Traumatic brain injury (tbi) affects people indiscriminately, with an increasing incidence over the past decade. According to the Centers for Disease Control (CDC), the combined rates of TBI-related deaths, emergency department (ED) visits, and hospitalizations have increased from 521 per 100,000 in 2001 to 823 per 100,000 in 2010.1 Physiatrists with expertise in brain injury medicine often manage patients with brain injuries in various medical settings. The purpose of this assessment is multifold but in essence aims to maximize function, provide additional insight into active medical and neurologic issues, and then assist with rehabilitation planning for the postacute setting. There are three main clinical settings in which assessment for TBI occurs by rehabilitation professionals: in the acute care hospital, in inpatient rehabilitation facilities, on the sideline of athletic events, and in the ambulatory setting. This chapter will describe aspects of the physical examination that are common to all three and highlight unique features that differ by venue.
TBI ASSESSMENT IN THE ACUTE CARE SETTING
When providing a physiatry consultation in an acute care setting, a thorough chart review and fact-finding mission is essential to piece together coherent recommendations. Basic information such as preexisting medical conditions, date of injury, initial Glasgow Coma Scale (GCS) score, dates and nature of any neurosurgical interventions, seizure history, and medical complexities are among the first things to be identified. From there, a current and recent medication list can be scrutinized for centrally acting agents that may impair cognition, arousal, or behavior. Analysis of recent imaging allows correlation of brain injury location with aspects of behavior, cognition, and communication issues.
It is also important to learn the nature of a patient's current sleep-wake cycle, elimination schedule, and behavioral patterns. These issues are often neglected by the primary team, who may be more focused on managing the most active neurologic or medical problems. When assessing a patient, it is important to determine how such patterns may affect a patient's future rehabilitation course or even their candidacy for acceptance into a rehabilitation program. For example, a patient whose sleep-wake cycle is inverted at the time of transition to an inpatient rehabilitation setting may sleep during several days of valuable therapy and cause unnecessary disruption on the unit overnight. Additionally, daily assessments in such patients may be more challenging and inaccurate. This common scenario often leads to anxiety on the part of the patient's family and can negatively affect the relationship with health care providers.
At the time of discharge from the acute care setting, it is sometimes the case that a plan for rehabilitation has not yet been formulated, or must be formulated quickly to correspond with pressures of increasingly regulated hospital-length-of-stay guidelines. From the time of initial physiatric consultation, careful attention to unique patient characteristics and psychosocial restraints should be factored into all planning. The goal of the physiatric assessment in the acute care setting ...