Table of ContentsAcknowledgements. 2Introduction . 3Welcome. 3Recommended Websites . 3VA POLYTRAUMA REHABILITATION CENTERS . 5PART I. THE REHABILITATION PROCESS . 6Interdisciplinary Team . 6What Happens at the PRC? . 10PART II: EQUIPPING YOURSELF WITH KNOWLEDGE ABOUT TBI. 12What are the Functions of the Brain? . 12Diagram of the Brain . 13WHAT IS BRAIN INJURY AND WHAT HAPPENS TO THE BRAIN WHEN IT IS INJURED? . 15Rancho Los Amigos Scale . 17Medical and Related Effects of TBI . 18Behavioral Effects of TBI . 22Cognitive Effects of TBI . 23Prognosis. 25Recovery from TBI. 26PART III: TAKING CARE OF YOURSELF . 29Learning to Deal With Your Own Reactions . 29“Quick Tip” Summary: . 33Glossary of Terms. 34Acknowledgements. 40ii


AcknowledgementsContributorsRichmond Polytrauma Rehabilitation CenterMcGuire VA Medical CenterHunter Holmes McGuire (Richmond) VA Medical Center – VA Mid-Atlantic HealthCare Network — Veterans Integrated Service Network (VISN) 6.Richmond, VirginiaTampa Polytrauma Rehabilitation CenterJames A. Haley VA Medical Center – North Florida/South Georgia Veterans HealthSystem – Veterans Integrated Service Network (VISN 8)Tampa, FloridaMinneapolis Polytrauma Rehabilitation CenterMinneapolis VA Medical Center — Midwest Health Care Network - Veterans IntegratedService Network (VISN) 23Minneapolis, MinnesotaPalo Alto Polytrauma Rehabilitation CenterVA Palo Alto Health Care System – Sierra Pacific Network – Veterans Integrated ServiceNetwork (VISN) 21Palo Alto, CaliforniaSan Antonio Polytrauma Rehabilitation CenterAudie L. Murphy VA Hospital — VA Heart of Texas Health Care Network - VeteransIntegrated Service Network (VISN) 17San Antonio, TexasSponsored by the Department of Veterans Affairs Employee Education SystemSpecial thanks to Dr. Sharon Benedict who compiled and edited the initial version ofthis manual. For questions or information about this manual, please contact Dr.Benedict at [email protected]

IntroductionWelcomeWelcome to the VA Polytrauma Rehabilitation Center (PRC). The term “polytrauma” isdefined as serious injury to two or more body systems which result in physical, cognitiveor psychological impairments that limit a person’s ability to function. Traumatic BrainInjury or TBI frequently occurs in polytrauma, therefore, much of the information inthis manual is provided to help educate you about brain injury and the process of braininjury rehabilitation. The information you will read was written and compiled fromseveral sources and is intended only as a general guide for families and friends ofpatients who have sustained a TBI. Please read the manual at your own pace.NOTE: To simplify the reading of this material the pronoun “he” has been usedthroughout the text to represent individuals with traumatic brain injury, although wecertainly recognize that TBI is not gender-specific.For your convenience, we have included a “Glossary of Terms” at the end of the manual.Terms included in the Glossary can be found throughout the pages in italics, also oftenfollowed by a definition. Additional information about the Polytrauma RehabilitationCenters, our VA Medical Center facility and patient and family rights andresponsibilities will be provided to you on or before admission.Recommended WebsitesAs you learn more about the brain and its functions, you are likely to have manyquestions. Members of our rehabilitation team are here to answer your questions and toprovide you with information about traumatic brain injury and recovery. Please usethem as a resource. You may also find additional information related to TBI by visitingthese websites:The Brain Injury Association of America:*Defense and Veteran’s Brain Injury Center:*National Institute of Neurological Disorders and htm*Centre for Neuro Skills: TBI Resource Guide:*National Resource Center for TBI:*For more information about the Polytrauma System of Care go information about military resources and service-specific benefits go to:3

Military OneSource: *(800-342-9647)Army Wounded Warrior Program (AW2):* (800-2371336)Marine For Life (M4L):* (866-645-8762)Safe Harbor (Navy):* (877-746-8563)Palace Hart (Air Force) (703-697-0974)Hope for the Warriors:**By clicking on these links, you will leave the Department of Veterans Affairs Web site.For other than authorized VA activities, the VA does not exercise any editorial controlover the information you may find at these links.4

VA POLYTRAUMA REHABILITATION CENTERSRichmondTampaSan AntonioPalo AltoMinneapolis5

PART I. THE REHABILITATION PROCESSRehabilitation is a method of treatment that uses state of the art care to help individualsrecover from traumatic brain injury and other polytraumaticinjuries. This comprehensive and integrated approach requiresindividualized and creative treatment that focuses on the exactneeds of patients. The goal of rehabilitation is to help an individualreturn to a life that is as independent and productive as possiblewhile preventing secondary complications or further decline. At theVA Polytrauma Rehabilitation Centers, our clinical specialists worktogether as an interdisciplinary team (IDT) to address the specificcognitive, behavioral, physical, and emotional challenges that aperson faces after TBI. We consider the patient’s family andsupport system to be an integral part of the rehabilitation process.Interdisciplinary TeamOur core interdisciplinary team includes specialists in physical medicine/rehabilitation(physiatrist), rehabilitation nursing, neuropsychology, rehabilitation psychology,physical therapy, occupational therapy, speech/language pathology, kinesiotherapy,social work, and recreation therapy. All clinical team members contribute to anintegrated team approach while providing treatment within their own specialty areas.The team also consults with specialists from other disciplines in the hospital asnecessary (i.e., neurosurgery, orthopedics, nutrition, chaplain services). In addition,there is at least one full time military liaison on the PRC unit who is available to assistyou with questions about benefits and other military-related issues.In the first few days at our facility, you will meet every member of the team who will beworking with your family member. To help you to better understand the specialty workof our clinicians, we have included a description of their team role, including specificdiagnostic and treatment methods and special equipment they may use.Physical Medicine & Rehabilitation Specialist (physiatrist).The physiatrist is a medical doctor and the team leader who directs and coordinates thepatient’s care. Physiatrists treat problems that touch upon all the major systems in thebody with a focus on restoring impaired function.Rehabilitation NursingRehab nurses combine traditional patient care skills with expertise in rehabilitationnursing. Nurses help to ensure a safe, supportive environment 24 hours a day. Theyeducate the patient and family members about traumatic brain injury and safety issues6

such as fall prevention and maintaining skin integrity. Nurses reinforce the skills thatthe patient and family are learning in the different therapies and help them carry out thetreatment plan developed by the team.Occupational Therapist (OT)Occupational therapists help patients with traumatic brain injury regain their ability tomanage everyday tasks or “activities of daily living”(ADLs) (i.e., eating, grooming, dressing, bathing andtoileting). OTs also help patients re-learn work, schooland home management skills (i.e., shopping, cooking,money management). OTs may provide adaptiveequipment (i.e. custom-fabricated splints) and makerecommendations for changes in the home environmentthat will enable your family member to function moreeffectively in the world after discharge (i.e., ramps,handicapped accessible bathrooms). The goal ofoccupational therapy is to help a person regain independence, prevent further disabilityand re-learn skills needed for daily life and work.Social Work Case ManagerUpon referral to the PRC, your family member will be assigned to a social work/casemanager who will be available 24/7 to answer your questions and to locate neededservices. When possible, the social work/case manager will speak with you before yourarrival to assist with transition issues (i.e., arranging for appropriate lodging,transportation, and help with financial concerns). Shortly after your arrival at the PRC,the social worker will take you on a tour of the facility and conduct an interview with youand/or your family member to obtain background information and to complete apsychosocial history. This assessment includes information about financial resources,education level, work history, living situation and level of social support. Informationfrom the psychosocial assessment will help to inform treatment and discharge planning.NOTE: Planning for transition to the next level of care often begins before your arrivalto the unit and is the responsibility of the social work/case manger. This planning is anormal, integral part of the rehabilitation process. Ongoing involvement with yoursocial work/case manager will help you to make informed decisions about your familymember’s discharge. Throughout your stay, your social work/case manager will presentand discuss different discharge options, provide resource information and will assist youin making a decision about referral for the next level of care. An outpatient socialwork/case manager will also provide follow-up for a period of one year after dischargefrom the PRC.7

Speech/Language Pathologist (SLP – Speech Therapist)Language deficits are among the most common problems for persons with a traumaticbrain injury. However, helping to improve speech is only one area in which speechtherapists provide intervention.SLPs also specialize in evaluating and treating cognitivedeficits, including problems with attention, memory,reading comprehension, writing, planning and sequencing.Another function of the speech pathologist is to evaluateand treat swallowing disorders. After a diagnosticassessment, diets can be adjusted or modified andspecialized swallowing strategies can be implemented.Physical Therapist (PT) and Kinesiotherapist (KT)Physical therapists (PTs) and Kinesiotherapists (KTs) provide services that help restorefunction, improve mobility, relieve pain, and prevent or limit permanent physicaldisability from injury or disease. PTs and KTs test and measure a patient’s strength,range of motion, balance and coordination, posture, muscle performance, respiration,and motor function. They also determine the patient’s level of independence and abilityto re-enter the community or workplace after injury. Treatment often includes patientand family training in transfers, ambulation and wheelchair mobility with the goal ofimproving a person’s functional ability at home and/or work. Therapists also teachpatients and family members to use assistive and adaptive devices, such as crutches,prosthetics, and wheelchairs. PTs and KTs are very involved in elements of dischargeplanning, including assessments for specialized equipment and recommendations forhome modification.Blind Rehabilitation Outpatient Specialist (BROS)BROS provide restorative treatment and compensatory strategies for patients who arevisually impaired to maximize the use of remaining vision and the use of alternativesensory modalities when more efficient or safe. BROS interventions may includetraining new visual skills (such as adaptive fixation and scanning for those withperipheral visual field loss, training the use of eye muscles, or development of a newarea of fixation for those with central blind spots), use of other modalities (such asreading with speech-output or using tactual markings for identification), organizationand mnemonic strategies, orientation to the environment and travel skills (e.g.,utilization of maps, long white cane, guide dog, etc.) and ergonomics. BROS providetraining in activities of daily living and instrumental activities of daily living toincorporate visual skills and blindness techniques leading to successful management ofdaily life. BROS teach patients to use technological devices such as adaptive computers(with speech output, Braille and/or enlarged text), global positioning systems, moneyidentifiers, color sensors, talking watches, audible prescription reading devices, etc.8

BROS partner with other professionals to foster adjustment to visual impairment for thepatient, and for the family.Recreational Therapist (RT)Recreational therapists help patients become independent in leisure activities, which arean important, enjoyable part of life. They assist patients in re-entering the communityby applying practical skills to real-life situations. The goal of recreational therapy is tomake sure that patients function safely in community environments where there arevarious barriers (i.e., curbs, stairs, uneven surfaces and ramps). When appropriate,therapy takes place in a community setting.Rehabilitation PsychologistThe rehabilitation psychologist is a licensed clinical psychologist who has been speciallytrained to assess and treat the many issues facing brain-injured patients and theirfamilies. Rehab psychologists have a doctoral degree in psychology and provide clinicaland counseling services for coping and adjustment problems related to chronic ortraumatic injury or illness. Rehabilitation psychologists work with the patient andfamily to identify and address specific issues (i.e., mood/emotions, stress management,healthy lifestyle practices, body image, role changes, and quality of life) that mayprevent the patient and family from achieving the highest level of functioning afterinjury.NeuropsychologistThe neuropsychologist is also a licensed clinical psychologist with a doctoral degree inpsychology. The neuropsychologist has additional training in understanding brainbehavior relationships including specialized training in brain anatomy, brain function,and traumatic brain injury or disease. Neuropsychologists are specially trained toadminister and interpret certain types of cognitive and emotional tests. The results ofthese tests are used to identify deficits and remaining strengths after injury and toclarify individual cognitive, vocational, and relationship goals.Department of Defense (DoD) Military LiaisonThe PRC has at least one full-time, active duty military liaison that is present on the unitto provide assistance and support to service members and their families as theytransition from Military health care to the VA health care system. The liaison has subjectmatter expertise in processing travel vouchers and claims (e.g., Traumatic ServiceMembers Group Life Insurance [TSGLI]) and facilitates communication between theinjured Servicemember and his chain of command. The liaison also serves as aconsultant to the interdisciplinary team on military matters.9

What Happens at the PRC?Following their initial assessments, the members of the interdisciplinary team will havean admission conference, typically within the first week or two of admission, to discusstheir findings and to formulate a rehabilitation treatment plan, including an estimatedlength of stay. You and your family member will be informed about the team’s findingsand recommendations following the conference and you will be encouraged to provideinput about your goals and expectations for rehab as well. The team also meets inweekly rounds to evaluate your family member’s progress and to adjust or redefine thetreatment goals accordingly.We encourage you to ask questions and strongly recommend that you keep a notebook(or use the note pages at the back of this manual) to write down questions, concerns orother information that you would like to discuss with the doctors or other teammembers. You will find that it is much easier to refer to a written list than to try toremember all of your questions on the spot.It is important to provide a structured environment for TBI patients and to establishnew routines to help them re-learn old skills and develop new compensatory strategies.We would like you to be involved as much as possible with nursing and the differenttherapies so that you can learn new critical care giving skills (i.e., positioning, transfers,feeding, bathing, toileting, and medication management). Throughout this process, theteam will be here to help and support you and your family member.You should anticipate that your family member will be participating in various intensivetherapies each day. NOTE: There may be times when a therapist feels that a one-on-onesession with your family member will be more productive. Likewise, nursing may needto conduct an assessment or complete an element of nursing care without interruption.This is not an effort to exclude you, but is rather an opportunity for the staff to workmore effectively on promoting your family member’s return to maximum independence.Family EducationOur polytrauma teams are committed to providing you with up-to-date informationabout traumatic brain injury and recovery so that you will be able to make informeddecisions about treatment and follow-up care. First and foremost, we are happy toanswer any questions that you might have. There are also written materials (i.e., books,pamphlets, traumatic brain injury resources) and computers with internet access on theunit. Keep in mind your social work/case manager and military liaison are the pointpersons for discharge planning and for helping to identify available resources duringyour stay at the PRC and beyond. The PRC also has a collaborative relationship with theBrain Injury Association of America at * (800-444-6443), which has awealth of regional and national information about services for which you or your familymember may be eligible after discharge.10

Finally, each Polytrauma Rehabilitation Center sponsors educational sessions forfamilies about aspects of recovery from polytrauma and traumatic brain injury. Topicsand presenters vary. We strongly encourage you to attend these sessions when offered,as they give you an opportunity to learn, offer your support to other families and askquestions that are important to you.11

PART II: EQUIPPING YOURSELF WITHKNOWLEDGE ABOUT TBITraumatic brain injury (TBI) affects not only the individual but also the family as awhole. One minute the person is fine, the next minute he is involved in a serious medicalemergency, perhaps even a fight for life. As a family member, you are also involved inthis complex process. Even as the initial crisis passes, you are suddenly involved inmaking sense of all the new and complicated situations in which you find yourselves. Inorder to gain the confidence to make decisions about your family member’s care, it isimportant to learn as much as possible about TBI, and how it can affect a person’scognition (thinking) and behavior (acting).In addition to providing basic information about TBI, this guide also offers someinformation about how treatment at our rehabilitation facility promotes the recoveryprocess and how we approach this treatment as an interdisciplinary team. Finally, wehave included information about some of the ways you can and should take care ofyourself during this difficult and challenging time.Please note that some of the information in this manual may not directly apply to yourfamily member - or to your experience thus far. No two people suffer the same traumaticbrain injury, and so the recovery process and the long-term effects of an injury will varyfor each patient. This is important to remember when coming to know other patientsand families on our unit. Your family member’s recovery will be individualized and mayproceed more rapidly or slowly than other patients. Please try to avoid comparisonswhenever possible.What are the Functions of the Brain?Though it weighs barely three pounds, the brain has an enormous job. It regulates all ofour physical movement and sensation as well as our ability to think, act, feel andcommunicate. Because the brain is such a complex organ, it is probably best to beginwith a basic explanation of its functions. This may help you to understand some of thechanges that you may observe in your family member over time.The brain is divided into several parts, each with very specific functions. Normally, thebrain manages to perform routine actions regularly and quickly through constantcommunication between one part of the brain and the next. When the brain in injured,communication between the different areas of the brain can become disrupted andinterrupt the simplest of tasks. Certain types of problems are commonly seen with injuryto specific parts of the brain. In fact, in some cases the areas of the brain that have beendamaged can be identified by changes in the individual’s behavior following injury. Thebest way to understand the deficits associated with traumatic brain injury is to12

understand the function of each area of the brain and its related systems and structures(see picture below).Diagram of the BrainSkullThe bones that come together to cover and protect the brain.Brain StemThe brain stem, located at the base of the skull, is a very small area that is responsiblefor life-sustaining functions such as regulation of blood pressure, heart rate, breathing,and body temperature. The system that is responsible for arousal and alertness is also inthe brain stem and is known as the Reticular Activating System (RAS). The RASfunctions like a dimmer in a light switch, increasing and decreasing the responsivenessto the environment. If the RAS is damaged, an altered state of consciousness such ascoma or a vegetative state may result.CerebellumThe cerebellum, located behind the brain stem, is responsible for muscle coordinationand balance.13

Cerebral CortexThe cerebral cortex (cerebrum) is what is most commonly thought of as “the brain”. It isdivided into left and right hemispheres. Generally, each hemisphere directs the oppositeside of the body (i.e., the left hemisphere directs the right side of the body and viceversa).Each hemisphere is then divided into four lobes that have specific functions:Frontal LobesParticularly vulnerable to trauma and necessary to higher level thinking, oftencalled “executive” functions. These functions include the ability to focusattention, organize and plan, problem-solve, make good decisions, and showappropriate judgment. Executive functions also play a role in controllingbehavior and emotions.Occipital LobesResponsible for aspects of visual function.Temporal LobesRegulates memory function, language information (comprehension andexpression), and aspects of emotional processing, and behavior.Parietal LobesImportant in sensation (touch, pressure, temperature, pain), perception,attention and complex aspects of brain processing.14

Other systems located within the right and left hemispheres:Sensory & Motor Strips (located in the parietal and frontal lobes)Primarily responsible for organization of higher level motor behavior, such as thecoordination of movement in walking.Limbic System (located inside the temporal lobe)In addition to the different lobes of the brain, there are systems within it thatconnect these lobes. The limbic system is an area of vital importance to mood andemotional regulation, motivation, attention, and memory. Injury to this systemmay result in behaviors ranging from a). flat affect (no expression) toaggressiveness, b). mild distractibility to the inability to pay attention and, c).slight memory problems to the inability to recall what happened 30 minutes ago.WHAT IS BRAIN INJURY AND WHAT HAPPENS TO THE BRAIN WHEN IT ISINJURED?Injury to the brain can occur when the head is injured by an external force (calledtraumatic brain injury or TBI) or by a non-traumatic event such as a tumor, stroke,aneurysm, or infection (called acquired brain injury or ABI). Any brain injury can causea wide range of functional changes that may affect thinking, sensation, language,memory and/or emotions.Initial EventsThree initial events can occur following injury to the brain. First, immediate damage canoccur if the brain hits or rubs against the bony structures of the skull, especially in thearea of the forehead (frontal area) and upper cheek and ear (temporal area). Thisimpact can cause tearing, bleeding, and bruising of brain tissue. Second, the brain isfixed to the spinal cord and as it turns and twists during injury tearing and stretching ofthe nerve fibers (axons) can occur all over the brain and in the brain stem. Third, thebrain can suffer diffuse (all over) swelling which, in 75 percent of cases, will result in anincrease in intracranial pressure, due to the inability of the skull to expand. Generalswelling and increased pressure reduces the blood flow necessary for undamaged braintissue to function properly. Unconsciousness or coma may result, depending on theseverity of these injuries.The types of injuries described thus far generally occur in the minutes, hours, and initialdays after the injury. Once brain swelling is reduced and blood flow returns to normal,the extent to which the brain tissue has been damaged becomes better defined. Somebrain tissue may return to normal functioning. Other tissue may be permanentlydamaged.15

Categories of Brain InjuryBrain injuries range from “mild” to “severe” and are categorized as penetrating (open)or non-penetrating (closed). A traumatic brain injury (TBI) which is caused by anexternal force can be either a penetrating or non-penetrating injury. A penetrating TBImeans the skull has been punctured or opened in some way as in the case of injurycaused by shrapnel or gunshot wound. In a non-penetrating TBI, the head is shaken orhit by an external force, which causes the brain to impact against the boney structure ofthe skull (e.g., exposure to a blast, fall or motor vehicle accident).The brain can also sustain injury from non-traumatic events such as anoxia (insufficientoxygen to the brain), aneurysm (burst blood vessel) or stroke. Brain injury from anycause can result in one or more of the following:contusion: a bruise to a part of the brainlaceration: a ragged tear in the tissue of the brainhemorrhage: bleeding following damage to the blood vesselsA hemorrhage may eventually develop into a hematoma (a blood clot) and can occur inany part of the brain. Clots fill the space between the skull and the brain and putpressure on the brain. The most common forms of hemorrhage are:epidural hemorrhage: forms between the dura (tissue that covers andprotects the brain) and the skullsubdural hemorrhage: forms between the brain and the durasubarachnoid hemorrhage: forms in between the layers of membranescovering the brainintraventricular hemorrhage: blood that enters the open spaces(ventricles) of the brainDamage to the brain from either an open or closed injury may be focal, meaning aspecif

Welcome to the VA Polytrauma Rehabilitation Center (PRC). The term “polytrauma” is defined as serious injury to two or more body systems which result in physical, cognitive . NOTE: To simplify the reading of this material the pronoun “he” has been used throughout the text to repre