In the final minutes of the first quarter, he gathered in another pass and took a minor bump to the helmet that left his legs wobbly. Brandon fell to his knees, and then left for the remainder of the game.

By his own admission, this was not his first concussion. Not counting a serious concussion in college, he counts 7 minor and 3 serious concussions during his 10-year NFL career. If he truly understood the seriousness of a concussion, and how a second rapid-fire head injury can cause uncontrollable brain swelling and death, Brandon Stokely would be thankful he’s even still alive.

Unfortunately, the competitive nature of sports entices players to downplay their injuries so they can continue competing. Double unfortunately, this leads to many players having short careers and short lives. For the sake of Brandon’s 4-year-old son, we hope he realizes how serious these head injuries can be and takes appropriate care of himself.

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• Brain Injuries in Sports
• NFL Concussions: Trent Edwards
• Concussion Management in Organized Sports
• Understanding Post-Concussion Syndrome

Fourteen days later, however, Edwards seemed to be none the worse for wear as he managed to lead the Bills to a 23-14 win against the San Diego Chargers, completing 25 of 30 passes and a touchdown.

After being hit in the Arizona game’s third play, Edwards lay on the field for several minutes before being helped up and assisted off the field by trainers. It was reported that he had no memory of events for about 15 minutes following the blow, and suffered a headache for several days. Loss of consciousness, loss of memory, and headache are clear signs of a concussion, if not something worse.

NFL rules require any player experiencing a concussion not be allowed to return to play the same day. Further, the player must have no continuing concussion symptoms and exhibit normal neurological and mental test results at rest and after exertion before returning at all. Otherwise, the situation is left up to the team and its physicians.

The NFL guidelines contrast with National Hockey League rules requiring a player with a concussion not practice or play for seven days. According to the concussion management guidelines of the American Academy of Neurosurgeons (AAN), a player suffering a concussion resulting in a loss of consciousness should not be allowed to play for at least one or two weeks, and then only if mental function is completely normal.

Though their concussion protocol was not detailed, the Buffalo Bills kept Edwards from practicing until the eighth day following his injury, which seems to adhere more closely to the AAN guidelines. It also seems a wise policy given the results against the Chargers on Edwards’ return to competition.

Related Articles

• NFL Concussions: Brandon Stokely
• Understanding Post-Concussion Syndrome
• Brain Injuries in Sports

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

If you’re trying to obtain compensation from someone else to pay the expenses associated with your head injury, you’re most likely going to need an attorney.

If a person or an average company is at fault for your injury, you will be collecting your compensation from their insurance company. Insurance companies profit by underpaying you for your claim. The adjuster will seem very kind and understanding, but his job is to get you to settle for less. He does his job all week long and he knows how to do it very well. You probably have not done this, and you won’t know how you’re being manipulated, but an attorney does.

If a large company is responsible for your injury, you will likely be dealing with their legal claims department. The lawyers and staff in this department have the same motivations as the insurance company. The less they pay you, the more they get to keep. Once again, they are very experienced at doing their jobs, while you are at a disadvantage. Having an attorney on your side levels the playing field.

When Do I Need to Involve an Attorney?

Given that most attorneys offer a free initial consultation, there is no need to wait to have that first meeting.

In the legal process for filing an injury claim, the law requires you to take certain actions almost immediately after an accident to make your claim defensible. Anything you’re required to do, but fail to do in time can reduce your eventual settlement or risk it entirely. Discussing the matter with an attorney will help you understand your obligations and prevent you from making significant errors before it’s too late.

You do not need to hire the attorney you speak with, and before you hire any attorney, you can discuss your case with as many as you like.

Though free initial consultations are common, they are not universal. You should confirm before your initial meeting that there is no fee. After speaking to one or more attorneys sooner rather than later, you will understand better when you need to have an attorney start handling your case.

What Kind of Attorney am I Looking For?

Attorneys are like doctors; everyone has a specialty. When you need brain surgery, you choose an experienced neurosurgeon who operates on people’s brains every day. For your attorney, you want a personal injury lawyer who specializes in head and brain injury cases. A personal injury lawyer without extensive background in brain injuries is like your family doctor attempting brain surgery. You don’t want either of them learning on your case.

How Do I Find a Good Brain Injury Attorney?

Don’t rely on advertising at all. Expensive television spots or big yellow page ads tell you nothing of a firm’s competence or experience.

A good way to find the best and nearest personal injury attorney specializing in brain injuries is to talk to another good attorney in your area, preferably one who does not handle personal injury cases at all. Lawyers tend to know one another and know who’s tops in their fields. If they don’t know someone personally, they know someone who knows.

Some firms specializing in brain injury cases have excellent, helpful web sites that provide background on the firms’ experience. Many of these firms will not be in your area, but some will be able to refer you to a competent nearby attorney.

It’s advisable to get at least three referrals and speak to them all before selecting the attorney you feel will best serve your case. Keep in mind that any referral you get may not necessarily be to the best-qualified person, or to someone you would feel comfortable with.

If you need assistance finding an attorney, please contact us using the form at the right.

What’s a Good Attorney Going to Cost?

Personal injury attorneys typically work on a contingency fee basis, meaning they charge you nothing for their services unless they obtain a settlement for you; then they will charge you a fixed percentage of the settlement, often between 30% and 40%. Any expenses associated with preparing your case are extra and will be deducted from your settlement share.

In the event expenses accrue and no settlement is collected, you need to find out from your attorney if you will be liable for such costs. You should also be consulted before any significant charges are added to your account so you have the opportunity to approve.

All of these matters should be explained in the agreement given to you to sign when you officially hire your attorney. Take your time reading and signing it, and ask for anything to be explained that you don’t understand. When you and your attorney have the same expectations regarding how things will work as you go forward, you will have a much more successful and satisfied relationship.

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• Head Injuries – Injury Claim Basics

Return to Head and Brain Injuries Home Page

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

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• Controlling pressure inside the skull
• Alleviating brain swelling
• Repairing blood vessels and removing blood clots or foreign matter

Controlling Pressure Inside the Skull

If a head injury causes fluid to build up inside the skull or causes the brain to swell, the pressure inside the skull increases. Excessive intracranial pressure (”ICP”) can cause damage to delicate brain tissues leading to additional brain injury and lasting disability. Even higher pressure can cause death.

Physicians will suspect problems with intracranial pressure buildup based on the patient’s age, description of the injury and the onset of symptoms, examining the pupils of the eyes and CT scans, and evaluating the patient’s Glasgow Coma Score. When these indicate potential pressure on the brain, a hole is drilled in the skull (a “burr hole”) for placing one of four types of devices:

• Subdural or epidural monitor
• Subarachnoid bolt
• Intraparenchymal monitor
• Intraventricular catheter

A subdural or epidural monitor is inserted in the burr hole made in the skull. The subdural monitor penetrates the dura - the leathery outer membrane surrounding the brain - while the epidural monitor does not. Neither of these monitors can drain cerebrospinal fluid (”CSF”) to relieve ICP. And neither is as accurate and reliable as the intraventricular catheter or intraparenchymal monitor. These simpler pressure monitors may be the best choice, however, when an experienced surgeon is not immediately available to place the more invasive devices

A subarachnoid bolt extends deeper into the skull, penetrating both the dura and the arachnoid membranes. To maintain its position in the small subarachnoid space, the sensor is physically attached to the skull when its inner and outer halves are screwed together. It does not provide for drainage of CSF.

The intraparenchymal monitor is inserted into actual brain tissue (the “parenchyma”). It provides a fast, accurate and reliable way to monitor ICP, but does not provide a way to relieve pressure by draining cerebrospinal fluid. This method is used when draining CSF is not expected to be necessary or when placing an intraventricular catheter is not possible.

The intraventricular catheter is by far the most preferred device for managing intracranial pressure. In a procedure called a ventriculostomy, the catheter is inserted through brain tissue into one of the vacant areas (”ventricles”) deep within the brain. The ventricles are filled with cerebrospinal fluid making this device the most accurate and reliable, as well as allowing it to drain excess cerebrospinal fluid to actually reduce ICP.

Alleviating Brain Swelling

Physicians will first try non-surgical methods for controlling brain swelling (or “edema”) and the resulting problems from excessive intracranial pressure. Draining CSF, using specific drugs, medically inducing a coma, or hypothermia treatments are all non-surgical options.

To alleviate brain swelling surgically, the neurosurgeon may perform a craniectomy. In this procedure, the surgeon removes a section of the skull (a “bone flap”) giving the swelling brain room to expand. If the amount of bone removed is large, the procedure is called a hemicraniectomy.

If the surgeon attempts to save the bone to be surgically reimplanted later, the first operation is called a craniotomy, and the procedure to replace the bone is cranioplasty. To save the bone for later use, it may be frozen, or implanted under the skin of the abdomen until needed.

If parts of the brain tissue are obviously injured and recovery in the injured area is unlikely, the surgeon may remove the damaged brain tissue to create additional space in the skull to relieve the pressure caused by swelling. This is a partial lobectomy.

Repairing Blood Vessels and Removing Blood Clots or Foreign Matter

Bleeding inside the skull also causes an increase in intracranial pressure and can be identified using CT scans.

If the injury is an open head wound, bits of bone or foreign matter may need to be removed from the brain tissue, and the membrane covering the brain repaired.

To correct these problems, the neurosurgeon performs a craniotomy to gain access to the injured brain area. He can then remove foreign materials or clots, evacuate blood, repair blood vessels, and suture the dura as needed.

When the bone is replaced after the surgery, temporary metal plates may be installed to hold the bone flap in place while the bone knits. The metal plates are removed after the bone heals.

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• Brain Injuries - Contusion, Hemorrhage, and Hematoma

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By understanding and recognizing the potential cognitive impairments of mild traumatic brain injury, we can identify them and obtain the appropriate therapy or treatment to lessen their impact.

Types of Mental Symptoms

Brain injury sufferers frequently exhibit any combination of these neuropsychological problems:

• Cognitive impairment – Reduction in intellect, memory, reasoning, math or language skills
• Behavioral issues – Anger, self-centeredness, aggressiveness, inappropriate behaviors
• Emotional problems – Depression, apathy, low self-esteem, social withdrawal, irritability

The patient with a serious brain injury may have many of these symptoms to a severe degree. Someone who otherwise seems to be fine after an accidental “bump on the head,” however, may have only a few of these symptoms.

Many of these symptoms are also commonly related to normal life stressors and to some physical diseases and mental disorders. This makes it even more difficult to accurately relate the symptoms to the cause in order to obtain the right treatment.

In a commonly recurring pattern, the mental symptoms of a brain injury appear within the week following the original injury, and most of the time the symptoms clear up within three to four weeks. In other cases, the symptoms may take 6 to 12 months to abate. When the symptoms persist longer than one year, they are frequently permanent, but often manageable with therapy.

Recognizing Cognitive Impairment

Slow Thinking

A subtle impairment clinically detectable only by comparative testing is a slow-down in thought processes. A study comparing the mental reaction times of injured and non-injured people with similar age and social background found the brain-injured patients lagged the control group measurably for several months following their injury. In the majority of cases, they caught up with their uninjured peers within three months without any specific treatment.

Memory Problems

Post-traumatic amnesia frequently occurs in association with a head injury. The patient does not remember events immediately preceding the injury, and often for a fixed period of time after the injury. Researchers are beginning to think that the overall duration of this amnesia is a far more significant indicator of residual mental deficits than the duration of unconsciousness following the injury.

Other types of memory problems also persist after injury. Difficulty in remembering objects (visual memory) is common in younger children, while difficulty in remembering words is frequent in adolescent children. These specific types of deficits are explained by the developmental stages of children’s brains.

Other problems associated with memory functions can include the inability to maintain short-term memory or the inability to store experiences in long-term memory. In an extreme case, a brain-injured man always greeted his wife with great enthusiasm as if he had not seen her in months, even if she had just left the room and returned moments later. More subtle memory issues can be difficult to diagnose as brain injury symptoms because memory can also be affected by psychological, pharmacological, and physical causes beyond brain injury.

Reduced Attention Span or Concentration

The inability to focus or concentrate on a task is frequently reported after a head injury; some cases may be due to the actual injury, while other cases may result from the psychological trauma following an accident. This symptom frequently resolves itself within weeks. When it persists longer, neuropsychological evaluation is called for.

A specific variation on this symptom is the inability to attend to more than one object at a time. An example is a printed paper form having many blanks to fill in that are simply overwhelming to the patient. Some patients can learn to mitigate this problem by covering the form with blank paper so that only one line item is visible at a time.

Another variation of this problem can be the inability to comprehend the contents of a closet. The contents appear as a unit and separate items are not intellectually distinguishable.

PET Scans

Positron Emission Tomography (”PET”) uses radioactive tracers to obtain images of organs and internal body structures. The PET scanner resembles a CT scanner but instead of measuring X-rays passing through the body, it measures gamma rays emanating from tissues where tracer elements have accumulated.

For brain imaging, different types of tracers are ingested or injected in the bloodstream depending on the type of information the doctor is looking for. Based on the tracer selected, images can focus on showing microscopic blood flow, oxygen or glucose consumption associated with brain activity, or variations in dopamine concentrations that can signal damaged areas.

Because the resulting brightly colored images show where biochemical processes are abnormal, the physician can more clearly see the degree and extent of an injury.

Though the images from PET scans are not as detailed as CT or MRI, new techniques are allowing doctors to fuse PET and CT images together. Newer machines perform a CT scan immediately after the PET scan while the patient is still on the table and in the same position. When the PET and CT images are combined, the anatomical and biochemical data are shown together so the doctor can see both what is wrong and precisely where.

Note that some insurance companies consider PET tests “experimental,” and will not cover their cost.

SPECT Scans

Single Photon Emission Computed Tomography (”SPECT”) is very similar to PET. It is a simpler technology, though, and is limited to showing blood flow. Still, it can be very effective in identifying damaged areas of the brain, and is less expensive than PET.

SPECT also requires a radioactive tracer based on the specific type of imaging desired, but the machinery is different from PET and CT scanners. Instead of the patent’s head being inside a donut-shaped ring, the SPECT camera rotates around the patient.

Preparation

The radioactive tracer is typically injected about one hour before the scan so that the targeted tissues can absorb it. The amount of radioactivity involved is so low that there is no risk to the patient even from having several scans done in a short period. On very rare occasions, someone may have an allergic reaction to the tracer compound.

Both PET and SPECT scans require the patient remain very still throughout the 30 to 90 minutes of the procedure. This can be uncomfortable and some patients may receive a sedative to help them relax.

Related Articles

• MRI vs. CT Scan in Determining Brain Injury

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Each year in the U.S., millions of children and adults experience a concussion from involvement in organized sports. In football, baseball, basketball, and soccer alone, nearly 100,000 will visit a hospital emergency room as a result of a head injury. Serious concussions and multiple mild concussions can lead to lasting disability and can sometimes be fatal. (See Brain Injuries in Sports.)

Given the potential for serious brain injury in sports activities, the American Academy of Neurology (”AAN”) has issued guidelines specifically for concussion management in sports. These guidelines for coaches apply to sports at any level, from pee-wee to pro.

Concussion Symptoms

Managing a concussion first requires recognizing its symptoms. Any player exhibiting any of the following conditions should be evaluated on the sideline before being allowed to return to the game.

• Confusion, disorientation
• Headache, dizziness, nausea, vomiting
• Uncoordinated or slow movement
• Impaired thinking or memory
• Slow or slurred speech
• Blurred vision, double vision, or sensitivity to light
• Ringing in the ears
• Loss of memory of events immediately before or after the injury
• Unconscious for any period of time

Evaluating the Concussion

Concussions can be mild or severe. Players can recover quickly from a mild concussion and the AAN guidelines allow the athlete to resume play after all concussion symptoms have cleared up. Any head injury other than the mildest concussion, however, requires a neurological examination and at least a 1-week or longer break from playing.

The following describes how to evaluate a concussion’s severity, with Grade 1 being the mildest.

• Grade 1. Temporary disorientation, no loss of consciousness, all symptoms clear up in less than 15 minutes.
• Grade 2. Temporary disorientation, no loss of consciousness, symptoms persist for 15 minutes or more.
• Grade 3. Any loss of consciousness, whether for seconds or minutes.

If the player remains unconscious, have emergency medical personnel transport the player to the emergency room. Because of possible neck or spine injuries, do not remove protective gear and do not move the player. In case of vomiting, roll the athlete gently to one side being careful to keep the head and spine aligned.

If on the other hand the player loses consciousness only briefly, take the player to get a neurological evaluation.

Sideline Assessment

A mild, Grade 1 concussion is the most common, but it can be the most difficult to identify since the symptoms may be brief. Nonetheless, it’s important to recognize even a mild concussion because a second mild concussion can have serious implications.

When no loss of consciousness occurs, evaluate the player for other symptoms. To determine if a player is suffering from deteriorated mental or physical function, ask the player to:

• Identify the date, day of the week, month, location, opponent (Orientation)
• Recall what happened, previous opponents, recent events (Memory)
• Count from 10 backwards; recite the months of the year in reverse order (Concentration)
• Walk or run a short distance, perform calisthenics (Intact senses and motor function)

Evaluate the athlete every 5 minutes for improvement. If the symptoms all clear up within 15 minutes, the player can return to the competition. If the symptoms do not clear up in less than 15 minutes, the player has a Grade 2 concussion.

Sidelining the Player

A concussion greater than a Grade 1, or two or more concussions of any grade, require a player to get a neurological evaluation and take a minimum of one to two weeks away from the sport. The risk of permanent or fatal injury from repeated brain trauma is too serious to be taken casually.

Detailed guidelines for evaluation, treatment, and limitations on sports activities are available in the complete paper from the American Academy of Neurology, Practice Parameter: The Management of Concussion in Sports.

Related Articles

• Understanding Post-Concussion Syndrome
• Concussion Symptoms

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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.