Brain Injury and Recovery

What is a brain injury Types of brain injury Levels of Brain injury Factors that impact recovery How are brain injuries treated Stages of recovery and how to respond
1

Why is brain injury called the silent epidemic?

Because of the magnitude of the problem, brain trauma has remained largely unknown by the American public. There are currently 5.3 million individualsa little more than 2 percent of the U.S. populationliving with a disability resulting from a traumatic brain injury. When considering an individuals family and circle(s) of support, brain injury touches the lives of approximately one in every 10 persons in the United States. The annual statistics of brain injury are staggering:
1 million people are treated and released from hospital emergency departments 230,000 people are hospitalized and survive 80,000 Americans experience the new onset of long-term disability following hospitalization for traumatic brain injury (TBI) 50,000 people die
2

What Is a Brain Injury?

The term refers to an injury to the brain that is usually the result of an accident, or sometimes and assault. Injuries can result from blows to the head such as suffered in an automobile accident or fall, as a result of lack of oxygen or blood supply to the brain.

Traumatic Brain Injury (TBI)

A traumatic brain injury occurs when an outside force impacts the head hard enough to cause the brain to move within the skull or if the force causes the skull to break and directly hurts the brain.

Types of TBI Closed Head Injury

Closed Head Injury: the result of a bow to the head which causes the brain to move or shake within the skull. The sharp and hard internal surfaces of the skull can cut and bruise the brain. Movement or shaking can cause the brain to be damaged in many areas, not only at the point of the blow. For this reason, persons with closed head injuries can show a wide range of problems. Often called diffused injuries
6

Types of TBI- Open Head Injury

An open head injury is the result of a sharp object entering the brain through the skull, such as a bullet. In this type of injury, damage to the brain tissue is seen mostly in one area-the area of penetration These types of injuries are called focal injuries

Primary Injuries

Diffuse Axonal Injury- A Diffuse Axonal Injury can be caused

by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident. Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.

Concussion-caused when the brain receives trauma from an impact

or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged.

Coup-Contrecoup Injury-This occurs when the force

impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion

Penetration Injury-Penetrating injury to the brain occurs from the

impact of a bullet, knife or other sharp object that forces hair, skin, bone and fragments from the object into the brain.

Contusion-A contusion is a bruise (bleeding) on the brain

Secondary Injuries

When a TBI occurs, other factors can affect the brain, called secondary injuries. These can cause further problems in addition to the trauma Bleeding (hemorrhage)- when deep blood vessels in the brain are
injured an bleed causing injury from loss of blood or pressure

Blood clots (hematomas)- clots can form when there is bleeding.

Clots can create pressure, which can lead to further damage

Swelling (edema)- causes pressure which can damage the brain

Lack of oxygen (anoxia)- because of bleeding in the brain or
injury to other parts of the body, the flow of oxygen to the brain may be poor and cause damage.
9

Symptoms of a TBI

Spinal fluid (thin water-looking liquid) coming out of the ears or nose
Loss of consciousness; however, loss of consciousness may not occur in some concussion cases

Dilated (the black center of the eye is large and does not get smaller in light)or unequal size of pupils
Vision changes (blurred vision or seeing double, not able to tolerate bright light, loss of eye movement, blindness) Dizziness, balance problems Respiratory failure (not breathing) Coma (not alert and unable to respond to others) or semicomatose state
10

Symptoms of TBI cont.

Paralysis, difficulty moving body parts, weakness, poor coordination

Slow pulse Slow breathing rate, with an increase in blood pressure Vomiting Lethargy (sluggish, sleepy, gets tired easily) Headache Confusion Ringing in the ears, or changes in ability to hear
11

Symptoms of TBI cont

Difficulty with thinking skills (difficulty thinking straight, memory problems, poor judgment, poor attention span, a slowed thought processing speed)
Inappropriate emotional responses (irritability, easily frustrated, inappropriate crying or laughing) Difficulty speaking, slurred speech, difficulty swallowing Body numbness or tingling Loss of bowel control or bladder control

12

Acquired Brain Injury

An acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth.

13

Causes of Acquired Brain Injury

Airway obstruction
Near-drowning, throat swelling, choking, strangulation, crush injuries to the chest

Electrical shock or lightening strike

Trauma to the head and/or neck Traumatic brain injury with or without skull fracture, blood loss from open wounds, artery impingement from forceful impact, shock Vascular Disruption
14

Causes Continued

Heart attack, stroke, arteriovenous malformation (AVM), aneurysm, intracranial surgery

Infectious disease, intracranial tumors, metabolic disorders

Meningitis, certain venereal diseases, AIDS, insect-carried diseases, brain tumors, hypo/hyperglycemia, hepatic encephalopathy, uremic encephalopathy, seizure disorders
Toxic exposure Illegal drug use, alcohol abuse, lead, carbon monoxide poisoning, toxic chemicals, chemotherapy (not all the time).
15

Levels of Brain Injury

the severity of neurological injury to the brain by using an assessment called the Glascow Coma Scale (GCS) to. The terms Mild Brain Injury, Moderate Brain Injury, and Severe Brain Injury are used to describe the level of initial injury in relation to the neurological severity caused to the brain. There may be no correlation between the initial Glascow Coma Scale score and the initial level of brain injury and a persons short or long term recovery, or functional abilities. Keep in mind that there is nothing Mild about a brain injuryagain, the term Mild Brain injury is used to describe a level of neurological injury. Any injury to the brain is a real and serious medical 16 condition

Mild Traumatic Brain Injury

Glascow Coma Scale score 13-15

Loss of consciousness is very brief, usually a few seconds or minutes

Loss of consciousness does not have to occurthe person may be dazed or confused

Testing or scans of the brain may appear normal

A mild traumatic brain injury is diagnosed only when there is a change in the mental status at the time of injurythe person is dazed, confused, or loses consciousness. The change in mental status indicates that the persons brain functioning has been 17 altered, this is called a concussion

Moderate TBI

Glascow Coma Scale Score 9-12

A loss of consciousness lasts from a few minutes to a few hours

Confusion lasts from days to weeks

Physical, cognitive, and/or behavioral impairments last for months or are permanent.

Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits.
18

Severe Brain Injury

Glascow Coma Score 8 or less

Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks, or months. Severe brain injury is further categorized into subgroups with separate features: Coma Vegetative State -Arousal is present, but the ability to interact with the
environment is not. Eye opening can be spontaneous or in response to stimulation.General responses to pain exist, such as increased heart rate, increased respiration, posturing, or sweating Sleep-wakes cycles, respiratory functions, and digestive functions return

Persistent Vegetative State Minimally Responsive State-demonstrate: Primitive

reflexes,Inconsistent ability to follow simple commands, and an awareness of environmental stimulation

Akinetic Mutism-a neurobehavioral condition that results when the

dopaminergic pathways in the brain are damaged.

Locked-in Syndrome

19

A Healthy Brain

Before we can understand what happens when a brain is injured, we must realize what a healthy brain is made of and what it does. The brain is enclosed inside the skull. The skull acts as a protective covering for the soft brain. The brain is made of neurons (nerve cells). The neurons form tracts that route throughout the brain. These nerve tracts carry messages to various parts of the brain. The brain uses these messages to perform functions. The functions include our thought processes, physical movements, personality changes, behavioral changes, and sensing and interpreting our environment. Each part of the brain serves a specific function and links with other parts of the brain to form more complex functions.

20

Functions of the Brain: Frontal, Temporal, Parietal, Occipital, Brain Stem

The brain is divided into main functional sections, called lobes. These sections or brain lobes are called the Frontal Lobe, Temporal Lobe, Parietal Lobe, Occipital Lobe, The Cerebellum, and the Brain Stem. Each has a specific function, as described below.

21

Frontal Lobe
oInitiation oProblem Solving oJudgment oInhibition of behavior oPlanning and anticipation oSelf-monitoring oMotor Planning oPersonality oEmotions oAwareness of abilities and limitations oOrganization oAttention and concentration oMental flexibility oSpeaking (expressive language) 22

Temporal Lobe

oMemory oHearing oUnderstanding language (receptive language) oOrganization oSequencing

23

Parietal Lobe

oSense of touch oDifferentiation (identification) of size, shapes, and colors oSpatial perception oVisual perception

24

Occipital Lobe

oVision

25

Cerebellum

oBalance oCoordination oSkilled motor activity

26

Brain Stem

oBreathing oHeart rate oArousal and consciousness oSleep and wake cycles oAttention and concentration

27

An Injured Brain

When a brain injury occurs, the functions of the neurons, nerve tracts, or sections of the brain can be effected. If the neurons and nerve tracts are effected, they can be unable or have difficulty carrying the messages that tell the brain what to do. This can result in Thinking Changes, Physical Changes, and Personality and Behavioral Changes. These changes can be temporary or permanent. They may cause impairment or a complete inability to perform a function.

28

Thinking Changes
Memory Decision making Planning Sequencing Judgment Attention Communication Reading and writing skills Thought processing speed Problem solving skills Organization Self-perception Perception Thought flexibility Safety awareness New learning

Physical Changes
Muscle movement Muscle coordination Sleep Hearing Vision Taste Smell Touch Fatigue Weakness Balance Speech seizures Sexual Functioning
29

Personality and Behavioral Changes

Denial Self-centeredness Anger management Coping skills Self-monitoring remarks or actions Motivation Irritability or agitation Excessive laughing or crying

Social skills Emotional control and mood swings Appropriateness of behavior Reduced self-esteem Depression Anxiety Frustration Stress

30

Right or Left Brain The functional sections or lobes of the brain are also divided into right and left sides. The right side and the left side of the brain are responsible for different functions. General patterns of dysfunction can occur if an injury is on the right or left side of the brain.

31

Left Side of the Brain

Difficulties in understanding language (receptive language)

Injuries of the Right Side of Brain can cause:

Visual-spatial impairment Visual memory deficits Left neglect (inattention to the left side of the body) Decreased awareness of deficits Altered creativity and music perception Loss of the big picture type of thinking Decreased control over leftsided body movements
32

Difficulties in speaking or verbal output (expressive language)

Catastrophic reactions (depression, anxiety)

Verbal memory deficits

Impaired logic Sequencing difficulties

Decreased control over right-sided body movements

Diffuse Brain Injury

(The injuries are scattered throughout both sides of the brain) oReduced thinking speed oConfusion oReduced attention and concentration oFatigue oImpaired cognitive (thinking) skills in all areas
33

Just as no two people are alike, no two brain injuries are alike. Appropriate treatment and rehabilitation will vary from individual to individual. Programs and treatments change, as a person's needs change. It is important to recognize that "more therapy" does not make a person "better", but that "appropriate" therapy may.
34

Factors that Affect Recovery

Age at the time of injury Area and amount of injury Time since the injury happened Skills and behavior before injury Motivation for recovery Substance use and/or abuse Past brain injury or concussion

35

How Are Brain Injuries Treated Medically (ICU)

Treatment is aimed at stopping any bleeding, preventing an increase in pressure within the skull, controlling the amount of pressure and removing any large blood clots Treatments may include: positioning, fluid restriction, medications, ventricular drain, ventilator, surgery (craniotomy, burr holes, bone flap removal)

36

The Recovery Process

Ranchos Los Amigos Scale of Cognitive Functioning

As recovery progresses, the Ranchos Los Amigos Scale of Cognitive Function becomes the tool most widely utilized to assess cognitive and behavioral functioning. This describes the cognitive and behavioral status of the individual at the time, and directs the planning and evaluation of treatment plans and goals throughout the entire recovery process. It also represents a non-medical framework for family members to begin to understand brain injury in a way that helps them interact with their loved one in a more sensitive, positive manner, contributing to the rehabilitation process. 37

The Ranchos Los Amigos Scale consists of eight levels, and is described below. Individuals go through these levels at different rates, and improvement may vary at any level. Individuals may fluctuate between two levels at the same time. Suggestions for working with your family member at each stage of recovery is provided.

38

Stages of Recovery
Level I - No Response Patient appears to be in a deep sleep and is completely unresponsive to any stimuli presented to him.

39

How to Respond to Level 1

It is not really known what an individual can hear and understand while in a coma or early stages of recovery. Family and staff should therefore monitor their interactions and conversations at bedside, always keeping in mind the possibility some activity may be remembered.
40

Stages of Recovery
Level II - Generalized Response Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. Responses are limited in nature and are often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalization. Often, the earliest response is to deep pain. Responses are likely to be delayed.
41

How to Respond to Level II

During periods of wakefulness, provide simple and meaningful stimulation. Describe activities to your loved one such as "now I am washing your right hand". Speak in slow, calm, and normal tones, and show affection often, in whatever way you can. When eyes are opened, try to have him/her look at you and at other visitors. Keep periods of stimulation brief (5-15 minutes), as your family member has to rest. Family and friends should share stimulation 42 responsibilities as you too have to rest.

Stages of Recovery
Level III - Localized Response

Patient reacts specifically, but inconsistently, to stimuli. Responses are directly related to the type of stimulus presented as in turning head toward a sound or focusing on an object presented. The patient may withdraw an extremity and/or vocalize when presented with a painful stimulus. May follow simple commands in an inconsistent, delayed manner such as closing eyes, squeezing or extending an extremity.
43

Once

external stimuli is removed, patient may lie quietly. May also show a vague awareness of self and body by responding to discomfort by pulling at nasogastric tube or catheter or resisting restraints. Patient may show a bias toward responding to some persons (especially family, friends) but not to others.

44

How to respond to Level III

Increase and direct stimulation efforts at reorienting your family member with who they are and what has happened. At each visit, describe who you are, provide the date, where they are and why. Bring familiar and significant objects to the individual; provide photographs of family and friends, identified by name on the back to assist staff who can also help stimulate his/her memory. With increased periods of alertness, discuss significant past, such as school, employment, longtime relationships, hobbies. 45

Continue

to ask for simple commands to be followed, initiate and assist with self-care tasks. Ask simple questions that require only "yes" or " no " answers, allowing time to respond. Remain patient and sensitive to signs of frustration.

46

Stages of Recovery

Level IV - Confused/Agitated

Patient is in a heightened state of activity with severely decreased ability to process information. Is detached from the present and responds primarily to his/her own internal confusion. Behavior is frequently bizarre and non-purposeful relative to his/her immediate environment. May cry out or scream out of proportion to stimuli even after removal, show aggressive behavior, attempt to remove restraints or tubes, or crawl out of bed in a purposeful manner. Patient does not, however, discriminate among persons or objects and is unable to cooperate directly with treatment efforts.

47

Verbalization

is frequently incoherent and/or inappropriate to the environment. Confabulation may be present; patient may be euphoric or hostile. Thus, gross attention to environment is very short and selective attention is often nonexistent. Being unaware of present events, patient lacks short-term recall and may be reacting to past events. Is unable to perform self-care (feeding, dressing) without maximum assistance. If not disabled physically, he/she may perform motor activities such as sitting, reaching, and ambulating, but as part of his/her agitated state and not as a purposeful act or on request, necessarily.
48

Responding to Level IV

The goals of this stage are to decrease agitation and increase awareness. Use calm, soft speech and slow careful movements to lessen the tendency for agitation. Continue to provide opportunities for the individual to respond to stimuli and simple commands, encourage and assist with self-care tasks, continue to associate the individual with familiar things. Remove distractions such as TV or radio, to restrict stimulation to one sense (auditory, visual or tactile) at a time. Attempt to correct an inappropriate or inaccurate response, but do not argue the point.
49

Responding to Level IV cont

If confusion and agitation is ongoing, do not try to rationalize with the person, allow him/her time to relax. Do not ignore them however, instead provide human contact and soothing reassurances. Avoid sedatives as they can slow the thinking process, and add to the confusion. Seeing a family member engage in unusual and aggressive behavior is very difficult to endure. Try to remember not to take any of the comments and behaviors personally. The Confused-Agitated stage is a sign of improvement, and a necessary step towards recovery.
50

Stages of Recovery
Level V - Confused, Inappropriate Non-Agitated

Patient appears alert and is able to respond to simple commands fairly consistently; however, with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or, at best, fragmented toward any desired goal. May show agitated behavior, but not on an internal basis (as in Level IV), but rather as a result of external stimuli, and usually out of proportion to the stimulus. Has gross attention to the environment, but is highly distractible and lacks ability to focus attention to a specific task without frequent re-direction back to it. With structure, person may be able to converse on a social51 automatic level for short periods of time.

Verbalization

is often inappropriate; confabulation may be triggered by present events. Memory is severely impaired, with confusion of past and present in patients reaction to ongoing activity. Patient lacks initiation of functional tasks and often shows inappropriate use of objects without external direction. May be able to perform previously-learned tasks when structured, but is unable to learn new information. Responds best to self, body, comfort, and, often, family members. The patient can usually perform self-care activities, with assistance, and may accomplish feeding with maximum supervision. Management on the ward is often a problem if the patient is physically mobile, as patient may wander off, either randomly or with vague intentions of "going home".

52

Responding to Level V

Continue to help the individual get back in touch with the world, discuss family and friends, and events he/she has experienced during the day. Try to have information recalled, providing hints to stimulate memory, for example, ask immediately after breakfast what he/she ate. If unable to remember, be more specific. Ask what he/she drank. If it was milk, describe it as white. Encourage success with generous praise, noting accomplishments.
53

Do

not allow tasks to become overwhelming however, as tolerance for frustration is decreased. Simple memory and card games may be tried at this stage. Try to keep routines consistent to help organize the individual. Discuss problems he/she is having related to the brain injury honestly and matter-of-factly. Use a calm soothing manner always remembering to address the individual in an age-appropriate fashion.
54

Stages of Recovery
Level VI - Confused, Appropriate

Patient shows goal-directed behavior, but is dependent on external input for direction. Response to discomfort is appropriate and patient is able to tolerate unpleasant stimuli (as NG tube) when need is explained. Follows simple directions consistently and shows carry-over for tasks he has relearned (as self-care). Is at least supervised with old learning; unable to maximally be assisted for new learning with little or no carry-over. Responses may be incorrect due to memory problem, but they are appropriate to the situation. They may be delayed to immediate and shows decreased ability to process information with little or no anticipation or prediction of events. Past memories show more depth and detail than recent memory.

55

May

show beginning immediate awareness of situation by realizing he doesn't know an answer. He no longer wanders and is inconsistently oriented to time and place. Selective attention to task may be impaired, especially with difficult tasks and in unstructured settings, but is now functional for common daily activities (30 min. with structure). He may show a vague recognition of some staff, has increased awareness of self, family and basic needs (as food), again, in an appropriate manner as in contrast to Level V.

56

Responding to Level VI

Work towards increasing independence during this stage, by gradually decreasing assistance provided for simple activities. Offer games and crafts that become more mentally challenging but not frustrating. Discuss TV shows, conversations, and events immediately after he/she has seen or heard them. Use each situation as a learning experience to help the individual begin to arrange and understand each part of daily life.
57

Activities

we take for granted may be difficult for the individual to accomplish.

Ask

to have familiar tasks such as making coffee, changing money, or washing clothes described in steps; or well-traveled trips such as to school, stores, or friends' homes mapped out.
Be

sensitive to tolerance levels and signs of fatigue.

Keep

activities at a moderate pace, and always allow time for rest.

58

Stages of Recovery
Level VII - Automatic, Appropriate Patient appears appropriate and oriented goes through daily routine automatically, but frequently robot-like, with minimal-to-absent confusion, but has shallow recall of what he has been doing. He shows increased awareness of self, body, family, foods, people, and interaction in the environment. He has superficial awareness of, but lacks insight into, his condition, decreased judgment and problem-solving and lacks realistic planning for his future.
59

Patient

shows carry-over for new learning, but at a decreased rate.

Requires

at least minimal supervision for learning and for safety purposes.

Patient

is independent in self-care activities and supervised in home and community skills for safety.
With

structure, Patient is able to initiate tasks as social or recreational activities in which he/she now has interest.
Judgment

remains impaired; such that he/she is unable to drive a car.

60

Responding to Level VII

The major goals of this and the next level of recovery are to promote independent skills to permit supervision to be safely withdrawn. During this stage, "real-life " activities of increasing complexity such as shopping or use of a telephone directory and/or map should be attempted. Situations of daily living at home and in the community should be discussed, with multistep planning and possible dangerous aspects explored. Use and expansion of judgment skills should be emphasized. Patience during interactions is needed as the processing of new information may be slowed.
61

Stages of Recovery
Level VIII - Purposeful, Appropriate

Patient is alert and oriented, is able to recall and integrate past and recent events, and is aware of, and responsive to, his culture. Shows carry-over for new learning if acceptable to him/her and his/her life role, and needs no supervision once activities are learned. Within physical capabilities, person is independent in home and community skills, including driving. Vocational rehabilitation, to determine ability to return as contributor to society (perhaps in a new capacity) is indicated.
62

May

continue to show a decreased ability, relative to premorbid abilities, in abstract reasoning, tolerance for stress, judgment in emergencies or unusual circumstances. Social, emotional, and intellectual capacities may continue to be at a decreased level, but functional in society.

63

Responding to Level VIII

Maximum involvement in home, school, or job within the individual's physical and intellectual capabilities should be encouraged. Responsibilities for one's own needs as well as in home and community should be resumed. Complex tasks such as total meal planning and preparation, organizing chores into a daily routine, and planning leisure activities can be initiated independently. The individual should be encouraged to develop and utilize aids such as memory books or reminder lists to assist him/her with 64 accomplishing goals.

During these later stages, counseling may be indicated to assist the individual in gaining insight into the changed levels of functioning that he/she may be experiencing, and to develop coping strategies if deficits preclude a return to previous educational or vocational status.
65

Acute Rehabilitation
In the Acute Rehab setting, a team of health professionals with experience and training in brain injury rehabilitation work with the person and their family. The goal of Acute Rehabilitation is to assist persons with brain injuries to achieve their highest level of independent life skills used in activities of daily living. Activities of daily living include dressing, eating, toileting, walking, speaking, and several other basic, yet essential activities that we perform in our daily lives. After a brain injury, people may have to relearn how to do these types of tasks. Rehabilitation requires the expertise of several healthcare professionals and Acute Rehab team members.
66

Subacute Rehabilitation

Subacute Rehabilitation provides services for persons with brain injury who need a less intensive level of rehabilitation services, over a longer period of time. Sub-acute rehabilitation programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing, but are not making rapid functional gains. Subacute rehabilitation may be provided in a variety of settings, but is often in a skilled 67 nursing facility or nursing home

Outpatient Therapy
Following acute rehabilitation or subacute rehabilitation, a person with a brain injury may continue to receive outpatient therapies to meet continued goals. Additionally, a person with a brain injury that was not severe enough to require inpatient hospitalization may attend outpatient therapies to address functional impairments.
68

Rehabilitation Treatment Team

Physiatrist is a doctor of physical medicine rehabilitation. The physiatrist typically serves as the leader for the rehabilitation treatment team and makes referrals to the various therapies and medical specialists as needed. The physiatrist works with the rehabilitation team, the person with a brain injury, and the family to develop the best possible treatment plan.

Physical Therapists evaluate and treat a persons ability to move the body. The physical therapist focuses on improving physical function by addressing muscle strength, flexibility, endurance, balance, and coordination. Functional goals include increasing independent ability with walking, getting in and out of bed, on and off a toilet, or in and out of a bathtub. Physical therapists provide training with assistive devices such as canes or walkers for ambulation. Physical therapists can also use physical modalities, treatments of heat, cold, and water to assist 69 with pain relief and muscle movement.

Rehabilitation Treatment Team

Occupational Therapists
use purposeful activities as a means of preventing, reducing, or overcoming physical and emotional challenges to ensure the highest level of independent functioning in meaningful daily living. Areas addressed by occupational therapists include: Feeding; swallowing; grooming; bathing; dressing; toileting; mobilizing the body on and off the toilet, bed, chair, bathtub; thinking skills; vision; sensation; driving; homemaking; money management; fine motor (movement of small body muscles, such as in the hands); wheelchair positioning and mobility; home evaluation; durable medical equipment assessment and training (such as, use of a raised toilet seat to assist with getting on and off the toilet easier). The occupational therapist also fabricates splints and casts to 70 reduce deformities and optimize muscle functioning

Rehabilitation Treatment Team

Speech/language pathologist : responsible for evaluating and treating language and cognitive difficulties that may cause challenges your daily life. Language refers to the skills of comprehension, verbal expression, reading, and writing. Cognitive skills refer to thinking skills such as attention/concentration, memory, reasoning, problem-solving, etc. work with any motor speech or swallowing difficulties. Therapy will focus on improving and working around any difficulties to make you more independent in the home, work, educational, and community environments. 71

Rehabilitation Treatment Team

Rehabilitation Nurses monitor all body systems. attempts to maintain the persons medical status, anticipate potential complications, and work on goals to restore a person's functioning. responsible for the assessment, implementation, and evaluation of each individual patient's nursing care and educational needs based on specific problems as well as coordinating with physicians and other team members to move the patient from a dependent to an independent role.
72

Rehabilitation Treatment Team

Social Worker: provides you and your family with information from weekly team staffings so that you remain updated on your progress, your discharge goals, and your estimated length of stay. can also give you information on community resources that you might need, such as support services in the home or Social Security Disability. will help you and your family set up your discharge to home or, if needed, will assist you in finding a living arrangement that provides you with more assistance.
73

Rehabilitation Treatment Team

Recreational Therapists provide activities to improve and enhance selfesteem, social skills, motor skills, coordination, endurance, cognitive skills, and leisure skills. plan community outings to allow the person to directly apply learned skills in the community. Additional programs may include pet therapy, leisure education, wheelchair sports, gardening, special social functions or holiday functions for persons and their family.

74

Rehabilitation Treatment Team

Neuropsychologist:
The Neuropsychologist has specialized training in evaluating and understanding how brain injuries affect thinking, behavior, and emotions. works with the rehabilitation physician to monitor your progress and response to medications. conducts formal tests to measure progress in thinking, behavior, and emotions. works closely with the treatment team to assist with recommendations on how independent you can be and how, or when, you can return to work. can help you and your family understand what long term difficulties you may have as a result of your injury. available to provide support to you and your family as you adapt 75 to your injury and to the changes in your life.

Other Community Based Treatment/services

Home Health Services Vocational Rehabilitation Support Groups: BIAI every 4th Thursday at IERH 7-9pm Brain Injury Association of Idaho 1-888-336-7708 www.biausa/idaho.org Brain Injury Association, Inc. www.biausa.org 1-800-444-6443
76

HOW DOES BRAIN INJURY AFFECT BEHAVIOR?

The majority of TBIs result in some degree of behavior change It is very important that the family realizes that misbehavior can be the result of brain damage as well as the frustration and anger that the survivor feels Impairments seen in self-care skills, cognition, and interpersonal 77 skills

Personality traits may become exaggerated or more extreme after a brain injury.
A reserved, quiet person may become even more even more withdrawn and quiet

An assertive, active person may become aggressive and even more outspoken
78

Behavior and Personality Issues

Fatigue Amotivation Agitation Emotional Lability Impulsivity Perseveration Sexual behavior

Memory

Problems

Poor concentration

Lack of Awareness
Lack of emotion

Self-centered thinking
79

Emotional Responses to TBI

Irritability
Fear/Anxiety Anger Depression Role changes Self-Esteem
80

FATIGUE
Fatigue is tiredness of the body (physical) or mind (mental). All people feel fatigue but it is especially common after an injury. The body use a lot of energy to recover. This tiredness may come and go, lasting for a few months to many years Symptoms of fatigue include: Takes more energy to do everyday things like brushing teeth walking, and dressing Activities normally done without thinking may take great care and planning Simple communication may take more effort May take more than one try and a lot of energy to finish a task People often have a lot of sadness, fear, and anger after an illness or injury. These feelings use up a lot of energy.
81

Causes of Fatigue
Things that can use up a persons energy include the following:
Stress Poor sleep Pain Medications

Depression
Lack of exercise Poor nutrition
82

What Are the Types of Fatigue?

There are different areas of life that fatigue (tiredness) can affect:
Physical Emotional Mental Spiritual

83

Ways to Increase Energy

The first step to increasing energy is to identify the causes of the tiredness
Follow a regular schedule for activity and rest. Make sure it does not affect nighttime sleeping

Celebrate progress, no matter how small

Find something enjoyable in everyday life Keep track of your schedule to see when you tend to be most awake and most fatigued

84

How to Use Energy Better

Make a daily schedule and follow it
Do harder tasks (high energy and/or thinking tasks) at times when you are most energetic Have two plans for the day. One for high-energy days and one for low energy days Use aids, such as notebooks for memory and wheelchairs to go long distances, to help save energy

Find a way to let go of anger, sadness, and fear. Holding these feelings in uses energy. Do the following: talk, relax, meditate, exercise, get counseling, if needed Ask for help
85

Amotivation/Apathy
Past Studies state that it is common for individuals with traumatic brain injury to experience apathy as a result of neurological changes.
Apathy refers to a syndrome of disinterest, disengagement, inertia, lack of motivation, and absence of emotional responsivity. The negative affect and cognitive deficits seen in patients with depression are not seen in patients with apathy. Apathy may be secondary to damage of the mesial frontal lobe

86

Agitation/Irritability
Damage to several areas of the brain can lead to difficulty controlling ones behavior, including control of temper
Irritability after brain injury sometimes relates to difficulties and frustration in doing things that the person was able to do easily before. Person may become angry over seemingly small matters
87

Ways to Manage Anger

After the person calms down, encourage them to write down what happened to cause the anger, what the person thought and did when angry, and what happened after he/she was angry. Encourage the injured person to take a time-out when anger starts to build. The person can say I am beginning to feel angry angry and would like to take a time out Get enough sleep
Avoid caffeine or alcohol Identify triggers then change or avoid them
88

Ways to Diffuse Hostile Behavior

Remain calm as you can, ignore the behavior

Agree with the person (if appropriate).

Validate feelings- let person know their feelings are legitimate

Do not challenge or confront person. Rather, negotiate.

Offer alternative ways to express anger Try to understand source of anger- is there a way to address the persons need/frustration Ask person if there is anything that would help them feel better 89

 Isolate the disruptive impaired person

Try to establish consistent, nonconfrontational responses from all family members Seek support for yourself as a caregiver

90

Suggestions to Prevent Agitation

Keep noise levels down

Adjust lighting in room

Limit visitors to one or two at a time for no more than 20 minutes

Follow rest schedule set by team

Allow no visitors in room during rest times Give simple directions Show calm behavior Respect the persons right for space and privacy
91

REMEMBER
Physical contact may increase aggression
Call for help if aggression is escalating Do not leave person alone Keep person in sight

Remove objects that may be thrown (maintain a safe environment)

92

Emotional Lability

Feelings are often show in an extreme and inappropriate way Expressions and moods may change suddenly
93

Helpful Suggestions
Keep a matter-of-fact attitude Ignore inappropriate emotions. It is natural to want to comfort the person, but this type of attention may make unwanted emotions last longer

Change the topic

Praise the person when he or she controls unwanted emotions Have the person take many rest periods
94