All brain injury that occurs after the developmental and birth processes is classified acquired brain injury (ABI); a smaller subgroup of ABI is traumatic brain injury (TBI). For a brain injury to be classified as traumatic, it has to be caused by an external force to the brain that impairs physical, emotional or cognitive abilities. These types of injuries are most commonly caused by motor vehicle accidents, but can also be caused by falls, assaults, gunshot wounds or abuse. Traumatic brain injury can result in either an open head injury (OHI) or a closed head injury (CHI) depending on whether or not the skull remained unbroken.

According to reports from the Center for Disease Control (www.cdc.gov) and the Brain Injury Association of America (http://www.biausa.org/), an estimated 5.3 million Americans currently live with disability from TBI. These reports also indicate that annually 1 million people are treated at hospitals while 50,000 will die from their injuries. Brain injury is the number one leading cause of death for children. Men are at twice the risk of injury as women while adolescents and young adults have the highest incidence rates. The Brain Injury Association of America reports that the estimated cost of hospitalization and fatal injury cost due to TBI exceeds $48 billion annually.

There is more than one way for brain injury to occur following a trauma. Initially, there is damage to the brain as a result of the actual trauma that caused the brain injury. As an outcome of that trauma, there is often swelling that may create further injury. Without immediate medical intervention, this swelling can be fatal. Medications to reduce the swelling and intracranial pressure monitors (ICP monitors) have increased the survival rates for many with brain injury. Sometimes the medications are not enough, and surgery is required to alleviate the swelling.

Physicians may use phrases such as diffuse brain injury or axonal shearing when speaking about brain injury. These terms are descriptors of the type of damage that has occurred as a result of a trauma related injury. Diffuse brain injury is the descriptor used to indicate that the injury is not isolated to one specific area but rather an injury located in several areas of the brain. Axonal shearing occurs when the brain sustains an acceleration/deceleration type of injury that causes the tiny axonal connections to tear or stretch beyond their working capacity. Many of the residual impairments are caused by axonal shearing occurring at a diffuse and extensive amount.

Traumatic brain injuries will sometimes result in coma. A coma is a deep state of unconsciousness. The person is still alive but not purposefully responsive to their environment. There are two causes of coma that may occur during the acute medical phase. One is the coma caused by the actual trauma resulting in acute disruption of neurological functioning; the other is a medically-induced coma used by medical staff to calm and quiet a person while their brain is healing. This is done in an attempt to prevent further injury.

There are many stages to coma. Hospitals and rehabilitation facilities use scales to rate a person’s cognitive recovery based on their functioning. Following are descriptions of some of the scales used in the treatment of brain injury. A Glasgow Coma Scale (a description can be found at http://www.neuroskills.com/glasgow.shtml) is often used by paramedics and emergency room physicians to rate a person’s initial level of consciousness immediately following the brain injury. This scale uses a numeric rating system and scores range from 3 (lowest) to 15 (highest). The three domains that are assessed with the Glasgow Scale are eye opening, best motor response and verbal response. With a score of 1 being non-response in each section, a 3 is the lowest score a person may obtain. There are specific criteria for meeting the rating levels. This aids in the communication between physicians and medical facilities when assessing injury status. For example, a rating of 3 on the eye movement section of the Glasgow scale means “eye opens to verbal command”. This rating is clear to all medical personnel. Another scale is The Rancho Los Amigos (original or revised version) Scale. This is used to rate level of consciousness in the days and weeks following the brain injury. (A description can be found at www.neuroskills.com/index.shtml?main=/tbi/rancho.html)

The Rancho Scale uses ten levels of cognitive functioning to describe the progress a person is making during recovery. A third type of scale is the Disability Rating Scale (a description of this scale can be found at (http://www.birf.info/home/bi-tools/qlinks_disabl.html). There are similar features to the Glasgow Coma Scale however this scale assesses cognitive ability for feeding, grooming and toileting. It also looks at level of functioning and employability. These scales are used to assess current functioning during recovery. While these scales are three of the most commonly used, there are other scales that may be used.

Medications may be used to help in the arousal of persons in a coma. (Information regarding specific medications can be found at www.pdrhealth.com/). Some* medications used for arousal of coma patients are Amantadine, Ritalin or Provigil. (*This is not intended to represent a complete listing of possible medications used.) These medicines are used in the early stages of recovery to assist the person in becoming more aware of their surroundings and more purposeful in their actions. For over-arousal and/or agitation, Tegretol, Depakote, Buspar, Respirdol, Neurontin, or Ativan are often used to help calm the person. While some of these medications are seizure medications, in many instances these medications are used for behavior management. It is important for family and caseworkers to know if a person is on seizure medication for seizures, or if the medication is being used to control behavior.

Seizures occur in around 5% of persons surviving a TBI. While 5% may not seem like a significant percentage, for those survivors exhibiting seizure activity, the seizures can be devastating. There are numerous seizure-control medications on the market today. Many people have great success with medication and show good control over their seizures. Others have a much more difficult time finding the right medication for their needs. (For information about specific medications used for seizure control go to www.pdrhealth.com/.)

When seizure medications are not a viable option, surgeries are sometimes used for seizure regulation. These surgeries are extreme measures and usually used as a last resort following numerous medication trials. One type of surgery is the insertion of a vagus nerve stimulator (VNS). This stimulator provides a mild electrical stimulation to the left vagus nerve in the neck. The VNS sends electrical signals to electrodes that are attached to the vagus nerve. The signal is sent into areas of the brain thought to be involved in causing seizures. It can be activated externally by a hand-held magnet when seizures occur.

While the force related trauma is occurring in the brain, there are often many other serious medical complications for which the patient might need treatment. Since motor vehicle accidents, violence and falls are the leading causes of traumatic brain injury, there can be other medical and orthopedic injuries simultaneously occurring. Depending on the cause and location of the brain injury, speech, memory and cognition may also be greatly affected. Most TBI survivors require some therapies once they are medically stable while many will need extensive therapy to regain skills.

Therapies following a brain injury are not all identical in purpose. For example, medical therapy is much different than school therapy in their approach and purpose. Medical therapy will spend time addressing cognitive issues (learning, memory, attention and concentration), range of motion, activities of daily livings (ADLs) and any other issues that might adversely interfere with a person returning to their home or work environment while school therapy’s focus is more on remediating those skills that prevent a student from accessing their education. Therapies in a school setting fall under the related services of special education. They are developmental, corrective and supportive services required to assist a child who has been identified with an exceptionality so that they may benefit from instructional services. Traumatic brain injury is a category of special education.

Physical therapy (PT) is often needed following a TBI to help regain the use of limbs affected by the brain injury. The initials PT are used in reports to name the physical therapy as well as sometimes being used to identify the physical therapist. Deficits addressed in PT may be due directly to injury in the brain itself, or as a result of an orthopedic injury resulting from the violent nature of most TBIs. After an accident, patients may be working on regaining the use of a limb that was injured in the accident and not a direct result of the brain injury. Leg strength, balance (standing or sitting postural control), coordination (bi-lateral leg control), mobility, and range of motion may all be things a physical therapist might be working on in a hospital, rehabilitation or out-patient rehabilitation therapy setting. Gross motor skills such as running, walking and stair climbing are also addressed in physical therapy. Therapists work on daily functioning skills (route finding, leg strengthening for toileting assistance, etc.) and orientation to environment. PT might look at how well a person navigates their surroundings in new or previously familiar locations.

Occupational Therapy’s (OT) focus is more on upper extremity and fine motor coordination (cutting, handwriting, pincer grasp, buttoning). The assessment of activities of daily living (ADLs) include such skills as eating, dressing, toileting, or any self-care issues and are an important part of OT. Occupational therapists also look at the person’s ability to exhibit bilateral use of their upper extremities for coordinated arm movements like catching a ball or buttoning a shirt. When working with the upper extremities, therapy will address strengthening, coordination and motor control. Assessments of visual skills are also a part of OT in medical and rehabilitation settings. Determining if someone can track an object, scan smoothly with their eyes, or track with both eyes at the same time will be part of the visual motor evaluation. An occupational therapist will also be interested in the visual perception of an individual following the injury. Can they do puzzles and see how the pieces go together, or can they complete word searches or seek-n-find type activities? These activities give great insight into how the brain and eyes are working together after a brain injury.

Speech and language therapies are often required following TBI. In the hospital/rehabilitation settings, speech therapy will look at many different aspects of daily functioning as well as communications skills. Speech therapists in a hospital or medical setting may identify and address deficits that are not the same as those addressed by a speech therapist in a school setting. For example, cognition and attention to task issues may be areas identified in a hospital or rehabilitation setting for direct therapy. In a school setting, these areas would be addressed by a classroom teacher rather than a school speech therapist. In some instances, areas identified for remediation overlap in all therapy settings.

Along with actual language issues, speech therapy at a medical facility will assess cognitive performance, memory, attention and concentration deficits. How a person organizes information and then uses that information is of major concern to speech therapists. They often begin the use of external organizers or planners to assist people with memory weaknesses to better navigate their environments. Medical or rehabilitation speech therapy not only looks at the production of speech but the pragmatics and use of speech following a brain injury. A focus is to determine how well individuals are interacting with other individuals in their environment.

A swallowing assessment is often done by speech therapists following a TBI to make sure the person can safely take food orally. Learning or relearning to take food by mouth is a critical part of rehabilitation. The inability to chew and swallow food without aspiration can be a major barrier to recovery and discharge from the hospital. The removal of the feeding tube is often a milestone in the recovery process for patients and families.

Following a TBI, many people require a driving evaluation to see if they can safely drive a motor vehicle. Delayed processing, decreased problem solving ability, visual fields cuts, limited range of motion and overall lack of awareness may be a few of the areas that should be evaluated before returning to drive. These evaluation costs are often covered through private insurance, workman’s compensation claims, or vocational rehabilitation referral. Occasionally, schools will provide funding for such evaluations if driver education is offered to all other students as part of the curriculum. The driving evaluations are the best predictor of actual performance on the road and should be done in conjunction with a complete driving evaluation.

Upon completion of their hospitalization and/or rehabilitation stay a patient will most likely return home. With very severe brain injury, a long-term care facility may be needed to ensure the person receives the attention they will need to be safe and continue to recover. Most patients however will return to their home or the home of a family member. When they are medically stable enough, they will return to the activities of work, school, or running a household. Careful consideration and planning needs to occur when returning to these activities to ensure the safety of all those involved. Whether it is because of aftereffects of physical injuries or the brain injury itself, people may not be able to return to their previous employment. Students may need a modified or altered curriculum upon their return and will likely need some related special education services (i.e.: OT, PT, Speech, or adaptive P.E. to name a few) initially.

Prior to a student’s return to school, a meeting should take place between the family and individuals from the medical and educational agencies. The medical facility should be in contact with the school system at the time of discharge. Before leaving the hospital, parents may want to be sure this information-exchange meeting has been scheduled. The school will need to assess the current status of the child to see what modifications and accommodations are necessary to transition the student into the school setting. This may mean a special education evaluation.

Schools often use the information gathered by the therapists in the medical facility to determine placement and programming needs. It is not necessary for the student to return to school and fail or struggle in classes before an evaluation is begun by the school. If the child has a neuropsychological evaluation completed during their hospitalization or rehabilitation, this information needs to be shared with the school. It is helpful if the family can provide the medical staff a school contact name and number. If the student was supported by an Individual Education Plan (IEP) or 504 Plan prior to the accident, copies of that document should be provided to the medical staff.

The school has several options for accommodating students upon their return to school. One document that schools may write is a 504 Plan. Some schools have their own name for these plans but will know what you are asking about if you say 504 Plan. This is a document used to make accommodations for people with an identified disability. It is a civil rights law intended to eliminate discrimination based on disability or perceived disability. It is not a special education document but can outline and explain the assistance for students who do not need the extensive curricular accommodations an IEP would provide. Related services such as therapies will need to be offered through an IEP due to funding resources.

Often students return to school on a shortened schedule to assist with the issues of decreased stamina and endurance that are common upon initial return. It is important to remember that while the brain is still healing, mental fatigue may be as critical an issue as physical fatigue. Headaches and irritability may also occur during initial recovery stages. While headaches and irritability are not uncommon, if they persist or increase in duration or intensity, it is important to give this information to the medical team. Regular non- prescription headache medications are usually used, but stronger prescription medications may be needed. Use of prescription medication would follow appointment with and consult from a physician. For any medications to be given at school, a parent should first contact the school nurse and follow the procedure outlined in the district policy.

A brief period of shortened day, preferred seating, early class dismissal, home bound services and minor curricular modifications can be made through a 504 Plan. If the student’s needs are such that substantial curricular modifications or significant alterations to the school-day schedule are necessary, a special education evaluation would be needed. The evaluation might result in the need for special education placement and the writing of an IEP. (http://www.ed.gov/parents/needs/speced/iepguide/index.html) The school will go through the process with the parents, and a booklet called Procedural Safeguards will be provided. This booklet outlines the process and responsibilities for evaluation, placement and programming. It also explains the grievance process in the event that parents do not agree with the school’s decisions. Students in private schools may have to contact their local public school district to see about the evaluation and related services. Many private schools contract with the public school for these services.

If you are a college-age student, you will have to notify the student support services department of your school. At the college level it is up to the student to request assistance following their injury. Many colleges recognize the challenges ahead for students that have sustained a TBI and have set up study groups or a way for students to obtain class notes. A lighter course load is often recommended initially. Contact your college to find all the services available to students with TBI.

For those persons that are out of school, returning to work is usually the next step. The hospital or rehabilitation staff should assist the patient with recognizing weaknesses that may impede their successful return to work as well as ways to accommodate for them. As with schools, a modified length of day may be needed initially. On-going therapy may interfere with a normal work schedule for awhile. Most medical settings have someone trained in vocational assessment to assist the person in their desire to return to work. The Vocational Rehabilitation part of the Kansas Department of Social Rehabilitation Services (http://www.srskansas.org/) might become involved with the patient’s rehabilitation programming. A vocational rehabilitation counselor may become part of the team. Usually this process is started with a referral to SRS from the medical site. If this is not done by the medical facility, the person or a family member may start the referral process. Again, if driving is part of their vocation, a driving assessment may be needed or even required by their employer.

Individuals in the state of Kansas should also be aware that through the Kansas Department of Social and Rehabilitation Services the person should be screened for the Home and Community Based Services Waiver (HCBS). The HCBS is a medicaid waiver for persons with brain injury available to residents of Kansas. Once the application or referral is made the person will be screened for eligibility. This waiver serves Kansas residents that are age 16 to 65 and provides services to assist a person in living independently and as integrated into their community as possible. More information on this waiver program can be found on the Kansas Department of Social and Rehabilitative Services website http://www.srskansas.org/

Part of the follow-up after sustaining a traumatic brain injury may include a neuropyschological evaluation. A neuropsychologist looks at brain functioning to evaluate the strengths and weaknesses following a brain injury. This information is valuable for schools and employers when the person is returning to school or work. Be sure if someone is having a neurpsychological evaluation that it is being done by a trained neuropyschologist. This testing is often done at time of discharge, especially for school-age patients. Depending of the length of the hospital/rehabilitation stay, this testing is often done just prior to discharge. The evaluation should not be done too early in the recovery process, or the scores may be inaccurately depressed. A period of healing and recovery should take place for the scores to be more accurate and a better predictor of functioning. A follow-up evaluation is usually done a year later to get a more accurate assessment of functioning.

Knowing the prior functioning levels is useful in determining the extent of the injury. Again, it is very important to remember that testing done during recovery, especially early on, gives you a quick view of current functioning and does not necessarily predict future functioning ability. In the early stages of recovery poor scores on testing indicate current difficulties, some of which may improve with the healing process. While the scores are certainly indicators of current strengths or weakness, it is difficult to rely solely on these scores for future prognosis. Neuropsychological battery consists of test that look at cognitive functioning, attention, memory, problem solving, manual speed and dexterity, achievement testing, language, executive functioning, and spatial perception. These are just some of the different areas assessed in a neuropsychological evaluation.

Another specialist that may become part of the medical team is a rehabilitation physiatrist. This is a doctor that specializes in rehabilitation medicine. They will often act as the coordinator for all services at the medical site. They work closely with other physicians in order to provide a holistic approach to recovery. They work closely and rely on the therapists and other specialists to provide the best care for the individual.

A neurosurgeon or neurologist may be the doctor that initially manages the individual’s care immediately following the trauma. The neurosurgeon will decide if surgery is needed to save the person’s life or to prevent further injury to the brain. If surgery is not needed during the acute medical phase, a neurologist will determine the neurological status of the individual as well as the time for a move to a rehabilitation setting or discharge home.

Finally, in thinking about transitions from medical settings to home, work, and/or school, another transition may be that of re-connecting with friend groups and other family members. This transition may need to be designed. Not all friends or family members will have the same understanding of what has occurred. Personality and behavior changes following a brain injury are not uncommon. Mental and physical fatigue may impact endurance for social interactions. Over-stimulation from the environment may create behavior responses not previously seen. Careful planning allows for a more successful integration into social settings with friends and family.