Today's excerpt is adapted from the chapter "Clinical Continuum of Care and Natural History," by Douglas I. Katz, Nathan D. Zasler, and Ross D. Zafonte.
Systems of care for patients with traumatic brain injury (TBI) should account for the particular characteristics of this disorder. First, TBI is a large problem. TBI is among the most common of serious, disabling neurological disorders. It is a major problem in all societies. In the United States, it is estimated that 1.7 million TBIs occur every year, and there are an estimated 3.2 million people living with disability from TBI. Systems of care must allocate resources for the large number of people who are affected by the disorder.
Second, TBI is more commonly a younger and older person’s disorder. Individuals younger than 30 years old, mostly males, make up the largest proportion of those affected by TBI. TBI frequently impacts people in the later stages of adolescent development or early adulthood. Therefore, TBI typically disrupts important periods of the life cycle that involve completing formal education, maturing social development, emerging vocational productivity, achieving adult independence, beginning spousal relationships, and child rearing. Older persons present particular problems related to aging, including comorbidities, slower and less complete recovery and vulnerability to complications of injury and treatment. Systems of care must address needs that include special educational requirements, independent living, vocational training and supports, and supports for family members.
Third, TBI commonly affects people with preexisting problems such as substance abuse, learning disability, behavioral disorders, psychiatric disorders, and other risk factors that may make people more prone to injuries. In addition, persons with brain injury are more prone to psychiatric comorbidities and psychosocial difficulties following injury. Systems of care must consider these preinjury and postinjury issues with respect to injury prevention, their interactions with the clinical effects of injury, and potential detrimental influence on recovery from TBI.
Fourth, the most important and consistent effects of TBI involve cognitive, emotional, and behavioral functioning. Motor and sensory perceptual problems also occur in varying amounts, more likely in those with more severe injuries. Cognitive and behavioral problems present more challenges to the health care system because they are often more difficult to recognize, characterize, and treat than traditional medical and physical problems. Persons with TBI may not have any physical markers or obvious signs of injury, although there may be profound effects on the individual’s ability to function, resulting from cognitive and behavioral problems. Criteria for medical rehabilitation reimbursement, length of stay, and utilization decisions are often centered more on physical and motor issues that affect function and less on cognitive and behavioral treatment issues. Some insurance payers even exclude coverage for cognitive rehabilitation, although there is expanding evidence to support the efficacy of a variety of cognitive rehabilitation strategies and models. Systems of care must support proper assessment and treatment of cognitive and behavioral problems after TBI, even though they may not fit the characteristics of medical rehabilitative systems that were originally developed for medical and physical disabilities.
Fifth, TBI, especially more severe injuries, can have a relatively extended natural history and lifelong effects. Recovery from TBI may be more protracted and extend over a relatively longer portion of the life span than most other acquired injuries or neurological disorders that evolve more quickly or affect persons at later stages of life. The natural history of TBI has a longer horizon than most other acquired injuries or neurological disorders of similar severity and systems of care for TBI need to recognize the potentially prolonged recovery timetable. Further, recovery after TBI has a somewhat predictable and characteristic course, with a variety of recognizable cognitive, behavioral, and sensorimotor syndromes at different stages of recovery. An appreciation of the natural history of TBI is essential in assessing the individual with TBI, applying treatment and services effectively and appropriately at different stages of recovery, and/or avoiding treatment that may be unnecessary or ineffective.
Finally, TBI is a disorder with a wide variety of pathophysiological effects, a broad range of severities, and a multitude of problems that can occur as the result of injury. Persons with apparently similar injuries may have significant variation in their presentation, course of recovery, secondary problems, response to interventions, and ability to reintegrate into community. Systems of care should have a breadth of treatments and services to intervene for the variety of problems that can occur after TBI and the flexibility to move persons with TBI through the system as their needs change and evolve at different times postinjury.
For more information on TBI, read Brain Injury Medicine, Second Edition, available now from Demos Medical.