Interdisciplinary Management of Traumatic Brain Injury
Original Editor - Anna Ziemer
- 1 Introduction
- 2 Team Members
- 2.1 Medical Specialists
- 2.2 Rehabilitation Trained Nurse / Professional Care Staff
- 2.3 Physiotherapist
- 2.4 Occupational Therapist
- 2.5 Speech and Language Therapist
- 2.6 Neuropsychologist
- 2.7 Vocational Therapist
- 2.8 Therapy Assistant
- 2.9 Social Work
- 2.10 Case Manager
- 2.11 Family & Friends
- 2.12 Others
- 3 Models of Team Based Care
- 4 References
"Team Based Care - when professionals from a range of disciplines work together to deliver comprehensive care that addresses as many of the patient's needs as possible. This can be delivered by a range of professionals functioning as a team under one organisational umbrella or by professionals from a range of organisations, including private practice, brought together as a unique team. As a patient's condition changes over time, the composition of the team may change to reflect the changing clinical and psychosocial needs of the patient.” Complexity of the traumatic brain injury sequela is so excessive and dynamic that none of the health or social care professionals can manage this diverse burden in isolation. Therefore, teamwork is one of the most fundamental factors in traumatic brain injury rehabilitation and an essential element of comprehensive patient care and improved patient outcome, including better survival rates. In the process of neurological rehabilitation the multi-professional team, often lead by a rehabilitation medicine consultant, with an appropriate range of knowledge and skills, mutual trust and respect, willingness to share knowledge and expertise and to speak openly, has been demonstrated to be the best placed to look after patients with complex needs. However, we must not forget that the individual who sustains a brain injury and their family are the most important members of the treatment team.
Individuals with traumatic brain injury typically present with mixture of medical, physical, sensory, cognitive, communicative, behavioural and social problems, which require specialist input from a wide range of medical and allied health professionals including:
Rehabilitation Medicine Physician, Neurologist, Geriatrician, Orthopaedic Surgeon, Neurosurgeon, Neuropsychiatrist, Endocrinologist, Anaesthetist and Intensivist, Pain Management Doctor, Ophthalmologist and others depends on an individual person’s needs.
Rehabilitation Trained Nurse / Professional Care Staff
Provide foundation for neurorehabilitation through the implementation of MDT/IDT strategies and programmes, look after patients’ medical needs like skin viability, epilepsy but also co-operate with therapy team with 24-hour postural management programme, splinting regime, etc.
Physiotherapist facilitates movements re-education, mobility and balance retraining, verticalisation, general fitness and one’s tolerance to being physically challenged; advise on physical activity including access to leisure activities like gym, swimming, golf, games, etc. to prevent other co-morbidities and support inactivity, fatigue, mood and other traumatic brain injury related issues’ management.
Occupational Therapist facilitate independence in activities of daily living (ADLs) like dressing, washing, cooking, leisure activities, budgeting and planning; supports home adaptations and environment organisation; facilitates higher cognitive and executive functions retraining, driving skills, vocational training and return to work; helps with fatigue management
Speech and Language Therapist
Speech and Language Therapist facilitates communication skills re-education including understanding and expressing both written and spoken language and improving speech clarity; helps to identify any communication aids strategies for effective communication at school, work, social network; assess swallowing difficulties (dysphagia) and provide guidance on safe swallowing management i.e.: type of diet, fluid thickening, environment organisation, etc.
Neuropsychologist conducts assessment and treatment of behavioural, emotional and cognitive problems following traumatic brain injury; can advise on minimally conscious state behaviour, challenging behaviour, strategies how to cope with deficits like memory loss or cope with emotions like low mood or anger
Vocational Therapist facilitates return to work, could be Vocational Psychologist or Occupational Therapist by background
Therapy Assistants supports individual therapy, i.e.: Occupational Therapy Assistant or Physiotherapy Assistant
Social Worker provides practical advice on benefits, housing, transport support at home and wider aspect or person’s welfare and wellbeing
Case Manager oversees the overall care of the person with traumatic brain injury; prepares an individually-tailored care plan or treatment programme meeting individual person’s specific health, social and emotional needs and often based on other clinicians and professionals assessment; comes from different professional backgrounds, such as social work, occupational therapy, or nursing and are usually available through private referrals and interim compensation payments for clients pursuing legal claims, is the central point of contact for professionals and relatives involved in person with traumatic brain injury care.
Family & Friends
Family members and friends allow better outcome through their knowledge about the person with traumatic brain injury, following rehabilitation programme and strategies in the community acting as an advocate. 
A range of other health and well being professionals may also be involved depending on the needs of the individual including Orthoptist, Audiologist, Rehabilitation Engineer, Orthotist, Therapeutic Recreation Therapist, Peer Mentors, Spiritual wellbeing facilitator like Priest, Imam, Rabbi, etc.
The extensive team requires a clearly designated leader with strong leadership skills. The effectiveness of the team is increased through multidisciplinary/interdisciplinary training. To ensure effective coordination and communication within the team and between patient and the team the key worker or case manager should be identified. The key worker / case manager role is described in recommendation G20 of the RCP Rehabilitation after Acquired Brain Injury Guideline:
G20 A designated member of the team (eg a ‘key-worker’) should be responsible for overseeing and coordinating the patient’s programme and acting as a point of communication between the team and the patient/family.
Models of Team Based Care
Both multidisciplinary and interdisciplinary models of care provide more knowledge and experience into patients’ neurorehabilitation than disciplines operating in isolation and apply a more patient centred approach to care. In some publications or amongst some clinicians the multidisciplinary, interdisciplinary and comprehensive rehabilitation are used interchangeably.
Multidisciplinary Team Model (MDT)
The multidisciplinary model utilises the skills and experience of clinicians from different disciplines, however, the professionals work parallel with a clear role established. MDTs are characterised by a hierarchy model, with a clear leading role of the physician in coordinating the individual patient’s care. The multidisciplinary team allows high autonomy with each clinical speciality setting own goals and treatment plan. Patient’s findings, goals and treatment plan related issues are communicated and discussed in case conferences with the patient not necessarily present.
Interdisciplinary Team Model (IDT)
The interdisciplinary model demonstrates a more integrated approach of working together towards collaboratively set goals. The relationship in the interdisciplinary team is significantly closer with joint patient-history taking, assessment, diagnosis, and management with shared goal setting involving various clinicians, patient and their family.
G21 All major decision-making meetings, eg. assessment, goal planning, case conferences, discharge planning, should be undertaken by the relevant members of the interdisciplinary team, in conjunction with the patient and their family/carers as appropriate, and should be documented in the case records.
Communication is effective when interdisciplinary individual patient’s record system is in place and all members of IDT input into the same case of notes. The hierarchical structure of team is less prominent; communication more intense and greater collaboration. The interdisciplinary team often demonstrates more a robust teamwork culture, increased effectiveness and work satisfaction.
It is demonstrated that specialist neurological rehabilitation of people with a traumatic brain injury is a long-term and ongoing process, which over time should involve various specialists’ input addressing traumatic brain injury sequela and prevention of secondary complications. The problems addressed in specialist neurorehabilitation should be managed using 24-hour interdisciplinary protocols and might include:
- 24-hour postural management programme for contracture prevention and spasticity management, tissue viability and respiratory management with an input from nursing and Physiotherapy staff and including positioning in various postural sets with verticalization and sitting out of bed, use of splints and orthosis, mobilising programme, manual chest clearing techniques, etc.
- Strategy for spasticity management with consideration of coexisting guidelines like “Splinting for the prevention and correction of contractures in adults with neurological dysfunction” or “Spasticity in adults: management using botulinum toxin”. The IDT should establish triggers of increased muscle tone like infection, pain poor postural management, constipation, agree use of equipment like splints and pharmacological antispasmodic agents including use of botulinum toxin and provide education to all professionals, relatives and patient. (G60-G62 of RCP Rehabilitation after Acquired Brain Injury Guideline) 
- Tracheostomy care, weaning and decannulation programme set collaboratively by interdisciplinary tracheostomy team including Nurses, Physiotherapists, and Speech and Language Therapists. (G43-G47 of RCP Rehabilitation after Acquired Brain Injury Guideline) 
- The swallowing impairment management programme set by Speech and Language Therapist, Physiotherapist, Nurse, Occupational Therapist with advice on swallowing, positioning and suitable equipment to ensure effective assessment, safe and successful implementation.(G49 of RCP Rehabilitation after Acquired Brain Injury Guideline) 
- Use of botulinum toxin IDT protocol advised to be agreed by the interdisciplinary team prior to injections with goals, evaluation tools, physical management, splinting, positioning and pain management.
- Heterotrophic ossification early identification and optimal treatment IDT protocol limiting the secondary range of motion lose and pain symptoms should engage medical professional, nursing and care staff, Physiotherapist and wheelchair/ seating engineer.
- IDT seating clinic should ensure provision of optimal wheelchair and alternative sitting meeting individual patient’s postural needs. Standing aids should be evaluated by IDT with the view to establish oppingortunities to weight bear and experience vertical position. Splints, orthosis and mobility aid should also be assessed to promote improved stability, tissue viability and sensory mot-r feedback.(G10 4-G105 of RCP Rehabilitation after Acquired Brain Injury Guideline) 
- The neglect management due to its complex nature require IDT involvement for the assessment, type to be determined (visual, auditory, tactile-kinaesthetic neglect) and implement strategies through 24-hour management protocol.(G110 of RCP Rehabilitation after Acquired Brain Injury Guideline) 
- ADL, leisure and vocational participation programmes promoting independence using various modalities and available treatment techniques and methods lead by Occupational Therapist and engaging nursing, care staff, physiotherapist to occur in meaningful environment including patient’s home local community.(G 141-G144 of RCP Rehabilitation after Acquired Brain Injury Guideline) 
- Challenging behaviour management protocol advised by Neuropsychologist, using of pharmacological agents prescribed by Rehabilitation Medicine Physician or Psychiatrist and to be followed by all members of interdisciplinary team regardless to facilitate consistent approach through agreed strategies.
- Epilepsy protocol with triggers, seizure symptomatic recognition and administration of rescue medication advised by IDT with physician and nursing staff advice and training of other members of the team and family members.
- Mitchell GK, Tieman JJ, Shelby‐James TM. Multidisciplinary care planning and teamwork in primary care. Medical Journal of Australia. 2008 Apr;188:S61-4.
- Neumann V, Gutenbrunner Ch, Fialka-Moser V, Christodoulou N, Varela E, Giustini A, Delarque A. Interdisciplinary Team Working in Physical and Rehabilitation Medicine. Journal of Rehabilitation Medicine, Volume 42, Number 1, January 2010;42(1): 4-8 DOI: https://doi.org/10.2340/16501977-0483
- Brain Injury Association of America. Treatment. Available from: https://www.biausa.org/brain-injury/about-brain-injury/treatment (accessed 2 May 2019).
- Headway. The Rehabilitation Team. Available from: https://www.headway.org.uk/about-brain-injury/individuals/rehabilitation-and-continuing-care/the-rehabilitation-team/ (accessed 2 May 2019).
- Royal College of Physicians and British Society of Rehabilitation Medicine. Rehabilitation following Acquired Brain Injury: National Clinical Guidelines (Turner-Stokes L, ed). London: RCP, BSRM, 2003.
- Physiopedia. A introduction to the new Physiopedia Plus. Available from: http://www.youtube.com/watch?v=UwHHUz4zNhU[last accessed 30/07/18]