TBI - Traumatic Brain Injury

Brain injuries, whether to an adult or a child, are among the most traumatic injuries that can occur. At the law firm of Toral Garcia & Franz, we are leaders in helping people obtain the resources they need to recover as fully as possible from the devastating effects of a brain injury.

Our firm’s commitment to brain injury survivors extends beyond the law.Our Senior Partner, Frank Toral, is the current president of the Brain Injury Association of Florida. We also provide, free of charge, a family handbook authored by Mr.Toral, with detailed information about brain injury to the public. To obtain a copy of our brain injury handbook, kindly contact our Fort Lauderdale office toll free at 866.747.7848.

Traumatic Brain Injury

According to the Florida Department of Health, Brain and Spinal Cord Injury Program, Brain Injury is defined as an insult to the skull, brain or its covering, resulting from external trauma which produces an altered state of consciousness or anatomic, motor, sensory, cognitive, or behavioral deficit.

• A brain injury can be caused by a direct force to the head, which can break the skull and directly injure the brain. This type of injury can occur from motor vehicle accidents, firearms, falls, sports, and physical violence, such as hitting or striking with an object.
• Another cause of a brain injury is due to a rapid acceleration and deceleration of the head. This causes the brain to have a back and forward motion inside of the skull, which may pull apart nerve fibers and cause damage to the brain tissue. This type of injury often occurs as a result of motor vehicle crashes and physical violence, such as Shaken Baby Syndrome.

Adopted by the Brain Injury Association Board of Directors, February 22, 1986. This definition is not intended as an exclusive statement of the population served by the Brain Injury Association of America.

Risk Factors

A brain injury can occur to anyone. However, statistics show that males are two times more likely than females to sustain a brain injury. The highest rates of brain injury typically occur in males ages 15-24. Individuals who have already sustained a brain injury are also at an increased risk of sustaining another brain injury due to the disruption in normal functions of the body.

According the Florida Department of Health, today about 369,600 people are living with TBI-related disabilities in Florida. By 2015, the number is expected to reach 435,350. In 2005, about 93,000 TBIs were sustained in Florida (511.5 per 100,000), which resulted in 3,900 deaths, 17,700 hospitalizations and 71,400 emergency department visits.

Total TBIs in Florida by Age TBI Rates for Florida and the US Total TBIs in Florida by

*Source: State of Florida, Department of Health, Office of Vital Statistics, Public Health Statistics, 2005; State of Florida, AHCA, Detailed Discharge Data, 2005; State of Florida, AHCA, Emergency Department Data, 2005; State of Florida, Department of Health, CHARTS, accessed Feb 2007. **Source: State of Florida, Department of Health, Office of Vital Statistics, Public Health Statistics, 2005; State of Florida, AHCA, Detailed Discharge Data, 2005; State of Florida, AHCA, Emergency Department Data, 2005; Traumatic Brain Injury In the United States: ED Visits, Hospitalizations and Deaths, 2006; State of Florida, Department of Health, CHARTS, accessed Feb 2007.

Effects of a Brain Injury

When one suffers a brain injury, the neurons, nerve tracts or sections of the brain are negatively affected. The neurons (nerve cells) are the only cells in the body that do not replicate. Therefore, if affected, they can be unable, or have difficulty, transporting the messages to the body. This disrupts the normal functioning of the body and can temporarily or permanently change the way a person thinks, acts, behaves, moves, and in instances, it can change the internal functions of the body such as blood pressure, bowel control and heart rate.

Cognitive Changes

Memory Communication Perception Decision-making Reading and writing skills Thought flexibility Planning Through processing speed

Safety awareness Sequencing Problem solving skills New learning Judgment Organization Attention Self-perception

Physical Changes

Muscle movement Taste Balance Muscle coordination Smell Speech Sleep

Touch Seizures Hearing Fatigue Sexual functioning Vision Weakness

Personality and Behavioral Changes

• Social skills
• Self-monitoring remarks or actions
• Frustration
• Stress
• Emotional control and mood swings
• Reduced self-esteem
• Denial
• Appropriateness of behavior
• Irritability or agitation
• Motivation
• Self-centeredness
• Coping skills
• Depression
• Anger management
• Anxiety
• Excessive laughing or crying

Injuries to the Right Side of Brain can cause:

• Visual-spacial impairment
• Visual memory deficits
• Inattention to the left side of the body
• Decreased awareness of deficits
• Altered creativity
• Decrease control over left-side body movement

Injuries to the Left Side of Brain can cause:

• 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

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

Understanding the Brain

It is important to understand how the brain functions in order to understand what takes place when the brain is injured. The brain is made up of neurons (nerve cells) and is enclosed inside a bony structure (the skull) which acts as a protective barrier. The neurons in our brain synapse, and send messages to our body to perform different tasks. The messages that are sent all over the body allow the body to function properly and naturally. Some tasks include coordinating breathing, heart rate, temperature, metabolism, movement, behavior, personality, and the senses. Each part of the brain is responsible for the connection of specific responses all over the body and most brain injuries affect several different areas of the brain.

Regions of the brain:

The brain has three main regions: the cerebellum, the brain stem and the cerebrum. All three regions work together. However, they have specific functions.

Brain Stem: The brain stem is the lower part of the brain and it extends to the spinal cord. It is responsible for controlling breathing, heart rate, arousal, consciousness, sleep functions, and attention concentration through twelve cranial nerves.

Cerebellum: The cerebellum is found under the lower back of the skull. It is divided into a right and left side, which handles two different functions: maintaining balance and coordinating movement.

Cerebrum: The cerebrum is the largest part of the brain and it is divided into two regions, right and left hemispheres. The right side of the brain receives information from the left, and controls movement of the left side of the brain. The left side of the brain does the same for the right. The dominant side (usually the left side for right-handed people) controls speech, understanding, reading, writing, and other functions. The non-dominant side processes non-verbal information including special orientation, relationships of objects to each other and recognition of shapes, forms and faces. The hemispheres are then divided further into lobes: parietal, frontal, temporal, and occipital.

Functions of the Brain:

The brain is divided into functional sections called lobes (Frontal Lobe, Temporal Lobe, Parietal Lobe, Occipital Lobe, the Cerebellum, and the Brain Stem).

Each has a specific function, as described below:

Frontal Lobe Functions

Attention and Concentration Speaking (expressive language) Self-monitoring Organization Initiation

Motor planning Speaking (expressive language) Awareness of abilities and limitations Personality Mental flexibility

Inhibition of behavior Emotions Problem solving Planning and anticipation Judgment

Temporal Lobe Functions

• Memory
• Hearing
• Understanding language
• Organization
• Sequencing

Parietal Lobe Functions

• Sense of touch
• Special perception
• Differentiation of size, shapes and color
• Visual perception

Occipital Lobe Functions

• Vision

Cerebellum Lobe Functions

• Balance
• Skilled motor activity
• Coordinating
• Visual perception

Brain Stem Functions

• Breathing
• Arousal and consciousness
• Attention and concentration
• Heart rate
• Sleep and wake cycles

Right or Left Brain Functions

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

Types of Brain Injury

Acquired Brain Injury

An acquired brain injury is an injury that occurs after birth and it indicates cellular damage to the brain caused by an event or disorder, such as a tumor or stroke, and unlike a traumatic brain injury, it can affect cells throughout the brain.

Causes of acquired brain injury can include, but are not limited to:

• Airway obstruction
• Near-drowning, throat swelling, choking, strangulation, crush injuries to the chest
• Electrical shock or lightning 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
• 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- poisonous chemicals and gases, such as carbon monoxide poisoning

Effects of an Acquired Brain Injury:

• An acquired brain injury commonly results in a change in neuronal activity, which affects the physical integrity, the metabolic activity or the functional ability of the cell.
• An acquired brain injury may result in mild, moderate or severe impairments in one or more areas, including cognition, speech-language communication, memory, attention and concentration, reasoning, abstract thinking, physical functions, psychosocial behavior, and information processing.

Adopted by the Brain Injury Association Board of Directors, March 14, 1997.

Symptoms of Acquired Brain Injury:

• Most symptoms of acquired brain injuries are very similar to that of traumatic brain injuries; however, there are some difficulties that are experienced more frequently or to a greater degree by persons with acquired brain injuries.
• This information is not intended to be a substitute for medical advice or examination. A person with a suspected brain injury should contact a physician immediately, go to the emergency room or call 911 in the case of an emergency.
• Symptoms can include thinking skills (especially memory), longer lengths of time spent in a vegetative state, severe behavioral problems (psychosis, depression, restlessness, combativeness, and hostility)
• Muscle movement disorders

Diffuse Axonal Injury

Neurons (nerve cells) have an extension to them called the axon. Axons allow for communication from one nerve cell to the other, through a chemical reaction. When there is motion in the brain, the axons can be pulled, stretched or torn, which results in cell death. When that occurs throughout the brain, it is called a diffuse axonal injury.

• Tearing of the axons cause brain chemicals to be released, causing additional injury.
• This kind of injury does not show up on a CT or MRI scan because the scan is not a microscope that can see these tiny cells.
• Diffuse axonal injury is often diagnosed on the basis of the person’s symptoms.
• Any time there is a loss of consciousness associated with a trauma event, there will be a diffuse axonal injury.
• A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.

Concussion

• A concussion can be caused by any significant blunt force trauma to the head such as a fall, car accident, or being struck on the head with an object.
• A concussion is the most common type of traumatic brain injury.
• A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.
• Both closed and open head injuries can produce a concussion.
• The blood vessels in the brain may stretch and cranial nerves may be damaged.
• A person may or may not experience a brief loss of consciousness (not exceeding 20 minutes).
• A concussion may cause headache, nausea or vomiting, blurred vision, and loss of short-term memory.
• A concussion may or may not show up on a diagnostic imaging test, such as a CT Scan.
• Skull fracture, brain bleeding or swelling may or may not be present. Therefore, concussion is sometimes defined by exclusion and is considered a complex, neurobehavioral syndrome.
• A concussion can cause diffuse axonal type injury resulting in permanent or temporary damage.
• A blood clot in the brain can occur occasionally and be fatal.
• It may take a few months to a few years for a concussion to heal.

Contusion

• A contusion is another name for a bruise or bleeding in the brain.
• It is caused when blood vessels are damaged or broken as a result of a direct impact.
• If the contusion is severe, it may require surgical removal.

Coup-Contrecoup Injury

• Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.
• This injury occurs when the direct blow to the head is strong enough to harm the impacted side and cause it to “bump” the opposite side of the brain causing a contusion.

Second Impact Syndrome "Recurrent Traumatic Brain Injury"

• “Recurrent traumatic brain injury” can occur when a person suffers a traumatic brain injury before coming to a complete healing from the initial traumatic brain injury.
• There is no specific time frame between injuries, a loss of consciousness is not required and the second injury is more likely to cause brain swelling and widespread damage.
• Emergency medical treatments are required immediately because death can occur rapidly.
• Long-term effects of recurrent brain injury include, but are not limited to muscle spasms, increased muscle tone, rapidly changing emotions, hallucinations, and difficulty thinking and learning.

Penetrating Injury

• Penetrating injury to the brain occurs when the direct blow to the head causes hair, bone or fragments from the penetrating object into the brain. It can occur from the impact of any sharp object such as a knife or bullet.
• The area of damage can be widened if the object travels through the skull at a low speed due to a ricochet within the skull.
• Another type of injury is labeled as a “through-and-through” injury, which occurs if the skull is penetrated by a sharp object that goes through the brain and exits the skull. These injuries will cause shearing, stretching and rupturing of brain tissue. (Brumback R. (1996). Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd Ed.). New York: Springer.)
• The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall. (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate]).
• Firearms are the single largest cause of death from traumatic brain injury. (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate]).

Shaken Baby Syndrome

• Shaken Baby Syndrome is also referred to as Abusive head trauma/inflicted traumatic brain injury or AHT. AHT can be caused by direct blows to the head, dropping or throwing a child or shaking a child, which causes the brain to be injured. Head trauma is the leading cause of death in child abuse cases in the United States.
• Blood vessels between the brain and skull rupture and bleed.
• The accumulation of blood causes the brain tissue to compress while the injury causes the brain to swell. This damages the brain cells.
• AHT can cause seizures, lifelong disability, coma, and in some cases, death.
• Irritability, changes in eating patterns, tiredness, difficulty breathing, dilated pupils, seizures, and vomiting are signs of Shaken Baby Syndrome. A baby experiencing such symptoms needs immediate emergency medical attention.

(The Shaken Baby Alliance. [Online August 22, 2002: www.shakenbaby.com])

Locked-in Syndrome

• Locked-in Syndrome is a rare neurological condition in which a person cannot physically move any part of the body except the eyes.
• The person is conscious and able to think.
• Vertical eye movements and eye blinking can be used to communicate with others and operate environmental controls.

Anoxic Brain Injury

• Adequate oxygen is vital for the brain to function properly and when the brain does not receive enough or any oxygen, neurons begin to die and permanent anoxic brain injury can occur.
• Types of Anoxic Brain Injury:
  • Anoxic Anoxia - Brain injury from no oxygen supplied to the brain.
  • Anemic Anoxia - Brain injury from blood that does not carry enough oxygen.
  • Toxic Anoxia - Brain injury from toxins or metabolites that block oxygen in the blood from being used.

Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor

Hypoxic Brain Injury

• A Hypoxic Brain Injury results when the brain receives some, but not enough oxygen.
• Types of Hypoxic Brain Injury:
  • Hypoxic Ischemic Brain Injury also called Stagnant Hypoxia or Ischemic Insult - Brain injury occurs because of a lack of blood flow to the brain due to a critical reduction in blood flow or blood pressure.

Zasler, N. Brain Injury Source, Volume 3, Issue 3 Ask the Doctor (Fuente sobre lesiones cerebrales, Volumen 3, Tomo 3, Consulte al médico)

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Open and Closed Head Injuries

Open Head Injuries

There are several types of skull fractures that can occur with open head injuries:

• Depressed Skull Fracture occurs when the broken piece of skull bone moves in towards the brain.
• Compound Skull Fracture occurs when there is a cut on the scalp and the skull is fractured.
• Basilar Skull Fracture occurs when the skull fracture is located at the base of the skull (neck area) and may include the opening at the base of the skull. These specific fractures can cause damage to the nerves and blood vessels that pass through the opening at the base of the skull.
• Battle's Sign fracture occurs when the fracture is located at the ear's petrous bone.This produces large "black and blue mark" looking areas below the ear, on the jaw and neck and it may include damage to the nerve for hearing. Blood or cerebral spinal fluid may also leak out of the ear. This is termed "CSF Oterrhea."
• Racoon Eyes occurs when the skull fracture is located in the anterior cranial fossa, whichThis produces "black and blue" or bruised areas around the eyes. Cerebral spinal fluid may leak into the sinuses. This is termed "CSF Rhinorrhea". Nerve damage to the nerves that control the sense of smell or eye functions may occur.
• Diastatic Skull Fracture The skulls of infants and children are not completely solid until they grow older. The skull is composed of jigsaw-like segments (cranial fissures) which are connected together by cranial sutures. Skull fractures that separate the cranial sutures in children prior to the closing of the cranial fissures are termed "diastatic skull fractures.”
• Cribiform Plate Fracture The cribiform plate is a thin structure located behind the nose area. If the cribiform plate is fractured, cerebral spinal fluid can leak from the brain area out the nose.

Closed Head Injuries

When there is a blow to the head which causes a head injury and the skull does not fracture, it is referred to as a "closed head injury." When there is a closed head injury, the brain swells and has no place to expand. This leads to an increase in intracranial pressure and causes tissues to compress, causing further injury. As the brain swells, it may expand into different areas of the skull, including the eye sockets, which can affect normal vision.

Levels of Brain Injury

There are different levels of brain injury, which depend on the severity of neurological injury to the brain. Medical professionals use the Glascow Coma Scale (GCS) to categorize the effects of the brain injury. 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 to a person’s short or long term recovery or functional abilities.

Mild Traumatic Brain Injury (Glascow Coma Scale Score 13-15)

Mild traumatic brain injury occurs when:

• Loss of consciousness is brief, usually a few seconds or minutes, but does not have to occur.
• 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 altered. This is called a concussion.

Symptoms of mild traumatic brain injury:

• Headache
• Fatigue
• Sleep disturbance
• Irritability
• Sensitivity to noise or light
• Balance problems
• Decreased concentration and attention span
• Decreased speed of thinking
• Memory problems
• Nausea
• Depression and anxiety
• Emotional mood swings

Department of Defense and Veteran's Head Injury Program & Brain Injury Association of America (1999). Brain Injury and You. Horn, L.J. & Zasler, N. (1996). Medical Rehabilitation of Traumatic Brain Injury. Hanley & Belfus, Inc: Philadelphia, PA. Kay, T. Brain Injury Association of America. Mild traumatic brain injury.

Moderate Traumatic Brain Injury (Glascow Coma Scale Score 9-12)

A moderate traumatic brain injury occurs when:

• 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 can generally make a good recovery with treatment or successfully learn to compensate for their deficits.

Department of Defense and Veteran's Head Injury Program & Brain Injury Association of America (1999). Brain Injury and You.

Severe Brain Injury (Glascow Coma Scale 8 or less)

Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks or months. There are several states that a person can undergo when he/she has sustained a brain injury:

• Coma
• Vegetative State
• Persistent Vegetative State
• Minimally Responsive State
• Akinetic Mutism
• Brain Death

Coma

Coma is defined as a state of unconsciousness from which the individual cannot be awakened, in which the individual responds minimally or not at all to stimuli, and initiates no voluntary activities.

• Persons in a coma appear to be asleep, but cannot be awakened.
• There is no meaningful response to stimulation.

Persons who sustain a severe brain injury can make significant improvements but are often left with permanent physical, cognitive or behavioral deficits.

Department of Defense and Veteran’s Head Injury Program & Brain Injury Association of America (1999). Brain Injury and You.

Vegetative State (VS)

Vegetative State describes a severe brain injury in which:

• Arousal is present, but the ability to interact with the environment is not.
• Eye-opening can be spontaneous or in response to stimulation.
• General responses to pain exist, such as increased heart rate, increased respiration, posturing, or sweating.
• Sleep-wake cycles, respiratory functions and digestive functions return.

There is no test to specifically diagnose vegetative state. The diagnosis is made only by repetitive neurobehavioral assessments.

Giacino, J. & Zasler, N. (1995). Outcome after severe traumatic brain injury: Coma, the vegetative state, and the minimally responsive state. Journal of Head Trauma Rehabilitation, 10, 40-56.

Persistent Vegetative State (PVS)

Persistent Vegetative State (PVS) is a term used for a vegetative state that has lasted for more than a month.

• The criteria is the same as for vegetative state

The use of this term is considered controversial because it implies a prognosis.

Giacino, J. & Zasler, N. (1995). Outcome after severe traumatic brain injury: Coma, the vegetative state, and the minimally responsive state. Journal of Head Trauma Rehabilitation, 10, 40-56.

Minimally Responsive State (MR)

Minimally Responsive State is the term used for a severe traumatic brain injury in which a person is no longer in a coma or a Vegetative State. Persons in a minimally responsive state demonstrate:

• Primitive reflexes
• Inconsistent ability to follow simple commands
• An awareness of environmental stimulation

The frequency and the conditions in which a response was made are considered when assessing the meaningfulness or purposefulness of a behavior.

Giacino, J. & Zasler, N. (1995). Outcome after severe traumatic brain injury: Coma, the vegetative state, and the minimally responsive state. Journal of Head Trauma Rehabilitation, 10, 40-56.

Symptoms of Brain Injury

There are a variety of symptoms that a person who suffers a brain injury may experience. However, they do not have to show all of the following symptoms. This information is not intended to be a substitute for medical advice or examination. A person with a suspected brain injury should contact a physician immediately, go to the emergency room or call 911 in the case of an emergency.

Symptoms of a traumatic brain injury can include, but are not limited to:

• A headache that gets worse or does not go away
• Repeated vomiting or nausea
• Convulsions or seizures
• Inability to wake up from sleep
• Dilation of one or both pupils
• Slurred speech
• Weakness or numbness in the arms or legs
• Loss of coordination
• Increased confusion, restlessness or agitation
• 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
• 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
• 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
• 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, difficulty swallowing
• Body numbness or tingling
• Loss of bowel control or bladder control

Brain Injury Rehabilitation

There are different types of hospitals, rehabilitation programs and health care professionals that one should become familiar with during the brain injury recovery process.

The rehabilitation process is different for everyone who sustains a brain injury. How well a person does following a brain injury depends on the individual’s health prior to the injury, the nature of the injury and the post-injury course of recovery. Rehabilitation programs following a brain injury should cater to each person’s needs.

A comprehensive Traumatic Brain Injury rehabilitation consists of at least the following elements:

• The rehabilitation physician (physiatrist) and the rehabilitation nurse have special training in diagnosing and treating people with disabilities. Their goal is to help patients who have suffered a brain injury, regain the most independent level of functioning possible.
• The prevention of secondary injuries is important. Rehabilitation facilities and the rehabilitation process are in place to prevent these secondary injuries from occurring.
• Rehabilitation builds upon natural recovery processes this allows the body to regain strength and re-learn natural functions, which aid in a quick recovery.
An optimal environment for neurological recovery is also provided by rehabilitation settings.
• Various techniques are provided and taught to promote recovery and help with the tasks of daily living.
• Adaptive and specialized equipment, such as wheelchairs or others are available in this setting.
• Environmental modifications are available. These include architectural and transportation interventions. Even more important may be interventions in the patient’s social milieu, which include modifications at home, at work and in the community.

Report of the Panel for Consensus Development Conference on the Rehabilitation of Persons with TBI, October 26-28, 1998. Cope, Nathan, “The Effectiveness of Traumatic Brain Injury Rehabilitation, a Review”; ‘Brain Injury’, Volume 9, No. 7 1995, pages 649-670.

Emergency Rescue

• Most of the time, an emergency team will be the first to attend to the person with a brain injury. They are the first to arrive and the brain injury care begins at the site of the emergency.

Intensive Care Unit (ICU)

• After the brain injured person arrives at the hospital, he/she may be admitted to the intensive care unit. Sometimes the injured person may be unconscious, in a coma or medically unstable at arrival.
• During this phase, the goal is for the injured person to achieve medical stability and to prevent a medical catastrophe.
• For this reason, the medical professionals may need to attach medical equipment to the patient in order to help sustain his/her life.

Acute Rehabilitation

• The next step in the continuum of care is acute rehabilitation.
• The transfer to an acute rehabilitation facility or unit within the hospital occurs when the brain injured patient is medically stable and has reached a point where he/she is able to participate in therapy.
• Here, a team of health professionals assists persons with brain injury to achieve the highest level of independent skills used in activities of daily living.
• Rehab team members include:
  • Physiatrist- 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, patient and the family to develop the best possible treatment plan.
  • Physical Therapists- Therapists who evaluate and treat a person’s ability to move the body. They focus on improving physical function by addressing muscle strength, flexibility, endurance, balance, and coordination. Physical therapists provide training with assistive devices such as canes or walkers for ambulation. Physical therapists can also use physical modalities, including treatments of heat, cold and water to assist with pain relief and muscle movement.
  • Occupational Therapists- Therapists who use purposeful activities as a means of preventing, reducing or overcoming physical and emotional challenges with the purpose of aiding the person with a brain injury to function independently.
  • Speech/Language Pathologists- Therapists who evaluate a person’s ability to express oneself (speech, written or otherwise) and comprehend what is seen or heard. They use assistive technology as an alternative form of communication if the person is unable to verbalize. The speech/language pathologist focuses on the muscles in the face, mouth and throat and addresses swallowing issues.
  • Rehabilitation Nurses- Nurses who monitor all body systems by maintaining the person’s medical status and set goals to allow the person to reach his/her maximum medical improvement. They are responsible for the assessment of the patient’s care and for coordinating with physicians and team members to allow patients to become as independent as possible.
  • Case Managers/Social Workers- Responsible for assuring appropriate and cost-effective treatment and the facilitation of discharge planning. They maintain regular contact with the patient's insurance carrier, family and referring physician to assure that treatment goals are understood and achieved.
  • Recreational Therapists- Therapists who provide activities to improve and enhance self-esteem, social skills, motor skills, coordination, endurance, cognitive skills, and leisure skills. They plan community activities that allow the person to directly apply learned skills in the community.
  • Neuropsychologists- Physiologists who focus on aiding the brain injured person to think, behave and to control his/her emotions. They provide services to reduce the impact of setbacks and to help the person return to a full, productive life. The neuropsychologist’s evaluations provide valuable information to assist with school, community or employment re-entry.
  • Aquatic Therapists- Occupational therapists, physical therapists or recreational therapists with specialized training to provide therapy in a heated water pool. Aquatic therapists assist a person to increase strength, coordination, endurance, muscle movements, and reduce pain, using water resistance. The ultimate goal is to increase the person’s functional ability for activities of daily living.

Sub-acute Rehabilitation

• Sub-acute rehabilitation provides services for persons with brain injury who need a less- intensive level of rehabilitation services, over a longer period of time.
• These 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.
• Sub-acute rehabilitation may be provided in a variety of settings but is often in a skilled nursing facility or nursing home.

Day Treatment (Day Rehab or Day Hospital)

• Day treatment provides rehabilitation in a structured group setting during the day and allows the brain injured patient to return home at night.

Outpatient Therapy

• Outpatient therapy is offered for those who do not need to be hospitalized, but require therapy to meet certain goals.

Home Health Services

• Some hospitals and rehabilitation companies provide rehabilitation therapies within the home for persons with brain injury who are unable or find it difficult to reach a facility.

Community Re-entry

• Community re-entry programs generally focus on developing higher level motor, social and cognitive skills in order to prepare the person with a brain injury to return to independent living, and potentially, to work.
• Treatment may focus on safety in the community, interacting with others, initiation, and goal setting and money management skills.
• Vocational evaluation and training may also be a component of this type of program.

Independent Living Programs

• Independent living programs provide housing for persons with brain injury, with the goal of getting the patient to regain the ability to live as independently as possible.
• Some facilities will give the patient different levels of independence according to his or her needs.

Brain Injury Support Groups

• Brain injury support groups exist to help individuals with brain injury and their family members to understand the effects of brain injury and to help cope with issues related to the injury.
• These groups also provide emotional support, networking opportunity and education for a better understanding of the impact and effects of brain injury.

Scales and Measurements of Functioning

There are several scales and measures used to rate and record a person’s progress in rehabilitation following a brain injury. Listed below are some of the more common ones:

Rancho Los Amigos - Levels of Cognitive Functioning Scale

Levels of Cognitive Functioning

Level I - No Response: Total Assistance

• Complete absence of observable change in behavior when presented with visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli.

Level II - Generalized Response: Total Assistance

• Demonstrates generalized reflex response to painful stimuli.
• Responds to repeated auditory stimuli with increased or decreased activity.
• Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization.
• Responses noted above may be same regardless of type and location of stimulation.
• Responses may be significantly delayed.

Level III - Localized Response: Total Assistance

• Demonstrates withdrawal or vocalization to painful stimuli.
• Turns toward or away from auditory stimuli.
• Blinks when strong light crosses visual field.
• Follows moving object passed within visual field.
• Responds to discomfort by pulling tubes or restraints.
• Responds inconsistently to simple commands.
• Responses are directly related to type of stimulus.
• May respond to some persons (especially family and friends) but not to others.

Level IV - Confused/Agitated: Maximal Assistance

• Alert and in heightened state of activity.
• Purposeful attempts to remove restraints or tubes or crawl out of bed.
• May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another's request.
• Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
• Absent short-term memory.
• May cry out or scream out of proportion to stimulus even after its removal.
• May exhibit aggressive or flight behavior.
• Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
• Unable to cooperate with treatment efforts.
• Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance

• Alert, not agitated but may wander randomly or with a vague intention of going home.
• May become agitated in response to external stimulation, and/or lack of environmental structure.
• Not oriented to person, place or time.
• Frequent brief periods, non-purposeful sustained attention.
• Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
• Absent goal directed, problem solving, self-monitoring behavior.
• Often demonstrates inappropriate use of objects without external direction.
• May be able to perform previously learned tasks when structured and cues provided.
• Unable to learn new information.
• Able to respond appropriately to simple commands fairly consistently with external structures and cues.
• Responses to simple commands without external structure are random and non-purposeful in relation to command.
• Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.
• Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.

Level VI - Confused, Appropriate: Moderate Assistance

• Inconsistently oriented to person, time and place.
• Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.
• Remote memory has more depth and detail than recent memory.
• Vague recognition of some staff.
• Able to use assistive memory aide with maximum assistance.
• Emerging awareness of appropriate response to self, family and basic needs.
• Moderate assistance for problem solving and task completion.
• Shows carry-over for relearned familiar tasks (e.g. self care).
• Maximum assistance for new learning with little or no carry-over.
• Unaware of impairments, disabilities and safety risks.
• Consistently follows simple directions.
• Verbal expressions are appropriate in highly familiar and structured situations.

Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills

• Consistently oriented to person and place within highly familiar environments. Moderate assistance for orientation to time.
• Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assistance to complete tasks.
• Minimal supervision for new learning.
• Demonstrates carry-over of new learning.
• Initiates and carries out steps to complete familiar, personal and household routine but has shallow recall of what he/she has been doing.
• Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work, and leisure activities.
• Minimal supervision for safety in routine home and community activities.
• Unrealistic planning for the future.
• Unable to think about consequences of a decision or action.
• Overestimates abilities.
• Unaware of others' needs and feelings.
• Oppositional/uncooperative.
• Unable to recognize inappropriate social interaction behavior.

Level VIII - Purposeful, Appropriate: Stand-By Assistance

• Consistently oriented to person, place and time.
• Independently attends to and completes familiar tasks for 1 hour in distracting environments.
• Able to recall and integrate past and recent events.
• Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with stand-by assistance.
• Initiates and carries out steps to complete familiar personal, household, community, work, and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.
• Requires no assistance once new tasks/activities are learned.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.
• Thinks about consequences of a decision or action with minimal assistance.
• Overestimates or underestimates abilities.
• Acknowledges others' needs and feelings and responds appropriately with minimal assistance.
• Depressed.
• Irritable.
• Low frustration tolerance/easily angered.
• Argumentative.
• Self-centered.
• Uncharacteristically dependent/independent.
• Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.

Level IX - Purposeful, Appropriate: Stand-By Assistance on Request

• Independently shifts back and forth between tasks and completes them accurately for at least two consecutive hours.
• Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with assistance when requested.
• Initiates and carries out steps to complete familiar personal, household, work, and leisure tasks independently and carries out unfamiliar personal, household, work, and leisure tasks with assistance when requested.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assistance to anticipate a problem before it occurs and take action to avoid it.
• Able to think about consequences of decisions or actions with assistance when requested.
• Accurately estimates abilities but requires stand-by assistance to adjust to task demands.
• Acknowledges others' needs and feelings and responds appropriately with stand-by assistance.
• Depression may continue.
• May be easily irritable.
• May have low frustration tolerance.
• Able to self-monitor appropriateness of social interaction with stand-by assistance.

Level X - Purposeful, Appropriate: Modified Independent

• Able to handle multiple tasks simultaneously in all environments but may require periodic breaks.
• Able to independently procure, create and maintain own assistive memory devices.
• Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work, and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them.
• Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies.
• Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action.
• Accurately estimates abilities and independently adjusts to task demands.
• Able to recognize the needs and feelings of others and automatically respond in appropriate manner.
• Periodic periods of depression may occur.
• Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress.
• Social interaction behavior is consistently appropriate.

Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R. Source: www.neuroskills.com

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale is used to determine the initial severity of a brain injury. It is often used at the emergency scene or emergency room.

I. Motor Response

• 6 - Obeys commands fully
• 5 - Localizes to noxious stimuli
• 4 - Withdraws from noxious stimuli
• 3 - Abnormal flexion
• 2 - Extensor response
• 1 - No response

II. Verbal Response

• 5 - Alert and Oriented
• 4 - Confused, yet coherent, speech
• 3 - Inappropriate words and jumbled phrases consisting of words
• 2 - Incomprehensible sounds
• 1 - No sounds

III. Eye Opening

• 4 - Spontaneous eye opening
• 3 - Eyes open to speech
• 2 - Eyes open to pain
• 1 - No eye opening

The final score is determined by adding the values of I+II+III.

This number helps medical practitioners categorize the four possible levels for survival, with a lower number indicating a more severe injury and a poorer prognosis:

Mild (13-15)

Moderate Disability (9-12)

Severe Disability (3-8)

Vegetative State (Less than 3)

Glasgow Outcome Scale

• This is NOT the same as the Glasgow Coma Scale
• The Glasgow Outcome Scale is a very broad scale and has been shown to have very little value for people in rehabilitation.

• 5 = Good Recovery - normal or near normal recovery
• 4 = Moderate Disability - disabled but independent
• 3 = Severe Disability - dependant with physical or psychological disabilities or both
• 2 = Persistent Vegetative State
• 1 = Dead

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