The guidelines provided by the New York State Workers Compensation Board offer general principles for the rehabilitation of Brain Injury. These directives aim to assist healthcare professionals in determining appropriate strategies for the rehabilitation and recovery of individuals with brain injuries as part of a comprehensive care plan.
Healthcare practitioners specializing in Brain Injury Rehabilitation can rely on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for aiding patients in their recovery.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the rehabilitation of Brain Injury should involve collaboration between the patient and their healthcare provider.
Key Recommendations
Occupational Therapy: Recommended for select patients with TBI and associated functional deficits. Indicated for individuals with TBI experiencing functional physical deficits. The frequency and duration of occupational therapy may vary, with a potential prescription for daily sessions in the inpatient setting or two to three times per week in the outpatient setting.
The duration of supervised exercise for TBI patients is contingent upon the severity of their deficits. Subsequent therapy should be guided by continuous functional improvement, eventually transitioning to a home-based program. The approach ensures a personalized and evolving rehabilitation process aligned with the patient’s progress.
Physical Therapy (PT):
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- Recommended – for select patients with TBI and associated functional deficits.
- Indications – For patients with TBI and functional physical deficits.
- Frequency/Dose/Duration – May be prescribed on a daily basis in the inpatient setting or two to three times per week in the outpatient setting.
- Duration – of supervised exercise is dependent on the severity of the deficits. Further therapy should be based on ongoing functional improvement with transition to a home-based program.
- Strengthening Exercises:
- Recommended – for patients with TBI and associated functional deficits.
- Indications – For patients with TBI and functional physical deficits.
- Frequency/Dose/Duration – May be prescribed on a daily basis in the inpatient setting or two to three times per week in the outpatient setting.
- Duration – of supervised exercise is dependent on the severity of the deficits. Further therapy should be based on ongoing functional improvement with transition to a home-based program.
Customized Approach
- Recommended – for patients with TBI and associated functional deficits.
- Indications – For patients with TBI and functional physical deficits.
- Frequency/Dose/Duration – May be prescribed on a daily basis in the inpatient setting or two to three times per week in the outpatient setting.
- Duration – of supervised exercise is dependent on the severity of the deficits. Further therapy should be based on ongoing functional improvement with a transition to a home-based program.
Additional Information:
- Indications – For patients whose TBI has resulted in a documented deterioration in their physical conditioning due to TBI and functional physical deficits.
- Frequency/Dose/Duration – May be prescribed on a daily basis in the inpatient setting or two to three times per week in the outpatient setting.
- Gradual increase in exercise intensity will be based on patient tolerance.
- Duration of supervised exercise is dependent on the severity of the documented deconditioning.
- Further therapy should be based on ongoing improvement in exercise tolerance and functional improvement, with a transition to a home-based program.
Manipulation for Chronic Cervicogenic Headache Pain:
- Recommended – for the treatment of chronic cervicogenic headache pain associated with TBI.
- Frequency/Dose/Duration – Once or twice a week for four to five up to eight total sessions.
Aquatic Therapy:
- Recommended – as a trial for the treatment of subacute or chronic TBI in select patients.
- Indications – When TBI impairments are sufficiently severe that removing the effects of gravity improves the ability to perform therapeutic activities, e.g., range of motion exercises. Land-based exercise is generally preferable for mild TBI or for patients largely recovered, as it tends to be more sustainable for most patients.
- Frequency/Dose/Duration – The program should generally begin with three to four visits per week. The patient should have demonstrated evidence of functional improvement within the first two weeks to justify additional visits. The program should include up to four weeks of clinically supervised aquatic therapy with progression towards a land-based, self-directed physical activity or self-directed aquatic therapy program by six weeks. Durations beyond 6 weeks should be limited to severe TBI patient injuries who are still demonstrating objective improvements at six weeks that cannot be achieved with land-based activities.
Biofeedback:
- Recommended – in the setting of post-traumatic headache.
- Not Recommended – in the treatment of TBI patients.
Vestibular Rehabilitation:
- Recommended – selectively for patients with mild, moderate, or severe TBI with vestibular dysfunction associated with dizziness, vertigo, visual blurring, oscillopsia (a jumping of the visual field associated with movement of the head), and feeling off balance.
- Indications – Post TBI with vestibular symptoms to decrease symptoms and improve dynamic and static balance.
- Frequency/Dose/Duration – Initially one to two times per week dependent on the severity of symptoms, and progress with revaluation and documentation of continued improvement.
Visual / Oculo Training:
- Recommended – for use in the treatment of TBI patients with visual and visual-cognitive disorders.
- Indications – TBI with any of the following: accommodation, blurred vision, ocular motility abnormalities, difficulty with gaze, tracking difficulties, diplopia, disequilibrium in visually stimulating environments, impaired visual memory, light sensitivity, visual-spatial processing, and problems with visual field integrity.
- Frequency/Dose/Duration – Dependent on the severity of symptoms, and progress with revaluation and documentation of continued improvement.
Oculomotor Training:
- Recommended – for the treatment of select TBI patients.
- Indications – TBI with accommodative dysfunction of at least two to four weeks duration. Identification and treatment of accommodative dysfunction related to TBI.
- Frequency/Dose/Duration – Two 60-minute sessions/week for nine sessions total; dependent on the continuation of symptoms.
Neurocognitive Behavioral Therapies:
- Recommended – for use in the treatment of TBI patients with cognitive deficits.
- Indications – Used to rehabilitate patients with moderate to severe TBI with cognitive deficits such as difficulty with concentration, memory, and/or psychological and psychosocial functioning. Rare mild TBI patients with ongoing and significant symptoms may be candidates.
- Frequency/Dose/Duration – Frequency is generally tailored based on individual factors of severity and need. Ten to 16 treatments with documentation of progress toward achievement of measurable goals every two weeks. Maximum Duration: 16 treatments. Therapy may need to be more frequent and of longer duration for patients with moderate to severe dysfunction.
Memory Rehabilitation:
- Recommended – for use in the treatment of select TBI patients with memory retrieval deficits post TBI.
- Indications – Memory problems post TBI. May be selectively indicated for mild TBI patients with significant memory deficits, with the goal to improve memory retrieval.
- Frequency/Dose/Duration – Frequency is generally tailored based on individual factors of severity and need, ten to 16 treatments with documentation of progress toward achievement of measurable goals every two weeks. Maximum Duration: 16 treatments. Therapy may need to be more frequent and of longer duration for patients with moderate to severe dysfunction.
Acupuncture:
- Recommended – for select use in patients with chronic TBI for treatment of headache, muscle spasticity, insomnia, and cervical disorders related to TBI.
- Indications – As an adjunct treatment option for a limited course during which time there are clear objective and functional goals that are to be achieved.
- Frequency/Dose/Duration – Usual program is ten sessions over three to four weeks. An initial trial of five to six appointments is recommended. Additional treatment should be based upon improvement in objective functional measures to justify an additional six sessions, for a total of 12 sessions.
Adaptive Devices, Casting and Orthotics:
- Recommended – selectively for treatment of TBI patients.
- Indications – Impairment significant enough to require a device to position the extremity for function, e.g., sufficient foot drop that a device may foster better walking and avoid stumbling; sufficient wrist drop that a device positions the extremity for better grasp. Manufactured devices typically suffice, but in some cases, custom-made orthotics and casts are required to accommodate specific circumstances or injury/patient-specific characteristics. Adaptive devices include but are not limited to ankle-foot orthotics, adaptive footwear, upper and lower extremity braces, walkers, canes, and rollators.
- Note – Evaluation for orthotics should include an evaluation of the footwear that is to be worn by the patient, including the nature of the fore-soles. Fronts of shoes and boots can catch on carpets and low-lying irregular surfaces, and modifications of shoes and boots may mitigate slip, trip, and fall risks posed by footwear.
Body Weight Support Treadmill Training:
- Recommended – for use in the treatment of TBI patients who have an inability to walk safely.
- Indications – Inability to walk or inability to walk safely while having sufficient ability to move the lower extremities.
- Frequency/Dose/Duration – The optimum regimen needs to be tailored to the patient’s abilities and stage of recovery.
- Indications for Discontinuation – Ability to walk with a walker or to walk unassisted.
Vocational Rehabilitation Programs:
- Recommended – for treatment of select patients with TBI.
- Indications – Vocational rehabilitation programs may be helpful for those with a mismatch between current abilities and job cognitive and physical demands, with a potential for greater impact in those with a greater mismatch.
