In the late 1970's, a specialty field emerged in rehabilitation focusing on survivors of traumatic brain injury (TBI). It was recognized, largely by private concerns who were financially liable for the considerable costs of care associated with survivors of traumatic brain injury, that rehabilitation strategies available in most rehabilitation centers were not adequate to address the long-term residual deficits observed following TBI. People who survived TBI were faced with debilitating physical, communicative, cognitive, social, and emotional impairments. Their medical condition was complicated by the fact that the brain, the organ of behavior, was so poorly understood and much of our knowledge about pharmacological intervention was derived from interventions with substantially different populations. Mechanisms of injury were not clearly understood, the neurophysiological substrates to learning and memory were ill-defined, and the overall physiology of the brain was, for the most part, vague.

Yet, despite significant shortcomings in our knowledge of such matters, families and professionals alike were faced with the real question of how best to help those persons who had sustained TBI. Professionals applied techniques developed for other neurologically compromised populations in an effort to deal with seemingly similar signs and symptoms but those interventions met with relatively poor success. The sequelae of traumatic brain injury proved to be far more complicated and resistant to treatment techniques of the day. The disabilities arising from TBI were far more extensive than any seen with more commonly observed strokes or other conditions and the persons affected were, on average, much younger and more numerous.

Pervasive disabilities translated to complicated long-term care requirements, often far more expensive to provide for than most people had financial resource for. In fact, private insurers were instrumental in the push to develop more effective means for reduction of disability so as to reduce long-term cost of care.

As the effort to identify specific treatment approaches to the TBI population began, it was commonly held that neurological recovery was restricted to a relatively short period of time following injury of approximately six months. Slowly, this time period extended to twelve months, and eventually it became necessary to differentiate neurological recovery from "social" recovery. "Social" recovery would come to encompass recovery of physical, communicative, cognitive, and emotional functions after the natural course of neurological recovery had been completed.

Early treatment approaches were guided by historical perspectives of specific techniques used with other populations. As such, specific treatment approaches to TBI rehabilitation developed from observation of both the successes and limitations of adapted treatments. Demand increased for treatment facilities specializing in treating persons surviving TBI as persons needing rehabilitative services increased in number and research efforts focused almost exclusively on emergency and acute medical treatment techniques. Rehabilitation treatments were implemented essentially on an educated, trial-and-error basis.

Today, information is available from which to develop rationales upon which to base rehabilitation treatments and techniques. Not only do we have knowledge gained from experiences of the last fifteen to twenty years, but science has also made tremendous gains in the study of neuroanatomy, neurophysiology, and neuropharmacology. Similar advances have occurred in medical technologies associated with acute medical treatment. We now need to review available resources to bring together this information in a useable format, together with information from other fields which will impact the rehabilitation of persons who have sustained TBI.

The purpose of this text is to provide the reader with a reference tool for use in developing and implementing treatment approaches in TBI rehabilitation. The subjects chosen were those subjects which have been neglected or have been dealt with sparingly in the literature to date. The subjects represent areas of interest wherein diagnosis and treatment are frequently poorly guided by available training and can be gained largely by experiential means only. The hope is that this text will shorten the learning curve of its readers in many of the areas addressed.

This text is not intended to review the advances of emergency and acute medical management of the traumatically brain-injured patient as these subjects have been dealt with by other authors. Instead, the focus for this text is rehabilitation of relatively persistent sequelae associated with TBI. The text has been organized to provide the reader with relevant literature reviews which form a basis of support or construct validity for the diagnostic and/or treatment approaches presented. The text provides pragmatic treatment information as well as important information which can be used to define a philosophical orientation to rehabilitation in TBI and development of refined treatment approaches therein.