There are different types of hospitals, rehabilitation programs and health care professionals that one should become familiar with during the brain injury recovery process.

The rehabilitation process is different for everyone who sustains a brain injury. How well a person does following a brain injury depends on the individual’s health prior to the injury, the nature of the injury and the post-injury course of recovery. Rehabilitation programs following a brain injury should cater to each person’s needs.

A comprehensive Traumatic Brain Injury rehabilitation consists of at least the following elements:

• The rehabilitation physician (physiatrist) and the rehabilitation nurse have special training in diagnosing and treating people with disabilities. Their goal is to help patients who have suffered a brain injury, regain the most independent level of functioning possible.
• The prevention of secondary injuries is important. Rehabilitation facilities and the rehabilitation process are in place to prevent these secondary injuries from occurring.
• Rehabilitation builds upon natural recovery processes this allows the body to regain strength and re-learn natural functions, which aid in a quick recovery.

An optimal environment for neurological recovery is also provided by rehabilitation settings.

• Various techniques are provided and taught to promote recovery and help with the tasks of daily living.
• Adaptive and specialized equipment, such as wheelchairs or others are available in this setting.
• Environmental modifications are available. These include architectural and transportation interventions. Even more important may be interventions in the patient’s social milieu, which include modifications at home, at work and in the community.

Report of the Panel for Consensus Development Conference on the Rehabilitation of Persons with TBI, October 26-28, 1998. Cope, Nathan, “The Effectiveness of Traumatic Brain Injury Rehabilitation, a Review”; ‘Brain Injury’, Volume 9, No. 7 1995, pages 649-670.

Emergency Rescue

• Most of the time, an emergency team will be the first to attend to the person with a brain injury. They are the first to arrive and the brain injury care begins at the site of the emergency.

Intensive Care Unit (ICU)

• After the brain injured person arrives at the hospital, he/she may be admitted to the intensive care unit. Sometimes the injured person may be unconscious, in a coma or medically unstable at arrival.
• During this phase, the goal is for the injured person to achieve medical stability and to prevent a medical catastrophe.
• For this reason, the medical professionals may need to attach medical equipment to the patient in order to help sustain his/her life.

Acute Rehabilitation

• The next step in the continuum of care is acute rehabilitation.
• The transfer to an acute rehabilitation facility or unit within the hospital occurs when the brain injured patient is medically stable and has reached a point where he/she is able to participate in therapy.
• Here, a team of health professionals assists persons with brain injury to achieve the highest level of independent skills used in activities of daily living.
• Rehab team members include:
  • Physiatrist- Doctor of physical medicine rehabilitation. The physiatrist typically serves as the leader for the rehabilitation treatment team and makes referrals to the various therapies and medical specialists as needed. The physiatrist works with the rehabilitation team, patient and the family to develop the best possible treatment plan.
  • Physical Therapists- Therapists who evaluate and treat a person’s ability to move the body. They focus on improving physical function by addressing muscle strength, flexibility, endurance, balance, and coordination. Physical therapists provide training with assistive devices such as canes or walkers for ambulation. Physical therapists can also use physical modalities, including treatments of heat, cold and water to assist with pain relief and muscle movement.
  • Occupational Therapists- Therapists who use purposeful activities as a means of preventing, reducing or overcoming physical and emotional challenges with the purpose of aiding the person with a brain injury to function independently.
  • Speech/Language Pathologists- Therapists who evaluate a person’s ability to express oneself (speech, written or otherwise) and comprehend what is seen or heard. They use assistive technology as an alternative form of communication if the person is unable to verbalize. The speech/language pathologist focuses on the muscles in the face, mouth and throat and addresses swallowing issues.
  • Rehabilitation Nurses- Nurses who monitor all body systems by maintaining the person’s medical status and set goals to allow the person to reach his/her maximum medical improvement. They are responsible for the assessment of the patient’s care and for coordinating with physicians and team members to allow patients to become as independent as possible.
  • Case Managers/Social Workers- Responsible for assuring appropriate and cost-effective treatment and the facilitation of discharge planning. They maintain regular contact with the patient’s insurance carrier, family and referring physician to assure that treatment goals are understood and achieved.
  • Recreational Therapists- Therapists who provide activities to improve and enhance self-esteem, social skills, motor skills, coordination, endurance, cognitive skills, and leisure skills. They plan community activities that allow the person to directly apply learned skills in the community.
  • Neuropsychologists- Physiologists who focus on aiding the brain injured person to think, behave and to control his/her emotions. They provide services to reduce the impact of setbacks and to help the person return to a full, productive life. The neuropsychologist’s evaluations provide valuable information to assist with school, community or employment re-entry.
  • Aquatic Therapists- Occupational therapists, physical therapists or recreational therapists with specialized training to provide therapy in a heated water pool. Aquatic therapists assist a person to increase strength, coordination, endurance, muscle movements, and reduce pain, using water resistance. The ultimate goal is to increase the person’s functional ability for activities of daily living.

Sub-acute Rehabilitation

• Sub-acute rehabilitation provides services for persons with brain injury who need a less- intensive level of rehabilitation services, over a longer period of time.
• These programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing, but are not making rapid functional gains.
• Sub-acute rehabilitation may be provided in a variety of settings but is often in a skilled nursing facility or nursing home.

Day Treatment (Day Rehab or Day Hospital)

• Day treatment provides rehabilitation in a structured group setting during the day and allows the brain injured patient to return home at night.

Outpatient Therapy

• Outpatient therapy is offered for those who do not need to be hospitalized, but require therapy to meet certain goals.

Home Health Services

• Some hospitals and rehabilitation companies provide rehabilitation therapies within the home for persons with brain injury who are unable or find it difficult to reach a facility.

Community Re-entry

• Community re-entry programs generally focus on developing higher level motor, social and cognitive skills in order to prepare the person with a brain injury to return to independent living, and potentially, to work.
• Treatment may focus on safety in the community, interacting with others, initiation, and goal setting and money management skills.
• Vocational evaluation and training may also be a component of this type of program.

Independent Living Programs

• Independent living programs provide housing for persons with brain injury, with the goal of getting the patient to regain the ability to live as independently as possible.
• Some facilities will give the patient different levels of independence according to his or her needs.

Brain Injury Support Groups

• Brain injury support groups exist to help individuals with brain injury and their family members to understand the effects of brain injury and to help cope with issues related to the injury.
• These groups also provide emotional support, networking opportunity and education for a better understanding of the impact and effects of brain injury.

Scales and Measurements of Functioning

There are several scales and measures used to rate and record a person’s progress in rehabilitation following a brain injury. Listed below are some of the more common ones:

Rancho Los Amigos – Levels of Cognitive Functioning Scale

Levels of Cognitive Functioning

Level I – No Response: Total Assistance

• Complete absence of observable change in behavior when presented with visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli.

Level II – Generalized Response: Total Assistance

• Demonstrates generalized reflex response to painful stimuli.
• Responds to repeated auditory stimuli with increased or decreased activity.
• Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization.
• Responses noted above may be same regardless of type and location of stimulation.
• Responses may be significantly delayed.

Level III – Localized Response: Total Assistance

• Demonstrates withdrawal or vocalization to painful stimuli.
• Turns toward or away from auditory stimuli.
• Blinks when strong light crosses visual field.
• Follows moving object passed within visual field.
• Responds to discomfort by pulling tubes or restraints.
• Responds inconsistently to simple commands.
• Responses are directly related to type of stimulus.
• May respond to some persons (especially family and friends) but not to others.

Level IV – Confused/Agitated: Maximal Assistance

• Alert and in heightened state of activity.
• Purposeful attempts to remove restraints or tubes or crawl out of bed.
• May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another’s request.
• Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
• Absent short-term memory.
• May cry out or scream out of proportion to stimulus even after its removal.
• May exhibit aggressive or flight behavior.
• Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
• Unable to cooperate with treatment efforts.
• Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

Level V – Confused, Inappropriate Non-Agitated: Maximal Assistance

• Alert, not agitated but may wander randomly or with a vague intention of going home.
• May become agitated in response to external stimulation, and/or lack of environmental structure.
• Not oriented to person, place or time.
• Frequent brief periods, non-purposeful sustained attention.
• Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
• Absent goal directed, problem solving, self-monitoring behavior.
• Often demonstrates inappropriate use of objects without external direction.
• May be able to perform previously learned tasks when structured and cues provided.
• Unable to learn new information.
• Able to respond appropriately to simple commands fairly consistently with external structures and cues.
• Responses to simple commands without external structure are random and non-purposeful in relation to command.
• Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.
• Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.

Level VI – Confused, Appropriate: Moderate Assistance

• Inconsistently oriented to person, time and place.
• Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.
• Remote memory has more depth and detail than recent memory.
• Vague recognition of some staff.
• Able to use assistive memory aide with maximum assistance.
• Emerging awareness of appropriate response to self, family and basic needs.
• Moderate assistance for problem solving and task completion.
• Shows carry-over for relearned familiar tasks (e.g. self care).
• Maximum assistance for new learning with little or no carry-over.
• Unaware of impairments, disabilities and safety risks.
• Consistently follows simple directions.
• Verbal expressions are appropriate in highly familiar and structured situations.

Level VII – Automatic, Appropriate: Minimal Assistance for Daily Living Skills

• Consistently oriented to person and place within highly familiar environments. Moderate assistance for orientation to time.
• Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assistance to complete tasks.
• Minimal supervision for new learning.
• Demonstrates carry-over of new learning.
• Initiates and carries out steps to complete familiar, personal and household routine but has shallow recall of what he/she has been doing.
• Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work, and leisure activities.
• Minimal supervision for safety in routine home and community activities.
• Unrealistic planning for the future.
• Unable to think about consequences of a decision or action.
• Overestimates abilities.
• Unaware of others’ needs and feelings.
• Oppositional/uncooperative.
• Unable to recognize inappropriate social interaction behavior.

Level VIII – Purposeful, Appropriate: Stand-By Assistance

• Consistently oriented to person, place and time.
• Independently attends to and completes familiar tasks for 1 hour in distracting environments.
• Able to recall and integrate past and recent events.
• Uses assistive memory devices to recall daily schedule, “to do” lists and record critical information for later use with stand-by assistance.
• Initiates and carries out steps to complete familiar personal, household, community, work, and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.
• Requires no assistance once new tasks/activities are learned.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.
• Thinks about consequences of a decision or action with minimal assistance.
• Overestimates or underestimates abilities.
• Acknowledges others’ needs and feelings and responds appropriately with minimal assistance.
• Depressed.
• Irritable.
• Low frustration tolerance/easily angered.
• Argumentative.
• Self-centered.
• Uncharacteristically dependent/independent.
• Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.

Level IX – Purposeful, Appropriate: Stand-By Assistance on Request

• Independently shifts back and forth between tasks and completes them accurately for at least two consecutive hours.
• Uses assistive memory devices to recall daily schedule, “to do” lists and record critical information for later use with assistance when requested.
• Initiates and carries out steps to complete familiar personal, household, work, and leisure tasks independently and carries out unfamiliar personal, household, work, and leisure tasks with assistance when requested.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assistance to anticipate a problem before it occurs and take action to avoid it.
• Able to think about consequences of decisions or actions with assistance when requested.
• Accurately estimates abilities but requires stand-by assistance to adjust to task demands.
• Acknowledges others’ needs and feelings and responds appropriately with stand-by assistance.
• Depression may continue.
• May be easily irritable.
• May have low frustration tolerance.
• Able to self-monitor appropriateness of social interaction with stand-by assistance.

Level X – Purposeful, Appropriate: Modified Independent

• Able to handle multiple tasks simultaneously in all environments but may require periodic breaks.
• Able to independently procure, create and maintain own assistive memory devices.
• Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work, and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them.
• Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies.
• Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action.
• Accurately estimates abilities and independently adjusts to task demands.
• Able to recognize the needs and feelings of others and automatically respond in appropriate manner.
• Periodic periods of depression may occur.
• Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress.
• Social interaction behavior is consistently appropriate.

Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R. Source: www.neuroskills.com

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale is used to determine the initial severity of a brain injury. It is often used at the emergency scene or emergency room.

I. Motor Response

• 6 – Obeys commands fully
• 5 – Localizes to noxious stimuli
• 4 – Withdraws from noxious stimuli
• 3 – Abnormal flexion
• 2 – Extensor response
• 1 – No response

II. Verbal Response

• 5 – Alert and Oriented
• 4 – Confused, yet coherent, speech
• 3 – Inappropriate words and jumbled phrases consisting of words
• 2 – Incomprehensible sounds
• 1 – No sounds

III. Eye Opening

• 4 – Spontaneous eye opening
• 3 – Eyes open to speech
• 2 – Eyes open to pain
• 1 – No eye opening

The final score is determined by adding the values of I+II+III.

This number helps medical practitioners categorize the four possible levels for survival, with a lower number indicating a more severe injury and a poorer prognosis:

Mild (13-15)

Moderate Disability (9-12)

Severe Disability (3-8)

Vegetative State (Less than 3)

Glasgow Outcome Scale

• This is NOT the same as the Glasgow Coma Scale
• The Glasgow Outcome Scale is a very broad scale and has been shown to have very little value for people in rehabilitation.

• 5 = Good Recovery – normal or near normal recovery
• 4 = Moderate Disability – disabled but independent
• 3 = Severe Disability – dependant with physical or psychological disabilities or both
• 2 = Persistent Vegetative State
• 1 = Dead

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Existen diferentes tipos de hospitales, programas de rehabilitación y profesionales de cuidados médicos que uno debe conocer durante el proceso de recuperación de una lesión cerebral.

El proceso de rehabilitación es diferente para cada persona que sufre de una lesión cerebral. La manera en que una persona mejora después de una lesión cerebral depende de la salud de la persona antes de la lesión, la naturaleza de la lesión y el período posquirúrgico de recuperación. Los programas de rehabilitación luego de una lesión cerebral deben cubrir las necesidades de cada persona.

La rehabilitación integral de la lesión cerebral traumática consiste como mínimo en los siguientes elementos:

• El médico de rehabilitación (fisiatra) y la enfermera de rehabilitación tienen una formación especial para diagnosticar y tratar personas con discapacidades. El objetivo es ayudar a los pacientes que han sufrido una lesión cerebral a recuperar el mejor nivel de funcionamiento independiente posible.
• Es importante la prevención de lesiones secundarias. Los centros de rehabilitación y el proceso de rehabilitación se encuentran preparados para prevenir que sucedan lesiones secundarias.
• La rehabilitación se basa en los procesos de recuperación naturales, lo que permite que el cuerpo recupere la fuerza y vuelva a aprender las funciones naturales, lo cual contribuye a una recuperación rápida.
• El entorno de rehabilitación también proporciona un ambiente óptimo para la recuperación neurológica.
• Se brindan y se enseñan diferentes técnicas para promover la recuperación y para ayudar con las tareas de la vida diaria.
• En este entorno hay disponibilidad de equipos adaptados y especializados, como sillas de rueda u otros dispositivos.
• Se encuentran disponibles modificaciones en el entorno. Estas modificaciones incluyen intervenciones arquitectónicas y de transporte. Es más importante que haya intervenciones en el medio social del paciente, que incluyan modificaciones en la casa, en el trabajo y en la comunidad.

Report of the Panel for Consensus Development Conference on the Rehabilitation of Persons with TBI (Informe del panel en la conferencia de desarrollo de consenso sobre la rehabilitación de personas con lesiones cerebrales traumáticas), 26-28 de octubre de 1998. Cope, Nathan, ‘‘The Effectiveness of Traumatic Brain Injury Rehabilitation, a Review’’ (La efectividad de la rehabilitación de la lesión cerebral traumática: una revisión) ‘Brain Injury’, Volumen 9, No. 7 1995, páginas 649-670.