An Overview of the Rehabilitation Process: Severe to Moderate Brain Injury

All survivors of a serious brain injury acquire a mix of lifelong impairments, but through hard work they can regain some abilities lost to their injuries. How is this possible?

• The brain begins to heal once the patient’s condition is stabilized.
• Damaged — but not dead — brain cells or neurons repair themselves.
• The brain rewires itself, growing new pathways among the billions of still-healthy neurons.
• Through a process called plasticity, healthy portions of the brain assume some of the functions previously performed by the injured areas.

This spontaneous recovery is not sufficient, though, to enable a patient to reach her full post-injury potential. For the best possible outcome, your survivor must participate in a specialized rehabilitation program.

In rehabilitation, your loved one will be evaluated and treated by a team of specially trained medical professionals, who will design a therapy program to treat her particular needs.

Depending on the severity of her deficits and how well she recovers, there may be three stages to your family member’s rehabilitation:

1. Acute inpatient rehabilitation in a specialized facility offering a full range of therapies
2. An outpatient day program in a structured group setting with a full range of therapies
3. Individual outpatient therapy to treat more troublesome impairments

Relearning and Compensating

Rehabilitation has two primary components:

• Relearning forgotten skills
• Compensating for more enduring impairments

Much of what a survivor has learned in her lifetime still is present in her brain after the trauma. Severed connections block access to this information and the patient can’t recall how to perform many activities. Through directed training and persistent practice, rehab reprograms the brain, establishing new connections among these still-present pockets of information, enabling the patient to reacquire forgotten skills.

Jessica had to relearn, not just how to dress herself, but even how to move from a prone to a sitting position. With the support of her therapists, Jessica gradually relearned her activities of daily living, also known as ADLs, which include bathing, dressing, walking, eating, toileting, and grooming. Mastering your ADLs is the first goal in rehab. From there, the patient and her therapists work on increasingly complex activities, with one accomplishment building on another.

Despite the best efforts of your survivor and her rehab team, serious brain damage always results in some impairment that cannot be remedied. To lead a full life, your survivor must learn ways to work around her new deficits. In rehabilitation, she will be taught to recognize and compensate for her impairments.

Sometimes, compensation means a change in behavior. This is called applying compensatory strategies. For example, a person with a diminished memory — nearly everyone with a brain injury — is taught to keep a detailed, daily schedule to keep her from aimlessly or inefficiently passing her time.

Jessica, for example, is lost when she forgets to consult her daily planner. Before going to bed, she organizes the items she will use in the morning — medications, cosmetics, her day’s schedule, and even the clothes she will wear — neatly in the bathroom. This allows her to start her day quickly and without that nagging feeling of having forgotten to do something important. When she remembers to set her alarm clock and if she climbs out of bed when it rings, her day is off to a good start.

At other times, compensation means using assistive devices, such as a watch alarm to remind the survivor to check her daily schedule, or to get ready to go to the movies. Three or four times a day, I remind Jessica to consult her daily planner or to stay focused on finishing one task before she starts two more.

Treating the Whole Person

A brain injury has the potential to transform your loved one in many areas: physical, cognitive, communication, emotional, behavioral, and social. Rehab is designed to treat all of these complaints.

Your survivor may have a variety of physical problems. Some may be related to the accident that caused her brain injury, such as bones fractured in a car crash. Others may be directly related to her brain injury, such as spasticity, impaired balance, or partial paralysis. A physical therapist will help her resolve, moderate, or adjust to these physical problems.

Brain trauma always upsets cognitive processes, such as memory, attention, and language. In rehab, your survivor will perform exercises to improve her memory, concentration, communication skills, and other cognitive functions.

A blow to the brain also can disturb the emotional and behavioral stability of your survivor. She may be atypically angry, depressed, or paranoid, for example. Or, she may act oddly at times: obsessive-compulsively, violently, or overly passive, for instance. A neuropsychologist or a rehabilitation psychologist will evaluate your patient and treat any emotional and/or behavioral complaints.

Finally, interacting with others in a socially acceptable manner is a learned behavior that can be skewed by a brain injury. In rehabilitation, your survivor gradually will be introduced to people: beginning with her medical team, then other hospital staff, fellow patients, and their families. When she is ready, the survivor is reintroduced into the community and her social skills are tested. A therapist may escort her to the library where she will be asked to locate books about her favorite hobby or to a restaurant where she will order lunch.

When Should Rehabilitation Begin?

In an ideal world, rehabilitation begins as soon as the survivor is medically stable. No patient should be kept in an acute hospital setting or a nursing home any longer than necessary. Combining the brain’s natural healing process with rehabilitative therapy is crucial to the success of one’s recovery.

We live, however, in the age of managed health care. Rehab dollars are doled out grudgingly by health insurers. Patients sometimes are limited to two weeks of inpatient rehab. Most receive only four to six weeks.

Researchers have learned that survivors benefit most from rehabilitation when they have reached Level 3 or 4 on the Rancho Scale. One of the most agonizing times for me was helplessly watching Jessica suffer the bewilderment of post-traumatic amnesia in an acute ward of the hospital, waiting for her doctor to agree with us that she had reached Level 4.

The value of rehab cannot be overstated. Maddeningly, nearly all survivors do not receive all of the rehab they need to reach their maximum recovery potential. Because of this short-sighted stinginess, all of society pays in two ways: (1) the high cost of caring for a survivor who would be more independent if a few more dollars were spent on her rehab, and (2) the loss of the potential productivity of a fully rehabilitated patient.

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