Brain Injury and Recovery

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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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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.

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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.

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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 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

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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 focal injuries

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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 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

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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 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.

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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 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

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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, 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

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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.
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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

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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-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).

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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 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 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 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
  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 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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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.
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Thinking Changes Memory
Decision makingPlanningSequencingJudgmentAtten
tionCommunicationReading and writing
skillsThought processing speedProblem solving
skillsOrganizationSelf-perceptionPerceptionTho
ught flexibilitySafety awarenessNew learning
Physical Changes Muscle movement Muscle
coordinationSleepHearing
VisionTasteSmellTouchFatigue
WeaknessBalanceSpeechseizuresSexual
Functioning
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Personality and Behavioral Changes Social
skills
Emotional control and mood
swings Appropriateness of
behaviorReduced self-esteemDepressionAnxietyFr
ustrationStress
DenialSelf-centerednessAnger managementCoping
skillsSelf-monitoring remarks or
actionsMotivationIrritability or
agitationExcessive laughing or 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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• 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 left-sided body movements

• Left Side of the Brain
• Difficulties in understanding language (receptive
  language)
• 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

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• Diffuse Brain Injury
• (The injuries are scattered throughout both sides
  of the brain)
• Reduced thinking speed
• Confusion
• Reduced attention and concentration
• Fatigue
• Impaired 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 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.
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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 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.

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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.
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Stages of Recovery

• Level I - No ResponsePatient appears to be in a
  deep sleep and is completely 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 activity may be remembered.

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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.

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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
  responsibilities as you too have to rest.

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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.

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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 responding to 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 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.

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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
  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.

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• 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.

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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
  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.

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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.

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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 social-automatic level for short periods of
  time.

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• 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".

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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.

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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 always remembering 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 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.

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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
  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.

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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 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.

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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
  insight into, 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, 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.

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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.

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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.

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• 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.

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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 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 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.

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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
  nursing facility or nursing home

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Outpatient Therapy

• Following acute rehabilitation or sub-acute
  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.

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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 with pain relief and muscle movement.

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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
  includeFeeding 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 reduce deformities and
  optimize muscle functioning

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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.

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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.

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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.

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Rehabilitation Treatment Team

• 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,
  leisure education, wheelchair sports, gardening,
  special social functions or holiday functions for
  persons and their family.

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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 to 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 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

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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 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 persons 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 most awake 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 damage of the
  mesial frontal lobe

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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

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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

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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 address the persons need/frustration
• Ask person if there is anything that would help
  them feel better

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• Isolate the disruptive impaired person
• Try to establish consistent, nonconfrontational
  responses from all family members
• Seek support for yourself as a caregiver

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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 persons 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 (maintain a
  safe environment)

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Emotional Lability

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

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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