The Survivor Forum has articles by survivors about their recoveries and their lives. It is a place for information and support for other survivors. It may also help families understand what it means for a survivor to live with a brain injury.

Professionals often have intensive but brief relationships with survivors while they are in their programs or receiving treatment. Professionals often wonder what happens to these survivors “down the road”. We believe that survivors can also educate professionals about the journey of recovery over time by sharing their experiences.

The road to recovery is often complicated, confusing and filled with ruts and potholes. It is also a journey that has no end. It is an ongoing path throughout the life of a survivor. We hope that this forum helps survivors navigate this journey.

Please Contact Us…
This forum will explore many areas. We will be constantly adding topics and articles. If you would like to send us an article to consider, we would like to hear from you. Below are guidelines to submit articles.

Topic…
Your choice as long as it is based on your experience.

Length…
2-4 pages double spaced

Format…
Microsoft Word file or file saved in rich text format.

You can send an article by e-mail…
Or you can mail your article to mlyn@lapublishing.com.

Marilyn Lash, Director
Lash and Associates Publishing/Training, Inc.
708 Young Forest Drive
Wake Forest, NC 27587
Tel 919-562-0015

Suggestions…
If there is a topic you’d like to hear about from survivors, please let us know.

By DeAnna Frye, Ph.D. and JoAnn M. Ovnic, M.A.,CCC/SLP

What are common memory problems following TBI?

Short term memory loss is a common impairment following TBI.  Generally long term memory, such as recall of historical information, childhood and other events prior to injury are preserved.  The degree and location of injury affects the severity of memory problems.  Some examples of short term memory loss include:

• forgetting what happened during the day
• forgetting placement of items
• forgetting tasks completed throughout the day
• losing train of thought during a conversation
• having trouble with note taking
• difficulty retaining information in class
• difficulty recalling the main details of a recently read article or book chapter

What is the difference between short term memory, long term memory and post traumatic amnesia?

In general, most neuropsychologists define short term memory as an individual’s ability to remember information over the course of a few hours or across a day or week after a TBI.  For example, the ability to recall what you did this morning is an example of short term memory.

Long term memory is generally reserved for recall of events that occurred prior to the injury.  Remembering an incident from childhood is an example of a long term memory for an individual injured in their 30s.

Post traumatic amnesia is the period of time that the individual is unable to recall events following the injury.  For example, some individuals may not recall the events of the day their injury occurred or being in the hospital for the next month after the injury.  Post traumatic amnesia is then estimated to be about 30 days long.

Please tell me about post traumatic amnesia – how long does PTA last?

Post traumatic amnesia refers to a disruption in the memory system of the brain as a result of an injury.  PTA begins at the time of the injury and includes the coma period.  It does not end until the individual is able to continuously report events that have occurred. In other words, a person may be out of coma and talking with their family members but has no recall of the conversations.  This individual is still experiencing PTA.  As a general rule of thumb, PTA usually lasts 4 times the length of coma.  So an individual who is in a coma for two weeks typically experiences PTA of eight weeks.

As an individual recovers from the injury, he/she will begin to remember events of the day and days before.  However, the person will have no memory of the events immediately following the injury.  This is not due to psychological trauma, but the neurological injury itself.

The inability to remember hours, days or weeks of your life can be stressful and uncomfortable.  Reassuring the individual repeating what happened during this period may be helpful.  Most important, however, is acknowledging that their PTA has resolved and that they can remember events now.

My CT scan of the brain was normal, yet I am still having problems with my memory.  How is this possible?

CT scans are helpful diagnostic tests used by physicians to identify physical changes to the brain.  CT scans can identify tumors, bleeding, swelling or bruises involving the brain.  They are not sensitive enough to identify the microscopic tearing and shearing that commonly occurs after a traumatic brain injury.  Therefore it is not unusual for a CT scan to be normal following a brain injury.  This simply reflects the CT scan’s limitations with regard to identification of the physical changes in the brain. 

A survivor of TBI may initially demonstrate abnormalities on CT scan, such as swelling or bleeding.  A repeat CT scan several months later, however, may be considered normal. However, the survivor may still be experiencing functional changes such as memory problems

My doctor has recommended a functional MRI. How is this different from a CT scan or MRI?

A functional MRI or fMRI is an image of brain activation as a function of change in cerebral blood flow or blood oxygenation. Usually the analysis is based on blood oxygenation changes.  When a part of the brain is activated there is an increase in oxygen rich blood.  Changes in neural activity are evaluated by measuring changes in local blood oxygen levels in the brain during performance of a specific task.

During the completion of an MRI, the individual is required to complete some cognitive activities, such as memory tasks.  The scan then reveals the changes in blood oxygen levels in the brain during the completion of the task.  This allows your doctors to determine how your brain is processing specific types of information.  Individuals who have had normal CT or MRI scans have shown abnormalities on fMRI.

I have been discharged from therapies but want to continue to work on improving my memory and other cognitive skills.  What are some things I can do to continue to work on my cognitive abilities?

Just as physical exercise is good for the body, mental activity is good for the mind.  Continuing with any strategies or home exercise activities that your therapists have recommended is important.  In addition, continuing to challenge yourself with mental activities every day will help you maintain the abilities you gained in therapy and help you continue to improve.  Reading the newspaper, magazine or a book can help with concentration, reading and memory.  Watching the news keeps you up to date on what is happening in the world.  There are many games that you can purchase that are not only good family entertainment but also require reasoning skills.  Doing crossword puzzles or word searches can help if you have difficulty with language skills.  The most important thing is that you find activities that you enjoy doing, as you will be more likely to continue them.  Consistently applying the strategies you learned in therapy to your daily life will allow you to adapt more quickly and accomplish your goals. 

How can I help my family member remember appointments and day-to-day events?

Daily routines are helpful.  Encourage your family member to keep a calendar and write down appointments.  If he can not do this himself, set aside a time during the day to review and write down information.  Keep a notepad and pen near the phone to write any phone messages.  Create a “To Do” list for the day.  Have your family member check off each task or activity as it is completed.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

After Brain Injury: Telling Your Story, A Journaling Workbook

By Barbara Stahura and Susan B. Schuster, M.A., CCC-SLP

This workbook guides survivors of brain injury and blast injury through the powerful healing experience of telling their own stories with simple journaling techniques. By writing short journal entries, survivors explore the challenges, losses, changes, emotions, adjustments, stresses, and milestones as they rebuild their lives.

The Memory Workbook

By Douglas Mason, Psy.D. and Michael Kohn, Psy.D.

Workbook for families and adults explains types of memory and effects of aging, brain injury, and brain damage on memory.  Includes practical exercises and tips for adults, family members and caregivers for brain injury rehabilitation. Recommended for persons with mild brain injury or mild cognitive impairments due to trauma, aging, or disease.

By DeAnna Frye, Ph.D.

What is the relationship between brain injury and depression?

Depression is the most common psychiatric diagnosis after brain injury.  Individuals may experience symptoms immediately after their injury or not until several years post injury.  Individuals with depression after brain injury have poorer rehabilitation outcomes, poorer quality of life, less social and recreational activity, greater caregiver burden and poorer subjective well-being.  As a result, it is important that individuals receive treatment for their depression.

The preferred form of treatment for individuals with depression following brain injury is psychotherapy.  Medications can also be beneficial but caution should be taken as individuals with brain injury are more likely to experience side effects from these medications.

Since her discharge home from the hospital my daughter has been telling us that she wished she hadn’t survived the accident.  This really upsets us, as it is a miracle that she is alive today.  How should we respond when she says this to us?

Your daughter may be expressing feelings of grief over the significant changes in her life as a result of her injury.  This is a normal part of the grief process and you should encourage your daughter to talk with you and a counselor about her feelings of loss.  While most individuals who recover from a brain injury experience similar feelings, it is also important to make sure that your daughter is not clinically depressed and suicidal.  While it is common for individuals to express feelings that they wished that they had not survived their injury, this does not mean that they currently wish to die. An individual who is expressing a desire to end their life needs immediate medical attention to ensure their safety.  If your daughter is expressing suicidal thoughts, you should call her psychologist or doctor immediately and alert them to the situation.

The holidays are approaching.  How much alcohol is a safe amount to drink after a brain injury?

Research has shown that there is no “safe” amount of alcohol after a brain injury.  Important factors to consider include interactions with any medications the individual is taking as well as history of alcohol abuse or dependence. Individuals also may react differently to alcohol after a brain injury, which may place them at greater risk for additional injury.

Why does my treatment team tell me not to drink alcohol now that I have had a brain injury?

It is important to realize that alcohol is a neurotoxin – in other words, it kills brain cells. After a brain injury, alcohol can interfere with the healing process.  Alcohol can also cause seizures.  While this is pretty rare for healthy individuals, your risk for seizures is higher after a traumatic brain injury.  Drinking alcohol increases that risk even further. Individuals who drink to the point of intoxication also demonstrate changes in their cognitive skills, with judgment being one of the first skills affected.  As a result, intoxicated individuals may do things that put them in situations where they may be harmed and perhaps sustain another brain injury.

Some individuals turn to alcohol as a means of coping with their loneliness, depression or anger.  Research that has been conducted to look at safe alcohol consumption for individuals with traumatic brain injury has concluded that there is no safe amount.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.
Many individuals struggle with depression after brain injury. This Tool Kit helps individuals, families and clinicians recognize symptoms and triggers ranging from mild depression to effects of PTSD.

For more information, see:

The Depression Tool Kit after TBI

Many individuals struggle with depression after brain injury. This Tool Kit helps individuals, families and clinicians recognize symptoms and triggers ranging from mild depression to effects of PTSD.

By Patricia Jackson, C.B.I.S.  and  Michael Davis, C.B.I.S.-C.E.

Case management over time

Since the 1960’s, the case manager has been a key organizer of services in traditional rehabilitative settings.  Case management has evolved over the years from a simple cost containment focus to a well-coordinated, systematic, comprehensive approach to quality cost-effective care.  Case managers today are routinely and almost universally involved in organizing and coordinating rehabilitative services and resources to maximize a person’s functional recovery after an injury.   

Most recently, the case manager has been recognized as a catalyst in the field of forensic or medical-legal rehabilitation.  Therefore neurolawyers are increasingly using professional case management services to ensure that their clients receive well-coordinated, quality care and treatment during the often lengthy process of litigation. Lawyers have a duty to provide comprehensive legal services, but they typically do not have the time to oversee the medical and rehabilitative aspects of a personal injury case. The provision of case management can have a direct positive impact on addressing the myriad of needs in a serious injury case.

Case managers, attorneys and personal injury claims

As more case managers are being employed by attorneys to oversee their clients’ case, it is important to clarify the role of a case manager in this specialty field of medical-legal rehabilitation.  A case manager is capable of wearing many hats.  This article describes how case management may be involved in a personal injury claim.   

The attorney weighs the benefits of involving a case manager right from the start.  Time is typically of the essence in catastrophic injury claims.  By using professional case management services to coordinate care that will maximize the client’s physical, cognitive and emotional functioning, the attorney can focus on the litigation process. 

The many roles of case managers

Case management assumes various roles throughout the different stages of a client’s recovery from an illness or injury. 

Hospital

In the acute medical arena, the case manager serves as a discharge planner and helps move an individual from the hospital to rehabilitation, home health care or outpatient therapies.  

Insurance Company

The insurance case manager serves mostly as a cost monitor to ensure that health care dollars are expended wisely.

Rehabilitation Program

Facility-based rehabilitation case managers usually serve on a team within that facility to guide therapies toward maximum potential recovery for the patient within the confines of their facility.

Forensic case manager

None of the case managers above are typically involved in the legal aspects of a patient’s case. The forensic case manager is concerned with every aspect of the above.  At the same time, the forensic case manager assures that the legal perspective is being addressed to maximize client recovery.  The personal injury attorney who utilizes the services of an experienced case manager is in fact assuring the client’s access to quality treatment and medical care.

Case manager as liaison

The weeks and months immediately following a traumatic injury are full of day-to-day stressors.  As a result, families usually are overwhelmed with information and decisions they may not be equipped to handle.  All too often, families do not feel fully informed or supported by many of the medical professionals whose expertise has preserved the life of their loved one in trauma.

If the attorney who has been retained in a personal injury case involves a case manager immediately, the family will benefit.  By using the expertise of an experienced rehabilitation professional, the case manager can assume a guiding role in the care of their loved one.

The attorney also benefits by identifying the case manager as the primary contact person for the family.  The case manager is able to field numerous questions and run interference.  This gives the attorney valuable time to proceed with the intricacies of the litigation process.

Families in trauma have special needs.  They can appear to be demanding at times.  But they may simply need someone to listen to their concerns, their ideas or even more importantly, their fears.  So first and foremost a case manager is a liaison for not only the client, but for the family, the rehabilitation team and the attorney, as well.

Case manager as advocate

Once given the opportunity to review medical records, discuss the case with all parties involved, and determine the priorities, the case manager can oversee a treatment plan, monitor progress, advocate as necessary and create a clear pathway through the rehabilitation maze.

The forensic case manager can objectively oversee the provision of services from a more holistic and client-centered approach.  The forensic case manager works in conjunction with the clinical case manager and the insurance case manager, but does not have their internal pressures or external financial obligations.

Attorneys who assign a case manager to their personal injury cases are assured that the:

• appropriateness and effectiveness of therapies and programming will be monitored, and

• care will be coordinated in the best interest of their clients’ long term needs.

If long term rehabilitation is necessary, the involved case manager has the ability to explore and identify possible funding sources early on.  Through their experience, case managers are familiar with federal, state and local resource systems available to the client.  The attorney may be a novice or have limited experience in that particular arena. Understanding the systems of Medicaid, Social Security, vocational rehabilitation, workers compensation, and the public schools is complex.  Gaining access to their services is a time-consuming process.  Rather than assume that task and breaking new ground, the attorney can rely on the case manager to fulfill this area of responsibility.

Case manager as negotiator

It is important for the client and family to have a skilled negotiator throughout the course of recovery.  The case manager is capable of creatively negotiating a proposed plan of care, length of stay, rates of service and when necessary, identifying appropriate vendors.  Negotiating services to develop a continuum of quality care is crucial as well as time consuming.  Whether it is acute care, outpatient rehabilitation or in-home care, the involvement of a case manager can make a difference.

Taking the long view or seeing the big picture

Where expert life care planning is necessary, identifying service providers and ensuring the implementation of the life care plan is a long term commitment.  The attorney who utilizes the expertise of a case manager is cognizant of the fact that a client’s needs continue long after the litigation process has ended.

There is no easy road to recovery following a catastrophic injury.  Recovery from traumatic injury can be a long arduous process, not only for the injured party but for the family as well. The family’s emotional needs can frequently be overlooked unintentionally while professionals focus on rehabilitation of the client.  The case manager functions as a support system for the family and as an educator and guide through the maze of rehabilitation.  

One of the most valuable tools a case manager brings to the table is the ability to listen.  A skilled case manager listens to concerns from all parties involved, pulls the information together, develops a plan and ultimately directs the implementation of that plan.  The case manager works closely with the rehabilitation team, medical consultants and the family.  By bringing forth the clinical perspective, the case manager helps the attorney strategize throughout the litigation process.

It is the attorney’s duty and obligation to provide clients with the best possible means available to ensure successful resolution to their case.  Financial recovery is only one aspect of a case.  Personal injury attorneys should also concern themselves with the more critical aspects of a case, i.e., emotional and physical well- being.  

An experienced forensic case manager is an asset to the plaintiff attorney’s case for many reasons, some of which have been described here.  Each personal injury case presents itself with a unique situation, specific needs and a vast range of priorities.  In collaboration with the attorney, the list of priorities can be defined, responsibilities delineated and an initial plan set in motion by the case manager.

Whether acting as liaison, advocate, negotiator or educator, the role of a forensic case manager is key in litigating personal injury claims in today’s legal arena.  Ethics dictate diligence by the plaintiff counsel.  Morally speaking, this diligence would serve the client equally as well in the pursuit of quality services, thus facilitating improved quality of the life for the client.

Bee, C.M.(1996) Damages/Running The Gauntlet From Soft Tissue to Head Injuries/From Chiropractor to Neurosurgeon. A non-published presentation.

Burke, W.H. (1995). The Rehabilitation Expert: Analysis and Management of Brain Injury and Other Neurologic Disorders. In Burke, W.H. (Ed.) The Handbook of Forensic Rehabilitation, Houston, TX: HDI Publishers.

Burke, W.H. (1995). The Forensic Analysis of Costs in Head Injury Claims. A non-published presentation. Insurance Defense network, Las Vegas, NV.

Evans, R. & Watke, M. (1995). Catastrophic Neurologic Injury: Improving Outcomes Through Case Management: The Case Manger, July/August / Sept. 83-88.

Fawber,H.& Zorger Orstein B. (1995). Case Management in Forensic Rehabilitation. In Burke, W.H. (Ed.) The Handbook Of Forensic Rehabilitation. Houston, TX: HDI Publishers.

Howe, R. (Ed.) Inside Case Management. 1 (11), 1 (12), 2 (6). 1995.

Mullahy, C. (1995). The Case Manager Is the Catalytic Collaborator in Managed Care. The Journal of Care Management. 1(1), June 7-9.

For more information from Lash and Associates Publishing/Training, Inc., see:

Brain Injury It is a Journey

By Flora Hammond, M.D. and Tami Guerrier

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions.

Head Cases

By Michael Paul Mason

Book on brain injury, blast injury and PTSD features chapters on adults, children and veterans discussing changes in memory, self-image, violence, suicide, family stress and war in Iraq.

By Patricia L. Jackson, BS, CBIS and Michael W. Davis, CBIS-T

Is it really happily ever after? 

The Life Care Plan is designed to identify long term needs through a comprehensive assessment of the client’s medical, physical, behavioral and emotional status.  Once the data is evaluated, a Life Care Plan outlines what services the client will need over the course of a lifetime to maintain physical health and emotional well being.  Contrary to popular belief, after a Life Care Plan is deemed necessary and finalized, the client, a.k.a. the subject of the Life Care Plan, is not set for life. 

In reality, it is after a Life Care Plan is finalized that the real work begins.  The Life Care Plan is a necessary map to direct the client’s way along the path of life.  If it is taken at its worth, the client will have access to the supports that were identified to facilitate successful care over the long run.  Unfortunately in a majority of cases, the Life Care Plan simply finds its way into a file cabinet and is stored along with other medical and legal documents.  

Who are the players in the plan? 

Somewhere along the way a major component is overlooked.  The medical and rehabilitation specialists do their jobs by identifying the needs of the client.  The family hires legal representation to help them do the best they can for their loved one.  The attorney’s obligation is fulfilled by presentation of a comprehensive Life Care Plan in court.  The judge (and perhaps jury) recognize the severity of the injury and find in favor of the client.  The decision is made about a financial settlement that will ensure access to whatever services had been deemed necessary for care over the client’s lifetime.  And then, everyone goes home.

Money doesn’t guarantee services 

Although life care planning focuses on caring for the needs of the injured person, a financial award in itself does nothing to guarantee client services.  There is a huge gap in the system.  The family is not always aware of the how-to’s in the rehabilitation community, yet they are most often the ones left holding the “plan” so-to-speak.  Even experts within the system find that it can be difficult to access services.  It is a grave disservice to expect that a client’s family members will know how to work through the complexities of a system, including as the maze of rehabilitation services. 

The case manager is the missing link  

A case manager who specializes in the implementation of Life Care Plans can fill that void.  Working with the family, a case manager takes charge of the Life Care Plan to access and arrange the services identified for the client.  

The role of each person involved in the Life Care Plan process is defined and is important.  Each specialist is responsible for their area of expertise.  However, the reality is that every individual involved in the case has an ethical responsibility to see that what they recommend is in fact carried out.  

It is not enough to identify, acknowledge and provide financial resources to help the client.  The care the client deserves and is entitled to should not be compromised simply because no one is identified to assume responsibility for implementing the Life Care Plan.  A case manager assures that the finances are utilized in the way that they were designated, rather than leaving follow-up client care to chance.  The Case Manager doesn’t have all the answers, but will find the resources to get the answers that the client and family deserve.

Case managers can help fulfill the intent of a life care plan

Surely it is the intent of the judge and our legal system as a whole to provide financial support by way of a settlement when they find in favor of a client.  When utilized properly, a financial award will provide support and services for the client who has sustained a serious injury.  A financial award that is misused or used improperly not only doesn’t help or support the client, but it also causes greater harm by decreasing the client’s chance for success and an improved quality of life.  Misuse will also most likely create a host of secondary problems resulting from lack of proper medical and psychological care. 

A case manager can be the critical missing link.  By monitoring the client’s status and maintaining communication amongst all the parties involved, the client’s care will remain in the forefront as the true priority.  After all, quality client care is the true intent of any financial settlement. 

Patricia Jackson is a Case Manager and Michael Davis is the President and Senior Case Manager with Neurological Case Management Associates, specializing in the field of neurological rehabilitation, in Charleston, WV.

For more information from Lash and Associates Publishing/Training, Inc., see:

Adult Mini Tool Kit on Traumatic Brain Injury for Families

This Adult Mini Tool Kit is designed for lawyers and life care planners to give to families with information on traumatic brain injury. 

Ketchup on the Baseboard: Rebuilding life after brain injury

By Carolyn Rocchio

By Dixie Fremont-Smith Coskie

This special book about a child’s traumatic brain injury is aptly titled UNTHINKABLE. Facing possible death or life-long disabilities of her child in the early days of hospital care and medical treatment, this mother reveals her fears as she faces an uncertain future.  

After her son’s traumatic brain injury, Dixie Coskie and her family move from horror and despair to find hope, healing, and even greater love.  The simplest of things have new importance —when her son is able to blink his eyelids again, lift his finger, utter a word.  This book on surviving brain injury from a family’s perspective is powerful, moving and very real. Not only are the emotions of parents explored and revealed, but siblings are included as well.

This book will provide emotional support, hope and guidance for other families whose child has had a brain injury.  The tips for caregivers are especially useful with practical suggestions for support, communication, coping, stress reduction and problem solving at all stages of care and recovery after traumatic brain injury.  It is also highly recommended for direct care staff and professionals as it provides insights into the emotional trauma that inevitably accompanies the physical and medical trauma of brain injury.

ISBN: 978-1-932279-10-8, 224 pages, $17.99

Order at www.DixieCoskie.com

By Dr. DeAnna Frye and JoAnn M. Ovnic, M.A.,CCC/SLP

My speech is fine, but after my brain injury my doctor referred me to a speech-language pathologist. Why?

The term speech-language pathologist is deceiving.  Speech-language pathologists (SLP) are skilled in assessment of speech, language, and cognitive functioning.  Following a head injury or other trauma to the brain there are cognitive (thinking skills) problems.  Sometimes these problems will be quite obvious, whereas other times they may be quite subtle.  In addition to speech and language, an SLP will observe and assess swallowing, memory, orientation, problem solving reasoning and attention.  Mathematical skills, planning and organizational skills are also areas in which speech-language pathologists evaluate and treat.  The speech-language pathologist is part of the rehabilitation treatment team.  Once the evaluation period is completed, results of testing and recommendations for treatment are shared with the client, family members, and the clinical treatment team.

What is aphasia?

Aphasia is a language disorder that results from damage to the language centers of the brain.  It can affect a person’s ability to understand language as well as the ability to express thoughts.  Aphasia commonly occurs following a stroke but can occur following traumatic brain injury, brain tumors or an anoxic episode (lack of oxygen to the brain).

Depending on the area of the brain affected, people may experience expressive or receptive aphasia, or a combination of both.  Expressive aphasia is commonly characterized by difficulty with coming up with the right word (”it’s on the tip of my tongue”) writing, and using gestures to communicate thoughts.  Receptive aphasia, on the other hand affects one’s ability to understand what is being said or read.  Even though a person may be able to hear or read words, they may sound or look jumbled.

Several factors may contribute to the severity of difficulties with language.  They include severity of damage to the brain, age, educational level and health prior to injury.  One person might only be able to speak in single words, whereas another may have occasionally have trouble finding the right word in a conversation.  Another person may be able answer simple questions and directions (i.e. “Did you like the movie?” or “Point to the comb.”) while another may have trouble following multiple directions or have difficulty reading more than a simple one or two paragraph article.

A speech-language pathologist assesses and treats people with aphasia with drills and strategies to improve communication.  Exercises vary based on the severity of the problem and take into account a person’s language needs.

My daughter is not able to communicate with us since she had a severe brain injury. Her doctor told us she has receptive and expressive aphasia.  Her arms and hands seem to work fine.  Why doesn’t someone recommend that she learn sign language?

Aphasia occurs as a result of an injury to the language center of the brain.  The degree and type of impairment varies based on the injury.  For example, some individuals may be able to understand what others are saying, but are not able to verbally respond.

When an individual is diagnosed with a language disorder, treatment from a speech therapist is indicated with a focus on regaining speech functions and developing compensatory strategies to help the person develop communication skills, such as through use of gestures or pointing out pictures on a daily communicator.  Learning sign language is a complex task.  While the hands are used as the primary means of communicating, the individual still needs to be able to access language functions in the brain.  Due to injury in the language center, this may not be possible.

What is dysarthria? 

Dysarthria is a speech disorder that results from involvement of the nervous system.  These conditions include stroke, progressive diseases such as Parkinson’s, and less frequently following traumatic head injury.  It affects the quality of speech production and is often characterized by slurred speech and facial weakness.  Symptoms include limited tongue, lip and jaw movements, breathy voice quality, drooling of saliva, chewing and swallowing difficulty, change in voice quality, slow or rapid rate of speech and abnormal intonation (rhythm).

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

After a Stroke

by Cleo Hutton

Book on stroke and brain damage for adults and families with practical suggestions and tips for coping with the physical, communicative, cognitive and emotional changes.

By Marilyn Lash, M.S.W.
Lash and Associates Publishing/Training, Inc.

Signs of stress and PTSD in the military 

As service members and veterans come home from Iraq and Afghanistan, many have psychological issues related to traumatic stress and post traumatic stress disorder (PTSD).  

• More than 90% of soldiers and Marines returning from Iraq reported stressors of…
  • roadside bombs
  • length of deployment
  • handling human remains
  • killing an enemy
  • seeing dead or injured comrades
  • being unable to stop a violent situation. 
• 30% of troops returning home from Iraq reported some type of mental health problem, including
  • anxiety
  • depression http://www.lapublishing.com/depression–brain-injury-family/
  • nightmares
  • anger
  • difficulty concentrating. 
• 15-17% of troops returning from Iraq in 2004 experienced acute stress or post traumatic stress disorder (PTSD).  http://www.lapublishing.com/PTSD-blast-brain-injury/

The stigma of mental health

Mental health treatment has always been carried more stigma or “baggage” than treatment for physical conditions in the U.S.  Common misperceptions in the general population are that seeking therapy, counseling or even medication for emotional help is a sign of weakness.  Even most private health insurers have strict limits on the scope and number of mental health services allowed.  There is a general belief among the public that those who seek mental health treatment are unstable, disturbed, and mentally ill.  This stereotype leads to patterns of avoidance by friends, neighbors and coworkers.  It contributes to denial by individuals and delays seeking treatment.   

This stigma makes it even more difficult for soldiers and service members to ask for help in a military culture that stresses being strong and avoiding signs of vulnerability or weakness. 

PTSD screening in the military

 The military has made a serious effort to address psychological issues among troops.  Despite this, there is still a lag of soldiers actually seeking help.  Before returning to their home stations, all soldiers undergo mandatory psychological and medical screening.  Based on the results of the psychological questionnaire to assess PTSD, depression and alcohol abuse, soldiers may be required to have an interview with a mental health professional.  Those who indicate medical symptoms are referred to medical professionals. 

Soldiers are more reluctant to report psychological problems, especially when returning with their units.  The findings are striking… 

• Only 38-45% of troops newly diagnosed with mental health problems were interested in receiving help.
• Fear of stigmatization and concern about barriers to getting psychological help was twice as likely among troops who scored positively compared to those who did not.
• Only 23-40% of troops who reported interest in seeking help during the previous year had actually received professional treatment.

Beliefs about mental health and mental illness

Beliefs that psychological distress is a sign of weakness are also linked to the perception that individuals are responsible for their problems.  There is a common belief among civilians and service members that individuals should be able to control their psychological symptoms through choice, determination, and sheer will power. 

Consequently, it is easy to see why service members fear exclusion by comrades if they report symptoms of PTSD or other emotional distress.  Seeking treatment may be avoided or delayed due to apprehension about its stigma and reactions of comrades. 

Interventions for reducing stigma in the military 

Organizational policies and programs directly impact whether service members seek mental health support.  Concerns about losing a job or security clearance are barriers to seeking mental health treatment.  Anonymity and confidentiality are other concerns reported by soldiers. 

Leaders and supervisors have a critical role in identifying and helping soldiers receive mental health support and treatment.  If leaders emphasize the importance of early mental health treatment, service members are more likely to seek help because it has less negative associations.  Leaders are instrumental for creating a climate where mental health problems such as PTSD are recognized and early treatment encouraged and supported.

References:

Greene-Shortridge, TM, Britt, TW, and Castro, CA. (2007). The Stigma of Mental Health Problems in the Military. Military Medicine, 172, 2:157.

For more information, see:

Understanding the Effects of Brain Injury, Blast Injury, Concussion and PTSD

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals and Army Medical Facilities.

Healing Together

By Suzanne Phillips, Psy.D and Dianne Kane, D.S.W.

Book for couples coping with effects of trauma and post-traumatic stress disorder (PTSD) from war, brain injury, violence, accidents, crime or health problems.

By DeAnna Frye, Ph.D. and JoAnn M. Ovnic, M.A.,CCC/SLP 

When I wake up in the morning I feel good and am usually able to get a lot of things done.  By afternoon, however, I’m pretty tired.  I’ve been told this may be due to cognitive fatigue.  What is cognitive fatigue and what can I do about it?

Everyone has a limited amount of energy available each day to accomplish our goals.  The amount of energy we have varies due to a variety of factors, including how well we sleep at night.  How quickly we “spend” our energy during the course of the day has an effect on our level of fatigue.

After a brain injury, individuals typically find that certain activities require more energy than they did before the injury.  For example, eating at a busy restaurant can use up more energy for an individual who has difficulty with attention and is easily distracted. Cognitive fatigue occurs when you are reaching your limit with regard to the amount of energy you have left to spend.

One strategy to combat cognitive fatigue is pacing.  Pacing involves first identifying how long an individual can work at various tasks before becoming fatigued.  For example, you may find that you can work for an hour on a task, such as paying bills, in a quiet environment but can handle attending to conversations  in a crowd for only thirty minutes.

Identifying your limits and then scheduling breaks throughout the course of the day can help you combat cognitive fatigue.  Planning your day in advance when possible can also help.  For example, if you know you have a family reunion to attend on Saturday afternoon at the park, you may want to plan quiet activities at home in the morning, instead of going to the grocery store.

I have difficulty focusing on what I’m doing. How come?

Attention is a vital part of our everyday functioning.  All of us from time to time become distracted, whether it is a phone call in the middle of cooking dinner, or being interrupted to attend a meeting while in the middle of writing a report.  When a person sustains a brain injury, attention is an area of cognition that impacts the ability to concentrate and focus for various amounts of time and in various conditions.  The following types of attention may be affected:

• Focused: the ability to attend to an activity or task with no other distractions. For example a person might do a crossword puzzle in quiet.
• Selective: being able to attend to a task and block out unimportant information. For example reading a book while playing background music.
• Alternating: the ability to switch between tasks. This is especially noted in real-life situations. For example: working in an office and being interrupted by phone calls, filing and greeting clients.
• Divided: The ability to do two or more tasks at the same time. One of the most common examples is driving a car while changing radio stations and looking for an unfamiliar exit.

Why would my doctor prescribe a medication that is used for people with attention deficit disorder when I have had a brain injury?

While Attention Deficit Disorder  is not the same as a traumatic brain injury, research has shown that individuals who have experienced a change in their attention abilities after a brain injury benefit from the same medications that are used for Attention Deficit Disorder.  Quite simply, attention is a function of our brains.  When attention abilities are impaired, certain medications may help to correct the problem, regardless of the underlying cause.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

Hero’s Journey

by Kit Malia, B.Ed., and Anne Brannagan, M.Sc.

Educational group curriculum on brain injury for adults and survivors to increase understanding and adjustment. For use by clinicians, caregivers and families in rehabilitation, community and home settings.

Survival Kit, A Planner and Organizer for Survivors of Brain Injury

by Debbie Leonhardt

TBI workbook and organizer for persons with brain injuries and cognitive disorders affecting memory, planning and organization. For use in rehabilitation, community programs or home.

By DeAnna Frye, Ph.D. and Denise Bailey, P.T.

Can physical therapy help with balance problems after a brain injury or should you just “learn to live with it”?

Although balance disorders are challenging, there are exercise protocols specifically designed to address our balance/vestibular systems.  This system integrates information from different parts of the body to give us good balance and tolerance to motion.  The programs are highly effective, but good outcomes are strongly correlated with thorough evaluation and a multidisciplinary approach.  Contact your physician to see if physical therapy may be appropriate to treat your balance dysfunction.

Chronic low back pain following an injury can limit one’s participation in exercise as part of a healthy lifestyle.   Is it okay to forget exercise because it can hurt and become a “couch potato”?

Unfortunately, chronic pain (low back or elsewhere), can induce a cycle of pain, decreased activity, increased dysfunction and heightened pain.  This pain disuse-dysfunction cycle must be broken.  By selecting an appropriate exercise modality, you can build a strong, healthy musculoskeletal system to manage pain and reduce the associated dysfunction, without provoking the pre-existing low back pain.  A physical therapist can help identify appropriate ways to accomplish this, along with cardiovascular conditioning to optimize function and reduce the debilitating effects associated with this cycle.

My brother had a brain injury and was in the hospital for three months.  He is home now and going to outpatient therapy.  It still takes him a long time to get dressed in the morning so I help him instead of letting him do it himself.  I figure that he is practicing how to dress himself in therapy, so it is not important that he dress himself at home.  My sister disagrees.  Who is right?

While it is important that your brother participate in outpatient therapy, it is also important that he practice these skills as often as possible.  The purpose of practice is to help the brain re-establish the connections that are needed to complete tasks such as dressing.  The more opportunity your brother has to practice, the more progress he will make in his recovery.  It can be frustrating to watch a loved one struggle to do tasks that used to be so simple.  Sometimes it’s hard for family members to allow the person to do things, as the family member feels it is their responsibility to do it for them.  Try to allow extra time for your brother to complete tasks so that you don’t feel rushed and frustrated.  Remember, encouraging your brother to do things for himself now whenever possible will help him be more independent in the future.

I often feel very tired and dragging, like I’m “out of gas”. It makes it hard for me to start a project or accomplish anything. What’s my problem?

After brain injury, physical deconditioning is prevalent. Your lifestyle may have become more sedentary, medications may cause lethargy, and recovery from injuries may have delayed your return to your daily routine.  All of these factors may contribute to reduced physical stamina/endurance.  In addition, changes in internal drive and motivation, plus initiation of activity, can be problematic following brain trauma due to cognitive impairments. 

Good, old fashioned physical activity is the best way for improving our physical endurance to combat the feelings of lethargy and deconditioning . A prescribed conditioning program can improve our energy levels and our energy reserves to support a more active and productive lifestyle. Cognitive aspects can be addressed by appropriate team members to support success in your program. A physical therapist can help identify conditioning activates that suit your interests and goals.

After my injury, it was recommended I use a cane for walking. I’d rather not use an “assistive device” to get around. Should I get rid of it?

Without question, we are driven by an inherent desire to be physically independent.  None of us want to feel we need a device to walk or may be uncomfortable with the attention it may create.  However, walking safety is the primary issue. If a device allows you to be independently safe and mobile, then it is well worth it.  We must minimize our risk of a potential fall and the injuries that may be associated.

Walking quality is another consideration; is your walking more energy efficient and even/symmetric using a cane?  Striving for the most normal quality gait is important for good biomechanical joint and muscle function, keeping additional stresses off our body to avoid pain and dysfunction.  Carefully consider these areas and discuss your feelings with your physician to determine if gait training/gait analysis may be of benefit before your decide to leave the cane behind. [Denise Bailey, PT Remed].

Why do doctors and therapists ask me if I lost my sense of smell when they are evaluating me?

Our sense of smell is also one of the functions controlled by the brain.  An individual who has sustained a brain injury can lose the sense of smell due to damage to the part of the brain that controls this ability.  You do not have to have an injury to your nose to lose your sense of smell.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

Daily Living Functional Rehabilitation Activity Manual

by Barbara Messenger, MEd, ABDA and Niki Ziarnek, MS, CCC- SLP/L

Brain injury rehabilitation manual with functional activities on daily living for brain injury programs and adults with disabilities.

Cognition Functional Rehabilitation Activity Manual

by Barbara Messenger, MEd, ABDA and Niki Ziarnek, MS, CCC-SLP/L

Brain injury rehabilitation manual with functional activities on cognition for brain injury programs and persons with disabilities.