The recent events in Tucson, Arizona demonstrate our ability to respond to and treat people with severe traumatic brain injuries. Representative Gabrielle Giffords was the recipient of lessons learned in Vietnam, Iraq and Afghanistan and the development of first class trauma centers, like the one at the University Medical Center in Tucson. As a result more and more people are surviving severe traumatic brain injuries and will require the same level of expertise in the rehabilitation phase of their injury. Fortunately we have made great strides in the rehabilitation of people with severe traumatic brain injuries.
The information released by Representative Giffords' physicians tells us that the bullet traveled through the left side of her brain. They also pointed out that the damage is not done just by the bullet passing through the brain but also by the shock wave or "cavitation effect" that damages the brain tissue around the bullet track. This makes it difficult to predict Representative Giffords' future and her physicians appropriately did not speculate on her degree of recovery. I am frequently gratified by the impressive recoveries that many patients make after extensive rehabilitation efforts. However, I think we can look at what problems most brain injury survivors experience after a severe traumatic brain injury.
Severe brain injuries damage multiple areas of the brain and patients are left with numerous problems. Once the life-saving surgery is completed and the patient eventually leaves the acute care hospital for rehabilitation, these problems can be placed in three categories: physical disabilities, cognitive problems and behavioral symptoms. We will take a look at these three main areas of disability.
Physical Impairments
- Seizures: Following a gunshot wound to the head, patients are placed on medications to prevent epileptic seizures. The chances of having seizures in the future are less if a person does not have seizures early in their course, and they may remain on medication for a period of time even if they do not have a seizure.
- Paralysis: The left side of the brain controls the movement of the right side of the body and vice versa. Depending on the part of the brain affected, the person can have paralysis, weakness or loss of coordination of the opposite side of the body.
- Loss of Sensation: Just like motor control, our ability to feel is controlled by the opposite side of the brain.
- Higher Senses: The nerves we use to carry our sense of smell are located in the front part of the brain and are susceptible to brain injury. Likewise, the small cranial nerves that move our eye muscles can be stretched or torn resulting in double vision.
- Speech and Swallowing Problems: When the left side of the brain is damaged the person may lose their ability to speak and in some cases even comprehend the spoken word. In other cases the speech is slurred or "thick tongued."
- Fatigue: It surprises many people that this is one of the most common complaints of people after a severe brain injury. Everything is more difficult: moving, thinking, talking. This leads to fatigue and cognitive fatigue can be more disabling than physical fatigue.
Cognitive Disturbances
Physical disabilities are the most apparent to the laymen meeting someone with a disability, but the cognitive and behavioral disabilities can represent a much greater problem. I have patients that run businesses and travel all over the world from a wheelchair, but cognitive and behavioral disabilities keep people from returning home or back to work.
Attention and Concentration: The ability to pay attention and concentrate exists at a number of different levels and is distributed throughout areas of the brain. A person with a brain injury may lose their ability to focus on a task for longer than a few minutes or may become easily distracted by things going on around them.
- Executive Functions: These are the real key to success for most of us. They are located in the front part of the brain or frontal lobes. They may have trouble starting or initiating a task and just sit for hours without doing an activity. Planning may be impaired and they are unable to implement that which they would like to do. Problem-solving skills are impaired and they may not be able to perform the necessary steps to solve simple or complex problems. They have difficulty keeping the steps of a task in order; things as simple as following a recipe or using a washing machine.
- Judgment and Perception: The best physician, lawyer, or other professional is the one who make the right decision at the right time. They have good judgment. People with brain injuries have problems with this and also interpreting the actions and intentions of others.
- Learning and Memory: The temporal lobe, located on the side of the brain above the ear, is intimately involved with memory; both short-term and long-term memory may be impaired.
- Speed of Information Processing: We are all expected to work at a certain pace, whether it is at home or in the workplace. After brain injury, simple tasks can take "forever". Information coming into the person's brain is processed slowly as is their response.
- Communication: They may have trouble naming objects, speak slowly or use the wrong words. The size and appropriate use of their vocabulary may be affected severely. They make talk without thinking first, not using their "social censor" that we all use on a day to day basis.
Behavioral Disturbances
As daunting as the above problems sound, behavioral problems can be the most challenging of all. Brain injury tends to exaggerate a person's preexisting personality traits. If someone was short tempered or irritable before the injury, they may be much worse afterwards. Here are some of the behavioral problems that we commonly encounter in patients after a severe traumatic brain injury:
- Irritability: It is not unusual for the person to have a shortened fuse and lose their temper much more easily.
Depression: This can be as a direct result of the damage to the brain and a change in the chemicals in the brain. However, depression tends to appear later when she realizes what she has lost and becomes aware of her disabilities. Hand in hand with depression goes a loss of self esteem, mood swings and anxiety.
- Verbal or Physical Outbursts: Along with the increased irritability comes a tendency to overreact. The outburst may be triggered by a trivial event or comment, but sometimes seems to come out of nowhere. Brain injured survivors may have difficulty controlling their impulses and placing them in noisy or frustrating circumstances can trigger one of these outbursts.
- Inappropriate Behavior: We all have a "social censor" even if we don't use it all the time. We know what to say and to do under the proper circumstances, but brain injury survivors may lose this ability to think of something, but not say it out loud or act on it. As a result they become disinhibited and say or do whatever comes to mind.
This is just a brief and superficial review of what a brain injured survivor and their family may face. The good news is that rehabilitation that starts at a Brain Injury Program in an Inpatient Rehabilitation Hospital and progresses to transitional and outpatient programs can make all the difference in the world. Additional information can be found in my book "Living with Brain Injury: A Guide for Families" or the educational DVD, "Brain Injury: A Look Inside" that also contains graphic pictures of actual brain injuries.
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PT/ OT treatment is based on the proven efficacy of high intensity training undertaken as early as possible following brain injury which has been shown to improve both lower and upper extremity movement ability. The HandTutor and ArmTutor systems are a glove for finger movement practice and an elbow brace respectively. The system uses dedicated rehabilitation software that provides customized virtual functional arm hand and shoulder exercise tasks regardless of the patients arm movement ability. Through intensive exercise practice the patient learns how to move their arm and fingers again. HandTutor and ArmTutor teach the patient how to move their arm again as the program incorporates all the acceptable principles of neuromuscular rehabilitation. The HandTutor and ArmTutor systems are used by all patients that have hand and arm movement dysfunction regardless of diagnosis. The system focuses on the sign and symptoms which are the amount and quality of patient’s active movement ability. This information provides the therapist and patient with real time feedback on movement ability and improvement. We all wish Gifford a full and complete recovery www.HandTutor.com.
Because repairing the damage they do is sometimes impossible.