Download HOW THE BRAIN RECOVERS - Davis Law Group, P.S.

Brain Injury and Recovery

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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 individuals—a little more than 2 percent of
the U.S. population—living with a disability resulting from a
traumatic 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 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
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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.
4
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

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
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
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Loss of consciousness; however, loss of consciousness may not
occur in some concussion cases
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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
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Respiratory failure (not breathing)

Coma (not alert and unable to respond to others) or
semicomatose state
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Symptoms of TBI cont.
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Paralysis, difficulty moving body parts, weakness, poor coordination
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Slow pulse
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Slow breathing rate, with an increase in blood pressure
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Vomiting
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Lethargy (sluggish, sleepy, gets tired easily)
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Headache
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Confusion
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Ringing in the ears, or changes in ability to hear
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Symptoms of TBI cont
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Difficulty with thinking skills (difficulty “thinking straight”, memory
problems, poor judgment, poor attention span, a slowed thought
processing speed)
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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
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Electrical shock or lightening strike
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Trauma to the head and/or neck
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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
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Infectious disease, intracranial tumors, metabolic disorders

Meningitis, certain venereal diseases, AIDS, insect-carried
diseases, brain tumors, hypo/hyperglycemia, hepatic
encephalopathy, uremic encephalopathy, seizure disorders
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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
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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 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 is
used to describe a level of neurological injury. Any
injury to the brain is a real and serious medical
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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 occur—the 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 injury—the person is
dazed, confused, or loses consciousness. The change in mental
status indicates that the person’s brain functioning has been
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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
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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 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
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Vegetative State -Arousal is present, but the ability to interact with the
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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
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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 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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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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Parietal
Lobe
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 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.
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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
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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 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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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
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
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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 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 Response
Patient 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
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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
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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.
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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

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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

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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
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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 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 patient’s 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.
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.
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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.
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.
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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
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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.
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Subacute Rehabilitation
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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
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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.
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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.
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Physical Therapists evaluate and treat a person’s 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 assist69
with pain relief and muscle movement.
Rehabilitation Treatment Team
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Occupational Therapists
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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
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reduce deformities and optimize muscle functioning
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Rehabilitation Treatment Team
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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
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Rehabilitation Nurses
monitor all body systems.
attempts to maintain the person’s 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
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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
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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.
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Rehabilitation Treatment Team
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Neuropsychologist:
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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
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to your injury and to the changes in your life.
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Other Community Based
Treatment/services
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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 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
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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
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Behavior and Personality Issues
Fatigue
 Amotivation
 Agitation
 Emotional Lability
 Impulsivity
 Perseveration
 Sexual behavior
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 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 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 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 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 person’s 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 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 (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
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