Rehabilitation

Basic Principles

Rehabilitation refers to the process of helping the patient return to as much normal function as possible. There are many ways to improve the patient’s function. One way is to teach him how to compensate for his deficits (for instance, by providing a walker when legs are weak or teaching the person how to dress with one arm). Ideally, however, we would like to help the patient recover the function that has been lost (and not just teach compensation for the loss). In some cases, recovery of function is possible and occurs because undamaged brain tissue can sometimes take over the functions of the damaged parts of the brain. This ability of the brain to “re-wire” itself is called neuroplasticity. This process is most likely to occur when the patient is exerting effort practicing the impaired function.  For example, if the arm is weak, the best chance for recovering strength in the arm is to use it as much as possible. This approach is sometimes called a “forced-use” philosophy, since the patient is encouraged to use the function as much as possible. It is thought that neuroplasticity applies not only to physical problems but may also be important to help patients improve impaired thinking skills (for instance, the ability to speak).

Of course there are limits to how much the brain can heal, but it is clear that in order to maximize the amount of recovery the brain can undergo, it is important to stimulate it with activity. Unfortunately, we do not know ahead of time how much, if any, of the patient’s function will be recoverable. Two patients can both undergo intensive rehabilitation for the same problem (for example, a weak arm) and have very different outcomes. This uncertainty about who will benefit from a “forced-use” approach means that it should probably be tried in everyone and then, if a patient does not improve, the focus can shift to compensatory techniques.

Unfortunately, rehabilitation to restore lost function (rather than just compensate for it) can be quite difficult and time-consuming. For instance, a patient may be able to dress faster with one hand than if he uses the weak arm (because of the time it takes to use the arm). Also, it is faster for therapists to teach compensatory techniques than to spend time trying to improve the impaired function. And for patients having a limited amount of time in the rehabilitation hospital, it might make more sense to focus on some compensatory techniques so that they can at least perform some activities on their own after discharge. They can then focus on the restoration of lost function in an outpatient setting. The decision on how best to approach a patient’s rehabilitation will vary from patient to patient and will depend on many different factors, both medical and non-medical. Recently, studies have shown that improvement in function can occur even years after a brain injury, if the patient receives intensive therapy. It is important to keep this in mind when decisions are being made about the possible benefit of further therapies for someone whose injury occurred a while ago.

Rehabilitation Professionals

Rehabilitation is provided by many different professionals.

Table 15. Some Rehabilitation Professionals

Physician (Physiatrist or Neurologist)

Nurse

Neuropsychologist

Speech-Language Pathologist

Physical Therapist

Occupational Therapist

Social Worker

Case Manager

Music Therapist

Recreation Therapist

Often, these professionals work as a team to help coordinate the care they provide. This happens most often on a rehabilitation unit or in a rehabilitation hospital. Usually, the rehabilitation physician leads the team. Rehabilitation physicians are usually either specialists in rehabilitation (sometimes called physiatrists) or in neurology (neurologists). In most situations, only one or the other leads the team. However, in some settings, both specialists are involved and work together. Other physicians may be consulted during the rehabilitation process as needed. The most common consultants include neurosurgeons, psychiatrists, internists, and orthopedists. Nurses are an important part of the rehabilitation process, especially while patients are still in the hospital. In addition to routine nursing care, they help manage issues with trach care, feeding, bowel and bladder function, and skin care.

Psychologists are often part of the team taking care of people with TBIs. Most often, they are neuropsychologists. A psychologist has a PhD in psychology and a neuropsychologist is a psychologist who has undergone additional training focusing on the brain. Psychologists have many roles on the rehabilitation team. They help address any emotional or behavioral issues that might arise for the patient. They also assess and guide treatment for any problems with thinking that the patient has (for example, problems with memory, attention, etc.). Often they perform testing on the patient. Neuropsychological testing is similar to standardized tests that are taken in schools such as the SAT. It is primarily a paper and pencil test and takes several hours to complete. The goal is to provide detailed information about exactly what kind of problem a patient might be having with his thinking. This information can then be used to follow a patient’s progress and help with guiding treatment.

There are several different types of therapists who work with people with TBIs. Physical therapists (PTs) tend to concentrate on patients’ legs and the activities they use their legs for (such as transferring and walking). Another name for the area that PTs focus on is mobility.

Table 16. Examples of Mobility Activities

Transfers (sitting to standing, bed to wheelchair, wheelchair to toilet, etc.)

Wheelchair Propulsion

Ambulation (walking)

Occupational therapists (OTs) focus on the arms and the activities that arms are used for (such as brushing and dressing). The activities that OTs address are called activities of daily living. Speech therapists (sometimes called speech-language pathologists) work on three main issues: swallowing, language (communication), and cognition (thinking). Difficulty with swallowing after TBI is called dysphagia.

Table 17. Examples of Activities of Daily Living (ADL)

Orofacial hygiene (brushing teeth, washing face, etc.)

Toileting

Bathing

Dressing

Feeding

Speech therapists help assess how safely patients swallow as well as treat the dysphagia. In addition, speech therapists address the problems patients may have with communicating using language (speaking, understanding, reading, and writing). Having problems with language after brain injury is called aphasia. In many centers, speech therapists also treat other problems with thinking (such as memory and organization). Besides physical, occupational, and speech therapists, some specialized centers also have music and recreational therapists. Music therapists use music to help advance the patient’s treatment. Recreational therapists attempt to use activities that patients find enjoyable (such as games or hobbies) to help their recovery.

Social workers also play an important role in the rehabilitation process. Patients and families often need help in dealing with the impact of a TBI on their lives. Social workers help them cope with the injury as well as help locate resources to meet their needs after injury. A case managers is the primary contact person between the rehabilitation team and the insurance company. For regular or commercial insurance, the case manager reports the patient’s progress and the treatment team’s recommendations. Government financed rehabilitation (for instance, through Medicare or Medicaid) usually doesn’t require weekly reports. In these cases, the case manager monitors the appropriateness of the patient’s treatment and follows the guidelines issued by these programs.

Family and friends are considered part of the rehabilitation team. Because the process of recovery after TBI can be a long one, families and friends are often trained to provide some of the care for the patient. This can include nursing care as well as therapeutic activities taught by the therapists.

The Continuum of Care

Rehabilitation after TBI occurs at all stages of recovery. It starts in the intensive care unit (ICU) and often continues long after a person goes home. It is important to remember that rehabilitation is not just something provided in a rehabilitation hospital; it is a process that can occur in almost any setting and can be provided by many different individuals.

Table 18. Settings for Rehabilitation

Intensive Care Unit (ICU)

Acute Care Hospital

Long Term Acute Care Hospital (LTAC)

Skilled Nursing Facility (SNF)

Acute Inpatient Rehabilitation

Nursing Home

Post-Acute Residential Rehabilitation Facility

Outpatient Community Re-entry Program

Outpatient Therapies

Home Therapies

Rehabilitation begins in the ICU; during this stage, it is primarily provided by nurses and therapists. The goals of rehabilitation when a patient is still unconscious are primarily to maintain the flexibility (range of motion) of the joints, manage spasticity (described in more detail in a following section), and mobilize the patient as much as possible (for instance, by putting him in a sitting position in a special chair).

Once the person’s medical condition is more stable, he is moved out of the ICU to a regular hospital floor. As the patient regains consciousness and is able to participate more, the goals of rehabilitation also increase. At this point, a decision will be made as to where the next phase of rehabilitation will be provided. The first decision is whether a patient needs to stay in some sort of medical facility or is able to go home (or to a nursing home). This decision is based primarily on how much medical care the patient still needs. If medical care provided by physicians is still needed, then the next question is how much medical care is needed. If a patient is still quite sick (for instance, requiring a ventilator to breathe), then he will often go to a long-term acute-care facility (LTAC). An LTAC is not a nursing home. LTACs provide intensive medical care (just like a regular hospital) for patients requiring this type of care for at least several weeks. Patients can still receive therapies in an LTAC; however, it is not as frequent or as intense as that provided by an inpatient rehabilitation facility.

If a patient’s medical needs are not quite so intense, then the options would be either a rehabilitation unit or a skilled nursing facility (SNF). There are two main differences between an inpatient rehabilitation facility and an SNF. The first is in the intensity of medical care provided. Most rehabilitation units or hospitals provide daily physician visits. In an SNF, physician visits may range from daily to just several times a week. The other main difference between the two facilities is in the amount of therapy provided. An acute rehabilitation unit or hospital provides from three to five hours of therapy a day. SNFs, on the other hand, provide less than three hours of therapy a day. SNFs can be located inside hospitals or inside nursing homes. However, even when an SNF is located inside a nursing home, it is important to realize that an SNF provides more care than the rest of the nursing home. In summary, in deciding between transfer to an inpatient rehabilitation facility or SNF, the two main considerations are how much medical supervision is required and how much therapy the patient is able to tolerate.

Even patients who first go to LTACs and SNFs will often go to inpatient rehabilitation facilities later, once their condition has improved. As mentioned, inpatient rehabilitation facilities can either be in a regular hospital or in a separate hospital dedicated to rehabilitation. Inpatient rehabilitation facilities in regular hospitals usually treat many types of patients, not just those with TBIs. They are appropriate for relatively uncomplicated TBI patients. However, most patients with TBIs would benefit from going to rehabilitation units that specialize in TBI. These are almost always located in hospitals dedicated to rehabilitation. Care in these TBI units is provided by a multi-disciplinary team with experience working with patients with TBIs. The length of stay on the rehabilitation unit varies considerably and depends on the clinical status of the patient, where he is able to go after rehabilitation, and even the type of insurance the patient has.

Decisions about where a patient goes after being discharged from the inpatient rehabilitation facility are based on several different factors. Almost all patients will still require some amount of care after discharge, even if it is just to have someone keep an eye on (supervise) them because of their problems in thinking. If there are no family members or friends who can provide this type of constant care, patients may go to nursing homes until their need for care is less. Many nursing homes still provide some therapies although these are not as intense or as specialized as those found in inpatient rehabilitation facilities. If patients can be cared for at home, then they may be discharged home and receive some form of outpatient therapy (described in the following section). Some patients may have the option to go to a post-acute residential rehabilitation program before going home. Although not hospital-based, patients in these programs stay at the facilities (which is why they are known as residential). They are called post-acute because they take place after acute rehabilitation. The focus of these programs is to continue the physical and cognitive rehabilitation begun in the acute inpatient rehabilitation facility. Because patients are further along in their recovery, the focus is usually on more advanced skills. Unfortunately, many insurance companies or government programs do not pay for post-acute rehabilitation.

For patients who go home, there are two main outpatient therapy options. One is traditional outpatient therapy, which involves visits with the PT, OT, and speech therapist as needed, usually no more than three times a week. Another option that may be appropriate is similar to the post-acute residential program described previously but is known as community re-entry or a community reintegration program. Goals are to help patients return to independent living, school, and/or work. In addition to PT, OT, and speech therapy, these programs also offer additional treatments addressing the cognitive and emotional changes that occur after TBI.

Understandably, the rehabilitation process can be quite long, often extending months from the time of the original injury. However, even when formal therapies end, patients and families may still need to continue to work on the skills they have been taught in order to continue to progress in their recovery.

Rehabilitation of Common Physical Problems

Low Endurance:

Patients often have very little endurance or stamina after a TBI. They have very low energy levels and are easily fatigued. This is partly caused by having been in bed for so long during the early part of their recovery (a process known as deconditioning). Patients who have been in bed even for a little while lose a lot of their muscle bulk and strength. In addition to changes in the muscles, most people’s heart and lungs are also deconditioned. This further limits the amount of activity they can perform. Although changes in the body are the main cause of low endurance after a TBI, some of the problem is caused by the brain damage itself. Even after the body recovers, many TBI patients report having continued problems with low energy levels. The reason for this is not entirely clear.

The treatment for deconditioning is to gradually build up one’s endurance through regular physical activity (such as  that provided by the therapists). This is identical to the conditioning that our bodies undergo whenever anyone begins an exercise program. In addition to physical activity, it is important that patients receive enough rest. This is one of the reasons that close attention is paid to how well patients are sleeping at night while in the rehabilitation hospital. Finally, sometimes the physician will prescribe a stimulant medication that might help with energy. The most commonly used medications are listed in the table.

Table 19. Some Medications Used to Treat Fatigue

(Sample Brand Names in Parentheses)

Amantadine (Symmetrel)

Dextroamphetamine (Dexedrine)

Methylphenidate (Ritalin)

Modafinil (Provigil)

Weakness:

Although people sometimes use the word weakness to describe being deconditioned, true neurological weakness refers to paralysis or near-paralysis of muscles after damage to the brain (sometimes also called paresis). It usually affects only certain limbs (for instance, the right arm and leg), although in severe cases all of a person’s limbs may be paralyzed. The muscles are weak because the parts of the brain that control those muscles have been damaged. The muscles themselves may be completely normal; it is the control center in the brain that is not working. The paresis can range from mild weakness to complete paralysis.

The treatment of paralysis is primarily through intense activity, which is initially provided by the therapists. As mentioned earlier, the more a patient uses a weak limb, the greater the chance of improvement. Even when the patient does not see movement in the weak limb, it is possible that changes are still occurring in the brain when they try to move the limb. With the legs, standing and beginning to walk seem to be especially helpful. The walking may help speed recovery of strength even when someone needs the help of one or two other people just to take a step. With the upper limbs, it is helpful to bear weight through arms that are just beginning to move and, for those with more movement, to use the arm for tasks.

Sometimes, it is even helpful to restrict the good arm to ensure that the patient uses the weaker limb. This is sometimes done with a sling or binder. This technique is known as constrained-induced therapy (CIT) and is one way of following the “forced-use” method described in the section on principles of rehabilitation. However, CIT is most often used in outpatient therapies. This is partly because patients have to understand and agree to this therapy; the confusion that patients have early after TBI might prevent that understanding.

Another method used to improve strength is functional electrical stimulation (FES). This involves the application of just enough electrical stimulation to cause certain muscles to contract on their own. In most cases, the goal is for the stimulation to occur only when the patient is actively trying to move the muscle (even if he cannot move it on his own yet). These systems have sensors that can detect activity in a muscle that does not appear to be moving when a patient tries to move it. The sensors trigger the electrical stimulation, which then helps the patient move the muscle. It is hoped that the “head-start” that the stimulation gives the patient will speed recovery of the muscle. FES can be used in the arms or legs. In the legs, it is most often used to help lift the foot up at the ankle (so the foot does not drag during walking). There are other uses of electrical stimulation in rehabilitation. Sometime it is used to make muscles contract regardless of whether or not the patient tries to move the muscle. For instance, this is sometimes done to shoulder muscles whose weakness is causing the shoulder joint to be loose (or subluxed).

Another method being used more frequently to treat weakness of the legs is the use of treadmills. Because the patient is still weak, however, some of the patient’s weight is supported by attaching him to a sling so that he can concentrate on moving the weak leg (rather than focusing on just trying to stay standing). The sling can support different amounts of the patient’s weight, from 0-100 percent. The therapist determines what would be the best amount of weight support to achieve the goals set for the patient. This treatment is sometimes called partial body weight supported (PBWS) treadmill training. It is not appropriate for all patients: some patients are not yet ready to use it whereas others are too advanced and would gain more from beginning to walk on solid ground.

Although not yet widely used, there is a growing interest in what is called robotic therapy. Robotic therapy uses a robot to help the patient move his limbs. For instance, the arm could be strapped to a machine that helps the patient straighten and bend the elbow repeatedly. The robot provides as much assistance as required for the patient to perform the complete movement. Hopefully, the help provided will decrease over time as the person’s strength improves. The robot basically does what a therapist would do and may therefore allow therapists to either treat more patients or focus on more complicated activities with their patients.

Incoordination/Ataxia:

Incoordination is very common after TBI. It refers to the inability to coordinate all the movements required for an activity so that the motion is not performed smoothly. When the movements involve the legs, the result is that the person’s balance is off, even if he has good strength in the legs and trunk. In the arms, it means that the movement is not well controlled; this can create problems for those activities that require fine motor control skills. In most cases, the incoordination is simply due to generalized damage affecting the communication between different areas of the brain that control different parts of the body. Like the treatment for weakness and low endurance, persistent physical activity seems to improve this type of incoordination.

In a few cases, however, the incoordination is due to damage to the part of the brain that directly controls coordination (the cerebellum). The incoordination in these cases is called ataxia and is much more severe than with TBIs that do not affect the cerebellum. Unfortunately, ataxia is much harder to treat than routine incoordination. Although therapy is important, it is not very effective. A technique that sometimes helps is to place weights on the arms and legs (for instance, by strapping weights to the wrists and ankles). It also helps to place weights on the devices the patient uses (for instance, walkers or spoons). The extra weight (whether on the patient or the devices they use) seems to help reduce the tremor that is part of ataxia.

Spasticity:

Muscle spasticity or increased muscle tone is common after brain damage and refers to a condition in which the muscles are continuously active. This does not mean that the muscle (or the limb) is moving but that it stays in one position because the muscle is keeping it in that position. For instance, a person may have trouble straightening out the elbow because the muscles that bend the elbow (such as the biceps) stay continuously active and keep the elbow bent. If someone else tried to straighten the elbow for the patient, that person would find it hard to do so because he would have to fight against the spastic muscles that are keeping the elbow bent.

Spasticity usually develops over time. Early after a TBI, the muscles can actually be too relaxed (flaccid). Gradually, weakened muscles will develop increased tone. If they develop too much tone, they are considered hypertonic or spastic. The arm muscles that are most often affected by spasticity cause the fingers, wrist, and elbow to be curled or flexed. The upper arm is also usually pushed against the chest because of spastic shoulder muscles. In the legs, the ankle is usually turned inward and the foot pointed down (like a ballerina). At the knee, people can either have spastic knee extensor muscles (so that they can’t bend their knees) or spastic knee flexor muscles (so that they have difficulty straightening the knees out).

Spasticity can cause several different problems. For one, excess muscle tone can prevent the person from using other muscles. For instance, even if a patient had normal strength in the muscles that straighten the elbow (triceps), he might still be unable to straighten his elbow because the triceps are not strong enough to overcome the spasticity in the biceps. The spasticity may also prevent the patient from using the spastic muscle. For instance, a patient will not be able to use his biceps because it is already continuously active. If the biceps are weak, this will prevent the patient from being able to exercise it. It is important to realize that a spastic muscle is not necessarily a strong muscle. The muscle could be completely paralyzed and it is just the spasticity that is making the muscle active. This means that a patient may still not be able to use the muscle even if the muscle is relaxed by treating the spasticity. It just depends on what the muscle strength is.

Spasticity can also cause pain (because the muscle is always contracting). Other problems caused by spasticity depend on where the spasticity is and how bad it is. For instance, in some patients, spasticity in the shoulder is so severe that they cannot lift their arm away from their chest. These patients are unable to reach their armpits to clean or apply deodorant and they are at risk of developing infections or even skin ulcers in that area. Finally, spasticity can make providing care to the patient more difficult. For instance, it may be hard to help the patient put on a shirt if severe spasticity in the elbow flexor muscles prevents him from straightening out the arm.

Despite the problems that it can cause, spasticity is sometimes beneficial. This is most often true in the legs where having increased tone in the knee extensors allows the patient to transfer or stand more easily (because it keeps the knees from buckling). Regardless of location, some cases of spasticity are relatively mild and do not cause problems.

The severity of spasticity can vary day to day or even within a day. Spasticity is also sensitive to changes in the environment (for instance, some patients find that spasticity increases when it is cold). Finally, the amount of spasticity can be affected by the person’s condition. For instance, the tone can increase if he or she is feeling stressed or getting emotional. Illness can also increase spasticity. Sometimes an increase in spasticity is the first sign that the person is getting sick (for instance, with a bladder infection). In fact, any unusual increase in spasticity should cause the patient or staff to look for a cause.

There are various treatments available for spasticity, some provided by the therapists and some by the physician. Most patients will require a combination of several different treatments to manage their spasticity most effectively. Both physical and occupational therapists provide a range of treatments for spasticity. One important intervention is simply to make sure that the patient is appropriately and adequately positioned, either in bed or in the wheelchair. This is not only to accommodate the change in a person’s body mechanics as a result of tone but also to minimize the spasticity itself (for instance, by minimizing the patient’s discomfort). Therapists will also use splints and braces to help keep the patient’s arms and legs properly positioned and stretched out. In addition to positioning, therapists will spend a lot of time regularly stretching spastic muscles. Not only will this maintain the range of motion of the muscles and joints but it will also reduce the amount of spasticity.

Although there are several medications available for spasticity, they are not often used in TBI rehabilitation (unlike rehabilitation for patients with spinal cord injury).

Table 20. Some Medications Used to Treat Spasticity

(Sample Brand Names in Parentheses)

This is because TBI patients are much more sensitive to the side-effects of these medications. In particular, they are much more likely to become sleepy. Because drowsiness and fatigue are already a problem for patients with TBI, the medications can have more disadvantages than benefits.

Because of the limitations of medications, it is much more common to treat spasticity after TBI with injections directly into the spastic muscles. The advantage of these injections is that they apply the medication directly to where the problem is and thus minimize the risks of side-effects. The effect can also last from 2-12 months (depending on which medication is used) so the patient is spared having to take medicines on a daily basis. The two medicines that are most often injected into spastic areas are botulinum toxin and phenol. Botulinum toxin is injected directly into the spastic muscles, whereas phenol is injected into the nerve that goes into the muscles. There are advantages and disadvantages to both treatments. In general, botulinum toxin is used more frequently early in the recovery whereas phenol is used more often later.

Finally, in severe cases, a patient may benefit from an intrathecal baclofen pump (ITB pump). The ITB pump is a device surgically placed inside the body so that it can infuse an anti-spasticity medicine (baclofen) directly into the cerebrospinal fluid in the lower back. Because this treatment requires surgery, it is important to know ahead of time if the patient will benefit from it. This is done by giving the patient a test dose of baclofen by a single spinal injection. The medicine will last about eight hours and its effects can be evaluated during that time. If the patient shows a benefit, than the test or trial is considered “positive” and he will probably benefit from having a pump placed.

Contractures:

Contractures occur when a joint is permanently frozen or unable to move beyond a certain point. They occur when a joint has remained in the same position for a prolonged period of time (sometimes as little as several days). In these situations, the tendons and ligaments (called the “soft-tissues” to distinguish them from bone) will shrink and prevent the joint from being stretched. Even though many cases of contracture were initially caused by spastic muscles that kept the joint in the same position, once the contracture occurs, it does not matter if the muscles eventually relax or not. This is because the soft tissues have already shrunk. When a joint cannot be fully stretched, it is important to determine whether this is because of spasticity alone or whether there is a contracture. This is because treatments for spasticity will not affect the contracture. The treatment for a contracture is aggressive stretching. Sometimes a cast like that used for fractures is applied to the limb (after it is stretched) to help provide a strong and persistent stretch. However, many patients will require surgery to treat their contractures. This surgery is usually performed by an orthopedic surgeon and involves either lengthening or even just cutting the shrunken tendons.

Apraxia:

Apraxia is a condition in which the difficulty patients have in performing tasks is not caused by weakness or incoordination. It seems to be caused by centers in the brain that help plan our movements. Examples include having difficulty using tools such as spoons or combs, difficulty dressing, etc. Patients do best when they are in situations where they are actually performing the activity rather than simply mimicking it. That is, they may have difficulty showing how to use a toothbrush if asked to demonstrate it but may do fine when actually brushing their teeth. Patients also seem to do better if someone else models the activity by performing it in front of them. Although therapy is helpful, apraxia can be difficult to treat.

Neglect:

Neglect refers to a condition where the patient has difficulty paying attention to one side of his body or his environment (for instance, the left side). In severe cases, the patient may not be aware of anything that takes place on that side. For instance, patients may only eat food on the right side of their plate. Or, they may only shave or apply make-up to one side of their face. Although in some cases this may be because patients have trouble seeing on the affected side, many patients do not have any trouble with their vision. Rather, the part of the brain that controls our knowledge of that side of the world is damaged. This can affect almost all of the senses. For example, in addition to not “seeing” objects on the affected side, patients often are not aware when someone is touching that side of their body either. In very severe cases, patients may not even recognize that the arm or leg on the affected side is their own. Neglect can be difficult to treat. In most cases, the focus is on trying to increase stimulation to the affected side as much a possible. For instance, people might stay on the patient’s neglected side when talking to them. The physician may try some medications to help reduce the severity of neglect, but there is no proven treatment yet.

Rehabilitation of cognitive problems

Cognitive or thinking problems are very common after TBI and are considered different from emotional problems (which are discussed in the next section). In general, cognitive problems are difficult to rehabilitate. Often, the best way to address them is to provide the patient with ways to compensate for the problem. In addition, the patient’s environment or activities can be changed so that his problems won’t have as much impact. In a few cases, the problem itself can be directly treated with medication or rehabilitation.

Arousal: Arousal refers to the state of being alert. People who have low arousal tend to be sleepy or lethargic. Reduced arousal is very common early after brain injury and results from damage to the parts of the brain that control alertness. There are several treatments that can increase arousal. The first is to ensure that the patient is sleeping well at night. In addition, increasing the amount of stimulation the patient receives also helps. For instance, simply having the patient sit up in a wheelchair rather than lying down can increase the arousal level. Finally, there are stimulant medications that can be used to help increase arousal.

Table 21. Some Medications Used to Treat Low Arousal

(Sample Brand Names in Parentheses)

Attention: Attention refers to the ability to focus or concentrate on something. It is different from arousal. A person may be fully awake and alert and still have a lot of difficulty in concentrating on his environment or on the task he is performing. Because of problems with concentration, patients are often easily distractible. Problems with attention are among the most common problems patients have after a TBI. Modifying a patient’s environment can help reduce the impact of problems with concentration. One can minimize the amount of distraction in the environment (for instance, by treating the patient in a quiet area without interruption). In addition, patients will often require frequent reminders to re-focus their attention on the tasks at hand. Finally, there are some medications that can improve attention in some patients.

Table 22. Some Medications Used To Treat Attention

(Sample Brand Names in Parentheses)

Amantadine (Symmetrel)

Atomoxetine (Strattera)

Dextroamphetamine (Dexedrine)

Methylphenidate (Ritalin)

Modafinil (Provigil)

Memory: Problems with memory are very common after TBI. The difficulty is with day-to-day memory (often referred to as “short-term memory”). Patients will have trouble remembering information or events that happened hours to days before. Patients rarely have difficulty with long-term memory. Although some patients may lose memory for events from weeks to months before the injury, it would be very, very rare for them to lose memory from farther back than that. This means that they should remember their past life and recognize people they know from the past. As with other cognitive deficits, addressing memory deficits involves a combination of helping patients compensate for their problem as well as trying to improve the memory with medications. To compensate for their difficulties, patients can use strategies such as writing things down in a book (memory book). The physician may also try a medication to help improve the memory. Most of these medications are ones that are used in Alzheimer’s disease, but there is some evidence that they might be useful after TBI.

Table 23. Some Medications Used to Improve Memory

(Sample Brand Names in Parentheses)

Donepezil (Aricept)

Galantamine (Reminyl)

Rivastigmine (Exelon)

Awareness/Insight: People with TBI often are not aware of the extent of their problems, especially in their thinking. For instance, they may feel that they have no issues with their memory, even though everyone around them sees the trouble they have remembering. This problem with insight into their condition occurs because the part of the brain that controls our self-awareness is often damaged after TBI. The technical name for this condition is anosognosia. It can be very frustrating for those who interact with the patient, precisely because the person is not aware of his lack of insight. Although presenting him with evidence of his problems sometimes helps, many times even that does not increase the patient’s insight. As with the other problems that people with TBI have, this condition is not under the patient’s control. It is important to realize that he is not being difficult or deliberately trying to avoid admitting his problems.

Executive Functioning: Executive functioning refers to the ability to control and use all of one’s thinking skills. In many ways, the executive center of the brain works almost like the chief executive of a company who sets goals for the company and decides the best way to achieve those goals. Examples of executive functions include planning strategies to reach goals, implementing those strategies, being able to switch strategies if current ones are not working, preventing irrelevant or inappropriate thoughts from becomming distracting, being able to see “the big picture,” being able to deal with new situations, etc. The executive functions are among the most complex thinking skills that humans have. At the same time, problems with someone’s executive functions may not be very obvious, especially from just talking to the patient. This is because these problems are most apparent when the patient actually tries to do something. Executive dysfunction can be very disabling, even in patients who have no other thinking problems. Treatment can be difficult and primarily involves changing a patient’s activities and environment so that he does not need to use executive functions so much. For instance, a person’s duties at work could be changed so that he does the same task daily. In addition, the need for making decisions during the task could be minimized.

Rehabilitation of emotional and behavioral problems:

Emotional problems are very common after TBI because the areas of the brain that control emotion are often damaged. Emotional problems not only cause the patient and family distress, but they can limit the patient’s function. In most cases, a combination of medication and psychological treatment can improve these problems.

Agitation: Agitation refers to a stage early after TBI, when patients can be very restless and sometimes aggressive. Usually the patient is also very confused. The agitation can cause problems with the patient receiving the medical care that he needs. For instance, the patient might pull out IV lines or refuse blood draws. Agitation is a phase that most patients will pass through; it is unusual for it to be permanent. When patients are agitated, it is important to check to make sure there are not any issues that might be making the agitation worse. For instance, if the patient is in pain or being over-stimulated, this can worsen or even cause agitation.

Early on, the patient may need to be restrained or sedated for his own safety. Ideally, however, the patient can be given a medication that can calm him down without sedating him. Several different medications are available to treat agitation.

Table 24. Some Medications Used to Treat Agitation

(Sample Brand Names in Parentheses)

Anticonvulsants	Antipsychotics	Anxiolytics	Stimulants
Valproic Acid (Depakote)	Aripiprazole (Abilify)	Buspirone (Buspar)	Amantadine (Symmetrel)
Carbamazepine (Tegretol)	Haloperidol (Haldol)	Lorazepam (Ativan)	Dextroamphetamine (Dexedrine)
Oxcarbazepine (Trileptal)	Olanzapine (Zyprexa)		Methylphenidate (Ritalin)
	Quetiapine (Seroquel)
	Risperidone (Risperdal)
	Ziprasidone (Geodon)

Anger/Irritability: Irritability and anger are common problems after TBI and can sometimes last long after the injury. Most patients and families describe the problem as the patient having a short temper or short “fuse.” Fortunately, there are many different medications to help treat the problem.

Table 25. Some Medications Used to Treat Irritability

(Sample Brand Names in Parentheses)

Antidepressants

Anticonvulsants	Antipsychotics	Anxiolytics	Others
Buproprion (Wellbutrin)	Valproic Acid (Depakote)	Aripiprazole (Abilify)	Buspirone (Buspar)	Lithium
Duloxetine (Cymbalta)	Carbamazepine (Tegretol)	Haloperidol (Haldol)	Lorazepam (Ativan)
Methylphenidate (Ritalin)	Oxcarbazepine (Trileptal)	Olanzapine (Zyprexa)
Mirtazapine (Remeron)		Quetiapine (Seroquel)
Selective Serotonin Reuptake Inhibitors:     Citalopram        (Celexa)     Escitalopram        (Lexapro)     Fluoxetine        (Prozac)     Paroxetine        (Paxil)     Sertraline        (Zoloft)    Venlafaxine        (Effexor)	Risperidone (Risperdal)	Ziprasidone (Geodon)

In most cases, medications can help reduce or eliminate the problem. In addition, it is helpful for the patient to learn anger management techniques from a psychologist or other counselor. Family and friends can also benefit from learning how to deal with and manage the patient’s anger.

Lability:Emotional lability refers to a condition in which patients cry or laugh much more easily than before. The condition is sometimes called “involuntary emotional expression disorder.” Most times, the laughter or crying is out of proportion to the situation. Sometimes the patient does not even feel sad or happy during these episodes. The episodes usually pass very quickly and the patient’s mood (if it did change) quickly returns to normal. There are medications that are usually effective in treating the disorder.

Table 26. Some Medications Used to Treat Emotional Lability

(Sample Brand Names in Parentheses)

Selective Serotonin Reuptake Inhibitors

Citalopram (Celexa)

Escitalopram (Lexapro)

Fluoxetine (Prozac)

Paroxetine (Paxil)

Sertraline (Zoloft)

Depression: Depression is very common after TBI and can occur at any stage of the recovery process. The symptoms of depression after TBI are the same as in depression in people who have not had TBIs. These symptoms can sometimes be subtle. The patient may not even feel particularly sad but instead may have low energy, trouble sleeping, or lack of interest in activities as the main symptoms. Because it is partly caused by chemical changes in the brain, patients can be depressed even if it appears that they are making a good recovery. However, usually their situation and the difficulties they face can make the depression worse. Since depression is caused by both one’s situation as well as chemical changes in the brain, treatment usually involves medication as well as counseling. This combination usually works very well in treating the depression.

Table 27. Some Medications Used to Treat Depression

(Sample Brand Names in Parentheses)

Buproprion (Wellbutrin)

Duloxetine (Cymbalta)

Methylphenidate (Ritalin)

Mirtazapine (Remeron)

Selective Serotonin Reuptake Inhibitors    Citalopram (Celexa)    Escitalopram (Lexapro)    Fluoxetine (Prozac)    Paroxetine (Paxil)    Sertraline (Zoloft)

Venlafaxine (Effexor)

Decreased Initiation: When patients have low initiation, they have difficulty starting activities. They may need to be cued several times to do an activity or accomplish a task. In severe cases, patients may literally not do anything unless constantly encouraged by someone else. The problem is caused by damage to the part of the brain that controls the will. Although a patient with low initiation may seem similar to a depressed patient with low motivation, the two conditions (depression and low initiation) are actually different. In addition, the medications used to treat both conditions are usually different. Sometimes it is hard to tell the difference between the two conditions (depression and low initiation) and in these cases, the physician may try several types of medications to treat the condition.

Table 28. Some Medications Used to Improve Initiation

(Sample Brand Names in Parentheses)

Amantadine (Symmetrel)

Bromocriptine (Parlodel)

Buproprion (Wellbutrin)

Carbidopa-Levodopa (Sinemet)

Dextroamphetamine (Dexedrine)

Methylphenidate (Ritalin)