluation with current RLAS level assessment

Step 1 — Classify Injury Severity and Track Recovery Markers

TBI severity classification:

Post-traumatic amnesia (PTA) tracking:

• Galveston Orientation and Amnesia Test (GOAT): 10 items, score 0-100
  • ≥76: Normal (PTA resolved)
  • 66-75: Borderline
  • ≤65: PTA present
• Orientation Log (O-Log): 10 items, 0-30; ≥25 = oriented (PTA resolved)
• Administer daily until PTA resolves; document date of PTA resolution

PTA duration as prognostic indicator:

• <1 hour: Good recovery expected
• 1-24 hours: Good recovery likely with some residual deficits
• 1-7 days: Moderate disability likely
• 1-4 weeks: Severe disability likely

• 4 weeks: Very severe disability; prolonged rehabilitation required

Step 2 — Apply Rancho Los Amigos Levels of Cognitive Functioning

RLAS Levels and rehabilitation approach:

Assessment frequency: Document RLAS level at admission, weekly (minimum), and with any significant change.

Step 3 — Implement Stage-Appropriate Cognitive Rehabilitation

For RLAS IV (Confused-Agitated):

• Environmental management: private room, minimal stimulation, consistent staff, dim lighting, reduced noise
• Agitation documentation: Agitated Behavior Scale (ABS); 14 items, scored 1-4 each; total 14-56
  • 14-21: Absent
  • 22-28: Mild agitation
  • 29-35: Moderate agitation
  • ≥36: Severe agitation
• Redirect, do not argue or reason; provide simple choices (2 options maximum)
• Medication management: coordinate with physician for agitation management; document behavioral data to guide pharmacology
• Physical safety: fall prevention, elopement prevention, padded side rails; document least restrictive interventions

For RLAS V-VI (Confused):

• Orientation training: reality orientation board, consistent daily schedule posted, repetition of key information
• Memory compensation: memory notebook introduction, written schedule, checklist for daily tasks
• Attention training: structured activities with graded duration (start 5-10 min, progress); minimize distracters
• Errorless learning: guide correct performance rather than trial-and-error
• Simple problem-solving: guided daily tasks (meal selection, schedule planning)

For RLAS VII-VIII (Automatic to Purposeful):

• Executive function training: planning, initiation, self-monitoring, flexible thinking
• Community skills: money management, transportation navigation, meal preparation sequencing
• Social pragmatics: turn-taking, topic maintenance, reading social cues, emotional regulation
• Vocational readiness: work simulation, cognitive demands analysis, graduated return-to-work/school
• Metacognitive strategy training: self-assessment of performance, error recognition

For RLAS IX-X (Modified Independent):

• Compensatory strategy independence: verify consistent use of memory aids, planning tools
• Community integration: independent living skills assessment, driving evaluation referral
• Return-to-work/school reintegration: graduated schedule with accommodation support
• Long-term self-management: awareness of residual deficits and compensatory strategy use

Step 4 — Address Motor, Behavioral, and Psychosocial Recovery

Motor rehabilitation:

• Balance: Berg Balance Scale, vestibular screening (TBI-associated dizziness in 50-80%)
• Gait: Community ambulation with dual-task challenge (cognitive + gait)
• Coordination: Ataxia management for cerebellar involvement
• Spasticity: MAS assessment, splinting/positioning, botulinum toxin coordination

Behavioral management:

• Document behavioral incidents with antecedent-behavior-consequence (ABC) format
• Develop behavior support plan with positive reinforcement
• Coordinate with neuropsychology/behavioral psychology
• Document medication effects on behavior and cognition (avoid sedating medications when possible)

Psychosocial rehabilitation:

• Depression screening: PHQ-9 at admission and monthly (depression prevalence 25-50% post-TBI)
• PTSD screening: PCL-5 if trauma-related etiology (MVA, assault)
• Family education: TBI education about recovery trajectory, behavioral expectations, and family adjustment
• Substance use counseling: pre-injury substance use is a risk factor for TBI and a barrier to recovery
• Peer mentoring: connect with TBI support groups and survivors

Step 5 — Track Outcomes and Plan Discharge Across the Continuum

Outcome measures:

• FIM: Admission, weekly, discharge (motor and cognitive subscales separately)
• RLAS: Serial documentation showing progression
• DRS (Disability Rating Scale): 0-29; tracks disability from coma to community integration
  • 0: No disability
  • 1: Mild
  • 2-3: Partial
  • 4-6: Moderate
  • 7-11: Moderately severe
  • 12-16: Severe
  • 17-21: Extremely severe
  • 22-24: Vegetative state
  • 25-29: Extreme vegetative state
• GOS-E (Glasgow Outcome Scale-Extended): 1-8; captures long-term outcome categories
• MPAI-4 (Mayo-Portland Adaptability Inventory): Post-acute community participation measure

Discharge planning across the continuum:

• IRF discharge → post-acute residential brain injury program (RLAS V-VII with continued recovery potential)
• IRF discharge → day program (RLAS VII-VIII; independent for home safety with supervision)
• IRF discharge → outpatient therapy (RLAS VIII+ with community access)
• IRF discharge → home with family supervision (document specific supervision needs and safety plan)
• Document driving restriction status and return-to-drive plan
• Seizure prophylaxis status and duration (typically 7 days post-injury per guidelines; longer for specific indications)

Checkpoint B — Pre-Finalization Review

Before finalizing TBI rehabilitation documentation:

• TBI severity classified with GCS, LOC duration, and imaging findings
• PTA tracked daily with GOAT or O-Log until resolution
• RLAS level documented at admission, weekly, and with changes
• Cognitive rehabilitation matched to RLAS level
• Agitation managed and documented with ABS and behavioral data
• Motor, behavioral, and psychosocial assessments completed
• FIM tracked with motor and cognitive subscales separately
• DRS scored for disability classification
• Family education documented with specific topics covered
• Discharge plan identifies appropriate level on the TBI continuum

Quality Audit

• GCS documented accurately with eye, verbal, and motor subscores
• PTA resolution date documented with supporting GOAT/O-Log scores
• RLAS level justified with behavioral observations, not assigned without basis
• Cognitive rehabilitation interventions are stage-appropriate (not teaching metacognition at RLAS IV)
• Agitated Behavior Scale used for RLAS IV patients with serial tracking
• FIM cognitive subscale tracked separately from motor subscale
• DRS scored at admission, discharge, and follow-up
• Seizure precautions documented with anticonvulsant status
• All [VERIFY] flags resolved or escalated to physiatrist/neurologist
• Documentation meets IRF-PAI, CMS, and CARF TBI program standards

Guidelines

• TBI rehabilitation is on a continuum — IRF is one phase, not the entire recovery; document projected post-acute needs early
• PTA duration is the single strongest predictor of outcome — track daily and document resolution date precisely
• RLAS level guides everything: therapy approach, environment design, behavior management, and goal complexity
• Never provide complex cognitive tasks to patients in RLAS IV-V — it is ineffective and can increase agitation
• Agitation in RLAS IV is a normal recovery phase — pharmacological management should be minimized; behavioral/environmental strategies are first-line
• Medications that impair cognition (benzodiazepines, typical antipsychotics, anticholinergics) should be avoided when possible; document medication effects on cognition at each assessment
• Dual-task testing (walking while performing cognitive task) is more sensitive to community-level deficits than single-task assessment
• Return to driving requires comprehensive driving evaluation — TBI patients should not drive until medically cleared
• Return to contact sports after concussion/mild TBI must follow graduated return-to-play protocol with complete symptom resolution at each stage
• TBI recovery can continue for years post-injury, especially for cognitive and psychosocial domains — document ongoing recovery potential at discharge even when progress is slow