Spinal Care, Neurology, Spinal Medical Advice and Information.

Traumatic Brain Injury Rehabilitation Behing the Miracles

by Amy O. Bowles, MD 

Recent events in Iraq and at home have brought traumatic brain injury (TBI) rehabilitation to the front of people’s minds, and media coverage is full of “miraculous recoveries.” In fact, these injuries are neither new nor rare and there has been tremendous skill, resourcefulness and plain hard work behind many of those miracles. The Centers for Disease Control (CDC) estimates that there are more than five million people living in the United States today with traumatic brain injury, and new TBIs occur at the rate of approximately 1.4 million per year. To give some perspective, there are just under 200,000 new breast cancer diagnoses in the U.S. each year. TBI, a long-time invisible epidemic, is now getting some much-needed exposure.

Frequent mechanisms of injury with TBI include falls, vehicle accidents, firearms, assaults and blast injuries. Brain injuries are often not in isolation, and they can be complicated by orthopedic, visceral, pulmonary and other neurologic trauma. Many of these patients require specialized acute care and intensive monitoring. 

Patients go through a number of cognitive stages during this acute recovery. As they regain consciousness and emerge from coma, they may begin to follow commands. At this point, patients go though a period called Post Traumatic Amnesia (PTA). For some, it may be brief and go unnoticed. For those with more severe injuries, the period of PTA is critically important and may be much more obvious. Most will remain hospitalized during this time, and many may participate in inpatient rehabilitation programs. This period is marked by confusion and disorientation. These patients are not forming new memories which can pose a number of challenges for the treating team. For example, these patients will not remember their weight-bearing precautions or not to pull at tubes, and they will need frequent redirection and reorientation. This period is sometimes notable for severe agitation which can necessitate medications and restraints to prevent the patient from hurting himself or someone else. As people continue to recover and emerge from PTA, the agitation usually subsides although cognitive deficits frequently remain. 

For many, this sequence of coma and post traumatic amnesia is condensed into a matter of seconds. This mild TBI is often called “concussion,” and many people have concussions without residual deficits. However, a significant number may have what is called “Post-Concussive Syndrome.” Symptoms may include headaches, trouble concentrating, irritability, memory problems, difficulty with problem-solving, poor attention, sleep derangements and mood disorders.

While some TBI survivors may have hemiparesis or some lasting physical reminder of their accidents, many TBI survivors (even those who’ve sustained severe injuries) do not, and they are often called the “walking wounded.” Their disability is more or less invisible. While strangers are patient when a wheelchair-mobile person takes extra time to do some-thing, they may be less tolerant of a TBI survivor’s delayed processing, disinhibition and cognitive disorganization. Family members, likewise, can have trouble understanding why their loved one acts differently, forgets things and gets lost now. 

To address these issues, rehabilitation programs for TBI survivors ideally include a multi-disciplinary team made up of the patient, his/her social support system, physicians, nurses, physical therapists, occupational therapists, speech language pathologists, rehabilitation psychologists, therapeutic recreation specialists and social workers or case managers. The team works together to provide consistency and structure as a critical part of the program. While there is a great deal of physiologic healing and repair, a large part of the rehabilitation process involves compensatory strategies. Patients will practice strategies like keeping a memory book for weeks or even months until it can become second nature. Group-based programs are helpful so TBI survivors can practice social pragmatics – like not interrupting, taking turns, self-monitoring, etc. Problem-solving skills and dealing with complex information are also addressed in tasks like taking a bus trip or planning and preparing a meal. 

The cognitive aspects of what we all do each and every day — almost without thinking – are rather amazing. Because of this, it can take a lot of time and a huge effort for a TBI survivor to return to living and working independently. Clearly, that family, that rehabilitation team and especially that survivor worked incredibly hard before returning home, returning to work or participating in an interview. There’s a lot of sweat behind those miracles. 

Amy O. Bowles, MD, is the Medical Director for the Brain Injury Program at Reeves Reha-bilitation Center, University Health System in San Antonio. She also is an Assistant Professor in the Department of Rehabilitation at the University of Texas Health Science Center and an Attending Physician with the South Texas Veterans Health Care System.