The Importance of Early Post Acute Rehabilitation

It was every parent's worst nightmare becoming a reality. Fearing the worst, R.A.'s father drove to the landfill where his son was working. Fire trucks and ambulances greeted him as he was trying to make sense out of what was going on at the accident scene. Apparently, his son, R.A., had been driving a landfill scraper up one side of a large hill, while another heavy equipment driver was going up the other side. The two pieces of equipment collided and pinned R.A. in the cab of the vehicle. R.A's father now stood helplessly watching as rescue crews spent the next 3 hours prying his 25-year-old son out of the landfill scraper.

R.A. was unable to open his eyes, follow commands or talk. He had sustained a severe traumatic brain injury in the accident, resulting from a bone fracture in his skull. A left tibia-fibula puncture wound, multiple lacerations on his scalp, face and chin, as well as upper and lower extremities were also sustained in the accident. Due to the seriousness of the accident, R.A. was intubated (a tube was placed into the trachea to allow him to breathe) and flown by helicopter to the local hospital.

Upon arrival at the hospital, R.A. underwent surgery to repair his fractured left leg. Two days later, he was extubated and able to open his eyes upon deep stimulation. However, he was inconsistently able to follow simple commands, was oriented to himself, but not to time, place, or date. Additionally, he was unable to read, perform simple math, or pay attention. R.A. was confused and often would become agitated and pull out his cathetar and feeding tube. To prevent R.A. from hurting himself, he was placed in 4-point restraints.

This once independent man was now totally dependent upon others for showering, walking, eating, brushing his teeth, and all the other activities of daily living that most of us do not even consciously think about. Part of R.A.'s difficulty was that he had severe dyspraxia-meaning that he understood the task but did not know how to perform it. For example, if a nurse told R.A. to comb his hair, he would not know how to pick up the comb and perform the task. But, if the nurse simply put the comb in his hand, he would automatically begin to comb his hair.

After 12 days in the acute hospital, R.A. was transferred to Centre for Neuro Skills® (CNS) in Bakersfield, CA, for post-acute brain injury rehabilitation. R.A.'s goals upon entering CNS-Bakersfield were to return home to live with his father, return to work at the landfill, and be able to independently drive again. Therefore, his treatment program emphasized independent ambulation, endurance, balance and coordination, visual deficits, cognitive skills, and adjustment to disability. In accordance with this, R.A. was involved in therapy four hours each day in the areas of occupational, physical, cognitive/speech, and counseling. After his therapy hours at the clinic, he would return to the residential setting where he would engage in cooking his own meals, therapeutic "homework", laundry, and other household tasks under the guidance of CNS staff. R.A. initially required 24-hour supervision due to impulsivity, not being able to ambulate independently, and being unable to recall information.

During the first two weeks at CNS, R.A. was confused and agitated. He would pound his fists on tables and was not able to understand what had happened to him and why he was in therapy. Sometimes, he would get frustrated at staff for challenging him and would try to swat them away or yell at them to leave him alone. Gradually, R.A.'s post-accident confusion cleared and with the structured environment of CNS, he no longer experienced these behavioral episodes.

R.A. was extremely hard working and motivated. His years spent in the Navy also seemed to have prepared him for the type of discipline and hard work that was required in post-acute, brain injury rehabilitation. He worked hard, rose to the challenges that the staff gave him and significant progress was made on a daily basis. For instance, he entered CNS in a wheelchair and was dependent on others to help him perform his activities of daily living. However, he gradually moved to ambulating with a walker, crutches, and eventually was completely independent and did not require any assistance. As he became more independent with ambulation, he also became more independent with his activities of daily living and no longer required 24-hour supervision.

After being at CNS for four months, R.A. had made significant progress and was discharged back to living at home with his father. He had passed a behind the wheel driving evaluation and was cleared to drive independently. His physical and cognitive issues had resolved and R.A. had met all of his goals. He was even allowed to go back to work at the landfill with no restrictions on his activity.

R.A. had the outcome that most brain-injured patients dream about. One important factor in R.A.'s recovery included his early entry into post-acute rehabilitation. He came to CNS only 12 days after sustaining his injury. This allowed for behavioral problems that started to arise to be caught early and dealt with in a structured environment rather than pharmacologically. Additionally, he was able to begin the process of rehabilitating his brain soon after his injury, possibly when the brain was in a state of "readiness" to be rehabilitated. Engaging in post-acute rehabilitation early following his injury may have made all the difference in R.A.'s outcome.