Rehabilitation
Traumatic Brain Injury - An Intellectual's Need for Cognitive Rehabilitation
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Traumatic brain injuries can happen at anytime, to anyone. A traumatic brian injury (TBI) occurs when the brain has undergone sudden injury. Traumatic brain injuries may occur when incidents such as strokes, gunshot wounds, physical assaults, sports, car accidents, falls, bicycle and motorcycle accidents, as well as when pedestrians are hit by vehicles cause damage to an individual's brain. Doctors, teachers, cognitive therapists, and health care professionals don't always recognize or properly diagnose the problems that arise for a traumatic brain injured individual: moreover, the intellectual who has suffered a traumatic brain injury does not receive the proper cognitive retraining. The professionals think nothing is wrong with the individual because s/he functions at such a high level.
Dr. Thomas Kay, in his article, "What You Should Know About 'The Unseen Injury: Minor Head Trauma'", stated the nerve cell damage can be widespread and microscopic, not appearing on diagnostic radiographic imageries or on neurological testings. He also stated a person's intelligence could still be measured as average or above average, yet their cognitive abilities are not as they once were. This possible inability to recognize the intellectual TBI's cognitive difficulties since the injury is frustrating to the intellectual TBI, because they know something is a miss cognitively. Dr. Kay advises patients, "not to fall victim to being told you are malingering or imagining your symptoms." Mary Ellen Jennison, in her report, "Project Able: Academic Bridges to Learning Effectiveness", supports the need for curriculum and programs geared to college students and the higher functioning TBI individuals. She outlined Project Able's program in which their curriculum and services assist the TBIs to attend/succeed in collegiate endeavors and re-enter the work force. Jennison stated that educators have little knowledge about head injuries. Kay discussed, in his paper, "Selection and Outcome Criteria for Community-Based Employment: Perspectives, Methodological Problems and Options", how TBI rehabilitators should not pick up whatever tool is closest at hand" in the rehabilitation of the TBI, but should custom tailor the cognitive retraining to the individual.
Without this custom tailoredness, the intellectual TBI emerges from cognitive retraining with little/no assistance for their cognitive deficits. Contusions to the head, skull fractures, or skull lacerations are not necessary components for a person to have undergone a TBI. A car accident in which a person has suffered a whiplash, a sudden jerk to the head, can results in a TBI without the person's head ever hitting anything. The brain can rotate violently or bounce off the skull's inner walls, reacting similarly as when a bowl full of coagulated gelatin is shaken, causing stretching or snapping of microscopic fibers, axons, which send messages to nerve cells, neurons, within the brain. This disturbance to the mental functioning within the brain is called a concussion, even if the disturbance is brief. The person need not loose consciousness to suffer a concussion. During the concussion the axons can stretch, twist, bend, or snap. Some axons may swell or even disintegrate. The axons transmit brain messages. The myelin sheath surrounding and insulating the axons can also be damaged or destroyed in the same fashion as the axons.
Concussions are now classified according to symptoms: grade 1 concussion - "seeing stars", the person remains conscious, only momentary confusion, headaches, dizziness, some short-term memory loss, head clears quickly, no medical intervention. grade 2 concussion - amnesia, nausea, ringing in the ears grade 3 concussion - unconsciousness Rest allows the brain to attempt to heal itself from a concussion. There are more neurons within the brain that were not previously used. Rest permits the brain to replace or repair the nerve connections. A second concussion before the brain has thoroughly healed itself can bring worse side effects, in some cases, even death. The brain can atrophy or shrink from repeated concussions further diminishing mental abilities. Some after-effects of concussion, also called post-concussion syndrome, are headaches; amnesia; lack of concentration; mood swings; dizziness; and/or ringing in the ears.
Each person has individualistic after effects. Dr. Robert Cantu, chief of neurosurgery and director of Sports Medicine at Emerson Hospital in Concord, Mass., and Dr. Joseph C. Maroon, chairman of the department of neurological surgery as Allegheny General Hospital in Pittsburgh, Pa., are in agreement that a person is more succeptable to more concussions after suffering a concussion. It is also believed each concussion has accumulative effects; the person suffering greater post concussion syndrome effects with each subsequent concussion.
Neuro-psychological tests are standardized tests conducted by neuropsychologists specifically trained in cognitive perceptual motor testing. The testing evaluates the functioning of numerous areas of the brain. It generally takes six hours and can show abnormalities and/or deficits; whereas, other medical diagnostic testing cannot, neuro-psychological testing is considered in the medical field as one of the most important means of evaluation to detect traumatic brain injury. The battery of testings include math skills, spatial relationships, memory recall, visual acuity, motor skills, vocabulary, historical recall, and current recall amongst other forms of testings. The neuro-psychological assessment may determine many facets of brain injury, according to Lance E. Trexler in his article, "Neuropsychological Evaluation of Persons with Traumatic Brain Injury":
- What brain functions may be impaired or spared by the damage.
- The severity of the impairments.
- The prognosis for recovery and long-term adaptation.
- A baseline for the monitoring of recovery.
- The need for rehabilitation and the approaches to be used in rehabilitation or case management.
- The degree of competence present to manage one's own affairs.
Trexler also stated there are generalizations utilized in determining cognitive deficits with brain injury: Injury to the left temporal lobe often results in impairments of verbal learning and memory and, depending upon the severity of injury, impairments of auditory attention and discrimination, along with disturbances of language. Right temporal lobe damage most commonly results in impairments of visual learning and memory, but it can also result in impairments in visio-spatial perceptual defects. Injury to the surfaces of the frontal lobes can result in a variety of cognitive and neurobehavioral disturbances; cognitive disorders frequently associated with frontal lobe injury include distractibility, loss of abstraction skills and problem solving abilities, a lack of organizational strategies and a dependence on external structure, impaired initiation of action (despite intact ability to verbalize the need to take action), and impaired mental flexibility. Neurobehavioral disorders often resulting from frontal lobe injuries include impulsivity, disregulation of affect, a lack of insight or awareness, and inadequate self-monitoring or self-control in a social context. Learning strategies are means to maximize one's functioning.
Many therapists term these learning strategies "compensations". (For a much more positive connotation, learning strategies will be used in this article.) The learning strategies should be utilized consistently and custom tailored to a specific activity, individual's lifestyle, and environment. It is not always easy for an individual to adapt learning strategies or to do things differently, as change is generally difficult. Some or many cognitive difficulties may become a lifelong challenge. One should not try to prove to oneself learning strategies are not needed, as everyone utilizes them, some learning strategies more than others. Some people will say they will remember something and quickly forget the information. It is much better to write important information down to assist in recall. The faster one employs and consistently utilizes learning strategies, the more successful and in control one will feel. Many therapists believe in the completion of a task not the quality or mode of achievement. However, most intellectuals place emphasis on completion as well as the quality of performance.
TBIs should embrace their major cognitive deficits and attempt to develop learning strategies suitable to try to avoid or facilitate the deficit. TBIs should become their own cognitive therapists, self-assessing on a continual basis. There are many learning strategies and one may develop one's own, for not all of the learning strategies will be personally applicable. According to the Michigan Head Injury Alliance, over 100,000 persons die annually due to head injuries. Seven hundred thousand individuals sustain head injuries requiring hospitalization. Up to 90,000 of the hospitalized head injured individuals suffer mental intellectual or behavioral deficits which prevent them from returning to their regular lifestyle. Of the mild traumatic brain injured individual, specifically the intellectual who has suffered a traumatic brain injury, cognitive rehabilitation may be nonexistent.
Most cognitive rehabilitators address TBI individuals with significant cognitive deficits. Programs are beginning to immerge for the intellectual TBI. Kay discussed the natural course of recovery for the TBI. He stated the severity of the head injury played an important part in the recovery processes of the individual. The severity of the injury was determined by the length of unconsciousness. Those who had been unconscious for 24 hours or less experienced much higher employment success rates than TBIs who were unconscious for longer than 24 hours. Age also appeared to play a role in the recovery. However, no TBIs under the age of twenty who were unconscious for more than four weeks ever returned to work, while no one unconscious for more than one day and over the age of 60 returned to employment. Kay reported on several studies concerning the re-employment of TBIs from comparable re-employment to the inability to return to work. The younger the TBI individual and the shortest period of unconsciousness showed the most favorable TBI recovery.
In the article, "Return to Work Following Traumatic Brain Injury", Patricia Goodall discussed the re-entry to the work force for the traumatic brain injured individual. She discussed how return to work is difficult for the individual due to physical, neurological, cognitive, and often personality changes that have resulted due to their traumatic brain injury. The severely brain injured job placement was 29%. In the mildly brain injured, a supported employment methodology is gaining support. With the supported employment methodology, a job coach or employment specialist is utilized. This job coach assists the individual at the job site, sometimes even performing needed job tasks. The article discussed the phases of assessment by the job coach from consumer assessment to job development. Listed were compensatory strategies to assist the individual at work: writing lists, auditory or visual cues, environmental structure, physical adaptations, and rearrangement of the work area.
Two successful case studies of employment concluded the article. Project Able provided college students who suffered a brain injury with skills to succeed in college in college and at workplace. The students took courses in basic reading, writing, mathematics, and key boarding. College survival skills, study skills, and career education were also offered. The students also met on a weekly basis as a support group with a psychologist as a facilitator. Project Able also works with the family members to address any concerns that should arise. The goals of the program are to engage the TBI with skills to gain control of their lives and learning so they can become successful with collegiate work, vocational programs, and the workplace. The paper also discussed the cost and community involvement of the program. It is crucial for the traumatic brain injured individuals to accept the knowledge, wisdom, and experience of others in the recovery process. Some people experience a psychological transformation in an attempt to find meaning and dignity in their now different learning strategies. They need to come to peace with themselves and enter a new life, one of acceptance to their changes. Kay found patients who do not come to realization of their changes fail at sustained employment. He stated the vocational rehabilitation programs who fail to address this issue with their clients doomed their clients to "endless cycles of vocational chase and miss."
More studies and programs are beginning to address the higher functioning TBI, as they have suffered cognitive difficulties from their injuries also. Projects such as Project Able are now assisting the higher functioning TBIs return to productive lifestyles. Previously, the higher functioning TBIs were left to their own accords, as programming to rehabilitate their cognition was nonexistent. More programs are needed as every TBI, including the higher functioning TBI, deserves to have their cognition rehabilitated to the best of their ability.
References
Goodall, Patricia. "Return to Work Following Traumatic Brain Injury." Special Issue, Volume 5, Number 1.
Jennison, Mary Ellen. "Project Able: Academic Bridges to Learning Effectiveness." Report 1993.
Kay, Thomas. "Selection and Outcome Criteria for Community-Based Employment: Perspectives, Methodological Problems and Options." 1993.
"What You Should Know About 'The Unseen Injury: Minor Head Traumas'". 1986. The Detroit News. December 1994.
Sports Illustrated. July 1995.