Medical Procedures
A Comprehensive Evaluation
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Persons who have suffered a traumatic brain injury may experience a variety of problems affecting day to day living. A brain injury may affect thinking ability, behavioral self control, control of movements and balance, sensation including the basic senses, swallowing, etc. Often times these problems are inter-related such that when an attempt is made to address one particular problem, the effects on another area may be unsatisfactory. For instance, medications used to treat agitated behavior, loss of balance, abnormal movement, or muscle tightness may negatively affect thinking abilities (cognition). Likewise, medications used to improve cognition may worsen certain maladaptive behaviors or worsen some movement problems. In other cases, a window of opportunity may exist to address a particular problem, which if neglected may lead to a worsened disability. One example is early treatment of muscle tightness (spasticity) before limbs become locked in abnormal positions. For these reasons, there is often a necessity to perform what is called a comprehensive evaluation. This evaluation is performed by a rehabilitation team, usually led by a physiatrist or case manager, and most importantly includes the person with the injury and their family. The team usually includes a rehabilitation nurse, physical therapist, occupational therapist, speech therapist, and recreational therapist, but may also include a neuropsychologist, pharmacist, and/or a vocational rehabilitation counselor. Consultants to the team may include medical specialists such as neurosurgeons, neurologists, orthopedists, otologists, ophthalmologists, plastic surgeons, urologists, gastroenterologists, and experts in the areas of bracing (called orthotists), wheelchair seating and mobility devices, and assistive technology.
The team works with the patient and family to identify all areas where problems exist, and also to predict how these problems impact future function. Functional goals are then set in the areas of: mobility in the home and community, performance of self care activities, maintenance of adequate nutrition, management of medications, management of money, management of the home, community participation in recreational and volunteer activities, driving, or possibly work reentry.
In order to evaluate the ability to perform basic and higher level daily living activities, it is necessary to determine how more basic physiologic functions have been affected by the brain injury. These basic functions may be broadly grouped into areas of cognition, behavioral self-control, emotional adjustment, movement control, sensation, balance, swallowing, bowel and bladder function, sexuality, etc.
For the best possible evaluation, the person with the injury and their family should first make a list of all problems, questions and issues before the evaluation is initiated. This includes making a list of all medications used, their dosages, and positive or negative reactions. Other information that should be provided by the family includes:
- Names and phone numbers of all treating physicians, psychologists, and therapists
- A list of past and present medications including effects and any undesirable side effects
- A list of medical/rehab equipment and equipment problems
- A description of any caregiver problems
- A description of any new physical, cognitive or behavioral problems
- A list of questions for the physician, therapists, psychologists, behavioral specialists
The following check list may be used to identify issues for the evaluation:
| Cognition | Behavior | Emotions |
| Hypoarousal | Agitation/ Restlessness | Depression |
| Fatigue | Irritability | Anxiety/Nervousness |
| Confusion | Low Frustration Tolerance | Mood Swings |
| Inattention | Impulsivity | Insomnia |
| Aphasia (impaired language) | Disinhibition | Posttraumatic Stress Disorder |
| Amnesia (impaired memory) | Opposition | Personality Changes |
| Impaired Spatial Functioning | Verbal Aggression | Delusions (false beliefs) |
| Left or Right Neglect | Property Aggression | Hallucinations (abnormal perceptions) |
| Impaired Problem Solving | Physical Aggression | |
| Impaired Reasoning | ||
| Impaired Judgement | ||
| Impaired Executive Functioning | ||
| Impaired Awareness of Deficits | ||
| Inflexible Thinking |
| Movement | Sensation | |
| Hemiparesis (paralysis on one side) | Hemisensory Loss (body sensation loss) | |
| Spasticity (abnormal muscle contraction) | Hemianopsia (visual loss on one side) | |
| Contracture (loss of muscle length) | Diplopia (double vision) | |
| Loss of Control of Movement | Hearing Loss | |
| Loss of Coordination of Movement | Tinnitus (ringing in the ears) | |
| Loss of Balance, Dizziness | Vertigo (inner ear imbalance)/Dizziness | |
| Impaired Walking (due to any of the above) | Headache |
| Mobility | Basic Activities of Daily Living | Higher Activities of Daily Living |
| Bed Mobility | Bladder and Bowel Function | Medication Management |
| Transfers | Toileting | Money Management |
| Bathroom Mobility | Hygiene | Household Activities |
| Wheelchair Mobility | Bathing | Cooking |
| Gait with Walker/Cane | Grooming | Cleaning |
| Gait with Orthosis (brace) | Dressing | Yard Work |
| Stair Climbing | Feeding/Swallowing | Driving |
| Gait on Uneven Surfaces | ||
| Mobility in the Community |
| Recreational Activities | Avocational Activities | Vocational Activities |
| Hobbies | Volunteer Activities | Supported Employment |
| Games | Community Service | Competitive Employment |
| Sports | Church Activities | |
| Exercise | Support Groups | |
| Meditation/Relaxation | Advocacy Groups |
After an initial meeting, team members will then evaluate the person’s problems using expertise of their respective disciplines. They in turn determine how problems in their area of specialty will affect problems addressed by other disciplines. Next, the person, their family, and team meet to list, discuss, and prioritize problems. After careful discussion, as many realistic goals as possible and some more or less optimistic goals will be set. The likelihood of achieving these goals should also be discussed. A treatment plan will then be developed along with time lines to achieve these goals. Some goals may be reached in days or weeks, others in years, and still other more optimistic goals may never be fully reached. Successful implementation of the treatment plan will depend on close collaboration between all team members, careful monitoring of progress, and periodic reassessment of the plan and the appropriateness of the goals.
The comprehensive evaluation pulls the injured person, their family, and rehabilitation experts together into a team to agree on problems, potential solutions, and a common philosophy. This integration of the team effort allows each team member to impact problems more successfully and in a greater number of areas. Collaboration in turn allows for the patient to reach the maximum functional outcome, with the most effective use of the rehabilitation team.