3.4 Community Rehabilitation

Following discharge from inpatient rehabilitation unit patients with moderate to severe brain injury typically receive ongoing therapy at a lesser intensity. While most patients move back to their former living environment with therapy intervention provided for them in the home or community, some go on to other facilities that may provide longer duration treatment for the slow-to-recover patient. The effectiveness of these interventions is reviewed in this section.

What evidence is there that ABI rehabilitation provided in the community improves outcomes?

  1. There is Level 1 evidence that a fitness center-based program is not better than a home-based program for improving cardio-respiratory fitness.
     
  2. There is Level 1 evidence that structured multidisciplinary rehabilitation in community setting can improve social functioning.
     
  3. There is Level 4 evidence that community-based social and behavioral rehabilitation of at least six months results in greater independence, higher social activity levels and less need for care support.
     
  4. There is Level 2 evidence from one RT that direct patient involvement in neurorehabilitation goal setting results in a significant improvement in obtaining goals from pre-test to post-test that are then maintained at a follow-up of two months.
     
  5. Based on the findings from two pre-shot studies there is a Level 4 evidence that participation in a comprehensive day treatment program reduces impaired self-awareness and distress. It also improves societal participation at one-year follow-up.

Powell et al. 85randomly assigned TBI patients to an outpatient support program where patients received 2-6 hours per week for a about 27.3 weeks in a community setting. During this time the group was given assistance individually by a multidisciplinary team.  The control group received a specially collated booklet with relevant resources highlighted.  The Outreach group scored significantly higher on Barthel Index, the BIRCO and two sub-sections of the FIM+FAM.

In a retrospective cohort study by Wood et al. 93data related to dependency, social activity, and care support were collected on seventy-six subjects who received community-based social and behavioural rehabilitation. They found that rehabilitation of at least six months led to greater independence, higher social activity levels, and less need for care support.   

In the RCT conducted by Webb and Glueckauf 94the effects of direct patient involvement in neurorehabilitation goal setting was evaluated. Sixteen subjects were randomly assigned to one of two groups: high involvement (HI) in goal setting or low involvement (LI) in goal setting. The main difference between the two groups was that subjects in the HI group were encouraged to be directly involved in their goal setting, while subjects in the LI group were not. At post-test, as compared to pre-test, both groups made significant improvements in obtaining their goals. However, only subjects in the HI group maintained the improvements at a two-month follow-up.

Two studies examined the effects of a comprehensive day treatment program (CDTP). While the former looked at its effects on impaired self-awareness (ISA) and distress, the latter evaluated its impact on societal participation. Using nonparametric analyses, Malec and Moessner 95discovered that after participation in the CDTP patients experienced reduced ISA and distress. With regards to societal participation,Malec 96found that at one year after participation in the program 72% were living independently, 39% were working independently, 10% were in transitional placements, and 18% were involved in supported or volunteer work.      

Ownsworth et al. 97compared performed a randomized trial to compare individual, group, and combined interventions for goal attainment and psychosocial functioning. Each group showed improvements in different areas. The individual intervention component contributed to gains in performance in goal-specific areas. The combined intervention was associated with maintained gains in satisfaction and performance, while the group and individual interventions were more likely to result in gains in behavioural competency and psychological well being.

Powell J, Heslin J, Greenwood R. Community based rehabilitation after severe traumatic brain injury: A randomized controlled trial. Journal of Neurology, Neurosurgery and Psychiatry 2002;72(2):193-202.

  • 92 individuals who had sustained a moderate to severe TBI participated in an outreach treatment program.
  • Participants were randomly assigned to either the experimental or information groups
  • 35% of the experimental group improved their scores on the BI and BICRO compared to 20% of the information group (p<0.05). 
  • When looking at the FIM and FAM scores significant changes were noted when measuring their level of personal care (p<0.06) and cognition (p<0.09) for the Outreach group compared to the information group.

Webb PM and Glueckauf RL. The effects of direct involvement in goal setting on rehabilitation outcome for persons with traumatic brain injuries. Rehabilitation Psychology 1994;39(3):179-188.

  • 16 participants randomly assigned to have high involvement (HI) in their neurorehabilitation goal setting or low involvement (LI) in their neurorehabilitation goal setting.
  • Both groups made significant improvements in obtaining their goals from pre to post testing (F(1,14) = 64.69, p<0.001).
  • However, only participants who had high involvement in their neurorehabilitation goal setting maintained the improvements at a 2-month follow-up.

What is the impact of community based rehabilitation program for patients with a diagnosis of TBI and substance abuse?

  1. There is Level 4 evidence that patients with a dual-diagnosis of TBI and substance abuse who participate in a community-based treatment program generally do not become chemical-free.  This is due to both an inability to keep them in the program for the six-month period desired and the failure of clients to follow recommendations for additional rehabilitation of psychiatric treatment at discharge.

Blackerby and Baumgarten 98conducted a series of single subject intervention studies on seven persons with TBI and substance abuse problems.  In this study, the intervention was a dual diagnosis treatment program known as RELATE (Rebound Lifestyle Adjustment Team) that took place within a community-based Alcoholics Anonymous or Narcotics Anonymous group. Complete abstinence from chemical substances was the program’s ultimate goal. The authors discovered that both of the clients who followed recommendations for additional rehabilitation or psychiatric treatment at discharge from the program remained drug-free. On the other hand, only one of the five clients who did not follow recommendations remained drug-free at follow-up, while three continued their chemical dependency and one’s follow-up status was unknown. The authors concluded that this program was relatively unsuccessful due to an inability to keep clients in the program for the six-month period desired and the clients’ failure to follow discharge treatment recommendations.

Two studies examined the outcomes of those who had previously participated in rehabilitation 99;100. In theOlver et al. 100study, patients reported no mobility issues, improved communication skills andcompleted basic daily activities independently; however two-thirds reported still having some cognitive issues. Many reported feelings of anger, irritability, and aggression. Of the 103 who completed the surveys, only 34 were employed and 12 were in school, suggesting that ongoing support is needed. Findings reported byKlonoff et al. 99indicate that approximately one third were in long term relationships and of those who had returned to work, the majority were younger and of higher education. The income of participants decreased significantly post injury with fewer patients returning to full or part-time work.

Summary

Continuity of rehabilitation strategy includes a community-based program following inpatient rehabilitation that is tailored to individuals’ needs in order to maximize their recovery. It is generally accepted as neither safe nor prudent to allow patients to be discharged from a rehabilitation setting without adequate follow through on the issues that they continue to face in the course of their recovery. Given that most patients will continue to make gains for two or more years, it is reasonable to ensure that they continue to receive therapeutic intervention for this period of time. When looking at patients years post injury, although gains were made there was still a need for continued support. However, the evidence to support or refute remains insufficient.