Multidisciplinary approach aids brain trauma recovery

At Mayo Clinic in Rochester, Minn., rehabilitation services for people with traumatic brain injury (TBI) and other acquired brain disorders are integrated into clinical practice across the entire spectrum of care. For example, the brain rehabilitation consultation service, an interdisciplinary team that evaluates all brain trauma patients on admission, works in tandem with hospital neurological and surgical services.

Allen W. Brown, M.D., who oversees the TBI clinical and research program in Rochester, says Mayo's approach to brain trauma management is unique because policies and protocols are decided by a multidisciplinary subcommittee representing providers who actually care for trauma patients.

"We have subspecialty rehabilitation teams who assess each patient's level of impairment and anticipate what will be needed in the future. The diagnostic aspects must be determined quickly, so there's no time lag before patients move on to the next level of care. Rehabilitation is a coordinated, team-based specialty that provides longitudinal care, and it makes the most sense for decisions to be made by the people who will be following patients long term," he says.

Services for patients and families

Injury to the brain can lead to difficulty with memory and concentration and can be very frustrating for patients and families alike. Depending on need, patients may be admitted to the inpatient Brain Rehabilitation Unit or referred to the Brain Rehabilitation Clinic, which provides comprehensive outpatient services to manage post-acute and long-term needs during recovery.

TBI specialist Anne Moessner, R.N., C.N.S., program manager of the outpatient clinic, says patients with more severe TBI may have reduced awareness of their problems and their rehabilitation can be uniquely challenging. "It can be a long road to recovery after severe TBI, but most people do better than early predictions. We have data that show they tend to get better over time, and most go back to living in the community and productive activity," she notes.

Another challenge is overcoming unrealistic expectations. "People think more therapy is better, but we try to figure out exactly the right balance," Moessner says. "Most people make the most noticeable gains early in the course of recovery. Fine-tuning can occur for a long while — years after the initial trauma, in some cases. We try to help patients and families understand that the window for recovery is wide open. Although a lot of recovery happens in therapy, a lot also happens in the real world."

To help patients with mild to severe TBI function as independently as possible as soon as possible, Mayo provides access to physical and occupational therapists as well as speech-language pathologists. Physical and vestibular therapists address neuromuscular, mobility, dizziness and balance problems; occupational therapists provide a broad range of services including cognitive rehabilitation, guidance on fatigue management, neuromuscular treatment, vision rehabilitation and help with activities of daily living.

The outpatient clinic also has a vocational coordinator to guide patients back to work and educate employers, a licensed clinical social worker who counsels and educates patients and families and assists with resource management, and neuropsychologists who evaluate cognitive, emotional and behavioral function and provide help when needed. "Our therapists are extremely creative. They look at the whole person and determine each patient's needs, Moessner says.

The TBI clinic has an open door policy — patients are followed as long as needed. "Patients may need to come back because they are having more cognitive or emotional difficulties, and that's just fine; we figure out what they need and give it to them," she notes.

Hard knocks

Moessner and Dr. Brown both agree that the dangers of mild traumatic brain injuries — concussions — have been overstated, especially in the press. "No one paid attention to concussions for years, and now it's all the talk," Moessner says. "We find ourselves having to reassure patients that the odds of developing premature dementia or some other devastating neurological disease after a single concussion are low. In the end, the majority of patients recover well in days to weeks."

Moessner acknowledges that rest after TBI has been controversial but maintains it's better for people to stay active.

"A couple of days' rest after a concussion is fine, but it doesn't need to be weeks and months. And even then, it's better to rest the brain in bits, not continuously. Kids can return to school — and adults to work — on a part-time basis while we monitor them. We help with return to school, work, and usual activities and collaborate with sports medicine on return-to-play issues. Athletes can often go back to school soon after their injuries. The return to high-risk activities, like sports, can take a bit longer. As with severe TBI, we follow patients until they don’t need to see us anymore."

More about TBI care at Mayo

Mayo Clinic was designated a Traumatic Brain Injury Model System by the National Institute on Disability and Rehabilitation Research in 1998, and is one of 16 current TBI Model Systems.