McPhail 1

Julie McPhail

Jill Boeck

Nature and Needs of the Exceptional Learner (EDU 211)

23 April, 2009

Traumatic Brain Injury

The accepted official definition for traumatic brain injury as used by the

federal government is as follows:

IDEA [Individuals with Disabilities Education Act] defines traumatic

brain injury (TBI) as an acquired injury to the brain caused by an

external physical force, resulting in total or partial functional

disability or psychosocial impairment, or both, that adversely affects

[an individual’s] educational performance (Turnbull, Turnbull, and

Wehmeyer 314).

Traumatic brain injury (TBI, also called intracranial injury) occurs

when an outside force traumatically injures the brain. TBI can be

classified based on severity, mechanism (closed or penetrating

head injury) or other features (e.g. occurring in a specific location or

over a widespread area). “Head injury” usually refers to TBI, but is

a broader category because it can involve damage to structures

other than the brain, such as the scalp and skull (Wikipedia

Traumatic Brain 1).

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However, the terms traumatic brain injury and head injury are often

used interchangeably in the medical literature (Wikipedia Head

Injury 1).

In addition to the classically accepted definition of the causes of traumatic brain

injury, there may be some confusion because there is a condition that is not often

thought of as being a part of the universally accepted standards. This is because in

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
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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

behavior while out in public.

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

she struggled to receive a four year degree in chemistry.

The term [traumatic brain injury] applies to open or closed head

injuries resulting in impairment in one or more areas, such as

cognition; language; memory; [ability to pay] attention; reasoning;

abstract thinking; judgment; problem solving; psychosocial

behavior; physical functions; information processing; and speech

(Turnbull, Turnbull, and Wehmeyer 314).

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

result of birth delivery.

...the term TBI applies to both open and closed head injuries:

An open head injury penetrates the bones of the skull, allowing

bacteria to have direct contact with the brain and potentially

impairing specific functions, usually only those controlled by the

injured part of the brain (Turnbull, Turnbull and Wehmeyer 314).

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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

decent job and living in a well-to-do area in the city.

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

and noticeable limp.

A closed head injury does not involve penetration or a fracture of

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,

Turnbull, and Wehmeyer 314).

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
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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/

Recovery from a TBI depends on a multiple of factors related to the

extent of the injury. Examples include associated medical

complications, and the patient’s premorbid [prior to the onset of]

status (Carlson and Umphred 158).

The number and magnitude of each person’s functional changes,

post-TBI, will vary according to the site and extent of the injury, the

length of time the person was in a coma (an unconscious state),

and person’s maturational stage at the time of injury. The extent of

functional changes and the course of recovery after the injury

depend largely on whether it was mild, moderate, or severe

(Turnbull, Turnbull, and Wehmeyer 315).

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

another player. He experienced a brief loss of consciousness and was disoriented

when the paramedics removed him from the field. Later in the week, while in class, he

complained of lightheadedness, and seemed at times to be utterly confused. These

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symptoms resolved themselves after a little less than a week, and he seemed to be

completely normal following that time.

Severe Traumatic Brain Injury is associated with loss of

consciousness for over 30 minutes, or amnesia. Symptoms of

Severe TBI include all of those of MTBI, as well as headaches that

gets worse or do not go away, repeated vomiting or nausea,

convulsions or seizures, inability to waken from sleep, dilation of

one or both pupils of the eyes (also known as aniscoria), slurred

speech, weakness or numbness in the extremities, loss of

coordination, and increased confusion, restlessness, or agitation

[sic] (Military Benefits 1).

Aides from a local healthcare agency are presently rehabilitating an 88-year-old

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

emotional, behavioural and cognitive deficits as well. He is depressed and unmotivated,

believing he will never be able to function like he did previously.

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
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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

overall understanding of the effects of the psychological, pathophysiological (changes of

normal mechanical, physical, and biochemical functions, either caused by a disease, or

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
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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.

Careful consideration must be taken to adjust the treatment plan accordingly as

to what the therapist can do to overcome the obstacles there may be to completing the

elements of treatment successfully, like lessening or alleviating the lack of motivation by

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

components of the overall treatment team to better understand how these

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

by his physicians, etc.

The etiology [referring to the causes of diseases or pathologies] of

injuries resulting from craniocerebral injury trauma is quite

extensive, but it can be classified as:

1. penetrating or open (e.g., gunshot wounds)

2. nonpenetrating or closed (e.g., impact injury from an automobile accident)

(Vargas 201).

Following an impact injury, laceration and contusions of the

underlying brain tissue can develop as a direct result of the impact

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and may be accompanied by skull fractures. These occur

secondary to the rupture of arteries and veins that supply the

underlying skull, meningeal and brain tissue (Vargas 201).

Subdural and epidural hematoma, which is caused by intracranial (inside

the skull) hemorrhage which is a result of the rupturing of arteries and veins can

lead to added damage and problems for the TBI patient.

Brain damage can be classified as primary or secondary. Primary brain

damage follows focal brain lesions, while secondary brain damage as a

result of systemically originated insults to the brain (e.g. hypoxia or

hypoglycemia). Common clinical manifestations include spasticity,

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],

hypotonicity [flaccid paralysis], areflexia [below normal or absent reflexes]

or dysreflexia [a massive sympathetic discharge], and hemiparesis or

quadriparesis (Vargas 201).

The patient Jane experiences decerbrative rigidity which is severe extensor

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

whatever it is she currently desires.

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Spasticity is a term used to define any abnormal increase in tone.

The term “rigidity” designates a degree of advanced or severe

spasticity that may proceed the onset of contractures (Vargas 202).

REHABILITATION

Jane benefits weekly from selected aquatic rehabilitation intervention utilizing

methods and exercises specifically designed to take advantage of the reduced gravity

and extra support that in-water work provides helping to prevent contractures.

Watsu ® is an applied intervention used in aquatic therapy which

incorporates static passive stretches and a structured sequence of

passive limb, head, and neck movements or patterns performed at water

surface level (Vargus 87).

Transitional flow is a procedure in which Jane’s physical therapist rotates her

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.

The Halliwick method offers selected techniques that can assist in

balance coordination, proprioception, and gait. It offers disabled people like

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.
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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

getting their limbs to move voluntarily as planned, making an interdisciplinary approach

to treatment involving all members of the rehabilitation team necessary on land and in

water. This coordinated team approach is required for a successful rehabilitation

outcome for the patient. If they notice there is evidence of contractures, the team will

make use of fabricated splints especially designed to be employed in the pool.

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,

coordination, and muscle strength.

MOOD DISORDERS FOLLOWING TRAUMATIC BRAIN INJURY

Mood disorders are those conditions in which a disturbance of moods is the

predominant clinical feature. The understanding of the mood disorder must take place

at 3 levels of severity. These include:

1. The experience of the mood disorder, which refers to the conscious feeling of

depression or sadness, falling at one end of the spectrum, or of euphoria and

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
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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

includes changes in appetite, sleep, decreased energy and feelings of

worthlessness. Example: A patient who will be referred to as “John”, is allowed

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

of hopelessness about his condition and is expressing to his workers that he

does not see the point of why he should even be bothering to continue with the

few steps he can achieve.

3. How the TBI sufferer reacts to the new disability. The cognitive components of

the disorder is characterized by the unduly negative or positive appraisal of internal

or external events. Example: John’s growing depression over his inability to

perform physically coupled with his unrealistically high expectations of what he

should be able to achieve.

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

to a noticeably higher rate of suicide among this younger population.

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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. Moderate depression involves the 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

functioning and motivational states).

The list below describes the function of each specialist and how their areas of

expertise relate to head injury patients:

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

the traumatic brain injury.

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

snore and experience a number of sinus infections.

3. Neurologist – This doctor, who deals with cerebral and neurological issues, is

more of a consultative specialist than a primary care physician. The neurologist

is responsible for administering an EEG (electroencephalogram) which is used to

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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

electromyograph or electromylogram (EMG), a test where small needles are

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

to sense isometric muscular activity where no movement is produced.

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.

5. Occupational/Physical therapist – these professionals work on a rehabilitation

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

dressing, hygiene, cooking or eating, grooming, etc.).

6. Case manager -- this professional comes to the patient's home, acquires a

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,
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home health aides, etc.) as well as finding an Independent Living Skills Trainer

(ILST) to assist the patient with functioning as normally as possible in society in

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

TBI patient is entitled to.

7. Insurance adjuster -- this individual is an agent of the insurance company having

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.

8. Psychologist/psychiatrist -- both Jane and Keith are under the care of a

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

emotional wellbeing to be prescribed in conjunction with those deemed

necessary by the neurologist for neurological recovery.

9. Speech/Language pathologist -- this professional helps deal with such areas as

speech, language and cognitive problems. Other areas include organization,

memory, planning, attention span, writing skills and reading skills.

10. Vocational rehabilitation counsellor -- this professional has been active in

assisting Jane and Keith with a successful return to work and school by setting

up job and school strategies. It is the vocational rehabilitation counsellor who is

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responsible for locating jobs, schools or volunteer sites that best match their

patients' individual needs.

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

activities as doctor appointments, social functions like going to church, etc.

CONCLUSION

Traumatic Brain Injury is caused by an external or internal physical force to the

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 bleeding or swelling.

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

or oxygen to the brain.

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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

finding appropriate adaptations to succeed by accepting help to have success where

necessary in daily living and vocational goals.

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

live as nearly a normal life as their non-impaired counterparts.

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Works Cited

Carlson, Connie and Darcy Umphred. Neurorehabilitation for the Physical Therapist

Assisstant. 1st print. Thorofare: Slack, Inc. 2006.

Crowe, Simon F. The Behavioural and Emotional Complications of Traumatic Brain

Injury. 1st print. New York: Taylor & Francis, 2008.

Military Benefits. Traumatic Brain Injury Overview: Range of Symptoms. 8 January

2009. Military.com 8 January 2009.

<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:

Pearson Prentice Hall. 2007.

Vargas, Luis G. Aquatic Therapy: Interventions and Applications. 1st ed. Ravensdale:

Idyll Arbor,Inc. 2004.

Wikipedia. Head Injury. 8 April 2009 Wikipedia.org 21 April 2009.

<http://en.wikipedia.org/wiki/Head_injury>.

- Traumatic Brain Injury. 17 April 2009 21 April 2009.

<http://en.wikipedia.org/wiki/Traumatic_brain_injury>.