How the Brain Recovers2

7/28/2019 How the Brain Recovers2

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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



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Why is

brain

injury

called thesilent

epidemic?

Because of the magnitude of the problem, brain trauma has

remained largely unknown by the American public. There are

currently 5.3 million individuals—a little more than 2 percent of

the U.S. population—living with a disability resulting from atraumatic brain injury. When considering an individual’s 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 hospitalemergency 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



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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 resultfrom 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.



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• A traumatic brain injury occurs when an

outside force impacts the head hard

enough to cause the brain to movewithin the skull or if the force causes the

skull to break and directly hurts the

brain.

Traumatic Brain Injury (TBI)



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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 internalsurfaces 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 closedhead injuries can show a wide range of problems.

Often called diffused injuries



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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 focalinjuries



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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 theskull, 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 brainmay 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 theopposite 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 andfragments from the object into the brain.

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



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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 areinjured 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.



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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 getsmaller 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



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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



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Symptoms of TBI cont

Difficulty with thinking skills (difficulty “thinking straight”, memoryproblems, poor judgment, poor attention span, a slowed thoughtprocessing 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



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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.

Acquired Brain Injury



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Causes of Acquired Brain Injury

Airway obstruction

Near-drowning, throat swelling, choking, strangulation, crushinjuries to the chest

Electrical shock or lightening strike

Trauma to the head and/or neck

Traumatic brain injury with or without skull fracture, blood lossfrom open wounds, artery impingement from forceful impact,shock

Vascular Disruption



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Causes Continued

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

Infectious disease, intracranial tumors, metabolic disorders

Meningitis, certain venereal diseases, AIDS, insect-carrieddiseases, brain tumors, hypo/hyperglycemia, hepaticencephalopathy, uremic encephalopathy, seizure disorders

Toxic exposure

Illegal drug use, alcohol abuse, lead, carbon monoxidepoisoning, toxic chemicals, chemotherapy (not all the time).



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Levels of Brain Injury the severity of neurological injury to the brain by

using an assessment called the Glascow ComaScale (GCS) to. The terms Mild Brain Injury,Moderate Brain Injury, and Severe Brain Injury areused to describe the level of initial injury in relationto the neurological severity caused to the brain.There may be no correlation between the initialGlascow Coma Scale score and the initial level of brain injury and a person’s short or long term

recovery, or functional abilities. Keep in mind that there is nothing “Mild” about a

brain injury—again, the term “Mild” Brain injury isused to describe a level of neurological injury. Anyinjury to the brain is a real and serious medical

condition



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Mild Traumatic Brain InjuryGlascow Coma Scale score 13-15

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

Loss of consciousness does not have to occur —the person maybe dazed or confused

Testing or scans of the brain may appear normal

A mild traumatic brain injury is diagnosed only when there is achange in the mental status at the time of injury—the person isdazed, confused, or loses consciousness. The change in mentalstatus indicates that the person’s brain functioning has been

altered, this is called a concussion



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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.



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Severe Brain InjuryGlascow Coma Score 8 or less

Severe brain injury occurs when a prolonged unconsciousstate or coma lasts days, weeks, or months. Severe braininjury is further categorized into subgroups with separatefeatures:

Coma

Vegetative State - Arousal is present, but the ability to interact with theenvironment is not. Eye opening can be spontaneous or in response tostimulation.General responses to pain exist, such as increased heart rate,increased respiration, posturing, or sweatingSleep-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



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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 isenclosed 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.



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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.



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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)



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Temporal

Lobe

oMemory

oHearing

oUnderstanding language (receptive language)

oOrganization

oSequencing



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ParietalLobe

oSense of touch

oDifferentiation (identification) of size, shapes, and colors

oSpatial perception

oVisual perception



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Occipital Lobe

oVision



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Cerebellum

oBalance

oCoordination

oSkilled motor activity



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Brain Stem

oBreathing

oHeart rate

oArousal and consciousness

oSleep and wake cycles

oAttention and concentration



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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 difficultycarrying 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.



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Thinking Changes

Memory

Decision makingPlanning

Sequencing

Judgment

Attention

CommunicationReading and writing skills

Thought processing speed

Problem solving skills

OrganizationSelf-perception

Perception

Thought flexibility

Safety awareness

New learning

Physical Changes

Muscle movement

Muscle coordinationSleep

Hearing

Vision

Taste

SmellTouch

Fatigue

Weakness

BalanceSpeech

seizures

Sexual Functioning



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Personality and Behavioral

Changes

Social skills

Emotional control and mood swings

Appropriateness of behavior

Reduced self-esteem

Depression

Anxiety

Frustration

Stress

Denial

Self-centeredness

Anger management

Coping skills

Self-monitoring

remarks or actions

Motivation

Irritability or agitation

Excessive laughingor crying



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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.





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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



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Just as no two people are alike, no

two brain injuries are alike.

Appropriate treatment andrehabilitation will vary from

individual to individual. Programs

and treatments change, as a

person's needs change. It is

important to recognize that "moretherapy" does not make a person

"better", but that "appropriate"

therapy may.



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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



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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)



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The Recovery Process

Ranchos Los Amigos Scale of CognitiveFunctioning

As recovery progresses, the Ranchos Los Amigos Scale of

Cognitive Function becomes the tool most widely utilizedto assess cognitive and behavioral functioning. Thisdescribes the cognitive and behavioral status of theindividual at the time, and directs the planning andevaluation of treatment plans and goals throughout theentire recovery process. It also represents a non-medicalframework 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.



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The Ranchos Los Amigos Scale consistsof eight levels, and is described below.

Individuals go through these levels at

different rates, and improvement may

vary at any level. Individuals mayfluctuate between two levels at the same

time. Suggestions for working with your

family member at each stage of recovery

is provided.



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Stages of Recovery

Level I - No Response

Patient appears to be in a deep sleep and iscompletely unresponsive to any stimuli

presented to him.



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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 activitymay be remembered.



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Stages of Recovery

Level II - Generalized Response

• Patient reacts inconsistently and non-purposefullyto stimuli in a non-specific manner.

• Responses are limited in nature and are often thesame 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.



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How to Respond to Level II

During periods of wakefulness, provide simpleand 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 showaffection 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

responsibilities as you too have to rest.



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Stages of RecoveryLevel III - Localized Response

• Patient reacts specifically, but inconsistently, tostimuli.

• Responses are directly related to the type of stimulus presented as in turning head toward asound 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.



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•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 respondingto some persons (especially family, friends)

but not to others.



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How to respond to Level III

Increase and direct stimulation efforts at reorienting your family member with who they areand what has happened.

At each visit, describe who you are, provide the

date, where they are and why.

Bring familiar and significant objects to theindividual; 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.



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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.



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Stages of Recovery• Level IV - Confused/Agitated

• Patient is in a heightened state of activity with severelydecreased 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 evenafter removal, show aggressive behavior, attempt toremove 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.



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•Verbalization is frequently incoherent and/or

inappropriate to the environment.• Confabulation may be present; patient may beeuphoric or hostile. Thus, gross attention toenvironment is very short and selective attention isoften nonexistent.

•Being unaware of present events, patient lacksshort-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 performmotor activities such as sitting, reaching, andambulating, but as part of his/her agitated state andnot as a purposeful act or on request, necessarily.



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Responding to Level IV The goals of this stage are to decrease agitation and

increase awareness.

Use calm, soft speech and slow careful movements tolessen the tendency for agitation.

Continue to provide opportunities for the individual torespond to stimuli and simple commands, encourage and assist with self-care tasks, continue to associate theindividual with familiar things.

Remove distractions such as TV or radio, to restrict stimulation to one sense (auditory, visual or tactile) at atime.

Attempt to correct an inappropriate or inaccurateresponse, but do not argue the point.



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Responding to Level IV cont

If confusion and agitation is ongoing, do not try torationalize 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 aggressivebehavior 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.



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Stages of Recovery

Level V - Confused, Inappropriate Non-Agitated

• Patient appears alert and is able to respond to simplecommands fairly consistently; however, with increasedcomplexity 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 highlydistractible and lacks ability to focus attention to a specifictask without frequent re-direction back to it.

• With structure, person may be able to converse on a social-

automatic level for short periods of time.



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•Verbalization is often inappropriate; confabulation may betriggered by present events.

•

Memory is severely impaired, with confusion of past and present in patient’s reaction to ongoing activity.

•Patient lacks initiation of functional tasks and often showsinappropriate 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, familymembers.

•The patient can usually perform self-care activities, with

assistance, and may accomplish feeding with maximumsupervision.

•Management on the ward is often a problem if the patientis physically mobile, as patient may wander off, either randomly or with vague intentions of "going home".



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Responding to Level V

Continue to help the individual get back in touchwith the world, discuss family and friends, and events he/she has experienced during the day.

Try to have information recalled, providing hintsto stimulate memory, for example, ask immediatelyafter 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.



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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 alwaysremembering to address the individual in an

age-appropriate fashion.



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Stages of Recovery

Level VI - Confused, Appropriate

• Patient shows goal-directed behavior, but is dependent onexternal input for direction. Response to discomfort isappropriate 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, butthey are appropriate to the situation.

• They may be delayed to immediate and shows decreasedability to process information with little or no anticipation or

prediction of events.

• Past memories show more depth and detail than recent

memory.



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•May show beginning immediate awareness of situation by realizing he doesn't know an answer.

•He no longer wanders and is inconsistently orientedto time and place.

•Selective attention to task may be impaired,especially with difficult tasks and in unstructured

settings, but is now functional for common dailyactivities (30 min. with structure).

•He may show a vague recognition of some staff, hasincreased awareness of self, family and basic needs(as food), again, in an appropriate manner as incontrast to Level V.



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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 mentallychallenging 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 theindividual begin to arrange and understand each part

of daily life.



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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.



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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 insightinto, his condition, decreased judgment and

problem-solving and lacks realistic planning for his

future.



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•Patient shows carry-over for new learning, butat a decreased rate.

•Requires at least minimal supervision for learning and for safety purposes.

•Patient is independent in self-care activitiesand supervised in home and community skillsfor safety.

•With structure, Patient is able to initiate tasksas social or recreational activities in which

he/she now has interest.•Judgment remains impaired; such that he/she isunable to drive a car.



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Responding to Level VII

The major goals of this and the next level of recovery areto 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 telephonedirectory and/or map should be attempted.

Situations of daily living at home and in the community should be discussed, with multistep planning and possibledangerous aspects explored.

Use and expansion of judgment skills should beemphasized.

Patience during interactions is needed as the processing of new information may be slowed .



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Stages of RecoveryLevel 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 onceactivities are learned.

• Within physical capabilities, person is independent inhome and community skills, including driving.

• Vocational rehabilitation, to determine ability to return ascontributor to society (perhaps in a new capacity) isindicated.



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•May continue to show a decreased ability,relative to premorbid abilities, in abstractreasoning, tolerance for stress, judgment in

emergencies or unusual circumstances.•Social, emotional, and intellectual capacitiesmay continue to be at a decreased level, butfunctional in society.



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Responding to Level VIII

Maximum involvement in home, school, or jobwithin 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 dailyroutine, 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

accomplishing goals.



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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.



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Acute Rehabilitation

In the Acute Rehab setting, a team of healthprofessionals with experience and training in braininjury rehabilitation work with the person and their

family. The goal of Acute Rehabilitation is to assistpersons with brain injuries to achieve their highestlevel 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 torelearn how to do these types of tasks. Rehabilitationrequires the expertise of several healthcareprofessionals and Acute Rehab team members.



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Subacute Rehabilitation

Subacute Rehabilitation provides services for persons with brain injury who need a lessintensive level of rehabilitation services, over

a longer period of time. Sub-acute rehabilitation programs may also

be designed for persons who have madeprogress in the acute rehabilitation setting

and are still progressing, but are not makingrapid functional gains.

Subacute rehabilitation may be provided in avariety of settings, but is often in a skilled

nursing facility or nursing home



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Outpatient Therapy

Following acute rehabilitation or sub-acute rehabilitation, a person with abrain injury may continue to receiveoutpatient therapies to meet continuedgoals. Additionally, a person with abrain injury that was not severe enough

to require inpatient hospitalization mayattend outpatient therapies to addressfunctional impairments.



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Rehabilitation Treatment Team

Physiatrist is a doctor of physical medicine rehabilitation. Thephysiatrist typically serves as the leader for the rehabilitationtreatment team and makes referrals to the various therapies andmedical specialists as needed. The physiatrist works with the

rehabilitation team, the person with a brain injury, and the familyto develop the best possible treatment plan.

• Physical Therapists evaluate and treat a person’s ability tomove the body. The physical therapist focuses on improvingphysical function by addressing muscle strength, flexibility,

endurance, balance, and coordination. Functional goals includeincreasing independent ability with walking, getting in and out of bed, on and off a toilet, or in and out of a bathtub. Physicaltherapists provide training with assistive devices such as canesor walkers for ambulation. Physical therapists can also usephysical modalities, treatments of heat, cold, and water to assist

with pain relief and muscle movement.



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Occupational Therapists

use purposeful activities as a means of preventing, reducing, or overcoming physical and emotional challenges to ensure thehighest 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; moneymanagement; fine motor (movement of small body muscles,such as in the hands); wheelchair positioning and mobility;home evaluation; durable medical equipment assessment andtraining (such as, use of a raised toilet seat to assist with gettingon and off the toilet easier).

The occupational therapist also fabricates splints and casts to

reduce deformities and optimize muscle functioning



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Speech/language pathologist :

responsible for evaluating and treating languageand cognitive difficulties that may cause challenges

your daily life. Language refers to the skills of comprehension, verbal expression, reading, andwriting. Cognitive skills refer to thinking skills suchas attention/concentration, memory, reasoning,problem-solving, etc.

work with any motor speech or swallowingdifficulties. Therapy will focus on improving andworking around any difficulties to make you moreindependent in the home, work, educational, andcommunity environments.



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Rehabilitation Nurses

monitor all body systems.

attempts to maintain the person’s medical status,

anticipate potential complications, and work on goalsto restore a person's functioning.

responsible for the assessment, implementation, andevaluation of each individual patient's nursing careand educational needs based on specific problems

as well as coordinating with physicians and other team members to move the patient from a dependentto an independent role.



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Social Worker:

provides you and your family with information fromweekly 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 communityresources that you might need, such as supportservices in the home or Social Security Disability.

will help you and your family set up your discharge tohome or, if needed, will assist you in finding a livingarrangement that provides you with more assistance.



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Recreational Therapists

provide activities to improve and enhance self-esteem, 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, leisureeducation, wheelchair sports, gardening, special

social functions or holiday functions for persons andtheir family.



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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 progressand 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 termdifficulties you may have as a result of your injury.

available to provide support to you and your family as you adaptto your injury and to the changes in your life.



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Other Community Based

Treatment/services Home Health Services

Vocational Rehabilitation

Support Groups: BIAI every 4th Thursday atIERH 7-9pm

Brain Injury Association of Idaho

1-888-336-7708 www.biausa/idaho.org

Brain Injury Association, Inc. www.biausa.org1-800-444-6443

http://www.biausa/idaho.org

http://www.biausa/idaho.org



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HOW DOES BRAIN I NJURY AFFECT

BEHAVIOR?

The majority of TBI’s 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

skills



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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



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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



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Emotional Responses to TBI

Irritability

Fear/Anxiety

Anger

Depression

Role changes

Self-Esteem



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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.



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Causes of Fatigue

Things that can use up a person’s energy include the

following:

Stress

Poor sleep

Pain

Medications

Depression

Lack of exercise

Poor nutrition



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What Are the Types of Fatigue?

There are different areas of life that fatigue (tiredness) can

affect:

Physical

Emotional

Mental

Spiritual



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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 mostawake and most fatigued



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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



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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 damageof the mesial frontal lobe



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Agitation/Irritability

Damage to several areas of the brain can lead

to difficulty controlling one’s 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





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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 addressthe person’s need/frustration

Ask person if there is anything that would help them feel

better



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Isolate the disruptive impaired

personTry to establish consistent,

nonconfrontational responses from

all family members

Seek support for yourself as a

caregiver

S i P A i i



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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 person’s right for space and privacy



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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 (maintai

a safe environment)

E ti l L bilit



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Emotional Lability

Feelings are often show in an extreme and inappropriate way

Expressions and moods may change suddenly

Helpful Suggestions



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

emotionsHave the person take many rest periods

Documents

How the Brain Recovers2