BJ LeJeune, CRC, CVRT
Mississippi State University
What is it all about??
`Traumatic brain injury is an insult to the
brain…caused by an external physical force,
that may produce a diminished or altered
state of consciousness, which results in an
impairment of cognitive abilities or physical
functioning. It can also result in the
disturbance of behavioral or emotional
functioning. These impairments may be
either temporary or permanent and cause
partial or total functional disability or
psychosocial maladjustment.’
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An acquired brain injury commonly results in
a change in neuronal activity, which effects
the physical integrity, the metabolic activity,
or the functional ability of the cell. An
acquired brain injury may result in mild,
moderate, or severe impairments in one or
more areas, including cognition, speechlanguage communication; memory; attention
and concentration; reasoning; abstract
thinking; physical functions; psychosocial
behavior; and information processing.
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Diffuse Axonal Injury
Concussion (mildest and most common)
Contusion (bruising)
Coup-Contrecoup Injury (two part blow)
Second Impact Syndrome "Recurrent Traumatic
Brain Injury“
Skull Fracture
Penetration Injury
Shaken Baby Syndrome
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Anoxia (lack of oxygen to the brain)
Brain Swelling – can restrict blood flow,
oxygen and can lead to death
Hematoma (pool of blood)
Hypovolemic Shock (loss of blood in brain
tissue)
Hydocephalus – build up of liquid that can
cause a secondary brain injury
Increased Intracranial Pressure (ICP)
Seizure Disorders
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Severity of insult to the brain
Length of time in coma
Deepness of coma
Functional physical and behavioral attributes
Area of the brain impacted may cause
devastating effects of even a mild injury.
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Range of high of 15 to low of 3
◦ Higher the score the lower the degree of
impairment.
◦ Mild Injury – 13-15
◦ Moderate injury 9-12
◦ Severe – less than 8
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Motor response (1-6)+ eye opening (1-4)+
verbal response (1-5)
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Loss of
consciousness for
less than 30
minutes
Glasgow Coma
Scale 13-15
Post Trauma
amnesia of <24
hours
Temporary or
permanent altered
mental or
neurological state
Post concussion
symptoms
Mild Brain
Injury
• Loss of
consciousness for
more than 30
minutes, but less than
24 hours
• Glasgow Coma Scale
8-12
• Possible Scull
fractures with
bruising/bleeding
Signs on EEG, CAT or
MRI scans
•Some long term
problems in one or
more areas of life (i.e.
home, work,
community)
Moderate Brain
Injury
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Coma longer than 24
hours
Glasgow Coma Score
3-8
Bruising/ bleeding in
the brain
Signs on EEG, CAT or
MRI scans
Long Term
Impairments on one
or more areas of life
(i.e. home, work,
community)
Craniotomy Surgical intervention
Severe Brain
Injury
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Pre-injury Health (General health, substance
abuse, IQ, and previous brain injuries)
Nature and severity of injury (Severity,
location, extent and complications)
Complications associated with injury
(litigation, secondary injuries, other disabling
conditions, etc.)
Post-injury course of recovery (Recovery time,
continuum of care and psycho-social issues)
Network of support
Where is the injury and what is
the impact?
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Frontal Lobe- associated with reasoning,
planning, speech, movement, emotions,
personality, motivation, judgment, inhibition,
and problem solving
Parietal Lobe- associated with sense of
physical awareness, touch, movement,
orientation, recognition, perception of stimuli
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Occipital Lobe- associated with visual
processing
Temporal Lobe- associated with perception
and recognition of auditory stimuli, memory,
taste, smell, putting things into memory,
interpretation of words, organization of time,
and speech
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Visual-spatial impairment
Visual memory deficits
Left neglect (inattention to the left side of the
body)
Decreased awareness of deficits
Altered creativity and music perception
Loss of “the big picture” type of thinking
Decreased control over left-sided body
movements
Manic episodes
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Difficulties in understanding language
(receptive language)
Difficulties in speaking or verbal output
(expressive language)
Catastrophic emotional reactions
(depression, anxiety)
Verbal memory deficits
Impaired logic
Sequencing difficulties
Depression
Decreased control over right-sided body
movements
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Visual perception is a brain issue
The eye processes light and changes it to
electronic impulses
The brain receives the impulses and changes
them into an image
Visual understanding is a combination of the
entry of light impulses to the brain and the
brain’s ability to interpret those impulses.
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Loss of half-field of vision in each eye
Characterized by bumping into things,
visually missing door jams, etc.
Left side causes difficulty reading or noticing
things on the left.
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Treatment: Visual Field Awareness System
(Dan Gottlieb)
Peli Lens
Training in scanning techniques
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Most frequently person will neglect certain
visual positions – usually on the left
Different from field losses
Tend to veer to the left when walking
Bump into things in the neglect area
Even visual memory may be missing
the neglected area
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Depth perception issues
Personal Boundary Issues – body space issues
Eyes functioning differently both in terms of
movement and focal points
Complexity issues
Difficulty locating obvious objects – Kite in
clear sky…
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Learning to attend to areas of neglect
Scanning – perhaps with each step
Memory Issues – remembering to look
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Saccadics (shifting gaze) Missing locations of
items
Accommodative ability (inability to change
focus)
Eye tracking (difficulty following movement)
Binocular abilities (Eye alignment/eye
teaming)
Nystagmus – fairly common result of vision
distruption from brain injury
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Retraining/strengthening muscles for
strabismus
Medicinal Options (Nystagmus – Xanex)
Rest – often worse when person is fatigued
Surgical Options
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Eye strain can be related to dry eyes – caused
by a number of things including lack of blink
reflex
Confusion concerning content or recognizing
words
Treatment: Frequent breaks, in some cases
relearning reading, use of audio reading
materials, artificial tears
fi uyo nca ared stih, uyo vhea a sgtraen nmdi too
i dcnuotl lvbeiee tath I lcudo aulaclty seudnatndr
awth I saw dranige.
The hpaonmnale wpero of the mhuna nmdi,
oaccdrgin to a srcheeahcr at mcabriged miuervtysi,
it sden’to tmaert in wath eorrd the tlterse in a rwod
are, the loyn piroamttn ithgn is atth the rfsti and
slta tltere be in hte grhti cplea. hte srte can be a
atolt smes and oyu can isllt arde it hwotuti a
bpoerml. iths is cbuseea the uhanm nmid edos ont
raed ervey lteter by sitlfe, ubt the rwod as a lwoeh.
Zanmig huh? yaeh and I walysa tghuhto pslelign
was ipmorattn!
fi yuo cna raed tihs, yuo hvae a sgtrane mnid too
i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd
waht I was rdanieg.
The phaonmneal pweor of the hmuan mnid,
aoccdrnig to a rscheearch at Cmabrigde
Uinervtisy, it dseno't mtaetr in waht oerdr the
ltteres in a wrod are, the olny iproamtnt tihng
is taht the frsit and lsat ltteer be in the rghit
pclae. The rset can be a taotl mses and you can
sitll raed
it whotuit a pboerlm. Tihs is bcuseae the huamn
mnid deos not raed ervey lteter by istlef, but
the wrod as a wlohe. Azanmig huh? yaeh and I
awlyas tghuhot slpeling was ipmorantt!
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Most frequent in the first year
Very real or awareness they are not real
Benign, threatening, traumatic
Charles Bonnet Syndrome
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Increased sensitivity to light
Causes headaches, pain, anxiety
Photophobia
Treatment: Filters (amber,
violet, brown with UV & BV
protection)
wide brimmed hat
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Inability to recognize faces, objects, letters
Concentration card game
Deficiencies are inclined to effect reading and
spelling
Treatment: Developing
 Memory Skills, Alternative
strategies (50 First Dates)
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Most common in children
blurred and double vision (lasts 6-12 months)
Can bring about the onset of vision related
mannerisms (Blindisms)
What to expect post injury –
the question everyone wants
answered!
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“There are three rules to be effective in
helping someone with a severe brain injury
become totally restored, but unfortunately no
one knows what they are.”
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Restoration – Life returns to what it was before.
What they want. What they may believe.
Rehabilitation – Individual maintains some
progress toward recovery, learns alternative
strategies and develops a support system to
meet needs where there will be no functional
return. What they may get if they work hard and
have appropriate support.
Status Quo – usually accompanied by depression
and lack of personal, community or disability
related resources. What often happens.
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Neuroplasticity (also referred to as brain
plasticity, cortical plasticity or cortical remapping) is the changing of neurons, the
organization of their networks, and their function
via new experiences. ...
Often thought of as the brain's ability, during
infancy, to be altered by environmental
stimulation as a child grows.
Now being applied to persons who have
experienced injury to the brain and are relearning
tasks and abilities they have always had.
Requires repetition, repetition, repetition.
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The Rest Theory - Immediate to a year – rest,
rest, rest. The brain needs to rebuild and
reorganize. Rest. Do nothing.
The Active Theory – As soon as ICP is stable
and the acute phases are over – get moving
and get the blood flowing to the brain. Rest –
exercise – rest – exercise…
Both – even early on in ICU, send as much
nutrition to the brain as possible – ingest at
least 2,000 calories per day.
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TBI is a chronic disease process, one that fits the World
Health Organization definition as having one or more of
the following characteristics: it is permanent, caused by
non-reversible pathological alterations, requires special
training of the patient for rehabilitation, and/or may
require a long period of observation, supervision, or
care.
TBI is associated with increased incidences of seizures,
sleep disorders, neurodegenerative diseases,
neuroendocrine dysregulation, and psychiatric diseases,
as well as physical symptoms that may arise and/or
persist for months to years post-injury.
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Brain injury rehabilitation involves two
essential processes:
1. Restoration of functions
that can be restored
2. Learning how to do things
differently when functions
cannot be restored to pre-injury level.
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Current estimates state that at least 5.3 million
Americans have a long-term or lifelong need for
help to perform activities of daily living as a result
of a TBI. In the Children's Health Act of 2000,
Congress recognized that the estimated figure of
5.3 million Americans living with TBI-related
disability is an under-count. This figure is based
on the number of individuals discharged from a
hospital following an overnight stay.
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Strike these words from your vocabulary!
With brain injury comes insecurity, anxiety
and sometimes an unwelcome dependency.
If you don’t have someone to encourage and
help you, you will likely not be able to be
independent.
Grieving and depression are difficult to shake
because of constant reminders of what you
can no longer do.
What can be done to restore functioning and
to find alternative methods of functioning?
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Fatigue (insomnia)
Poor Time Management
Lack of ability to identify or solve problems
See self as pre-injury person. Difficulty selfregulating
Inappropriate social interactions (especially
with frontal lobe injuries)
Easily distracted with difficulty returning to a
task
Difficulty coping with noise, crowds, high
stimulation environments and stress
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Brain Injury Check List
http://www.headinjury.com/checktbi.htm
Then, on a scale of 0 to 4 rate the effect of
the impairment on you during the past 24
hours. For example: 0 = not present; 1 =
minimal, present but does not interfere with
activities; 2 = mild, some effect, interferes
with activities but not disabling;3 =
moderate, greatly interferes with activities;
and a score of 4 = extremely
disabling, unable to function.
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Move person toward employability and
independence.
Identify non-functional areas, and develop a
plan to address those areas.
Coordinate resources – interact with a team
including Certified Brain Injury Specialists
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Evidence-based practice (EBP) "is the
integration of best research evidence with
clinical expertise and [consumer] values"
(Sackett, Straus, Richardson, Rosenberg, &
Haynes, 2000, p. 1). Clinical expertise
refers to the use of practice skills and past
experience to rapidly identify each
[consumer's] unique circumstances and
characteristics, "their individual risks and
benefits of potential interventions, and their
personal values and expectations" (p. 1).
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Literature Review of Research Findings
Randomized Controlled Experimental
Research
Unrandomized Controlled Experimental
Research
Single Subject (Retrospective, Replicated)
Case Studies (Retrospective)
Expert Opinion
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Article by Faydl, & McPherson: A Review of
the Evidence
Systematic Literature Review
Goal 1 – To identify approaches most
commonly used with persons with TBI
Goal 2 – To evaluate the evidence of prior
research to determine effectiveness of various
approaches
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A Case Coordination Approach
Program-Based VR program based on the
NYU Medical Center Head Trauma Model
(Ben-Yishay, 1987)
Individualized Placement Model of Supportive
Employment
Faydl, & McPherson rated findings as weak,
moderate and strong evidence of
effectiveness
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Holistic approach based on individual
assessments and implemented by a case
manager
Focus on early intervention and continuity of
care
Coordination of post-acute rehabilitation
services with integration of VR services and
appropriate and available community
resources
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Based on 9 research articles
Moderate evidence that it produces higher
employment and productivity outcomes than
previously reported.
80% in community based employment, 50% in
paid competitive employment without any
supports up to one year after placement.
Weak evidence that people who receive
intervention in first year are placed in
employment more quickly than those who did
not receive intervention in the first 12
months.
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Early and quick job placement with minimal
pre-employment training. Training is
primarily delivered in the context of the
working environment.
Intervention is delivered almost entirely onthe-job by a job coach and continues until
competency is reached.
Intervention time and depth are not limited or
specified but evolve as needs arise.
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Weak evidence that persons who were not
employed post injury were able to become
employed within the model.
Weak evidence that employment can last
longer than 90 days
Outcome is competitive wage employment
with on-going job coach support.
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Based on NYU Medical Center Head Trauma
Program model
Intensive individualized work skills
rehabilitation and intervention in a structured
environment (i.e. Center)
Guided work trials
Assisted job placement with transitional job
support
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Weak evidence that individuals have better
vocational outcomes after completing a
program
Weak evidence that people in this type
program are more likely to gain competitive
employment, work more hours and receive
higher wages
Weak evidence that approximately half retain
employment more than a year.
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78 participants randomly selected from pool of 220
in Missouri.
Young, male, uneducated and relatively low
intelligence with moderate and severe head injuries
Time from injury to VR referral approximately 9
years, number of jobs held in previous 3 years 2
1/3 had additional physical disabilities
1/5 had history of a learning disability
¼ reported history of substance abuse
1/3 lived in rural areas – 1/2 in urban areas
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Successful employment outcome for 17%
All but 2 in either industrial or service industry
10% unsuccessful,72% services interrupted
Reasons for unsuccessful closures (n=64)
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Client refused services
Failed to Cooperate
Unable to contact client
Too severe a disability
Not severe enough
Unknown
35
11
4
4
2
8
This means 71% (n=64) of unsuccessful closures
had some type of non-cooperation.
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On-the-Job-Training
Counseling and Guidance
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Providing VR services early in the
rehabilitation process (question related to
how early)
Create a supportive work environment
Provide cognitive skills training
Provide AT and train on its use
OJT helps (Johnstone, Vessell, Bounds et al,
2003)
Those with lowest rates of return to work
(RTW) receive SSDI benefits
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Behavioral Control must precede Cognitive
and Physical Rehabilitation (Falconer)
Head Injured Individuals require tight
structure in their daily lives to survive, grow
and improve (Falconer).
The most effective rehabilitation following a
head injury occurs in familiar settings.
(Falconer)
To be effective, the entire family must be
part of the rehabilitation process.
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Avoid alcohol (for at least 2 years)
Keep your brain stimulated – keep learning
new things.
Repetition, repetition, repetition – you are
teaching your brain to think in different ways.
You will continue to improve, but you may
not ever be exactly the same as before.
Self-examination is difficult, but it is the first
step to improvement.
Find someone you trust to give you nonjudgmental feedback
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Initially, it is easier and more productive to
modify the environment than the person.
At first, it is often difficult to reason with a
person who has a severe head injury because
they perceive themselves as functioning at their
pre-injury levels and get frustrated when they
cannot.
Repetition, Repetition, Repetition to improve
brain plasticity. Patience is the key.
Always tell the Truth
Always be positive and encouraging.
Important to be able to:
◦ Identify areas that need work
◦ Plot progress and regressive areas
◦ Develop a plan
 Brain Injury Self-Assessment Checklist
www.headinjury.com/checktbi.htm In the last 24
hours have you noticed…
 Three areas of functioning 1) intellect 2)
emotionality 3) control
 Rating scale 0 = not present, 1=minimal, 2=mild,
3 =moderate, 4 = extremely disabling
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Memory
Easily distracted
Fear of loss of control
Mood swings
Easily fatigued
Trouble sleeping
Irresponsibility
Overly sensitive
Double vision
Blurred vision when fatigued
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“Use metaphors frequently when trying to
explain complex ideas.” (John Blyer)
Beware of “Cognitive Fatigue.” (John Byler)
“When you have a great success, be aware
of the rebound of fatigue that often
follows.” (John Byler)
“To speed up your recovery – go slow.” (Just
Joe)
“Even a “mild” traumatic brain injury
impacts your whole life.” (Fran Coleman –
former CO legislator)
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“Over stimulation is paralyzing. The more
complex the situation, the more difficult it is
to decide what to do - all input has equal
value to you.” Gail Denton
“I thought I had a good attitude and I would
get well – but, how many naps do you have to
take?”
“People will tell you that you look great to
encourage you, and if they are around you for
short periods they will think you are fine –
maybe even malingering. But you are not
fine.”
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“It is hard to realize that you can never live up
to who you remember yourself being before
the injury.” Lisa
“Failure and disrespect from colleagues is
difficult to accept. Before my injury, I hardly
ever experienced failure, now I fail all the
time. But failure is not the opposite of
success, it is part of success. You have to
have the courage to keep trying through the
pain… Support of family is critical.” Lisa
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What can the person learn?
What strategies will enhance learning?
◦ Familiar settings
◦ Situational instruction
◦ At least daily, at time when the person is not
fatigued.
◦ As much as possible, include a significant other
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Brain Plasticity – In order to retrain the brain
you must repeat, repeat, repeat.
Patience in the key for both the consumer
and the instructor
Restructure the when’s, what’s, and where’s
of instruction…
 Old Lesson Plans will not work – small
increments and repetition – work on
generalizability
 Need tangible reminders
 Environment changes are
more productive than trying
to change people.
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What every person wants ….
If you have worked with one person with a
brain injury, you have met one person with a
brain injury. Everyone is different.
Rosa Schwarz Cifu, PhD
“You cannot reason with someone
who has had a severe brain
injury…”
Nurse on Trauma
Floor, UTMC –
Knoxville, TN
It is often more
productive to change
environments rather than people
(or bears)!
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Ben-Yishay, Y., Silver, S.M., Piasetsky, E., and
Ratok, J. (1987). Relationship Between
Employability and Vocational Outcome after
Intensive Holistic Cognitive Rehabilitation.
Journal of Head Trauma Rehabilitation, 2(1),
35–48.
Brain Injury Association of America
www.biausa.org
Brainline www.Brainline.org
Defense and Brain Injury www.dvbic.org
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Catalano, D., Pereira, A.P., Wu, M.Y., Ho, H.,
and Chan, F. (2006). Service patterns related
to successful employment outcomes of
persons with traumatic brain injury in
Vocational Rehabilitation.
NeuroRehabilitation, 21, 279–293.
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Fadyl, J.K. and McPherson, K.M. (2009).
Approaches to Vocational Rehabilitation after
traumatic brain injury: A review of the
evidence. Journal of Head Trauma
Rehabilitation, 24, 195–212.
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Falconer, Judith (2011) Recovering from Brain
Injury: A continual process. Retrieved from
http://www.braintrain.com/articles/recoveri.htm
Johnstone, B., Vessel, R et al.(2003).
Predictors of success for vocational
rehabilitation clients with traumatic brain
injury. Arch Phy Med, 84.
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Masel, B. & Dewitt, D. (2010). Traumatic brain
injury: A disease process not an event.
Journal of NeuroTrauma 27, 1529-1540.
Ownsworth, T. & McKenna, K. (2004).
Investigation of factors related to
employment outcome following traumatic
brain injury. Disability and Rehabilitation, 26
(13) 765-784.
Severe Brain Injury www.severe-braininjury.com
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Traumatic Brain Injury Information Page
www.ninds.nih.gov
You look great!” – Inside a Traumatic Brain
Injury, by John Byler Series of videos (1-6)
http://www.youtube.com/watch?v=x9Xso4qG
dlI&feature=BFa&list=UU4rKJPrfkyM5g_mdnY
HZe3A
Just Joe Image www.justjoeimage.com
VR Research in Brief: Achieving Vocational
Success after Traumatic Brain Injury .
http://www2.ed.gov/rschstat/research/pubs/
vrbriefs/vrbrief-success-after-tbi.pdf
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“You look great!” – Inside a Traumatic Brain
Injury, by John Byler Series of videos (1-6)
www.youtube.com/watch?v=x9Xso4qGdlI&fea
ture=BFa&list=UU4rKJPrfkyM5g_mdnYHZe3A
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Don’t Give Up After Brain Injury
www.youtube.com/watch?v=R76RMK4EXUc&f
eature=related
Understanding Traumatic Brain Injury
www.youtube.com/watch?v=9Wl4nNOGJ0&feature=related