NORA can provide you with the name of a specialist in your geographical area and the status of that individual’s certification.
Neuro-optometric examination of TBI patients involves the exploration of the many integrated subsystems that comprise the visual process. Such an examination will usually require more than one visit and may involve two to four hours of examination and analysis. The first step in a comprehensive neuro-optometric examination is the establishment of the integrity of each eyeball as a receptive organ representing the first step in the visual process. Next, a refractive analysis is performed (similar to a routine eye glasses or contact lens examination). After establishing the state of integrity of the structures of the eyeball and its refractive status, then a 21-point probe battery is performed to evaluate the oculo and sensory motor subsystems of the visual process. The result of that probing process directs the examining doctor to further in-depth, sustained, performance-based visual studies to evaluate the integrity of information processing of the visual system and visual perceptual status.
It must be appreciated by patient and all health care professionals dealing with the head-injured patient that it is rarely the eyeball that is the problem. The problem exists in the brain stem, the infra and supra nuclear processing centers that integrate the visual information accessed by the two receptor organs (eyeballs) to a final binocular perception Efficient binocular input facilitates cerebral processing and association with previously acquired (learned) experience, information, and new input information, producing a final meaningful and accurate cognitive perception. This in-depth examination and analysis will result in a diagnostic statement/report describing the domains of dysfunction (diagnosis), a clinical estimate of potential for rehabilitation and recovery (prognosis), and a plan recommendation for rehabilitation.
REFERENCES:
*For those professionals interested in further research, NORA maintains a bibliography in excess of 200 citations relating to visual dysfunction secondary to traumatic brain injury and optometric rehabilitation.
QUESTION:
Since the accident, I can’t see as well as I used to. My visual field is limited. In other words, sometimes I can only see a narrow focal point; my peripheral vision is limited. I’m wondering if my eyeball is damaged or if this problem is due to brain damage. Should I see a neurologist or an eye doctor?
ANSWER
The patient’s experience of limited or loss of visual field is a common occurrence in head injury. This phenomena may be a mild field compression that is the result of stress secondary to binocular decompensation (refer to the related FAQ on vision problems) or it may be as serious as neurological damage of the retina, optic nerve, optic visual pathway (from eyeball to brain ), or damage within the visual cortex of the brain .
In mild closed head injury, this phenomena is statistically most frequently a field compression that is secondary to stress of decompensation. This type of field restriction is generally resolved as the components of binocular decompensation are rehabilitated. The diagnostic probes to determine the nature of the visual field restriction, neglect or scotomotous (retinal zone) loss. The in-depth and hierarchical diagnosis of this problem is the domain of the rehabilitative (neuro) optometrists. If retinal damage is identified, the rehabilitative optometrist will refer that patient to a vitreo-retino specialist. If damage to the brain is identified, this is usually diagnosed by the neurologist prior to the patient being examined by the rehabilitative neuro-optometrist. The MRI is usually the definitive diagnostic tool for delineating brain lesion location and extent. The MRI, however, is supported by functional/behavioral diagnostic analysis.
In summary, visual field constriction or loss rarely exists in the absence of the other common dysfunctions of vision subsequent to head injury. When in doubt, the patient should see the rehabilitative (neuro) optometrist who will provide the triage to determine the appropriate management of the condition.
QUESTION:
What are some vision problems that people with traumatic brain injuries may experience? How are such problems diagnosed and treated?
ANSWER
Ten years ago, I started treating people with traumatic brain injury. At that time, the typical treatment that these patients were receiving involved prescribing lenses, if necessary, to enable the patient to see clearly. If double vision were reported, the person would be patched. Many of these patients were visually frustrated trying to read, write and drive. In short, visually guided activities presented difficulties and frustrations they had not experienced prior to their injury.
Sight is the ability to see clearly; vision is the ability to derive meaning from what is seen. As a developmental Optometrist, my standard examination evaluates many aspects of human visual performance. In addition to a standard eye exam, I do an in-depth evaluation of areas such as tracking (eye movements), focusing, depth perception and binocular vision.
Typical symptoms resulting from traumatic head injury include:
1. Intermittent double vision and/or blurred vision when attempting sustained visual activities (i.e., reading or driving). Many individuals experience constant double vision.
2. Headaches, fatigue and loss of concentration while reading.
3. Loss of depth perception.
4. Loss of visual field.
5. Difficulty with eye-hand and eye-foot coordination.
6. Lack of ability to visualize; frustration doing simple puzzles.
Due to the nature of the rehabilitation process, impairments of the visual system are generally diagnosed last. Often the patient has been discharged from the hospital and the rehabilitation services available in that setting. As they attempt to resume "normal activities" in less structured surroundings, they may realize that their visual system is limiting their progress.
Typically a patient with traumatic brain injury has a significant problem in one or more areas mentioned above. The use of lenses is one of the first options available to the patient. In addition to a prescription for clarity at distance, patients can benefit from lenses used for reading. Double vision can be reduced significantly, often eliminated, by the use of specific prism lenses. Appropriate lenses have been used successfully to alter gait, movement patterns and balance. Very recently, a new lens has been developed that can allow the patient to detect motion earlier in those areas of a visual field where sight has been lost.
The patient's decreased efficiency of ocular movements and focusing abilities, binocular vision skills, and visual thinking schemes can be improved through a program of Visual Training/Therapy. Many developmental Optometrists offer this therapy which provides a unique opportunity to improve these critical areas of functioning. Treatment involves a series of activities that provide the experiences that facilitate relearning the visual processes once taken for granted by the patient. The activities do not involve "muscle building;" they instead result in changes in the thinking, perception and processing of information. It is vital that this treatment be done in an office setting and that the optometrist monitor the therapy. The treatment requires specific equipment, experience and expertise. I feel it is crucial that every patient who has experienced a traumatic brain injury be examined by a developmental Optometrist. For many, treatment can provide a pathway to improved performance in their daily activities.
QUESTION:
I have experienced significant balance problems since sustaining a severe brain injury over a year ago. I cannot tell if the balance problems are tied to my vision impairment or some other problem. Is it possible to regain my equilibrium, and if so, how?
ANSWER
Balance is maintained using a combination of systems in the body including vision and ankle, hip and trunk movements. A deficit in any of these areas has the potential to cause balance disturbances. The good news is that most balance problems can be improved with exercise and practice. Here are a few common problems which cause balance disturbances and simple ways to correct them. However, if your balance problem interferes with your ability to accomplish tasks during your day, you may want to consult your physician and ask to be evaluated by a physical therapist.
Vision Disturbances
We rely heavily on our vision to inform us of the type of surface we are walking on and use it to prep -- re for changes we may need to make to accommodate our environment. Without the use of vision, it becomes more difficult to detect changes in the angle of the surface we are walking on or to prepare for sudden changes in the surface we are walking on. If your head injury altered your vision you may need to find a way to compensate for your loss. A new pair of glasses may be needed, or you may need to use a cane to help you sense changes in the ground that you cannot see clearly. A good use of this strategy would be for someone who has difficulty going up or down stairs due to the inability to determine the height or depth of the step.
Ankle Problems
Our feet are the first part of our body to hit the ground. Deficits in our ankles cause our entire balance system to be off. If you cannot sense the ground beneath your feet, they can't properly tell the rest of your body what to do. If your ankle motion is restricted, then your feet don't have the motion needed to keep the rest of your leg and body over the area you are standing on. Performing simple Achilles' tendon or heelcord stretching can help improve motion. Practicing standing on one foot, for as long as possible, can also improve ankle strength.
The Achilles' tendon stretch is performed by standing and facing a wall. Place both hands on the wall and one foot flat on the floor behind the other. Keep your back knee straight and your front knee slightly bent. Lean forward until you feel a stretch in the back of your calf in the back leg. Hold this position for 10 seconds then stand up straight. Repeat 5 times, then switch your feet so the one that was just stretched is now in front.
Hip and Trunk Weakness
The muscles of our thighs, stomach and back all work to keep our bodies centered over our legs. If these muscles have become weak, they are less effective in helping us regain our balance and keep our bodies over our feet. Exercise can greatly improve this type of problem but the program must be tailor-made to each patient. If you suspect this type of problem, consult your doctor for a referral to a physical therapist.
]]>ANSWER
Brain injury is one of many causes of epilepsy. Epilepsy is not a disease; it is a symptom of a neurologic disorder that affects the brain. The word "epilepsy" comes from a Greek word meaning "to possess, hold or seize" and medically it describes a short-lived burst of energy in the brain . A seizure can strike anyone as a result of a variety of causes, such as a blow to the head, allergic drug reaction, and infections, for example.
There are many different forms of epilepsy, some involving convulsive episodes, while others more subtly affect a person’s ability to sustain attention or create a brief unexplained restlessness and/or experience of feeling "spaced out." Epilepsy can develop immediately after a brain injury or some months or years later, and large numbers of individuals with brain injury never develop epilepsy. The good news is most epilepsy is controllable with medication, and a person can live a normal life. Federal laws prevent discrimination against persons with epilepsy. You may wish to gather more general information about epilepsy by contacting the Epilepsy Foundation of America:
Epilepsy Foundation of America
8301 Professional Place
Landover, MD 20785
1-800-332-1000 (Voice - Toll-free)
301-459-3700 (Voice)
301-577-2684 (FAX)
1-866-748-8008 (Voice - Toll-free Spanish)
www.epilepsy.com
[email protected]
The Epilepsy Foundation offers more than 125 individual pamphlets and other publications directed to specific aspects of living with epilepsy. All the educational materials are reviewed and approved by medical experts and provide up-to-date information for many audiences. Another resource is your local public library or medical library.
]]>ANSWER #1
One of the most frequently stated complaints from survivors of brain injury is reduced memory capacity. Statistics suggest that 70% of TBI survivors continue to experience memory problems 1 year post injury. Although the degree and nature of memory impairments varies in each situation, there are common patterns. Early in the recovery many, if not most, survivors suffer from post-traumatic amnesia after a period of unconsciousness. As recovery advances, the survivor will notice continued improvements in recalling events occurring prior to the injury. Short-term memory will generally be delayed in the recovery, with few individuals having suffered moderate or severe brain injuries ever realizing 100% recovery.
Memory rehabilitation programs have been developed around the country and are a part of many inpatient and outpatient cognitive rehabilitation programs. These programs focus on teaching compensatory skills, retraining attention ability, and retraining memory processing. The research has demonstrated that "memory notebooks or logbooks" are the most cost effective ways of enhancing recall. These books act as data banks for all important dates, personal information, and anything else you want to remember. For those with a few more dollars, Neuropager has been assisting many individuals with memory impairments. This is essentially an easy-to-use "programmable" pager system that alerts you of your schedule and other information that you have instructed it to recall for you. You also can attempt to use other memory "tricks" to enhance your recall (e.g., associate names with images). Also, the old standby of rehearsal or repetition still has its place. No one strategy works for everyone.
ANSWER #2
Memory is usually one of the first problems people experience after a head injury, and it is one of the last of the cognitive functions to return. However, there are a number of things you can do that will substantially improve your memory in a short amount of time. Many of these things are simple but they require changing your lifestyle which may seem difficult at first.
First, you must get enough sleep and change your diet so that you are avoiding stimulants and nicotine. Regular exercise also will improve your memory quickly. Putting yourself in a position where you are using your memory every day also will help. For example, taking non-credit courses at a community college will improve memory. Other forms of mental activity also may help like doing crossword puzzles, playing computer games, or reading books. Learning new ways to remember also can help. For example, learning how to form mental pictures of things you want to remember or using other memory tricks such as "mnemonics" can be useful. This usually requires some amount of training and you may have to substitute these new memory habits for some older, less efficient ones. This may take time and can be frustrating.
Probably the best way to train your memory is to use the TRRAP mnemonic. These letters will remind you of all the things you need to do to enhance your memory.
T ranslate into your own words. When learning something new, say it your way.
R ehearse (repeat at least five times) immediately.
R elate the new event to something you are familiar with.
A picture is worth a thousand words. Try to picture what you hear, see, or read.
P ractice output. Practice explaining, doing, or teaching the new thing to someone else.
Memorize the Memory TRRAP mnemonic and use it to remind yourself of the things that you need to do to remember effectively. Most importantly, however, practice doing these things until they become "second nature."
QUESTION:
Ever since my car accident, I have no recollection of the event itself. I can remember things that have occurred since then and things before. However, all efforts to recall some detail of the actual wreck and the hours following during which I was taken to the hospital have failed. Is this normal? Will memories of the accident appear later in life, or with counseling or hypnosis?
ANSWER
The memory system is very sensitive to trauma, and many survivors of traumatic brain injury suffer severe memory loss. In short, the memory loss you are experiencing is very normal and you will not recover these memories. Unlike memory loss due to emotional trauma, amnesia due to brain injury has not been shown to be treatable by counseling or hypnosis.
QUESTION:
My son has played football throughout high school; he is a senior and is likely to play for a college team. Within the past year he sustained a concussion. At the time of the injury he was dazed but not knocked out. I have heard that repeated concussions are dangerous, and I am worried about my son’s future health risks. Would a second concussion compound the effects of the first injury, or would a second injury be an entirely separate concern? Are concussions which appear to be as mild as this (no loss of consciousness) anything to worry about?
ANSWER
Any concussion, including head injury which results in no loss of consciousness (yet perhaps a change in consciousness or awareness) is of medical/neurological concern. A concussion typically implies a temporary injury to the brain. Such an injury makes the brain more vulnerable to a second injury, which can create more severe impairment and a potentially longer recovery period. An applicable analogy would be the athlete who suffers an ankle sprain which, although not a permanent injury, does impair some functions on a short-term basis. That same ankle is more vulnerable to a second injury while it is healing and a resultant longer recovery curve and possibly more chronic or permanent impairment if re-injured during recovery.
The greatest concern regarding repeated concussions is for what is termed "second impact syndrome." This refers to catastrophic injury resulting from a second concussion in close time proximity to the first. Although this is a rare occurrence and can result in permanent brain injury or death, there is recent neurophysiological data which suggest that the still developing brain (under age 21) is more vulnerable to such a second impact syndrome.
As in the ankle injury scenario, there are several key variables to determining when it is safe to return to contact sports (games or practices). These include the severity of the original injury, the completeness of recovery from the original injury, and the time between first and second injuries. Most professionals agree that any concussion, regardless of severity (even without loss of consciousness), should be completely healed (no neurological, cognitive, or psychological symptoms), before the athlete should be allowed to return to games or practices (see the Cantu and Colorado Severity and Return to Play Criteria). Although there are little scientific data on which to base return to play decisions, most team physicians and high school/college guidelines suggest that risk of catastrophic second impact injury is low if return to play follows complete recovery (no symptoms) from concussion.
If a player sustains three mild concussions in a season, regardless of the fact that he/she may have fully recovered between each of these concussions, there is some limited agreement by health care professionals that the athlete should terminate any contact sports for the rest of that season and should, perhaps, consider terminating involvement in such sports in the future (Quigley’s rule).
QUESTION:
After being seriously injured in car crash, I am unable to recollect several years of my life (the years prior to the accident). Sometimes bits and pieces of memory come back when a certain familiar odor or image stimulates my mind to recall an image from the past. However, there are extensive parts of my life that I cannot recall. Is this normal? Will I recover my memory or parts of it?
ANSWER
Recall or memory problems are a common sequela to head injury. The most common form of memory problems is short-term memory for events post-accident that interfere with executive function or the normal performance of administrative duties. Amnesia for events preceding the accident are less common and more serious in nature.
The first category (short-term memory difficulties following accident) are primarily the result of binocular/ocolo sensory motor decompensation (see FAQ’s on vision). Amnesia for events preceding injury typically relate to cerebral damage and may be identifiable by MRI as a focal lesion. This type of injury is more serious and has a poor prognosis for recovery when identified as a focal lesion. However, the brain has remarkable capability for adaptation. It is always necessary in neurological matters of the brain and information processing systems to think in terms of a hierarchical model. While each of our senses contributes to memory and provides its own specific stimulus to recall, visual input to the brain is by far the most powerful and highest leverage stimulus input to the brain .
In all aspects of intellectual and cognitive function, it is essential to first re-establish the highest possible efficiency in binocular information processing. The visual information processing of the brain is analogous to the DOS system for management of computer processing and file management. Thus, the establishment of clear, single, efficient, comfortable binocular vision provides a stimulus input of lowest stress, thus facilitating more efficient cerebral processing, relieving stress that can secondarily cause memory problems.
Recall, pre-injury memory loss (amnesia), does frequently improve spontaneously with time. All such neuro-processing defects are enhanced by rehabilitative therapies that minimize cerebral processing stress, re-establishing the highest degree of normal executive function.
ANSWER #1
While moodiness is common in adolescents, dramatic mood swings are much less common. The timing of your son’s mood swings suggests they may in fact be due to his brain injury, and such alterations in mood are known to occur following a severe brain injury. I recommend that your son be seen by a neuropsychiatrist (a psychiatrist specializing in brain-related disorders). A trial period of medication may be indicated. There are medications that have been shown to stabilize the mood of persons with a brain injury. In addition to, or instead of medication, a behavior management plan put together by a neuropsychologist (a psychologist specializing in brain-related disorders) may help to reduce the extent and frequency of mood swings. Such a plan might focus on helping your son increase his awareness of when a swing may occur and train him in strategies for coming up with alternative behaviors. He must be motivated for change, of course, for this strategy to work. It is unlikely that your son is emotionally upset by the trauma of the accident. In fact, it is likely that he does not even remember the accident at all. Serious brain trauma typically wipes out all memory traces of the accident that caused it. However, his sadness could be related to his awareness of how much things have changed, or how much he has lost, since the accident. Perhaps he has had to work so hard to stay afloat in school and there has been no time for fun things. Is it possible that he might benefit from some academic support? Have his friends stuck by him? It may be helpful for him to see the school counselor in order to explore these issues and he/she will be able to make a referral to a brain injury specialist if necessary.
ANSWER #2
Youngsters who have survived severe brain injuries, like adults, can and do have delayed problems. Within the context of the excitement and thankfulness for "remarkable recovery" comes the disappointment and surprise of the delayed onset. The delayed reaction can have either a neurologic or psychological basis. About one of every four persons with a TBI experiences depression in the first few years following the injury. Some have depression early onset in their injury and frequently this is based on the brain injury (location and type of injury), while others have depression onset that emerges over the next two years. Late onset depression can be due to the emotional reaction to the changes that have taken place and more frequently have psychological factors in addition to the brain injury. The factors causing the depression are very important because your doctors and clinical specialists will choose different approaches based on the causative influences either neurologic or psychosocial. The more neurologic based the depression, the more the doctors may recommend medications to help. In contrast, the more psychosocial features, the more psychotherapeutic and social development resources may be needed in addition or by themselves.
With your youngster, the effects of his developmental age are also important. Your son’s normal adolescent development can be playing a part in the depression either because he is an adolescent or the injury interfered with his expected social development. Get a complete diagnosis that includes medical and psychosocial considerations; explore the use of both medications and psychosocial treatments. Remember the delayed onset is not unusual and your son may have recovered well enough to confront the more subtle and complex problems of social membership. In your consideration for supports, remember that the entire family is struggling and eager to succeed, so supports for all should be considered.
QUESTION:
My 19-year-old son sustained a severe brain injury when he was in elementary school. He recovered well enough to go back to school with additional help from tutors and the school counselor. Seemingly out of the blue, when he was in high school, my son began to exhibit irrational behavior, including paranoid delusions. He had never behaved this way in his life, but now he requires the care of a psychiatrist. Is it possible that the brain injury caused his psychiatric problems? If so, what specifically is the connection between brain injury and psychiatric illnesses?
ANSWER #1
Brain injuries can result in psychiatric problems directly, particularly when areas of the brain involved in emotional functioning and/or behavior are damaged. It is difficult, however, to link your son’s brain injury and his current psychiatric problems in a causal fashion given the long gap between the injury and the onset of the irrational behaviors. Also, late adolescence or early adulthood is the time when paranoid behaviors typically show up in the general population. Many believe this is due to the fact that adolescence is a time when demands on the individual are greater than ever before (e.g., higher educational load and expectations, peer pressures and dating). A family history of similar problems would suggest that your son was at risk for these problems even without his brain injury. It is also possible, however, that your son’s brain injury increased his risk for the development of such a disorder in a variety of ways. These might include: (1) interfering with the way information is processed in the brain -- perhaps making it more difficult for him to attribute cause and effect or sift through competing stimuli in his environment, (2) altering communication skills (e.g., reducing the ability to handle the subtleties of language, read non-verbal signals) and (3) reducing problem solving ability -- thereby leaving him with fewer resources to cope with the challenges of adolescence. It is important to note that any sudden behavioral change in a young person could suggest the possibility of substance abuse, and this should be investigated. Work on keeping the communication channels open with your son.
ANSWER #2
Psychiatric illness following TBI is being more aggressively studied, but is not well understood as of present. Especially severe psychiatric symptoms like "paranoia" and thought disorders that produce "irrational behaviors" are more under study presently. Early after injury, difficulties with thinking, reasoning, and social conduct are expected. However, the delayed onset of significant disorders is now being considered a more frequent occurance than previously expected. Also, there are psychiatric illnesses that first emerge during the young adult years. Therefore, the relationship between your son’s condition and the brain injury is not necessarily one-to-one. First, you must have a comprehensive diagnostic, which may include psychiatric, neuropsychological, and psychosocial evaluations. A complete diagnostic is a must, given the possibility of both a brain injury related illness and a psychiatric illness.
Also, following your diagnostics, consider a wide range of treatment resources. Medications can be very useful in helping your son. However, the physician should have experience and familiarity with medications that are best for psychiatric and neurological patients, like TBI survivors. In addition, individual therapies that promote improved cognitive and reasoning skills could be very appropriate. Furthermore, the development of social skills and the ability to promote social maturity strongly support recovery and have been found to help establish the individual’s ability to prosper with others.
Therefore, consider a complete diagnostic, and explore the use of an array of treatments including medications and psychosocial therapies.
ANSWER #3
The development of irrational behavior several years following brain injury in childhood is a situation that is described in the medical literature. This development may occur whether or not there is any family history of mental illness or paranoid disorders. There appears to be a relationship between the individual’s impaired ability to understand complex situations occurring socially and a premature judgment regarding the causes of those situations. This premature conclusion typically is reached on impulse and is based upon the individual’s perception of being slighted or excluded from a social activity. The care of a psychiatrist or neuropsychiatrist is often necessary to assist with medication adjustment as well as appropriate supportive psychotherapy to assist in reality testing and socialization.
QUESTION:
Since my brain injury a year ago, I have had many problems that will not go away: depression, memory loss, difficulty expressing myself, and an inability to keep up at my job. Since losing my job for poor performance, I have consulted a counselor, a psychiatrist, and my general practitioner. The GP and counselor both say that my problems are psychiatric, and the psychiatrist has me on Prozac. However, I am no better. How can I get the help I need? I am looking for someone who will at least believe that my problems are not imaginary.
ANSWER #1
The symptoms that you describe are very common residuals (or persistent deficits) in persons who have suffered a mild-moderate brain injury. I am confident that your depression is real (either due to your reaction to the changes and losses you describe, or an alteration of your brain chemistry, or both) but this does not mean that your problems are solely psychiatric. Anti-depressant medication is not a bad idea particularly if your mood is depressed enough to interfere with daily activities. However, if your mood has not improved on Prozac you may want your psychiatrist to consider switching you to another medication, or you may want to cease medication altogether. Please consider individual therapy with a psychologist or rehabilitation counselor familiar with brain injury. I would definitely suggest a brain-injury support group. The individuals there will be very familiar with the difficulties and frustrations you describe and may have some good suggestions to improve things. Contact the nearest Brain Injury Association for information. A neuropsychological evaluation may help convince others (professionals and non-professionals alike) that you have deficits related to your brain injury. A good report detailing the results of such an evaluation would specify your current strengths and weaknesses, describe skill areas possibly affected by your injury, and contain specific recommendations for facilitating recovery and coping with the deficits you are experiencing. It may also be helpful to see if you qualify for assistance getting back to work through a government agency such as the Department of Rehabilitative Services. These agencies work with your employer, provide job coaches, etc. to persons with disabilities trying to return to work. A social worker may be helpful in making a referral.
ANSWER #2
Your problems are frequently found with persons who have suffered a brain injury. Unfortunately, there are many clinicians, including physicians who are not familiar with your problems. For those clinicians you are presently working with, introducing them to written material from the Brain Injury Association can help introduce them to your problems. You do have the job of educating them if you intend to remain in their services. Written materials, names and numbers of specialists in your area familiar with brain injury can help introduce your clinicians to the type of problems you have. Seeking other help can best be done by contact with your local Brain Injury Association. The national Brain Injury Association in Washington, D.C. (202-296-6443) can direct you to local resources. Also, there are Model Systems Programs funded by the Federal Government in various locations around the country (for information on Model Systems Programs nationwide, see the Medical College of Virginia’s Model Systems homepage at: http://www.tbi.pmr.vcu.edu).
QUESTION:
I am a case manager working with a person who sustained a severe brain injury. My client is also working with a drug/alcohol counselor, a social worker, and an attorney. I have talked with these other professionals and we all agree that our client’s progress is impeded by his behavioral difficulties (e.g., lack of follow-through, emotional highs and lows, lack of insight). How can we help this person make the most of the services we have to offer?
ANSWER #1
To ensure that a plan is in place to assist the individual to meet his goals and to become an active participant in community life, the case manager may wish to consider the development of a supportive team which is composed of the individual, family members, service providers, and members of the community. The function of the team is to build supports around the individual based on his unique capabilities, aspirations, and needs. Team members can assist the individual to express his preferences, encourage his participation in decision-making, and emphasize the importance of taking responsibility for the achievement of goals.
For individuals with challenging behavior, the team process encourages the exchange of information and ideas regarding strategies which can be used effectively by the individual at home and in the community. A team format is also an extremely effective mechanism for enhancing communication between team members, sharing information on resources, and offering a safe environment for giving and receiving feedback. The development of a cohesive team which is invested in the individual’s success avoids excessive reliance on one member of the team and increases the likelihood that support will continue to be available even if some services are discontinued.
ANSWER #2
Your client has one of the most difficult problems in someone recovering from TBI. He is dual diagnosed and will require treatment for both conditions either in series or simultaneously. Family supports and family systems dynamics are important in both conditions. Stability of family and living environments is a must in order to establish a sound foundation for the clinical interventions. When such stability is not possible on an outpatient basis, an inpatient stay may be necessary. In addition, the integration of therapies needed for his care is as important as the individual therapies themselves. Each therapist must be integrated with the other, and the case manager serves as the coordinator and organizing influence. It is best when all services are included within one setting. Many brain injury programs can provide the combined therapies. When evaluating services for your client, this will be an important consideration. In addition, the therapists must have familiarity with both diagnostic groups. This helps with integration and coordination. However, where this is not possible, then the external case manager is the organizing influence. Services that include drug/alcohol counseling, cognitive therapies, psychosocial therapies, and possibly medication therapies are all possible positive influences. However, it is the identification of the management component that will best serve the synergy of the combined therapies. Your client will have a protracted recovery because of the dual conditions. Your resource management and allocation of funds and services must be used with this in mind. Even with knowledgeable and integrated care, long-term management will be required if relapse and recidivism is to be minimized or prevented.
QUESTION:
Since his injury, my son lacks sexual inhibition to an embarrassing degree. He makes graphic sexually-oriented remarks to anyone, and he is constantly touching females he barely knows (holding hands, grabbing at various body parts). How should we, his family, address this? Should some type of medical professional be involved?
ANSWER
This depends on a number of factors including your son’s living situation, marital status, level of dependency on others for care, his age, history of sexual activity, family and community values.
Sexual desires are a natural part of our lives, in fact the reason that each of us is here. Following brain injury, many people do become dis-inhibited about many things, and it is not surprising when this includes basic biological urges. Damage in certain areas of the brain, such as within the limbic system, can serve to increase a person’s sexual arousal. Other neurologic damage, especially in the areas of the frontal lobes, can result in a person becoming dis-inhibited, to say what is on their mind more quickly, or to "fail to engage their brain before engaging in their behavior." Thus, increased sexual arousal combined with decreased inhibition can contribute to the challenges that your son is facing. (On the other hand, different types of neurologic damage can contribute to the opposite situation of hypo-sexuality among some people, as well.)
However, there are other factors to consider including what sexual outlets, if any, your son has access to. Remember, sex is a natural human function. Life-long abstinence is rarely a realistic solution. At the same time, many people who experience severe disability following brain injury are unable to find reasonable, safe and acceptable partners, or are prevented from doing so by others. Helping your son find satisfying and acceptable means of sexual relief may help to address some of the issues. Unfortunately, too few people with severe disability are successful finding a special someone for a full fledged intimate relationship. In the past, some people have used sexual surrogates, although this practice is less common today with AIDS and other virulent sexually transmitted diseases. For most people, masturbation may be the most frequent option. It is better to set reasonable settings and outlets for such sexual activity than to try to suppress it.
Another factor may be the level of your son’s social awareness. If he is aware of his actions and how other people respond to his behavior, social skills training may help him learn how to better interact with members of his sexual preference. This can take a lot of time and training, but such patience can pay off handsomely.
If your son relies on caregivers for daily needs it is important that they be able to handle the situation. Again, if he is responsive to social re-direction, a person of your son’s sexual preference who can handle "embarrassing" situations calmly and re-direct him in a supportive and non-shaming manner, while at the same time establishing clear boundaries for such behavior will be of great benefit. If your son is more obtuse to social cures and social re-direction, then caregivers that are not of his sexual preference may be the most appropriate to employ for his care. (This must be carefully balanced with the right of each consumer to identify who may care for him or her.) Similarly, you may want to establish specific environments and situations where your son can explore and attain sexual release that are clearly distinguishable from other situations.
There are medications such as Deprovra that have been used with some success in cases of extreme sexual acting out to reduce sexual urges in males. However these are not panaceas by themselves and do not always guarantee results. Too often they can offer false hope and promise.
Ultimately, this challenge may require all who are involved with your son to take on a new perspective, just like many of the other challenges that you have come across. Removing shame from the situation, supporting his overall value, and finding ways to establish effective boundaries are the best first approaches to the situation. Remember, biological evolution is a much stronger force than social mores.
QUESTION:
Is a person more likely to develop psychiatric dysfunction after a traumatic brain injury? Are there certain psychiatric illnesses that show up more often than others in the population of brain injury survivors?
ANSWER
Psychiatric conditions seem to be more prevalent in patients after brain injury compared with the general population. There are few-to-no good studies that have addressed this issue, but depression and anxiety problems seem to be the most common. Depending on the studies, depression and anxiety problems occur in 50-60% of patients with brain injuries, compared to up to 20-25% of the general population.
If cognitive problems are considered to be psychiatric dysfunction, then this is also not uncommon. Most commonly, the cognitive deficits are manifested by slowing of calculations and problem solving and altered memory and concentration. If the deficits are significant they may constitute a diagnosis of delirium and/or post-traumatic amnesia. Many of these deficits resolve or improve by three to six months. Post-traumatic dementia appears to be quite rare.
The best treatment for major depression is a combination of counseling and medications. The counseling and medications vary some with the psychiatrist. The most commonly used antidepressants for patients with major depression after brain injury are the same used in patients with major depression without brain injury, and they include: fluoxetine hydrochloride (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), nefazadone (Serzone), venlafaxine, (Effexor), desipramine (Norpramin), nortriptyline (Pamelor), bupropion, (Wellbutrin), imipramine (Tofranil) and amitriptyline (Elavil). I do not feel that Ritalin is an adequate medication for major depression.
QUESTION:
What is emotional lability? Are there prescription drugs to treat it?
ANSWER
Emotional lability refers to sudden, often frequent, and unexpected mood changes that can occur after brain injury but is not solely related to brain injury. It has probably been most formally studied in post-stroke patients and is also referred to as "emotional incontinence." In its milder forms, it can be seen as more irritability but in its more severe forms can require formal treatment. Rarely, it is part of a seizure disorder. When the main emotional manifestation is crying, the patient needs to be further evaluated for a clinical depression. Other psychiatric conditions that involve emotional ability are manic depression (Bipolar illness), delirium, and dementia. The most commonly used medications are antidepressants, but other medications include buspirone (Buspar), carbamazepine (Tegretol), valproate (Depakote or Depakene), as well as benzodiazapines and antipsychotics. There is no good consensus about length of treatment, but once the lability is under control, a trial at weaning the patient off the medication is not unreasonable to see if the symptoms return. Additionally, behavioral treatments can also be quite effective.
QUESTION:
I have heard that an injury to the frontal lobe of the brain can result in significant personality changes. Why does this happen? Does the injured person ever return to normal?
ANSWER
If by normal you mean exactly the way things were before the injury, then the answer is usually not, although some mild and very focal injuries may diminish completely in terms of their behavioral effects. The frontal lobe is very involved with how we behave. Think of the frontal lobe as the conductor of an orchestra. Without the conductor leading all of the orchestra members, the music probably will not sound too great even though all of the instruments are well-tuned and the musicians are skilled (an over-simplified view but very accurate). So, when the frontal lobe is injured we may exhibit changes in our ability to start activities (i.e., initiation), stop activities (i.e., perseveration), switch from one activity to another, withhold responses that are overly angry, etc. Sometimes medication can be helpful, and many times behavioral therapies can also promote changes. It's always important to separate issues of a personality nature -- there are personality factors which existed before an injury, those which are adjustment concerns, and organic factors relating to the brain injury. This is not an easy task and often requires professional help (i.e., from a neuropsychologist and/or neuropsychiatrist).
QUESTION:
A friend of mine exhibits behavior problems since his brain injury, and I would like to help. I understand that there may be "behavior management programs" that could address his specific problems. If so, how would I go about finding such a program, and what should I expect from the program?
ANSWER
Your friend is lucky to have you; all too often friends fade away from someone with a brain injury. The type of program you would want is called a "post-acute neurorehabilitation program." You are already ahead of the game by the fact that you are using the Internet to find information! Check with your state Brain Injury Association (BIA) and get a listing of the post-acute neurorehabilitation programs in your region; you may need to travel to find a good program.
The key element you are looking for is behavioral services. Ask who is in charge of the service and what are their credentials? The best answer is someone who has a graduate degree in Applied Behavior Analysis, as this person would specialize in behavior and learning. However, qualified behavior analysts working in brain injury rehabilitation are hard to find. You may call the Association for Behavior Analysis International at (616) 387-8341 and ask for help in locating a behavior analyst in your region or one who is working in brain injury rehabilitation. Neuropsychologists can also be effective if they have sufficient experience in applied behavior analysis.
Another service to look for is cognitive rehabilitation to go along with the behavioral aspect. The credentialing for cognitive rehabilitation is less clear. Most cognitive programs are experimental and work off a neural networking model based on computer simulation. This research is very interesting; however, the translation to applied cognitive rehabilitation is lagging far behind. But don't give up! There are many very talented and creative speech and occupational therapists out there who conduct cognitive therapy. Look for those trained in assessing and prescribing compensatory tools and strategies for functional skills, i.e., memory, problem solving, planning, organizing, etc.
Also, there are some neuropsychologists who are very talented and also provide cognitive therapy. You will have to see who carries out the cognitive therapy, as neuropsychologists are frequently called upon to conduct neuropsychological assessments and may not have time to consistently treat clients. You can start by reviewing the literature and seeing who's who and where they are located. You can also contact CARF (an accreditation organization for rehabilitation facilities) for a listing of accredited brain injury community integrated programs: (520) 324-1044. Finally, the Brain Injury Association has begun a credentialing program for brain injury rehabilitation professionals; you may contact the association at (703) 761-0750.
ANSWER
Balance or equilibrium difficulties are common sequela to head injury. They are associated with vision and hearing (the oculovestibulo mechanism). Post-trauma vision syndrome, a common sequela to head injury, frequently includes a subclassification referred to as midline shift syndrome. The midline shift syndrome results in a patient experiencing a constant sense of disequilibrium, difficulty with maintenance of balance, an inappropriate posture and weight distribution on the balls of the feet, and inappropriate gait, combined with a directional drift. Such patients also often express that they perceive their world in a strange way, in that the horizon may be tilted, walls may be tilted or compressing in upon them.
These symptoms of midline shift syndrome are effectively addressed in most cases with a concept referred to as yoked prism reorientation. It must not be concluded that this is a cure for this problem. It is an immediate amelioration of the symptoms in most cases that are correctly diagnosed as midline shift damage. This requires a differential diagnosis eliminating damage to the vestibular mechanism. The most common imbalance experience following head injury is oculo motor decompensation and binocular visual-motor-perceptual imbalance decompensation resulting in midline shift syndrome. This case is symptomatically treated with yoked prism reorientation therapy.
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