scope:

Preface

Interventions for traumatic brain injury (TBI) at the acute level have changed relatively little in the last decade, particularly in comparison with changes seen in other fields such as cardiology. There have been few clinical advances made in emergency or intensive care management, most probably due to poor public awareness of TBI and poor research funding. At the same time, managed care has resulted in tremendous changes in hospital lengths of stay and access to care for people with TBI. While it may be argued that managed care has had a beneficial impact on the management and costs of some health conditions, catastrophic diagnoses like TBI are not well addressed within the managed care environment. Consequent to both of these points, people with TBI face substantial levels of disability with relatively little recourse in the form of treatment. Treatment which is rendered must be succinct and the most effective possible. There are certainly limitations to what can be expected, however. We must question whether it is possible to provide fast, inexpensive, and effective rehabilitation for people with TBI. A determination of whether such a goal is attainable is dependent upon one's definition of "effective rehabilitation" and the extent of recovery that is to be achieved.

It can be argued that far too little is offered to people with TBI and their caregivers, in general. Our societal disposition is away from provision of rehabilitative care, perhaps because the field has been slow to properly document the financial benefits of disability reduction. Be that as it may, there is evidence that both postacute and late rehabilitation can be effective in reducing disability, improving quality of life, enhancing life satisfaction, and reducing the long-term financial expenditures associated with TBI. The population of persons with TBI is maturing, and support systems, which were in place for many years in the form of nuclear family members, are reaching the point where they can no longer be relied upon. Lifestyle changes in the last 20 years call into question the willingness and/or ability of families to bear the burden of caring for an injured family member. Depression rates and life satisfaction are abysmal among persons who have suffered TBI and their families. Rehabilitation can be an effective means of combating both and contributing to improved long-term financial benefits in healthcare management of this population.

This text is intended for a broad audience of professionals involved in treating and caring for people with traumatic brain injury. Injury to the brain produces a wide array of deficits which must be addressed during rehabilitation of the person with TBI. Recovery can extend well beyond the period of time most individuals have access to rehabilitative services, particularly those which are hospital-based. Deficits seen following TBI can include physical, cognitive, psychological, communicative, educational, vocational, social, and medical domains. In general, severity of injury bears on the nature and number of deficits seen, though this is not always the case. TBI occurs frequently, but it is the rare professional who sees enough people with TBI to develop ready expertise in the area. It is difficult, at best, to develop expertise due to the fact that TBI presents so uniquely in each person and many settings restrict either the severity of injury treated and, therefore, encountered by the practitioner, or length of stay due to financial constraints imposed by funding sources. Professional turn-over rates vary from setting to setting, but clearly impact the level of institutional knowledge available to benefit the person with TBI.

This text attempts to address a number of deficits which are prevalent and persistent following TBI. The text does not attempt to be absolutely comprehensive in this pursuit, however. The goal is to provide therapists, case managers, and physicians with information about the longer-term issues faced by this population. The second edition has been enlarged with the addition of eight new chapters. The book's purview has been substantially broadened to address some of the issues faced by people with TBI and their caregivers over a lifetime. These include medical, environmental, social, financial, and legal arenas. All readers will be intrigued by the discussion of ethical issues in relation to treatment and living life after TBI. Chapters have been added to address some of the needs of the educator, discharge planner, and neuropsychologist. The importance of cognitive function following TBI is underscored by the addition of a third chapter on the topic. The case manager should derive a great deal of new information from chapters on audiological issues, discharge planning, and neuromedical issues of aging in TBI.

Reader reaction to the first edition indicated that the text was educational for the inexperienced clinician and served as a reference tool for the experienced clinician. This text is designed to allow its use both for education about TBI treatment and as a reference tool for the practitioner. Each chapter begins with an outline to allow quick access to specific material. Specific diagnostic and treatment interventions are provided and, in some cases, the theoretical constructs upon which they are based are included. Some chapters are largely treatment oriented, some will be used both as a source of information about treatment and as a reference tool, and others will be largely used for clinical reference.

The reader is encouraged to use the information contained herein for treatment of the person with TBI, education of that person and his/her caregivers, and advocacy for all people with TBI. The TBI population is somewhat unique in that our job as rehabilitation professionals is to work to return control over their lives to those injured. The sequelae of TBI are so pervasive as to make this difficult, at best, if not impossible. The person with TBI faces a daily struggle to survive and return to preinjury functioning levels. They and their caregivers can exhaust personal energy and financial reserves in a seemingly neverending stream of day-to-day challenges following TBI. To that end, it is encumbent upon us all to advocate for ongoing rehabilitative treatment for specific individuals with TBI as well as for all people with TBI.

Preface: Ashley, Mark J.