Arizona

• Arizona MENTOR Brain Injury Services

Arkansas

• Baptist Health

California

• Centre for Neuro Skills – Bakersfield
• Centre for Neuro Skills – Encino
• Rehabilitation Center at Santa Clara Valley Medical Center
• Sharp HealthCare

Colorado

• Craig Hospital
• REM Colorado Brain Injury Services – Colo Spgs
• REM Colorado Brain Injury Services – Littleton

Delaware

• Christiana Care Health System

Florida

• Center for Comprehensive Services – Bay View
• Center for Comprehensive Services – Jacksonville
• Center for Comprehensive Services – Tampa
• Florida Institute For Neurologic Rehabilitation, Inc.
• West Gables Rehabilitation Hospital

Georgia

• Shepherd Center

Hawaii

• Rehabilitation Hospital of the Pacific

Idaho

• Idaho Elks Rehabilitation Hospital

Illinois

• Center for Comprehensive Services – Carbondale
• Rehabilitation Institute of Chicago

Indiana

• Howard Regional Specialty Hospital

Iowa

• REM Iowa Brain Injury Services

Mild, Moderate, or Severe?

Doctors have no reliable ways to predict the outcome of seemingly minor head trauma. As a testament to the complexity of traumatic brain injuries and recovery, you won’t know for certain whether your injury is mild or moderate until three to four weeks have passed. If you feel pretty much back to normal in a few weeks, then it was a mild TBI. If you don’t, then it was more serious.

The same can be true with moderate and severe injuries. In these cases, evidence of brain lesions may be visible in CT scans or MRIs, but these images are not great for predicting recovery time or the degree to which rehabilitation will be successful. Much of that is dependent on the individual.

The recovery process for moderate to severe injuries has several stages that will typically overlap:

• Physical Rehabilitation
• Behavioral Rehabilitation and Emotional Recovery
• Cognitive Rehabilitation
• Occupational Rehabilitation

And though this is a recovery process, not everyone will complete it, and not everyone will make a full recovery.

Physical Rehabilitation

In mild and moderate cases, there may be no external injury, or nothing worse than a cut, bump, or bruise. A full medical recovery is often quick.

In cases of extreme physical trauma, however, injuries to the body and to the brain’s motor-control areas, combined with lengthy confinement can make extensive physical therapy necessary.

In a successful scenario, the patient regains substantial or complete recovery of physical abilities within a few months to a year. A moderately successful outcome has the patient continuing to make progress in regaining motor function though never returning to pre-injury capabilities. A poor outcome finds the patient’s mobility and physical functioning severely and permanently limited.

Behavioral Rehabilitation and Emotional Recovery

Behavioral problems following brain injury have been well documented and include:

• Aggression
• Cursing
• Extreme temper
• Self-centeredness
• Manipulative behavior
• Inappropriate sexual behavior

Emotional problems are also very common, including:

• Irritability
• Anxiety and depression
• Mood swings
• Apathy or lack of emotional response

Not everyone will suffer from these conditions. Sometimes some of these issues arise as a direct result of the injury’s location in the brain, while other times they arise as a psychological or emotional response to being injured.

From a therapeutic standpoint, behavioral problems and emotional problems are considered together because they are psychological issues often treated using typical psychotherapy techniques and medications.

From a recovery standpoint, on-going behavioral and emotional problems will make it impossible to achieve cognitive and occupational rehabilitation. The severity of these problems must be brought under control before recovery can proceed.

For some TBI survivors, one or more of these psychological problems may remain lifelong issues.

Cognitive Rehabilitation

When thinking ability is compromised by a brain injury, patients can often regain some or all of their previous mental skills through relearning and practice. In other cases, they can learn alternate ways to perform tasks that minimize the importance of their particular deficit. For example, people with short-term memory issues learn to compensate by keeping a notebook and writing everything down in it.

Cognitive rehabilitation programs are obviously tailored to the TBI survivor’s specific deficits and needs. The individual typically makes steady gains in capabilities for the first 18 to 24 months and then reaches a plateau where further progress seems to be made slowly. Most therapists agree that such plateaus are only temporary, and do not represent the limit of the individual’s ability to continue recovering cognitive function.

Occupational Rehabilitation

The TBI survivor who makes it to occupational therapy has come a long way. It means that behavioral and emotional problems have been addressed adequately to allow functioning in the workplace, and the individual has achieved a positive outlook and the desire to be productive. Also, the significance of cognitive impairments has been suitably overcome by adaptive techniques, so the individual has a meaningful opportunity to fulfill a job role.

For the survivor of a serious traumatic brain injury, returning to work, even in the presence of significant and permanent performance limitations, has to be considered a successful recovery.

Related Articles

• Cognitive-Behavioral Brain Injury Rehabilitation
• Living with Brain Injury: Post-Rehabilitation Recovery

Return to the Head and Brain Injuries Home Page

But no more therapy is scheduled and there doesn’t seem to be any progress; maybe he’s even lost some of the skills he learned during rehabilitation. There are times when you see a glimmer of the person you used to know: that wry sense of humor, the winning smile, maybe he even remembers an incident from before the accident. Other times he is an unlikeable stranger masquerading in the body of the person you knew: he has angry outbursts, messes up the house, repeats the same stories, asks the same questions, forgets things from one moment to the next, and never gets things done unless you’re there every minute.

You ride an emotional roller coaster: guilt, depression, anger, frustration, regret, and hope. It dawns on you that your whole family has been injured, not just one person. You’ve all had to change your lives. You can’t even remember what it used to be like. You wonder if things will ever return to normal, if there’s anything you can do to change the way things are now. You’re willing to try anything but don’t know where to start. You’re afraid to “rock the boat,” fearing anything you try might make things worse. If only there were a magic wand you could wave, a miracle pill you could take. Where’s that fairy godmother when you need her?

When you reach that point, you may be ready to start your own program to make things better. The following information may help guide you in your quest for a more normal life for you and all members of your family, including the injured individual:

Objectively analyze the strengths/weaknesses of the injured person: Physical and medical limitations are generally quite clear-cut and can be explained by physicians and therapists who have been involved in the rehabilitation process. As most family members soon learn, however, physical and medical limitations are relatively easy to understand and work around. It is cognitive and behavioral deficits which prevent return to a normal life for the injured individual and it is these deficits which cause stress for family members on a daily basis.

Two of the most common reasons for problems after a head injury are (a) overestimating or underestimating the cognitive and behavioral abilities and limitations of the injured individual and (b) failure to understand the practical implications of deficits. Expecting too much from the injured individual frequently causes significant behavioral problems; expecting too little may also cause behavioral problems but, more importantly, limits recovery and the acquisition of new skills. At either extreme, the stress experienced by family members is exacerbated and increases over time.

Neuropsychological evaluation is useful in determining which cognitive functions are intact (or nearly so) and which are impaired. Unfortunately, family members only occasionally have an opportunity to discuss test results. When such discussions do occur, the words used by the neuropsychologist may be quite technical and family members may not understand how things like “impaired initiation”, “left neglect”, or “apraxia” might be observed in daily life. If you are able to discuss results with the neuropsychologist, make sure you ask for specific examples of how you might see the deficits in daily life. If you don’t understand (or you don’t agree), ask for additional examples. Make sure you have a clear picture of how the test results apply to daily life before you leave the office. Ask what specific activities the injured individual should be able to do independently, which can be done with assistance, and which are probably totally beyond current ability levels. Ask how you can structure activities to maximize independence. Get the information you need to develop a reasonable plan to maximize recovery.

Until recently, the major focus of head injury rehabilitation was on medical and physical problems. Individuals who sustained head injuries received medical treatment and occupational, physical and speech-language therapy. When maximum physical and medical recovery had occurred, the patient was discharged and the family advised to “learn to live with the remaining deficits.” As more individuals survived head injuries, it became painfully clear that the major long-term problems faced by head injured individuals and their families were in the area of cognition and behavior. Physical problems, while important, were managed more readily than the decreased memory, impulsivity, poor judgment, and social inappropriateness which frequently accompanied head injury. In fact, many family members discovered that if the injured individual remained in a wheelchair, he or she was easier to supervise and control than when fully ambulatory. The wheelchair itself served as a reminder that the injury had occurred and that some behaviors were no longer possible.

Clearly, if it was worthwhile to save head injured individuals, programs which addressed cognitive and behavioral problems and thus improved the quality of life for survivors and their families were required. Since psychologists are trained in evaluating and changing behavior and cognition, their role in rehabilitation needed to be expanded to achieve maximum rehabilitation. Over the past several decades, that transition has occurred: in many programs psychologists serve as directors or have key roles in the rehabilitation process.

I practiced in a medical setting until January, 1984. I found that medical goals had priority: the patient and the patient’s needs had to fit the needs of the medical establishment. Almost every family member we encountered was on the road to becoming a “rehabilitation addict”: the only cure would come from the medical model and success would be evaluated in terms of range of motion, seizure control, bowel program management, degree of dependence in ADL’s, etc. Families were frantic, driven by the belief that progress would grind to a halt after the magical 18 months. I hold a number of beliefs which influence the type of client I can work with, the rehabilitation goals my clients establish, and the way we work toward those goals. Allow me to share some of these beliefs with you:

1. Head injuries make the individual different but not necessarily worse.

The first task of a rehabilitation program is the identification of the injured individual’s strengths and weaknesses. Within a medical model, this assessment usually focuses on CT scans, neurological examinations, nursing and other therapy evaluations and, in some cases, brief neuropsychological screening. Such procedures, conducted in a medical setting, overlook critical data about how the individual functions in the home setting and how the individual’s family deals with behavioral and cognitive problems. Furthermore, these assessments tend to focus on deficits to be remediated to the exclusion of assets which could be developed and strengthened.