To treat traumatic brain injuries, PTs must expand their roles as therapy providers.

A 19-year-old man leaves a party with far too much alcohol in his blood and wraps his new car around a telephone pole, slamming his head against the windshield. A 26-year-old gang member takes a bullet to the head in a drive-by shooting. A 41-year-old female is attacked from behind and thrown against a concrete support as she walks to her car in a dark parking garage; her head is bleeding badly, and later she won’t remember most of the details of the assault. A 78-year-old grandfather slips in the shower, and his head hits the tile walls repeatedly as he falls.

These patients will end up in an emergency department with, among other things, traumatic brain injury (TBI). If, in the course of their follow-up treatment, they are admitted to the Drucker Brain Injury Center at MossRehab’s main campus in Elkins Park, Pa, the team that treats TBI patients will include a PT. Due to the fact that these patients are among the most difficult, challenging, and complex that a rehab center will face, the PTs on the team do not stop at traditional physical-therapy treatment. Tough cases call for creative care and a focus on end results rather than specialization, explains Andy Packel, PT, NCS, physical therapy team leader at the Drucker Brain Injury Center. Therefore, PTs on his team often assist with behavioral, cognitive, and occupational therapy as well.

Beyond Traditional Therapy
"Physical therapists have a definite role in helping with mobility," Packel says. "However, we might also address behavioral, cognitive, or other issues as well. To someone who has not worked with the TBI population before, some of the things we talk about doing might not seem like traditional physical therapy. We may help with activities of daily living, for example, and that is typically associated more with occupational therapy. Or, we may cotreat with a neuropsychologist. If a patient is less affected by mobility issues but exhibits poor route-finding, we might tend to focus more on the cognitive-therapy aspects of treatment. However, we usually tie it into traditional physical-therapy functions."

When it comes to mobility—perhaps the most traditional area of physical-therapy intervention—some TBI patients are "higher-level," with more or less normal walking patterns, so their rehab problems tend to be focused on cognitive and behavioral therapy. Others cannot move at all when they leave acute care. "People tend to think that physical therapy is focused exclusively on mobility," Packel adds. "And while we do tend to address different therapy needs according to our individual disciplines, you cannot address mobility without addressing cognitive and behavioral issues in TBI patients—and vice versa. That’s what makes these patients so challenging and interesting." Many TBI patients, he explains, are minimally responsive and may not be able to interact with the outside world.

Falls send a fair number of patients to Drucker. "We get a lot of patients with work injuries," Packel reports. "Especially people working in trees or on roofs. We also treat a lot of elderly patients who have fallen. For a number of reasons, including atrophy of the brain, an older person might respond worse [to the injury] to the same type of impact than a younger person."

PTs, he adds, often notice physical therapy-related symptoms with far-reaching impact that other specialists might not catch right away. One is inner-ear problems affecting patients’ equilibrium and ability to ambulate. A patient who is flat on his or her back in the intensive care unit (ICU) might not show evident balance problems nor be able to communicate sensory problems—PTs notice such things as soon as patients begin to move about. Car-crash victims—who represent about half of Drucker’s patient load—may have sizeable breaks in major bones that are noticed early on. When PTs get them moving even slightly, they may notice additional ankle problems, for example, that the patients are unable to communicate. A silent wince as a patient moves tells the PT immediately that something—vestibular issues, for example, or a small fracture or ligamentous or muscular injury—is amiss. "We might be the first to pick up on those things," Packel says. "When we do, we follow up immediately with the physicians."

It helps, he emphasizes, to have a few difficult TBI patients under your belt when it comes to navigating the complexities of team treatment. "When you work with a number of different patients," he says, "you do get a sense of what specifics each one will need. One patient may remind you of a previous case, for example. While each patient is unique, experience gives you a big grab bag of tricks you’ll need to be able to apply the appropriate one to each patient." Some of the recent additions to that bag of tricks are body-weight-supported treadmill training, robotics-aided training, innovations in protheses, and the use of electrical stimulation devices, as appropriate.

Having as many tricks in the bag as possible is something of a necessity at a facility like Drucker, which sees a lot of what Packel terms "lower-level patients": those who are the most injured, and, thus, require the most intensive intervention by the broadest variety of practitioners. "Our minimally responsive program is unique," he reports. "We do not just perform physical therapy; we assist in assessing the patient. Is he or she vegetative? Is he or she minimally conscious?" That critical evaluation, he adds, gets an important assist from Drucker’s evidence-based evaluation system. It’s one of the reasons the facility can treat patients who might not be considered appropriate for rehab at other places; indeed, some can’t interact with caregivers at all when treatment starts.

That level of patient complexity—and Drucker’s ability to handle it—gives the institution an important clinical edge over community rehab facilities, Packel comments. "I don’t think most of them are equipped to deal with a lot of the significant TBI cases," he says. "The toughest patients require us to carefully integrate an entire team of professionals accustomed to dealing with TBI—from nurses to neuropsychologists. And, our facility has outcomes managers, case managers, and social workers who have long-term relationships with insurance companies. The insurers understand that we know what we’re doing and that we’ll get patients back to a setting that’s appropriate. In the end, that’s cheaper for an insurance company than a nursing home. I don’t think everyone can be on the same page like that at a community rehab hospital."

The critical cases that Drucker specializes in often start with a surgical intervention and a stay in ICU. Then, they are transferred to a step-down unit or a non-ICU floor for follow-up and observation, and then they make the move to the Drucker specialists. "They stay with us for varying lengths of time," he says. "It’s unusual for a stay to last less than 2 weeks. The average is about a month, but TBI rehab can easily last 2, 3, or even 4 months. Then, we hope, they are headed home to their communities." Drucker also provides outpatient services—including physical therapy—to discharged TBI patients, as well as home-based visits; indeed, some patients with milder injuries may skip the inpatient stage altogether. In that postacute care, Packel emphasizes, "It can be really critical to get patients into brain injury-specific programs. If a patient has physical-therapy issues and you send him or her to an outpatient-care provider that does not have experience in TBI, the providers may not understand why the patient cannot follow instructions—and he or she may be incorrectly labeled a malingerer." Drucker, he adds, also offers back-to-school and back-to-work retraining as part of "a whole continuum of care."

Drucker Details
The organization, which, as part of MossRehab, is also part of the Albert Einstein Healthcare Network, supports four inpatient PTs and four inpatient occupational therapists, assigned specifically to treating TBI patients. In addition, three inpatient speech therapists, two social workers, and two neurologists work exclusively with inpatient TBI cases. A recreation therapist is also available. Typically, Packel reports, a PT will manage up to six TBI patients at a time.

Because he’s a team leader, he sees half a patient case load—seeing patients in the facility and at their homes—and handles coordination of the other physical-therapy staff members, including assigning patients to individual PT’s and covering for colleagues during vacations and sick days.

Packel is also a mentor in MossRehab’s neurological physical-therapy residency program. The program is not specific to TBI, he notes, but it is "a significant piece" of the TBI program—and it is one of just two in the country. Most patients at Drucker receive 90 minutes of physical therapy per day, along with 60 minutes of daily occupational therapy and 30 minutes of speech therapy per day. Each patient is assigned a neuropsychologist, a social worker, and an outcome manager. In the last 2 decades, Drucker has cared for more than 11,000 TBI patients; each year, it treats about 200 inpatients, with about 90% returning to their homes. For its achievements, the institution says, it’s been "repeatedly" recognized as one of the "Best Hospitals in America" by US News & World Report.

Specific offerings at the Drucker Brain Injury Center include:

• The Responsiveness Program, which evaluates people who are either in, or emerging from a coma, or who have a questionable ability to participate in rehabilitation therapy;

• The Neuro-Orthopaedic Program, which provides help for people whose arms and legs have limited or no mobility due to TBI or other neurological disorders;

• Comprehensive Outpatient Rehabilitation Evaluation, which assesses a patient’s mental status and daily-living skills, the structure needed for daily living, assistance that will be provided, and the costs involved;

• The Drucker Day Program, which provides additional therapy to further establish basic skill levels after a person has returned to his or her community;

• The Community Re-Entry Program, which helps people build familiar routines that can help them prepare meals, dress themselves, or pay bills;

• The Clubhouse, which Drucker calls "an innovative, community-based day program that promotes personal success and self-sufficiency for brain-injured individuals";

• A "Life-Long Living Support System" that offers ongoing psychosocial support and education to individuals with brain injuries and their families; and

• The Community Residential Program, which offers people with brain injury "a beautiful, home-like setting to live in and learn skills of daily living."

An important element of all of the programs at Drucker, Packel emphasizes, is family involvement. "Every Drucker program includes education and training for family members," he says, "who play a vital role in helping a loved one with brain injury make progress. We also provide support for family members, helping them deal with the stress often associated with caring for someone with a disability. Many of those family members stay in the area the whole time patients are in rehab, so we often develop relationships with them as well." Of course, that’s the double-edged sword all practitioners must deal with. Forging close ties with patients and their loved ones can lay the emotional groundwork for speedier recovery. But it can also be wrenching for the providers—especially if treatment does not progress as well as everyone hopes it will.

"It can be very satisfying working with younger patients," Packel says. "In our minimally responsive program, patients, at first, may not notice you or may not be able to talk or follow commands. However, we really do see change in some of them. They end up being able to laugh and interact with family members and even participate in their own care. It is really good seeing their progress."

"Sometimes it really strikes you that their [the younger patients] lives have changed a lot," Packel continues. "Some are just out of college or have young kids. You know that, even as they make progress and will continue to, they’re not ever going to be the same as before the injury." Indeed, he says, "there’s no way you can stay distant from your patients. You maintain a level of professionalism, naturally, but you may be seeing the patient for 90 minutes a day for months. Sometimes you have a good feeling about a patient, and your best clinical guess is he or she will progress. It’s very frustrating if the patient doesn’t."

If failure to progress is frustrating for the provider, it’s doubly so for the patient, who must face the fact that fully restored mobility simply won’t ever occur. "With TBI patients, there’s no way to factor out psychological care," Packel says. Suicidal thoughts, in fact, pose a real problem for TBI patients undergoing what can be difficult and extremely frustrating physical therapy. "A teenager or early-20s young adult who just gained independence can be devastated if he or she suddenly becomes dependent again," he explains. In addition, he notes, people with clinical depression are at a greater risk of TBI in the first place. Indeed, the brain injury may have resulted from a suicide attempt or other risk-taking behavior.

Reimbursement Restrictions
As with all medical specialties, though, physical therapy for TBI patients is driven not just by patient needs and provider expertise. "A lot is driven by cost-containment," Packel reports. Patients are coming out of acute care much sooner than they used to, and there’s pressure to move them out of inpatient rehab much sooner as well. "You have to keep making progress," he says. "That’s a change in treatment. Also, people used to say you needed a full year of recovery after TBI. We’ve come to recognize that that definitely isn’t true." Previously, he explains, as long as a patient was making progress, he or she could stay in therapy. "Now," he adds, "the driving question is, ‘Why can’t this person go home and be managed at the next level of care?’ Under the ‘1-year’ guideline, the thought used to be that people stopped making progress after 1 year, and whatever level they were at, that is where they would stay. Now, it is recognized that people can continue to make progress for years and years."

PTs at Drucker meet the challenges of tighter reimbursement and changing treatment philosophies in part through that team effort Packel is so proud of. "Our challenge is to get someone home and safe," he says. "If we can get people to a level where they can be well-managed and avoid future hospitalization and other future problems, it’s worth it for the insurance companies to put some extra money out." That doesn’t mean the insurance companies will, however.

In the meantime, PTs "need to be able to address patients’ specific impairments, but it’s hard given the time pressures," Packel says. "The most important aspect of care is the team approach. Cotreating with other therapists is critical."

Russell A. Jackson is a contributing writer for Physical Therapy Products.