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Traumatic brain injuries bring more than 400,000 people to hospitals every year. Approximately three-quarters are diagnosed as having suffered a mild to moderate injury – injuries that can be subtle, persistent, and  long term.

Yet, many times survivors suffer minimal outward physical manifestations of brain injury. These patients are reassured that they will recover. As a result many do not receive appropriate evaluation, care and treatment for the disabilities that follow, including physical, cognitive, psychological, and social impairments. Reassurance should only follow a realistic assessment, but often there is not enough time, or the family doctor has insufficient skill to identify the hallmarks of brain damage, except in the severest case. This is why many survivors of brain injury never see a neuropsychologist for testing.

Diagnosing traumatic brain injury, except in the severest cases, is often delayed because the symptoms are difficult to separate from the temporary symptoms of post-concussion syndrome.

Post-concussion syndrome presents with headaches, spasticity, dizziness, reduced coordination, sensory dysfunction, memory losses, problems in concentrating, difficulty in perceiving, sequencing, judgment and communication, fatigue, loss of empathy, depression, anxiety, sexual dysfunction, depressed motivation, emotional volatility, slowed thinking and impaired writing and reading skill.

Patients complain of trouble organizing thoughts, inability to express themselves, difficulty selecting and recalling words, short-temper, learning new information and retaining it, getting lost, confusion and agitation.

These are the same symptoms and complaints observed and experienced by survivors of severe brain injury.

Those who suffer skull fractures, loss of consciousness and coma and typically are diagnosed as having moderate to severe brain injuries, with obvious physical impairments.

Because they have suffered objective physical injuries, their resulting impairments are readily accepted as having been caused by the initial insult. Some of the physical consequences that may occur after a brain injury include decreased muscle control, paralysis, weakness, seizures, sensory losses, and difficulty speaking or swallowing.

Lost motor control or weakness of one arm or leg or on one side of the body is known as hemiparesis. Poor balance, decreased endurance, loss of the ability to plan movements of arms, legs and poor coordination are evident. Survivors experience spasticity or abnormal tone and muscle stiffness.

Seizures can occur immediately or may be delayed until months or even years after the initial trauma. A seizure is a burst of abnormal electrical energy in the brain. In generalized seizures, or major motor seizures, the entire body stiffens. Loss of consciousness, irregular breathing, and loss of bowel and bladder accompany severe shaking. After regaining consciousness, the patient reports soreness and confusion. A second category of seizures are known as focal motor or partial seizures which present as jerking movements or twitching. Consciousness remains intact and often is viewed as a loss of concentration. Often the patient does not know that a seizure has taken place.

Survivors of severe, moderate and mild brain injury will experience common symptoms which vary in the degree of severity.

Survivors, and their families, should review the following symptoms and report these symptoms to family doctors.

Following traumatic brain injury  sight, sound, taste, touch and smell can suffer decreased or increased sensitivity, or a complete loss. Loss of sensation to parts of the body and hypersensitivity are also common. Double vision, loss of depth perception, and an inability to see on one side of the body can occur. Loss of proprioception, the inability to know where arms and legs are in relationship to the body, also takes place.

Fatigue is extremely common in the early stages following brain injury. In many cases the fatigue is profound and staying alert and awake for these patients is difficult. This can easily be confused with being unmotivated because these patients have difficulty paying attention and are sleepy.

Speech disorders follow damage to the cranial nerve which enervates the face. Dysarthria, difficulty in pronouncing words, characterized by slurred or slow speech or loss of the ability to vocalize, results from weak muscles or reduced coordination of the muscles required to produce speech. A closely related condition, dysphagia, the inability to swallow and chew properly, can be readily observed when a patient extends his/her neck or engages in some accommodating movement when swallowing. Reports of choking or the need to soften food with water before swallowing are significant.

Sleep disorders are another area of inquiry. Total reversals of sleep patterns, the need for multiple naps and rest periods and loss of bowel and bladder control are reported.

Neurologic brain injury readily disrupts how a person thinks and processes information. Memory, attention, organization, planning and perception are functions disrupted by TBI. Attention and concentration is something most of us do well. We pay attention and focus on a specific task and block out distractions both internal and external. Survivors of TBI quickly change subjects and have difficulty following through an idea or a sequence to completion. The slightest distraction causes a complete loss of concentration and results in confusion. Without attention and concentration, learning cannot occur.

Significant confusion following a brain injury is so common that the primary medical inquiry is to establish if the patient is oriented. Not knowing the day, week, year, where they are or what happened results in the patient asking searching questions. Coping with confusion is extremely frustrating and leads to more confusion. As a defense mechanism to bring rationality to their existence, many patients will develop their own explanation or history, integrating some accurate information, into a fabric of reality and fantasy. Confabulation is not coping with reality, but it is more closely associated with denial and is a defense mechanism.

Survivors of brain injury have difficulty planning which is known as impaired executive function. Planning requires good memory, learning, judgment, attention and organizational skills. Difficulty in following a logical progression or focusing or getting stuck on one step, stage or activity raises frustrations. Dealing with abstract concepts as literal facts is additionally confusing. Aphorisms, such as a complimentary “you are a tough cookie,” are interpreted to mean that the listener is a piece of food that is extremely hard to chew.

The most significant hurdle to learning after brain injury is memory loss and impairment. The mind’s capacity to receive, store and retrieve information is effected. Short-term memory and recalling what happened yesterday is more common than the loss of recall for older information. This should not be confused with retrograde amnesia, which is the inability to recall events before injury. Anterograde amnesia is the inability to recall events that have occurred since injury.

Impaired communication skills, such as aphasia, the inability to understand or recall the simplest words, is caused by brain cell damage, not by physical inability to speak. Survivors who have difficulty understanding are diagnosed with receptive aphasia. Expressive aphasia is the diagnosis for those having difficulty remembering words, naming objects or expressing ideas.

Impaired judgment occurs when abstract thinking is impaired. Being stimulus bound is when the brain only recognizes and reacts to objects and events in the immediate environment. Applying a task to a similar but different situation cannot be accomplished. Difficulty in interpreting the actions or inaction or others is common. Those who show concern and attention can be viewed as being angry toward the survivor.

People with impaired memory may remember and retain old skills, but learning new ones require repeated instructions and extended practice. Even then they can be readily forgotten, with accompanying frustration, depression, and anger.

Frontal lobe brain injuries can be interpreted as causing dullness because this area of the brain controls impulses, motivation and initiation. These survivors need to be reminded and prompted in simple tasks, such as daily care and living tasks. Regular encouragement and visual cues are helpful in prompting initiation.

In addition to physical consequences of TBI the ability to understand feelings and the ability to control emotions are impacted. A whole range of behavioral symptoms occur with TBI: agitation, depression, frustration, rapid changes in emotion and severe mood changes, insensitivity to others, self-centeredness, rage tantrums, poor impulse control, loss of inhibition, decreased libido, inappropriate sexual expression and loss of self-esteem. Pre-existing conditions may be amplified following TBI.

It is important for these symptoms or conditions to be reported to the patient’s treating doctor for several reasons.

First, repeated and consistent documentation will support a referral to a neuropsychologist for a professional evaluation. A neuropsychologist specializes in evaluating brain function and performs sophisticated tests of brain function necessary to identify specific brain injuries and to select appropriate rehabilitation efforts.

Second, the range of concerns reported over time will help identify deficits for specific testing and monitoring by the neuropsychologist. Many patients will request referral to a neurologist who will order a CT scan or MRI. While these technologies continue to offer increased definition, the axonal injuries suffered in brain injury cases simply cannot be identified by older MRI machine.  Only an MRI on a T-3 unit providing diffuse tensor imagery with fiber tracing, read by an experienced neuro-radiologist, can identify axonal shears.

When TBI is confirmed by neuropsychological testing, cognitive therapists teach survivors how to learn. The goal is to help survivors identify techniques to improve their ability to remember ideas. Computers are used extensively as a training tool by cognitive therapists.

Vocational rehabilitation counsellors identify skills, aptitudes, and abilities that will help restore the patient to the world of work. To determine the level of vocational functioning the counsellor also evaluates the patients ability to follow instructions and social skills. Testing helps determine the survivors ability to learn, to make judgments and to evaluate productivity, punctuality, reaction time, distractibility and tolerance for frustration. Once the evaluation is completed a specialized training program is designed and implemented to promote a smooth transition to being able to once again be gainfully employed. Survivors of TBI face monumental challenges to job re-entry and having realistic expectations are important from the outset. Many times work adjustment training, driver’s training, job seeking and interviewing skills may be insufficient and a job coach is needed to facilitate a smooth transition. Still, educating employers is the chief obstacle for the family and representatives of TBI survivors.

The educational therapist teaches the basic skills needed to return to school or work and arranges for a special educational environment from designing course work that will develop reading, writing or math skills to arranging for note takers or real time court reporters in class.

Social workers provide the important connection between the health care staff, rehabilitation professionals, family, school, work and often the insurance carrier funding the rehabilitation. The chief task for the social worker is to prepare a detailed background study and normally includes the patient’s pre-injury personality, lifestyle, emotional and financial resources, educational history, work and leisure interests, special relationship and previous problems. Long-term and short-term goals are usually developed with the social worker. Because the family will be in regular contact with the social worker, they will seek advice and will share confidences with the social worker.

It is important for the patient’s personal injury lawyer to have a strong and responsible working relationship with the social worker. The social worker’s background study is one of the most significant documents in the rehabilitation chart.

Therapeutic recreational specialists evaluate interests and hobbies and integrate them into therapy goals that are readily enjoyed by the survivor. The focus is to develop physical, cognitive and social skills so leisure activities can once again be enjoyed.

The rehabilitation case manager or rehabilitation specialist coordinates the goals of the patient, family and rehabilitation staff as an advocate for the patient and oversees the overall treatment plan. The case manager is routinely in charge of reporting to the insurance carrier funding the recovery program.

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Richard Alexander