B r a i n I n j u r y[ P A T I E N T / F A M I L Y E D U C A T I O N ]

T A B L E O F C O N T E N T S

Introduction to Brain Injury . . . . . . . . . . . . 3

Brain Anatomy . . . . . . . . . . . . . . . . . . . . . . 4

Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . 6

Ranchos Los Amigos Scale of Cognitive Function . . . . . . . . . . . . . . . . . . 8

Impact of Brain Injury on Function . . . . . . 9

Activities of Daily Living . . . . . . . . . . . . . . 14

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . 17

BIRS Treatment . . . . . . . . . . . . . . . . . . . . . 19

Family Involvement . . . . . . . . . . . . . . . . . . 20

Patient Needs . . . . . . . . . . . . . . . . . . . . . . . 23

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . 24

3 | W A K E M E D R E H A B

If you have received this notebook insert youor a family member or loved one hassustained a traumatic brain injury and arereceiving rehabilitation services throughWakeMed. The following information isbeing provided to help you understand thecomplex nature of traumatic brain injury andthe process of rehabilitation and recoveryfrom traumatic brain injury.

According to the Centers for DiseaseControl and Prevention (CDC), a traumaticbrain injury (TBI) is the result of “a bump,blow or jolt to the head or a penetratinghead injury that disrupts the normalfunction of the brain.” In the U.S. it isestimated that that there are approximately1.7 million brain injuries per year. Theleading causes of TBI are falls-35.2%, motorvehicle-traffic crashes-17.3%, events when aperson is struck in the head -16.5%, andassaults-10%. These injuries may producechanges in the person’s level of

consciousness, cognitive abilities andphysical functioning. A TBI may also resultin changes in behavioral and emotionalfunctioning. These impairments may betemporary or permanent and cause partial ortotal functional disability or psychosocialmaladjustment.

WakeMed’s Brain Injury RehabilitationSystem (BIRS) is the most comprehensivebrain injury program in the region and theonly accredited inpatient and outpatientbrain injury program in the Triangle. Thebrain injury program at WakeMed begins inthe emergency room with trauma servicesand provides a continuum of services frominpatient rehabilitation services tooutpatient/day treatment rehabilitation. TheWakeMed BIRS continuum is designed toprovide appropriate services for the patient’sspecific level of functioning.

[INTRODUCTION]

[THE BRAIN]

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 4

The human brain consists of millions ofnerve cells (neurons). It weighs about 3pounds and is jello-like in consistency. Itfloats in fluid (cerebral spinal fluid), iscovered by protective membranes(meninges), and is enclosed in the bony skull(cranial vault). It communicates with the restof the body through nerves running throughthe spinal cord and the peripheral nervoussystem. The brain is a large consumer ofoxygen, which is supplied by a complexsystem of blood vessels.

The brain is sometimes referred to as “theorgan of behavior” as it controls almosteverything we do. It controls thoughts,memory, speech, emotions, sensoryinformation, body movement, and thefunction of many other organs in the body.It is also responsible for the patterns ofbehavior we refer to as personality.

The brain has four main sections, whichinclude: the brainstem, cerebellum, thelimbic system, and the cerebral cortex.

• Brainstem: The brainstem is the lowestpart of the brain and connects the brain tothe spinal cord. It is involved in regulatingour level of alertness, and also controlsbasic bodily functions such as heart rate,breathing, body temperature, anddigestion.

• Cerebellum: The cerebellum is located atthe back of the brain. It is involved withmovement, coordination, and balance.

• Limbic System: The limbic system islocated above the brain stem deep insidethe brain. It is involved in our emotionalfunctioning and also plays a role in theability to remember new information.

• Cerebral cortex: The cerebral cortex is theouter layer of the brain and is divided intoleft and right hemispheres, or halves. Eachhemisphere controls movement and feelingin the opposite side of the body. Theoutermost inch of the cerebral cortex iscomposed of neuron cell bodies and isreferred to as “grey matter”, because of itsgrey color. Below the grey matter is the“white matter”, which consists of incomingand outgoing axons that can be thought ofas the arms of the neurons. These axons, orarms, start out at the neuron’s cell body,and reach out to connect with otherneurons in different areas of the brain sothat these different areas of the brain cancommunicate with one another. Thecerebral cortex controls the highest levelsof thinking and behavior. Each hemisphereis further divided into four lobes.

• Frontal lobes: The frontal lobes areinvolved in complex cognitive functionssuch as planning, organizing, initiating,monitoring and controlling behavior.These are often referred to as “ExecutiveFunctions”. The center for speech is alsolocated in the frontal lobe. In most peoplethis is in the left frontal lobe.

5 | W A K E M E D R E H A B

• Temporal lobes: The temporal lobescontrol hearing and the left temporal lobeis involved in understanding language.Both temporal lobes are also involved withmemory, the left temporal lobe for verbalmemory and the right temporal lobe forvisual memory.

• Parietal lobes: The parietal lobes processincoming bodily sensory information fromthe opposite side of the body. They arealso involved in visual spatial informationprocessing, and the left parietal lobe isinvolved in reading.

• Occipital lobes: The occipital lobes processvisual information. They allow us torecognize and understand what the eyesare “seeing”.

[THE BRAIN]

Injury to the brain may be incurred frommany causes. The term “acquired braininjury” (ABI) refers to brain injury thatoccurs after birth, from any cause, and mayinclude strokes, anoxia, infections, toxins,tumors, or traumatic brain injury (TBI).

Traumatic brain injury is caused by anexternal physical force or blow to the head.These injuries are most frequently sustainedin motor vehicle collisions or falls, but mayalso be sustained in other ways, such as inassaults, sports, pedestrians being struck by avehicle, or by gunshot wounds. Every injuryto the brain is different in its effects andseverity as well as the in mechanisms ofinjury. Injuries to the brain are oftendescribed as Primary Injuries or SecondaryInjuries.

Primary injuries occur at the time of thetrauma and may include:

• Contusions: Bruising of the surface of thebrain from impacting the interior of skull.Contusions are most commonly found onthe frontal and temporal lobes. They canbe found at the point of impact (coup) ordirectly opposite the point of impact(contrecoup) due to the brain reboundingfrom the initial impact inside the skull.

• Lacerations: Tears or cuts to the surface ofthe brain. The brain sliding over sharpbony ridges inside the skull often causeslacerations. Blood vessels may also be cutcontributing to bleeding inside the skull.

• Shearing/Diffuse Axonal Injury (DAI):The generalized stretching and breaking ofaxons caused by deceleration and rotationalforces found in high-speed injuries such asmotor vehicle crashes or falls of somedistance.

• Skull Fractures: Fractures of the skullbone. They may be simple non-displacedlinear fractures or more serious compounddepressed fractures. The latter may requiresurgical intervention and may injure thebrain by impinging on the brain tissue.

Secondary injuries develop at various lengthsof time following the initial impact and mayinclude:

• Edema: Swelling of the brain tissue insidethe skull, which can cause an increase inpressure inside the skull.

• Hematoma: A pooling of blood from ableeding vessel. Frequently found betweenthe surface of the brain and thesurrounding protective membranes.Hematomas may compress brain tissueand often need to be surgically drained.

• Hemorrhage: Bleeding within the braintissue from severed blood vessels.

• Anoxia / Hypoxia: A complete loss of, orreduced supply of oxygen to the brain.

• Hydrocephalus: An abnormal increase ofcerebral spinal fluid (CSF) within theventricles usually due to a blockage of theCSF pathways, which causes a buildup ofpressure on the brain.

[BRAIN INJURY ]

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 6

• Seizures: Abnormal, uncontrolledelectrochemical discharges within thebrain.

Brain injuries can also be differentiated asopen or closed head injuries. Open headinjuries are those in which the skull andmeninges have been penetrated and theremay have been direct damage to the braintissue. A gunshot wound to the brain wouldbe an example of an open head injury.Patients with open head injuries are atgreater risk for developing seizures andinfection. In closed head injuries, the brainis injured by an external force that does notpenetrate the skull.

In the rehabilitation process, the initialseverity of a brain injury, as well as recovery,is determined by the patient’s level ofcognitive functioning. It has been observed

that individuals with moderate to severebrain injuries tend to follow a fairlypredictable pattern of recovery of cognitiveabilities. The Rancho Los Amigos Scale ofCognitive Functioning is a scale that is usedto describe this pattern of recovery, and toquickly communicate a person’s level ofcognitive functioning at a given time. Youmay hear hospital staff members referring toyour family member as being at “RanchoLevel __”. A person with a brain injury mayenter the scale at any level, and may or maynot progress to the highest level. There is noset amount of time a person will spend atany given level. Sometimes a person willseem to fluctuate between 2 levels, or mayexhibit characteristics of more than one levelat a given time.

[BRAIN INJURY ]

7 | W A K E M E D R E H A B

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 8

Level I Total Assist: No Response.Unresponsive to stimuli. Also referred to as“coma”

Level II Total Assist: Generalized Response.Inconsistent, nonpurposeful, nonspecificresponses to stimuli, such as intermittent eyeopening, or random movement of limbs.Also referred to as “vegetative state”.

Level III Total Assist: Localized Response.Inconsistent reaction directly related to typeof stimulus present. For example, visuallytracking objects or people around the room,or occasionally following a simple, one-stepdirection. Also referred to a “minimallyconscious state”.

Level IV Maximal Assist: Confused,Agitated. Disoriented, unaware of presentevents; frequent bizarre, inappropriatebehavior; very short attention span, impairedability to process information; often veryrestless and resistant to care.

Level V Maximal Assist: Confused,Inappropriate, Nonagitated. Nonpurposeful,random, fragmented responses when taskcomplexity exceeds abilities; appears alertand responds to simple commands; performspreviously learned tasks, but is unable tolearn new ones. Very little recall of day today events.

Level VI Moderate Assist: Confused,Appropriate. Behavior is goal-directed;responds appropriately to the situation, buthas memory difficulties and may not beconsistently oriented to time, place, orsituation and may respond incorrectlybecause of memory difficulties

Level VII Minimal Assist: Automatic,Appropriate. Correct routine responses arerobot-like; appears oriented to setting, buthas poor insight, judgment, and problemsolving.

Level VIII Stand-by Assist: Purposeful,Appropriate. Correct responses, carryover ofnew learning occurs. No supervisionrequired, poor tolerance for stress, and someremaining cognitive difficulties.

Level IX - Stand-by Assist on Request:Purposeful, Appropriate. Can independentlyshift between and focus on tasks for anextended period of time. May still useassistive memory devices and require helpwith more complex memory and unfamiliartasks. Demonstrates awareness of difficultiesbut needs assistance with adjusting to taskdemands.

Level X - Modified Independent:Purposeful, Appropriate. Able to multi-taskin all settings but may require rest breaks.Independently utilizes memory aides butmay need strategies or extra time tocomplete tasks. Can now anticipate andadjust to needs/task demands independently.May experience increased irritability whensick, fatigued or stressed.

[RANCHO LOS AMIGO SCALE OF COGNITIVE FUNCTIONING]

9 | W A K E M E D R E H A B

A brain injury has the potential to affectmany areas of a person’s functioning. Inorder to ensure rehabilitation iscomprehensive, the rehabilitation treatmentteam addresses all the major functionalareas. These include medical, cognition,communication, behavior, mobility, self-care,and psychosocial. WakeMed’s Brain Injurytreatment pathways and the patient’s Plan ofCare are organized in this manner. Thesefunctional areas, and how a brain injuryimpacts them, are described below:

M E D I C A L

Depending on the nature and severity of thebrain injury, there may be other medicalissues resulting from the injury that canimpact recovery and the course of a patient’srehabilitation. Some individuals may havedifficulty breathing initially, so that atracheostomy tube needs to be placed in theneck to help them breathe. Even when theyrecover the ability to breathe on their own,the tube may remain in place for a whilelonger to help clear secretions from thetrachea. The ability to produce an audiblevoice is temporarily affected by the presenceof this tube.

Many individuals with brain injuries havetrouble swallowing safely, so a feeding tubemust be inserted through the nose to giveliquid nutrition. When the swallowingproblems are likely to last a long time, agastrostomy feeding tube (PEG) can besurgically placed in the stomach. This allows

liquid nutrition to be given in large amountsseveral times a day instead of continuouslydripped in, and is often more comfortablefor the patient. Generally, this tube can beremoved once swallowing improves.

When a brain is injured, it becomes moresensitive to developing seizures. Seizures arecaused by abnormal electrical discharges inthe brain. Symptoms may vary depending onthe part of the brain that is affected, butseizures often cause unusual sensations,uncontrollable muscle spasms, and even lossof consciousness. Medications can be used tostop seizures and to prevent them fromoccurring.

Another problem commonly seen inindividuals with brain injury is spasticity.Spasticity is a condition in which musclesare continuously contracted. This abnormalincrease in muscle tone results from a faultysignal from the brain to the muscles. Thestiffness and tightness of the muscles mayinterfere with movement, speech, and thequality of walking. The degree of spasticitycan vary from mild muscle stiffness tosevere, painful, and uncontrollable musclespasms. Treatment for this will depend onthe particular individual’s circumstances, butcould include such things as medicationsand stretching exercises

Finally, a rare occurrence in individuals withbrain injury is the development ofheterotopic ossification (HO). This refers tothe formation of calcium deposits in the softtissue of the body where it should not be. It

[IMPACT ON FUNCTIONAL AREAS]

often forms around the joints and producespain and increasing stiffness. If allowed togrow, the joints may become completelyfused. Early identification is key, andphysical and medical treatments can bestarted to slow down this calcium depositionprocess.

C O G N I T I O N

Cognition is another word for thinking skillsand includes such things as attention,memory, language, visual-spatial abilities,and executive skills. Cognition is almostalways adversely affected by brain injuries.Cognitive deficits can vary from mild tosevere or profound, depending on theseverity of the brain injury and the stage ofrecovery a person is in. Cognition oftenshows improvement as recovery progresses.Also, some areas of cognition may be moreimpaired than others. For example a personmay have severe memory problems, butrelatively intact visual perceptual skills.

Individuals with very severe brain injuries, orin the early stages of recovery from a moremoderate brain injury, may have difficultymaintaining staying awake and alert. In fact,in some cases cognitive skills can be soimpaired that the patient may not respond atall. This level of cognitive impairmentcorresponds to Rancho Los Amigos Levels Iand II. The patient may eventually graduallybegin to respond to simple directions (suchas “squeeze my hand”, or “close your eyes”),but responses may be very inconsistent, and

may not always be accurate. While thepatient may follow simple directions attimes, it would not be unusual for him orher to make no attempts to speak, and tonot show much ability to help him orherself. This level of cognitive impairmentcorresponds to Rancho Level III.

Sometimes, individuals with a brain injuryare awake and alert, but are very confusedand restless and have a limited ability tounderstand the world around them. This isoften seen in individuals who arefunctioning at Rancho Los Amigos LevelIV and V. If the patient is functioning atthis level of cognitive impairment, he or shemay have problems with irritability,restlessness, poor attention, poor memory,difficulty solving everyday problems, andinsight (difficulty understanding whatchanges have happened since the braininjury). Because of confusion and memorydifficulties, the patient may “confabulate” ortalk about things he or she thinks happenedbut which did not. Patients at this level offunctioning often begin to participate moremeaningfully in therapies and otheractivities. For example, the patient may beable to start to participate in dressing,feeding and bathing him or herself again,with assistance and guidance.

Some individuals with brain injuries willhave less severe cognitive impairments, orwill have more severe impairments in someareas of cognition, and mild or noimpairment in others. Many patients whostart with more severe cognitive deficits may

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 1 0

[IMPACT ON FUNCTIONAL AREAS]

1 1 | W A K E M E D R E H A B

show significant improvement, andeventually have less severe impairment insome or all areas of cognition. This wouldtypically be associated with Rancho LosAmigos Levels VI-VII. The patient mayremember some things from day to day, andmay be fully oriented (meaning they knowwho they are, where they are, and what dateand time it is). The patient may be able todress independently, and eat independently.However, some amount of supervision andassistance might be needed due to thingslike poor short-term memory, poorperceptual skills, or other cognitive deficits.The patient may not be able to see thesecognitive problems and may try to do thingsthe same way he or she did before the braininjury.

In brain injuries of the least severity, or inpatients with the highest recovery (RLAVIII - X), cognitive deficits are subtle, andwould not be noticed by people who did notknow the person before the injury. They maystill include mild memory deficits, but alsodifficulties in planning and organizing theirday-today functioning, particularly incomplex activities like working or going toschool. Rehabilitation efforts at this level arefocused on teaching the patient strategies tohelp them in these areas.

C O M M U N I C A T I O N

Speaking, listening, reading, writing andgesturing are all ways we communicate.Patients with brain injuries may haveproblems doing some or all of these things.Problems communicating can range fromprofound to mild depending on the natureand severity of the brain injury, and thestage of recovery the person is in. Individualswith the most severe brain injuries areunable to communicate at first. They maysometimes have their eyes open, and appearto be awake, but may not be able to speak orrespond to you.

Some individuals can follow simpledirections and may be able to talk usingsimple words or gestures (for example, thepatient may point to a cup to tell you he orshe wants something to drink), but mayhave difficulty finding the right words to say.Words said may not always make sense.Generally as the patient improves,communication skills become more andmore accurate.

B E H A V I O R

Behavioral disturbance is common amongindividuals with brain injury. In the mostsevere injuries, patients will not respond tothings around them. Other times, behaviorsmay be present, but not have a purpose. Forexample, an individual may be moving his orher arms and legs but not for any particularreason. A patient’s behavior will usuallybecome more purposeful as he or sherecovers.

As a patient recovers from a severe injury,there may be unwanted behaviors that goalong with getting better. It is not unusualfor a patient to become agitated, aggressive,or even combative. Cursing, restlessness, andconstant motion are common during thistime. It is important to not take thisbehavior personally or try to reason or arguewith the patient as he or she has littlecontrol of the behavior and will notremember it later. These patients havedifficulty with attention and processing ofinformation. They also tend to be easilyover-stimulated. Their surroundings shouldbe kept quiet with minimal stimulation.Televisions, radios and lots of visitors are notappropriate at this time.

Sometimes a patient’s behavioral difficultiespose a danger to themselves. They areunaware of their injuries or limitations, andhave poor safety judgment. For example apatient who is unable to walk may attemptto climb out of bed or stand up from a chair,and be at risk for falling and further injury.

Or, a patient who can walk, but is confused,could wander away and place themselves indanger. In these instances, safety devicessuch as lap belts, enclosure beds, and alarmsare used to protect the patient.

As the patient improves these behaviorsusually become less frequent. Patients maycontinue to have behavioral issues such asdoing things quickly without thinking,which puts them at risk for injury. Inaddition, patients at this level may havetrouble interacting with others in socialsituations. They may not recognize theirbehavioral problems even though they maybe obvious to you. Sometimes patientsbecome more irritable, or anger more easily.Other patients may laugh at inappropriatetimes, or make inappropriate comments.

M O B I L I T Y

Mobility is about movement, whether it isfrom laying down to sitting up, walking tothe bathroom, or wheeling a wheelchairdown the hall. In order to move the body,the brain must coordinate balance, strengthand motor control.

Areas of function that can affect mobility ina person with a brain injury are:

• Balance – allows upright posture withoutfalling over.

• Strength – the amount of power that yourmuscles have.

• Coordination – the smooth movement of

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 1 2

multiple body parts in harmony.

• Sensation – the body has several types ofsensation, all of which are interpreted bythe brain:• Hot/cold and sharp/dull• Deep pressure• Proprioception – tells the body where itis in space

• Tone – an increased resistance tomovement, a common problem in braininjury, is particularly troublesome if itoverpowers available active movement.Tone can increase with laughing,coughing, sneezing, infection, fever orimpaction. Tone is easily mistaken foractive movement, but it is not under thepatient’s control.

• Orthopedic Restrictions – The patientmay have orthopedic injuries in addition tothe brain injury, such as fractures orsprains. This may limit the activitiesallowed or the weight put on a limb.

• Range of Motion – Orthopedic injuries,increased muscle tone, or changes in motorcontrol can reduce the patient’s ability tomaintain joint flexibility.

• Posture – An individual’s ability to sit upor stand including head position iscontrolled by the brain. The brain injurymay also affect vision, perception, andmotor control, all of which play a part inposture.

• Motor Control – a combination ofstrength, balance, coordination andsensation to produce purposeful, controlledmovement.

• Motor planning – the selection of thecorrect motor plan, including starting,continuing, and stopping a desiredmovement appropriately.

1 3 | W A K E M E D R E H A B

[IMPACT ON FUNCTIONAL AREAS]

Activities of Daily Living (ADL’s) are all theactivities people engage in on a daily basisincluding work, school, leisure, and self-careactivities. Self-care activities include:grooming, bathing, dressing, toileting, andperforming toilet and shower transfers.Initially, in moderate to severe brain injury,it’s obvious a patient can’t work or go toschool, but he or she also may not becapable of basic self-care due to acombination of cognitive and physicalfactors. Patients may be totally dependentupon others to care for them. In less severebrain injuries, or as patients with moresevere injuries begin to recover, they areoften able to resume aspects of self-carestarting with the simplest (such as assisting atherapist with wiping one’s face) and movingto the more complex (such as dressing one’sself with little or no assistance). Patientswith less severe injuries, or who are moreadvanced in their recovery may continue torequire assistance, but to a lesser degree.

Some patients may regain completeindependence in self-care (this wouldtypically be associated with Rancho LevelsVII or higher). Individuals at this level offunctioning often transition to a DayTreatment Program, where work begins onhigher order activities of daily livingincluding issues of community re-entry suchas returning to work or school.

P S Y C H O S O C I A L

A brain injury patient’s psychologicalfunctioning and psychosocial situation maybe severely disrupted by the injury. Thedegree of disturbance is usually determinedby the severity of the injury and degree ofcognitive deficits. Early in the injurypatients often cannot understand what hashappened to them and are highly confused.They may be very fearful or angry and haveno control over their emotions leading toinappropriate behavior. To families, theymay not seem as if they are the same person.Because of their continued cognitiveproblems explanations or even attempts to“counsel” them are ineffective. They do,however, sometimes respond well to familysupport. As patients recover they may beginto be able to understand their situation andwhat’s happened to them. At this point theyare at risk for depression or other adjustmentdifficulties and need to be closely monitored.

Every family is different but for most theidea of long-term recovery from a braininjury can be overwhelming. However, theinjured brain can often heal and the changescan be inspiring. Along with the hope thatrecovery brings is the balance of acceptanceof more permanent changes. This sets thefoundation for effective coping and canoften be the most challenging aspect ofrehabilitation for patients and families.

Patients are affected by their brain injury inmany ways, beyond their cognitive andphysical functioning. Family members and

[ACTIVITIES OF DAILY LIVING]

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 1 4

caregivers are also affected by the patient’sbrain injury. Patients and families mayexperience a range of emotions that willchange from time to time. Some examples ofthese emotions can be:

• Disbelief

• Anger

• Guilt

• Depression

• Isolation

• Panic

• Hope

It is important to recognize that theseemotions are normal, and an expected partof the process of trying to understand andcope with a patient’s severe injury. A braininjury affects not only the patient, buteveryone else who knows and cares aboutthat person. It is also important to recognizethat the young children or siblings ofpatients can be very distressed and upset bythe injury. It can be a very confusing timefor children, and their daily routine is oftenvery disrupted. We recommend that familiestry to “normalize” children’s routines. Ifpossible, children or young siblings ofpatients with brain injuries should return totheir normal school and activity routine assoon as possible. If you are not sure how toexplain the patient’s brain injury to a child,or if you have questions about how toprepare the child to visit the patient for thefirst time, a consultation with a pediatricspecialist can be arranged.

Similarly, spouses and other family membersmay want to consider trying to return to asnormal routine as possible. You should try toget adequate rest and good nutrition, andnot feel guilty that you are not at thehospital continuously, particularly after thepatient transfers to the Rehab Hospital orNeuroCare Unit. The patient will be busyduring the day with therapies and otheractivities, and will need rest breaks betweentherapies.

R E C O V E R Y

One of the first questions families ask whentold a family member has had a brain injuryis “how long will it take my family memberto get better?” Unfortunately, we usuallydon’t know the exact answer to thatquestion. While most people with a mildbrain injury will have a complete, or nearlycomplete recovery within a few months,people who suffer moderate or severe braininjuries may continue to progress for manymonths, or even years after their injuries.

One thing we do know is that recovery frombrain injury is a gradual process. Sometimestelevision shows or movies portray braininjuries incorrectly. They may show someonebeing in a coma, then suddenly “waking up”,and immediately being completely back tonormal. This is not an accurate portrayal ofwhat really happens with a moderate orsevere brain injury. Usually, a person willcome back to full consciousness gradually,

[ACTIVITIES OF DAILY LIVING]

1 5 | W A K E M E D R E H A B

and for some time may be confused anddisoriented. The patient will likely have nomemory of how or when the injuryoccurred. You should refer to the RanchoLos Amigos Scale of Cognitive Functioningto get an idea of the typical naturalprogression of cognitive recovery from amoderate or severe brain injury, which cantake from days to months or even years tooccur. Unfortunately, some individuals arenever able to return to their former level offunctioning.

Part of the reason it is so difficult to predictrecovery after brain injury is that every braininjury is different – and it really is true.There are many factors that contribute to aperson’s ability to recover. Of course, theseverity of the injury itself is very important.However, there are many other factors thatcan affect how long it takes a person torecover from a brain injury. For example, theelderly may have slower and less complete

recoveries from brain injuries. Havingabused drugs or alcohol in the past canimpact recovery. And sometimes a personwith a brain injury has suffered other seriousinjuries at the same time, which can affectrecovery. A few of the things that can havea positive affect on recovery are good familysupport, good health before the injury andgood psychosocial adjustment before theinjury.

It is everyone’s goal to maximize thepatient’s recovery and ability to liveindependently or with very little help. Someindividuals will eventually reach the goal ofbeing able to live independently, and returnto activities such as work and driving;however, others may continue to need morehelp from family and friends. There is nopromise how much or how quickly eachperson may recover. Each person recovers athis or her own pace.

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 1 6

Brain injury rehabilitation occurs in manysettings throughout the WakeMed system.The patient may pass through severaldifferent rehabilitation settings as he or sherecovers from the brain injury, and differentpeople spend different amounts of time ineach setting. When a person progresses fromone setting to the next, therapistscommunicate with one another to maintaina good continuity of care.

T R A U M A C E N T E R /

A C U T E H O S P I T A L

If a patient sustains a brain injury and isadmitted to WakeMed for emergencymedical management of his or her injury, heor she will typically begin to receiverehabilitation services as soon as medicalstabilization occurs, often within the first 24hours following an injury.

N E U R O C A R E U N I T

This acute hospital unit at WakeMed isspecially designed for individuals with moresevere injuries, who are medically stable, andcan benefit from coordinated rehabilitativeservices, but may need more time to recoverbefore being ready to move to the next step.

While on the NeuroCare Unit, eachpatient’s schedule will be individualized toaccommodate the patient’s current level offunctioning. Therapies available includeoccupational therapy, physical therapy, and

speech therapy. In addition, patientstypically receive neuropsychological services,and therapeutic recreational services areavailable on an as-needed basis. Therapiesare available Monday through Friday, with atypical schedule being occupational,physical, and speech therapy one to twotimes per day. However, this may varydepending on the individual needs of thepatient. Patients may be scheduled fortherapies any time between 9:00 am and4:00 pm, usually with a break over lunchfrom 12 to 1:00.

WA K E M E D R E H A B I L I TA T I O N

H O S P I T A L

If your family member needs intense,inpatient rehabilitation, he or she may beadmitted to WakeMed RehabilitationHospital, where a coordinated,comprehensive rehabilitation program willbe developed. While in the Rehab hospital,each patient will get a minimum of threehours of therapy per day. Available therapiesinclude occupational therapy, physicaltherapy, and speech therapy. In addition,patients will receive neuropsychological, andtherapeutic recreation services on an asneeded basis. Pet therapy dogs visit onoccasion as well. Typically, between 7:00 amand 8:30am, the occupational therapist willbe assisting patients with ADL’s (grooming,bathing, dressing, toileting, feeding).Patients may be scheduled for therapies anytime between 8:30 am and 5:00 pm, with a

[REHABILITATION SETTINGS]

1 7 | W A K E M E D R E H A B

break over lunch from 12 to 1:00. Thetherapists assigned to the patient will set upthe patient’s Monday through Fridaytherapy schedule on the day of admission. Aschedule card is placed in a plastic sleeve onthe patient’s wheelchair. Saturday andSunday therapy schedules will be posted inthe same place, each Friday evening.

D A Y T R E A T M E N T

P R O G R A M S

WakeMed Rehab offers “day treatment”services. Individuals live at home, but comein several days a week for continuedcoordinated, multi-disciplinary care withoversight by a case manager. Whenattending day treatment program, eachpatient’s schedule is individualized. Thenumber of hours per day, and days per weekof therapy to be given will be determined bythe treatment team upon admission to theprogram, after the initial evaluation iscompleted. Therapies offered includeoccupational therapy, physical therapy, andspeech therapy. In addition,neuropsychological services, nursing services,and case management services are available.

O U T P A T I E N T T H E R A P Y

S E R V I C E S

If less intensive services are needed, or if justa single service is needed, an individual mayreceive outpatient treatment at one ofWakeMed’s many outpatient rehabilitation

sites. WakeMed currently offers outpatientrehabilitative services at several sites inRaleigh, as well as in Cary, Apex andClayton. When receiving outpatient therapyservices, each patient’s schedule isindividualized. The number of hours perday, and days per week of therapy to begiven will be determined by each individualtherapist upon admission to the program,after the initial evaluation is completed.Therapies offered include occupationaltherapy, physical therapy, and speechtherapy.

H O M E H E A L T H T H E R A P Y

S E R V I C E S

If after discharge from the hospital thepatient is home-bound, and meets certaincriteria, WakeMed may send rehabilitationtherapists to your home to providerehabilitative services. The number of hoursper day, and days per week of therapy to begiven will be determined by each individualtherapist upon after the initial evaluation iscompleted. Therapies offered includeoccupational therapy, physical therapy, andspeech therapy. In certain cases, a nurse mayalso visit the home.

The BIRS program includes treatmentpathways for use in guiding treatmentthroughout the continuum. There are 4different pathways. The particular pathway apatient is placed on is determined by his orher Rancho Los Amigos Level of CognitiveFunctioning. Each patient will be assigned

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 1 8

to a particular pathway upon admission,based on his or her Rancho Level ofcognitive functioning at the time ofadmission to the program. If a patient showsimprovement in cognition, he or she will beadvanced to the next pathway. Thetreatment pathways include specific areas oftreatment across all functional areas,including time frames in which those areasare to be addressed, and which treatmentteam members will be addressing them. Thisinsures timely and comprehensive treatmentappropriate to each individual patient’s levelof functioning.

The different pathways are as follows:

• Sensory Regulation – for patientsfunctioning at Rancho Levels II & III

• Neurobehavioral – for patients functioningat Rancho Level IV & V

• Cognitive Rehabilitation – for patientsfunctioning at Rancho Levels VI & VII

• Executive – for patients functioning atRancho Level VII or higher

[BIRS TREATMENT PATHWAYS]

1 9 | W A K E M E D R E H A B

Family involvement in a patient’s care isboth encouraged and appreciated. Familymembers are considered important membersof the treatment team, and good familysupport and involvement can be veryimportant to a patient’s overall recovery.There are a number of ways in which weinvolve families.

C A S E M A N A G E M E N T

The clinical case manager serves as the teamleader and as a point of contact for patientsand their families with the medical/therapystaff. The case manager can help the patientand his or her family with personal,financial, emotional, and social issues thatmay arise during the hospital stay. The casemanager will meet with the patient and/orfamily upon admission to rehab to providean overview of the rehab process. At thismeeting, the case manager will gatherinformation about the patient in order toassess needs and allow the team to know thepatient better. The case manager can alsoarrange individual and group counseling tohelp patients and families learn to cope withproblems resulting from the brain injury.The case manager also provides informationto insurance companies for their review ofthe patient’s hospital stay.

The case manager can assist patients andfamilies in coping with the emotions thatoccur throughout the recovery process. Thecase manager can also refer patients and

families to ongoing counseling in thecommunity as well as support groups.

There are also a number of legal andfinancial issues that may need to beaddressed, if the patient is going to behospitalized and/or incapacitated for aperiod of time. Examples of these issues can be:

• Guardianship

• Advanced Directives

• Short Term/Long Term Disability

• Supplemental Security Income (SSI)

• Social Security Disability Income (SSDI)

The case manager will also be the patientand family’s point-person for dischargeplanning. Throughout a patient’s hospitalstay, the case manager will be discussingoptions that are available for discharge, andwill work with the patient and family to planfor a safe discharge. Patients are typicallydischarged from the rehab program whenthey have achieved their discharge goals orprogressed to a level that allows them toreceived rehab services in a home caresetting, outpatient center or alternative caresetting. Occasionally, patients are dischargedif they fail to demonstrate significantprogress in therapies over a period of time,or cannot tolerate the level of therapyrequired by the program. Preparing fordischarge from the rehab unit can be veryoverwhelming for many patients andfamilies. The case manager will be availablethroughout a patient’s stay to discuss

[FAMILY INVOLVEMENT]

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 2 0

discharge needs and options, and to ensure asafe, smooth discharge from the rehab unit.

Whether a patient is going back home or toanother location, the case manager will workwith the patient and family to help todetermine the best way to make thistransition. If going home at discharge is notan option, the case manger will help to finda nursing home or assisted living facility thatcan continue to meet the patient’s needs. Ifthe patient is to return home at discharge,and will continue to need therapy, outpatientrehab, day treatment, or home healthservices can be set up, depending onindividual need. The case manager willarrange follow up therapy and order anyequipment needed before the patient leavesthe hospital. The case manager can makereferrals to community resources that cancontinue to help the patient and family afterdischarge.

M E D I C A L R O U N D S

During the stay in the Neuro Care Unit orRehab hospital, the physiatrist (a physicianwho specializes in physical rehabilitation)and a physician assistant (PA) or nursepractitioner (NP) will visit with patientsevery morning. They will address any activemedical issues and make any necessarychanges in care. This may include changingmedication, ordering tests to diagnose newproblems or monitor existing ones, andreferring to other healthcare specialists toaddress specific issues. The doctor and the

PA or NP will work closely with the nursingstaff, case manager and the therapy staff, andwill meet with them formally every week tocoordinate care. If necessary, they will alsobring in other physician specialists to assistwith a patient’s care.

If there are medical questions or concerns,please bring them to the attention of thenurse or case manager.

N U R S I N G C A R E

Upon admission to the Neuro Care Unit orRehab hospital, the admitting nurse will doa complete physical assessment includingheart and lung sounds and examination ofskin for wounds, rashes or reddened areas.The patient and family will be given a copyof My Important Papers which will havehelpful information including patients’rights, advance directives, pain management,and unit-specific information. The patientand family will be asked to answer questionsas part of a nursing admission assessment.They will also be asked to sign a consentform granting permission for use of the“whiteboard” in the patient’s room. Thewhite board is used to record importantinformation needed to coordinate thephysical care of the patient. For example, itwill indicate how much, and what type ofassistance a patient needs with transfers toand from the wheelchair. Caregivers canlook at this board and have a snapshot ofwhat is needed to care for the patient.

[FAMILY INVOLVEMENT]

2 1 | W A K E M E D R E H A B

We always encourage family participation ina patient’s day-to-day care. We will try toinclude families during personal care, iffamily is present and willing to participate.We ask that families do not try to transferpatients to or from the bed, wheel chair, orcommode, or provide personal care, untilthey have had training by the nursing ortherapy staff (formal family educationsessions will be set up by the case manager).Because brain injured patients may becomeover stimulated or agitated easily, we reservethe right to ask visitors to step out, and tolimit visitors to 2 at a time. Nursing staffwill provide education to patients andfamilies regarding care, medications, andmedical conditions to patients and familiesand do much informal education. Our goalis to enable the families to care for patientsin the safest possible way as they reach theirfullest potential.

Upon admission to one of our day treatmentprograms, the patient and family will meetwith a Rehabilitation Nurse who will do acomplete physical assessment. During theinitial session with the nurse the patient andfamily will be asked to provide informationregarding any current medical issues, a list ofcurrent medications, and a list of follow upphysician’s appointments. The nurse willprovide written and verbal education topatients and families regarding brain injuryand recovery and will continue to beavailable as needed throughout the daytreatment stay.

F A M I L Y T R A I N I N G

S E S S I O N S

At some point in a patient’s rehabilitation,often shortly before discharge from thehospital, or prior to a planned day pass,family members who will be responsible forcaring for the patient will be invited toaccompany the patient to his or hertherapies, so that instruction can be providedon such things as assisting with walking,assisting with bathing and dressing, assistingwith transferring the patient to and from thewheelchair, bed, commode, car, etc. Teachingon special dietary or swallowing precautions,or administration of medications might beprovided as well. This training is designed toprepare families to be able to care for thepatient when he or she is discharged fromthe hospital. Depending on the needs ofeach individual patient, sometimes familieswill only need to attend one session. Othertimes, multiple sessions will be needed. Thecase manager will be responsible forarranging these sessions at a time that is asconvenient as possible for the patient’sfamily.

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 2 2

Patients who are receiving inpatientrehabilitation on the NeuroCare Unit, or inthe Rehab hospital will typically be dressedin street clothes each morning, so they willneed several changes of clothing. Loosefitting clothing like T-shirts and elastic waistpants are the best choice. The patient willalso need a good pair of shoes such assneakers. Dirty linen will be gathered in abag in the patient’s bathroom, to belaundered by the family. Families are askedto bring in personal toiletries, such asdeodorant, shampoo or body wash that thepatient prefers to use. Electric razors mayalso be brought in. Other personal itemssuch as radios or CD players can be broughtin, but the hospital cannot be responsible forlost or stolen items.

This notebook insert was meant to provideyou with introductory information aboutbrain injury and the rehabilitation process.

W H A T T H E P A T I E N T W I L L

N E E D W H I L E I N T H E H O S P I T A L

2 3 | W A K E M E D R E H A B

As you become more familiar with braininjury, you will probably have many morequestions. WakeMed’s staff has a great dealof expertise and experience in this area andwill provide you further information oranswer your questions throughout therehabilitation process. In addition, you mayfind the resources listed below helpful:

Brain Injury Association of North Carolina6604 Six Forks Rd. Suite 104Raleigh, NC 27615Phone: 919-833-9634 Fax: 919-977-0044Toll Free: 800-377-1464 bianc@bianc.net

Brain Injury Association of America105 North Alfred StreetAlexandria, VA 22314Phone: 703-236-6000National Family Help Line: 1-800-444-6443www.biausa.org

B R A I N I N J U R Y S U P P O R T

G R O U P S :

RaleighMeets the third Tuesday of each month at 7pm in WakeMed Conference Dining. Formore information, call Monica McGrath,800-377-1464.

CaryMeets the first Monday of each month from6:30-8 pm at WakeMed Cary Hospital,Conference Room A. For more information,call Amanda Benson, 919-469-9880 orDavid Baack, 919-460-9094.

[RESOURCES]

B R A I N I N J U R Y P A T I E N T E D U C A T I O N | 2 4