Julie McPhail
Jill Boeck
23 April, 2009
The accepted official definition for traumatic brain injury as used by the
Wehmeyer 314).
other than the brain, such as the scalp and skull (Wikipedia
However, the terms traumatic brain injury and head injury are often
Injury 1).
injury, there may be some confusion because there is a condition that is not often
certain circumstances where traumatic brain injury is acquired, the condition is caused
by a vector infecting humans. There is a patient who will be known as “Jane” for the
purposes of this paper. Jane’s traumatic brain injury was caused by an insect bite
which resulted in a systemic infection that damaged several key areas in her brain.
According to the criteria of the agencies that now provide services to her, she has been
classified as having a traumatic brain injury due to the areas of damage to her brain,
although it was not acquired in the ways which will be examined in this work. She is
unable to speak and must use a talking board or computer to communicate, cannot
walk, and has had major mood swings which are characteristics of a depressive state.
Jane has exhibited episodes where she is devious, ill tempered and combative. She
will be pleasant to people if she deems it is in her best self interest. For example, her
caregivers frequently find going to the grocery store shopping with her to be a long and
tedious ordeal. While she is sitting in a wheelchair endlessly reading the labels line by
line, it is not unusual for her aides to have to remain standing on their feet for hours at a
time nearby her. If, however, Jane and the workers go to eat afterwards, and she
discovers that she is out of money, Jane is now suddenly concerned about the aide’s
comfort and physical wellbeing and suggests they sit while eating. It is then, after her
McPhail 3
seeming sudden concern for the welfare of those accompanying her, that Jane asks if
the aide could please buy her lunch. This request is rarely refused her because the
aides often can't help but feel that they need to accommodate her to continue her good
Jane is well-educated. She graduated from high school with honors prior to her
accident, and afterwards went on to attend college at the University of Buffalo where
It is essential to keep in mind that traumatic brain injuries as defined do not apply to
injuries that are congenital or degenerative in origin. Traumatic brain injuries are
certainly not due to birth traumas as some used to believe. Traumatic brain injury must
be an acquired injury, which means acquisition after an individual is born, but not as a
...the term TBI applies to both open and closed head injuries:
A handsome young man who attended school locally at the same time as the
author of this paper was considered to be very popular with the girls and the guys. It
was believed by those around him that he would do well for himself in life, having a
Some 20 years later, while shopping at a local convenience store, this young
man was noticed by chance while patronizing the store. He appeared to be in line for
the purpose of cashing a Social Security disability check. He bore a puckered scar
which he didn't have during his time in school. It started at his right temple and ended
at his jaw. More than likely, this unfortunate individual had been the victim of a shooting
which left him forever scarred and impaired, as evidenced by the slurring of his speech
the bones of the skull. It results from an external blow or from the
brain being whipped back and forth rapidly, causing it to rub against
and bounce off the rough, jagged interior of the skull (Turnbull,
A local health care agency was asked to provide assistance for a male patient
known as "Keith", for the purposes of this paper. Keith resides in the Riverside area.
His medical chart clearly detailed and listed his condition. He had been injured in a
horrific car accident. Keith had been a relatively young man when he decided to go for
a ride with a so-called friend. For some reason, the driver in the accident, Keith's
"friend", decided to show off and started speeding. Realizing that he was losing control
of the vehicle and to minimize the damage he would sustain to himself, the driver
McPhail 5
deliberately crashed the vehicle so that the passenger side would take the brunt of the
impact. The car hit the guardrail, causing Keith to fly out the window and land on his
head, causing a closed TBI. Today Keith is able to speak, but is constantly repeating
the phrase, "Do you know my brothers, Brent and Brian?" When the nurse arrived at
his apartment one particular day as his aide was providing care, the worker inquired of
her if Brent and Brian ever came to visit Keith as she had never seen or met either
individual. The aide was stunned to learn from the nurse that Keith has no brothers/
post-TBI, will vary according to the site and extent of the injury, the
Mild traumatic brain injury example: a young man who played defense on a local
high school football team sustained a mild traumatic brain injury when he collided with
when the paramedics removed him from the field. Later in the week, while in class, he
symptoms resolved themselves after a little less than a week, and he seemed to be
male patient, “John”, who sustained his traumatic brain injury from a stroke. Two years
prior to his stroke, he fractured his hip after a fall in the bathroom, and earlier in his life,
at the age of 42, he had been diagnosed with diabetes. Rehabilitation is challenging for
the patient because he is not only dealing with his sensory-motor deficits, but also with
The psychological considerations have an effect on the patient, his family and the
attending therapists. In John’s case, his deepening depression has adverse affects on
his mood, emotional outlook, and motivation. He often exhibits ill temper towards both
therapists and support, acting as though it is somehow their fault that he cannot meet
the extremely high expectations he has set for himself concerning his ability to assume
McPhail 7
a more independent lifestyle, like the one he had prior to the onset of his disability. In
the case of his family, a number of whom who have gone out of their way to try and
accommodate his new needs and do anything they can to help him, there is a sense of
frustration because they do not understand John’s current psychological state and how
it affects his daily ability to cope. They are experiencing a high degree of frustration at
John’s lack of progress in the physical area, as well as expressing a deepening sense
of dissatisfaction with John’s apparent feeling that whatever they are doing to help is
somehow “not quite good enough” despite the sacrifices they have made, often at a
considerable personal cost, to try and help him in his current situation.
John’s depression is also affecting his relationship with the therapists who work
with him due to an increasing lack of motivation. This is sometimes the genesis of
feelings of anger and hostility directed towards his friends, family and therapists if they
try to encourage him to participate in the activities designed to move his treatment
along.
Healthcare professionals who treat patients that sustained a TBI should have an
resulting from an abnormal syndrome) and social factors affecting patients with
craniocerebral injury. If the patient is in a depressed state, the plan of treatment will be
affected by such factors as how the patient receives the therapist during times the
treatment must be carried out, the lack of motivation the patient may experience when it
comes time to carry out treatment alone or with aides and/or family members, and the
displaced feelings of anger and frustration the patient exhibits that ultimately will be
McPhail 8
directed at the help and support network. Patients in this state can also experience
lower pain thresholds and increased fatigue which work to limit the physical gains that
can be made.
to what the therapist can do to overcome the obstacles there may be to completing the
dealing with the patient’s depression, alleviating pain and fatigue levels and positively
redirecting any hostility the patient exhibits to better the relationships the patient has
with family, friends and other treatment professionals whose duty it is to aid the patient
in the areas where he cannot function without help. Naturally, these steps must take
into account how to better ally the family and other healthcare professionals who are
emotional/psychological symptoms can affect outcomes. In this way, the individual TBI
patient can be best allowed to progress in the overall plan of rehabilitation as set down
(Vargas 201).
the skull) hemorrhage which is a result of the rupturing of arteries and veins can
decerebrate rigidity [the head is arched back, the arms are extended by
the sides, and the legs are extended], decorticate rigidity [with elbows,
wrists and fingers flexed, and legs extended and rotated inward],
spasticity in both upper and lower extremities. Whenever she becomes very upset or
agitated, she screams and locks her jaws, clamping her teeth shut with an undue
amount of force. In order to alleviate this condition and allow Jane’s muscular state to
return to normal, her aides and workers have to basically accommodate Jane in
REHABILITATION
methods and exercises specifically designed to take advantage of the reduced gravity
and extra support that in-water work provides helping to prevent contractures.
right and left legs passively. This motion enables the therapist to move her hands
toward Jane’s ankle on each leg and then proceeds to flex her hip and knee above the
water until the leg passes over the therapist’s head which rests on the back of Jane’s
neck.
Jane and Keith confidence and improved control of their bodies in the water.
They will progress to the next level of swimming once the strokes have been
mastered. They also provide aquatic therapy along with walking and physical
therapy on land.
McPhail 11
Patients with TBI are often apraxic (apraxia is a neurological disorder characterized
by the loss of the ability to execute or carry out purposeful, learned movements, despite
having the desire and the physical ability to perform the movements. It is a disorder of
motor planning which may be acquired, but may not be caused by incoordination,
sensory loss, or failure to comprehend simple commands) and have problems with
to treatment involving all members of the rehabilitation team necessary on land and in
outcome for the patient. If they notice there is evidence of contractures, the team will
Depending on the degree of and severity of the traumatic brain injury, once initial goals
are attained, other dynamic aquatic therapy activities may be integrated into the aquatic
rehabilitation plan of care which includes improvements in the areas of gait, posture,
predominant clinical feature. The understanding of the mood disorder must take place
1. The experience of the mood disorder, which refers to the conscious feeling of
elation on the other. Example: On one Sunday morning while getting Jane ready
for church, her aides found her very pleasant and accommodating. She became
emotional in church, crying from the sermon she heard. Her reaction was so
McPhail 12
overwhelming that her aide began to cry, as well. Later that same evening, Jane
became so upset that her worker would not let her take food by mouth, Jane
decided to ram her wheelchair into the aide at full speed, pinning her into the
corner.
2. The ways the TBI sufferer feels about the situation. This expression of the
disorder can affect the level of activity and nervous system functioning, which
care only on Fridays, Saturdays and Sundays each week. He went from walking
25 steps with his worker to barely accomplishing 10 steps due to suffering a bout
of the flu which set back his mobility. John is now beginning to feel a huge sense
does not see the point of why he should even be bothering to continue with the
3. How the TBI sufferer reacts to the new disability. The cognitive components of
Depression can be expressed differently with age. For example, infants exhibit
aggression, acting out or with an increase in activity. In older adults, ease of distraction
and memory problems have been noted. Depression in children is of great concern due
The severity of depression ranges from mild to severe. Mild depression features
symptoms such as requiring an extra conscious effort to accomplish the things that
need to be done for daily living and minor impairments of social or occupational
functioning and levels of effort midway between mild and severe, including symptoms
that prevent the individual from accomplishing those things that need to be done to
succeed in daily living. Severe depressions feature the marked impairment of social
and occupational functioning and levels of effort needed to complete daily tasks and
may also include psychotic symptoms (i.e., disturbances in eating, sleeping, sexual
The list below describes the function of each specialist and how their areas of
1. Dietician -- Keith and Jane both currently receive services relating to nutrition
following their head injuries. Both of them gained weight from their underlying
depression and the new lack of activity brought on by the limitations caused by
2. Ear, nose and throat physician -- Keith had to have a specialist come in following
his accident. He took a blow to the front of his head, causing trauma to his
nose, although not apparent to observers. The result of this injury caused him to
3. Neurologist – This doctor, who deals with cerebral and neurological issues, is
measure brain function, and to determine what kind, if any, impairments there
may be in normal brain function. Other tests which may be requested include the
inserted into muscles and a mild current is run along nerve pathways to see how
neuroimpulses from the brain are being received and utilized by the muscles (it
detects the electrical potential generated by muscle cells when these cells are
mechanically active, and also when the cells are at rest). An EMG can be used
4. Nurses -- this professional carries out the medical orders of the physicians and
applies any prescribed medical treatment. The nurse is responsible for getting
the patient up, giving medication and charting how the TBI patient is progressing.
plan suggested by the nurse and neurologist. While the two specialists work in
close conjunction with each other, in general, the physical therapist may be
considered as being the one who provides rehabilitation in issues relating to the
lower half of the body (i.e., walking and mobility) while the occupational therapist
deals with the conditions that affect the upper extremities (sensation of touch in
the fingers, the use of fine and gross motor skills to accomplish tasks like
lengthy history from the TBI patient, and helps to decide in conjunction with the
physician the type and number of healthcare workers and other professionals
who need to work with the patient (i.e. physical therapist, speech pathologist,
McPhail 15
home health aides, etc.) as well as finding an Independent Living Skills Trainer
light of the patient's new limitations. The case manager, in conjunction with the
ILST, will work with any social service agencies to gain the maximum help the
the responsibility of figuring out what medical bills, etc., the insurance company is
liable for. This person also functions as an advisor to the insurance company,
and it is the insurance adjuster who will ultimately authorize or deny treatment.
counsellor who will help them adjust their behavior and coping abilities following
the new disability. The psychologist is usually called upon to help the TBI
patients cope with their new emotions resulting from dealing with rehabilitation or
to help the patient's family deal with different aspects of the recovery process.
The psychiatrist is also an MD, which allows certain medications, necessary for
assisting Jane and Keith with a successful return to work and school by setting
responsible for locating jobs, schools or volunteer sites that best match their
11. Home healthcare workers (PCA, HHA, HCSS) – these workers come into the
home to help the TBI patient with such things as cooking, light housekeeping
duties (like cleaning, doing dishes, laundry, etc.), grocery shopping, etc. That the
TBI sufferer cannot accomplish alone. Certain aides receive training that also
allow them to do hands-on care such as helping with bathing, eating, dressing,
passive range of motion and other tasks that the patient cannot accomplish
unaided. These workers can also accompany the patient for such outside
CONCLUSION
head. External agents include injuries such as a gunshot, car accident, falls and/or a
sports injury which is accompanied by open trauma allowing the brain tissue to come in
contact with external bacteria and/or fractures of the bones of the skull. A countercoup
injury is a closed injury involving no penetration to the skull, and where the brain can be
whipped back and forth inside the skull, either from blunt force trauma or extreme
movement, causing it to collide with the rigid surface of the bone, bruising the delicate
tissue or doing other damage like causing tearing of blood vessels, which leads to
Internal forces suffered by the patient can be the result of such organic causes
as a stroke, heart attack, diabetes or anything which causes an obstruction of blood flow
Whatever the cause, traumatic brain injury is devastating for the patient mentally
and physically. The sufferer is no longer able to be as cogent as prior to the injury, and
depending on the extent of the injury, exhibit normal rational thinking. Other limitations
usually include attention deficits and mood swings. Physical effects include loss of
mobility and other motor skills necessary to walk, or perform simple tasks like dressing,
bathing or even eating without assistance. This new loss of independence can leave
the individual feeling vulnerable, which circles back to other psychological impairments.
Rehabilitation is a very important step for the TBI patient because it keeps the
new physical impairments from becoming permanent and problematic for the individual.
Lack of movement can result in skin break down and bed sores, muscle weakness and
neurological impairments can lead to muscle atrophy and contractures, which further
lead to a decrease in motor function and mobility. By working with these limitations early
on, the physical and occupational therapist can enable the patient to eventually provide
care for themselves. By rehabilitation, the TBI patient can rebuild self esteem as they
are able to regain control of aspects of their life even with the new limitations.
Other specialists on the rehabilitative team can aid in regaining control of areas
of life through improvement in daily living skills like paying bills and household
management, improved coping skills, improving speaking and cognitive skills, and
Although difficult to do so, it has been proven that with the appropriate motivation
and team support, the TBI patient can overcome the new limitations and disabilities to
Works Cited
Carlson, Connie and Darcy Umphred. Neurorehabilitation for the Physical Therapist
<http://www.military.com/benefits/resources/traumatic-brain-injury-overview>.
Turnbull, Ann, Rud Turnbull, and Michael L. Wehmeyer. Exceptional Lives: Specioal
Education in Today’s Schools: Fifth edition. 3rd print. Upper Saddle River:
Vargas, Luis G. Aquatic Therapy: Interventions and Applications. 1st ed. Ravensdale:
<http://en.wikipedia.org/wiki/Head_injury>.
<http://en.wikipedia.org/wiki/Traumatic_brain_injury>.