THE interdisciplinary team has long been recognized as an important component of effective rehabilitation for persons with traumatic brain injury (TBI).1-3 The hallmark of an interdisciplinary team is collaboration in setting rehabilitation goals, developing individualized treatment plans to reach goals, and assessing progress toward goals. The composition of interdisciplinary teams can vary by rehabilitation setting and program, but typically includes representatives of physiatry, rehabilitation nursing, speech-language pathology, physical therapy, occupational therapy, social work/case management, neuropsychology or psychology, and therapeutic recreation.
Interdisciplinary collaboration is considered beneficial to persons with TBI and their caregivers by allowing for coordinated and efficient service delivery. However, effective collaboration may be challenging. Training programs often do not emphasize interdisciplinary collaboration, and rehabilitation professionals may begin their careers with minimal understanding of the roles and contributions of other disciplines or how to handle the overlap that often occurs. The Joint Committee on Interprofessional Relations between the American Speech-Language-Hearing Association and Division 40 (Clinical Neuropsychology) of the American Psychological Association was established in 1989 to foster communication and collaboration between speech-language pathologists and neuropsychologists. In a 1989 position statement, members of the Joint Committee emphasized that "[horizontal ellipsis] mutual respect and cooperation between disciplines and professions is an ongoing necessity."4 In a subsequent document, the Joint Committee proposed guidelines for an interdisciplinary brain injury rehabilitation team.5
The topic for the current special issue was born out of the work of the Joint Committee and the issue editors, a neuropsychologist and a speech-language pathologist, who are committee members. The rationale for the special issue was to highlight research that involved collaboration among members of the interdisciplinary team and studies that have implications for the process and/or outcomes of the interdisciplinary team. The 6 articles in this issue meet these goals: 1 article directly addresses the issue of collaboration, 2 articles involve interdisciplinary assessment of outcomes, and 3 articles describe interventions conducted by or within the interdisciplinary team.
The article by Wertheimer and colleagues, all members of the Joint Committee, describes the results of a series of focus groups on collaboration between speech-language pathologists and neuropsychologists. Qualitative analysis of participants' responses yielded several messages that are important for rehabilitation professionals. First, collaboration is more likely to occur when there is institutional support, including locating disciplines in close proximity to each other, providing protected time for interactions between disciplines, and promoting an overall philosophy of collaboration. Second, there are substantial areas of overlap in assessment and treatment that have the potential to result in conflict in the absence of communication. Third, both informal, process-oriented approaches to assessment and standardized, norm-based approaches have benefits on the rehabilitation unit but the differences in conclusions drawn from each can result in inconsistent feedback to persons with TBI and their caregivers in the absence of collaboration. The results of this article can serve as a basis for improving collaboration within the interdisciplinary team.
The articles by Slomine and colleagues and deGuise and colleagues report on interdisciplinary assessment of outcomes. Slomine et al describe the Cognitive and Linguistic Scale-a new measure that can be used to assess outcomes following inpatient rehabilitation for pediatric TBI-developed with input from various members of the interdisciplinary team. Scores on this measure showed good interrater reliability, sensitivity to change from admission to discharge, and moderate to strong correlations with the cognitive domain score of the Functional Independence Measure for Children. Use of this measure has the potential to result in consistency between interdisciplinary team members regarding description of cognitive and linguistic impairments and can be used to measure patient progress.
The article by DeGuise and colleagues reports on long-term (2-5 year) assessment of outcomes in a prospective sample of persons with severe TBI admitted to a trauma center. A novel aspect of this study was the use of an interdisciplinary team functional assessment to rate widely used measures of outcome, including the Functional Independence Measure and the Glasgow Outcome Scale-Extended. This in-person approach to assessing long-term outcomes has the potential to yield more accurate data than self-report phone interviews, although the differences in outcomes need to be empirically assessed. The study is also interesting because it reports on outcomes in persons who had universal access to healthcare services including rehabilitation. In spite of this, significant cognitive and functional deficits remained at 2 to 5 years after injury.
The final 3 articles describe interdisciplinary interventions. Beaulieu and colleagues describe the impact of training interdisciplinary rehabilitation staff in management of agitated behaviors. Contrary to hypotheses, the training did not appear to result in a decreased use of physical restraints or in a decreased use of prn medications for agitation. The study raises important questions regarding the generalization of structured staff training sessions to actual practice on the rehabilitation unit.
The article by Constantinidou and colleagues reports on the results of a randomized control trial of a systematic, hierarchical training program for improving categorization abilities in persons with TBI. The treatment was implemented in 3 postacute interdisciplinary treatment settings. The results showed that while participants in the treatment and control groups both demonstrated gains over time, those who received categorization training showed greater improvements on neuropsychological tests and greater generalization of skills learned to novel situations (based on probe task performance). Although the results of this study need to be replicated with a larger sample size, the findings of this study indicate that categorization training is a promising tool that can be used in a postacute rehabilitation setting. The impact of this training on functional outcomes (eg, employment, independence in household activities) should be investigated.
Evans and colleagues describe an intervention aimed at improving therapeutic alliance on an interdisciplinary postacute rehabilitation team. The alliance between therapists and clients has been hypothesized as an important contributor to progress in postacute rehabilitation. The authors developed a program to train rehabilitation staff in such techniques as developing rapport, listening effectively, conducting motivational interviews, and dealing with challenging clients. Relative to a historical control group, clients who were treated after implementation of the training program showed better functional status at discharge. However, the 2 groups did not differ in client, family member, or therapist ratings of therapeutic alliance, calling into question the impact of the intervention on alliance. Nevertheless, the proposed intervention has the potential to increase the confidence of rehabilitation team members to handle difficult cases and to promote overall team building.
In closing, the articles comprising this special issue emphasize the outcomes that can be achieved through interdisciplinary collaboration. Both assessment and treatment have the best likelihood of being effective when they involve a coordinated effort of the various disciplines involved in rehabilitation. Collaboration between disciplines can result in increased knowledge, improved clinical practice, and ultimately to improved outcomes for persons with TBI and their caregivers.
Angelle M. Sander, PhD
Associate Professor, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine/Harris County Hospital District, Director, Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas
Fofi Constantinidou, PhD
Associate Professor and Chair, Department of Psychology, University of Cypruss, Professor, Department of Speech Pathology and Audiology, Miami University, Oxford, Ohio