Table Of ContentTo Thrive. Not just Survive.
[FAMILY GUIDE INTRODUCTION]
A Family Guide to Understanding Traumatic Brain Injury
and the Early Recovery Process
This guide was developed to answer the most common questions families have in the first few hours, days, and
weeks after a loved one's traumatic brain injury. Survivors with brain injury and their relatives, doctors, nurses, and
other health care experts have contributed to the development of this guide with information obtained from several
leading national and state resources.
In an instant, lives are changed forever. A brain injury often leaves a family with little time to prepare for, come to
terms with, or adjust to the changes that such an injury brings. Not knowing what to expect or how to help can
make the first hours, days, and weeks very hard for your loved one, family and your friends.
It's normal for you to feel overwhelmed by all of the new information you are getting at a time when you feel as if
you just can't deal with anything more. But you have just become a very important member of your loved one's
health care team. To help your loved one the most, you must learn as much as you can about his/her type of brain
injury and how to choose the best medical care. If someone you love has had a brain injury, this guide will be
helpful to you. It will help you understand what a brain injury is, what you may expect during the early recovery
process, and what you can do to help your loved one, yourself, and others get through this very difficult time.
This guide answers many of the questions asked most often about brain injury. Understanding how the brain
works can be helpful in terms of understanding traumatic brain injury and the recovery process, as well as prepare
yourself and your family for the next few days and weeks. If you or your family still have questions after reading
this guide, write them down in the back of this book, then ask one of the members of the health care team; they
will be able to answer your questions. Also, it will be helpful to write down their answers so you can refer to them
later. There is comfort in understanding what is happening and what to expect. This understanding can help you
become more comfortable working with the health care team and supporting your loved one's recovery.
Table of Contents:
• Brain Injury: Basic Questions Answered
• Understanding Coma
• Clues That Brain Injury Has Occurred
• Glasgow Coma Scale/Rancho Los Amigos Scale
• Continuum of Care: TBI Recovery Stages
• Cognitive Skills of the Brain
• Parts of the Brain and their Functions
• Rehabilitation: After Brain Injury
• Choosing a Rehabilitation Hospital
• Information and Resources
• Glossary of Terms
Resource Guide l Arkansas Trauma Rehabilitation Program 1
[BRAIN INJURY: Basic Questions Answered]
BRAIN INJURY: Basic Questions Answered
1. What is traumatic brain injury? skull fractures result in mild to severe problems
Traumatic brain injury is an injury to the brain associated with daily functioning such as walking,
caused by an external physical force. It may memory, vision, and behavior.
produce a diminished or altered state of
6. What is a hematoma?
consciousness, which results in impairment of
The collection of blood in one or several locations
cognitive abilities and physical functioning. These
of the brain creates a hematoma. A hematoma
impairments may be either temporary or
may be between the skull and the covering of the
permanent and cause partial or total functional
brain (epidural) or may occur between the
disability or psychosocial maladjustment.
membrane covering the brain and the brain itself
2. Who is at risk and what types of brain injuries (subdural). Hematomas may require surgery (a
are there? craniotomy) to be performed.
The highest risk for traumatic brain injuries are
7. What is a coma?
children, young adults between the ages of 15-24,
Coma is defined as a prolonged state of
and adults 75 years and older. There are two types
unconsciousness. A person in a coma does not
of traumatic brain injuries: penetrating brain
respond to external stimuli. There is no speech,
injuries and closed head injuries. Penetrating head
the eyes are closed, and the person cannot obey
injuries occur when a foreign object enters the
commands. A coma can last from hours to days,
brain and causes damage to specific areas of the
depending on the severity of the brain damage. It
brain. Closed head injuries result from a blow to
is possible for a person to remain in a comatose
the head. A majority of survivors of traumatic
state for months or even years. A person may
brain injury experience brain swelling also called
eventually open their eyes, but remain
edema. Edema is a result of damage to blood
unresponsive. See Glasgow Coma Scale, pg. 5.
vessels in the brain and is the body’s response to
brain injury. 8. What happens in the emergency room and
intensive care unit?
3. What is a concussion?
Most accident victims enter the hospital through
A concussion results from a blow to the head
the emergency room. The injury is diagnosed and
which causes the brain to strike the skull. A
appropriate action is taken. Some patients must
concussion does not cause any structural damage
go to the hospital’s intensive care unit (ICU) for
to the brain, but can cause temporary loss of
close, 24 hour monitoring. Other injuries sustained
functioning. Headaches, memory loss, and sleep
at the time of the brain injury may require ICU
disturbance are common symptoms a person may
services not necessarily related to the head
experience after such an injury.
trauma.
4. What is a contusion?
9. What is medical stabilization?
A contusion is a more serious blow to the brain.
Many patients with a brain injury require time in
Contusions result in bruising of the brain and more
the hospital for other medical treatment such as
noticeable loss of functions. More comprehensive
recovery from surgery, healing of wounds, and
care is required for a contusion. Follow-up
setting of fractures. This is known as medical
treatment and evaluation are required on a
stabilization. This process can take from several
regular basis.
days to several months. Patients may be
5. What is a skull fracture? transferred from the emergency room or ICU to a
A skull fracture results in damage to the skin and medical floor for observation, medical treatment,
bone of the skull as well as to the brain itself. The and the beginning of rehabilitation services such
form of medical treatment varies with the location as physical therapy.
and severity of the fracture. Close observation and
follow-up treatment are always required. Many
2 Resource Guide l Arkansas Trauma Rehabilitation Program
[BRAIN INJURY: Basic Questions Answered]
10. What happens after medical stabilization? goes through the stages of recovery, so does the
After the patient has gone through medical family. The key is to take it one day at a time.
stabilization, there are a variety of directions that
14. Signs of stress?
treatment can take.
The stress placed on the family is tremendous. Each
The patient may be transferred to a physical individual and family will cope with stress differently.
rehabilitation unit within a general hospital, a The signs of stress may include the following:
specialized rehabilitation treatment center, or a inability to sleep, poor appetite, lack of interest in
skilled nursing unit. Physical, occupational, personal care or appearance, a strong sense of guilt,
speech/cognitive, and neuropsychological services reduced self worth, loneliness, excessive use of
may be provided on an intensive basis in any area drugs or alcohol, forgetfulness, or an inability to
of these settings. understand things that are said. When stress builds,
seek support from friends, clergy, and the medical
Some patients will not require skilled nursing care
staff caring for your loved one.
and may be transferred to a unit for brain injury
patients. Some patients will go home with their 15. What can the family expect?
families and return to the hospital or a specialized Every brain injury is different. You cannot compare
outpatient program for therapy and treatment. brain injuries to a broken arm or leg. The effects of
Patients who require extended skilled nursing care each brain injury vary. No one person has all the
may be transferred to a long term care facility, answers. Begin to read and gather information
while some patients will return home to receive about brain injury, its effects and possible
therapy and around the clock nursing care. treatments available. Educating yourself is
important in setting realistic expectations.
11. What is rehabilitation?
Rehabilitation is the process which helps an 16. Helpful suggestions for families.
individual reach optimum function by providing a • Establish a balance between pushing the
variety of services. Rehabilitation hospitals should person with the injury beyond his/her
use a team concept which includes services of ability to function and not giving enough
physicians, as well as physical, occupational, and encouragement.
speech therapists, neuropsychologists, social • Establish and maintain a daily routine.
workers, therapeutic recreational specialists, and • Approach the individual on their good
nurses. However, the most important members of side.
the treatment team are the patient and the • Use familiar photographs of family
patient’s family. members, friends, pets, or possessions.
• Speak of familiar names, places, interests,
12. What is the best choice?
or activities.
The appropriate choice for continued treatment is a
• Be yourself with your family member.
major decision to be made by the patient, family,
• Do not overwhelm or overload the
and physician. It is important to talk to your
person with information.
treatment team and fully understand the patient’s
• Provide the individual with ample time to
needs. You must seek out as much information as
respond.
possible to educate yourself about available
• Do not present the person with a task
resources.
that is too complex.
13. What do families go through? • Try to reduce confusion in his/her
Shock, anger, hurt, denial, and depression are surroundings.
common reactions that families experience. A • Talk openly about his/her gains and
loved one’s brain injury can change the family’s abilities.
life as well. Your adult child may require more • Communicate with the doctors, nurses,
attention from you. An injured parent may need therapists, and your loved one.
the assistance of adult children. As the patient
Resource Guide l Arkansas Trauma Rehabilitation Program 3
[BRAIN INJURY: Basic Questions Answered]
Clues That Brain Injury Has Occurred
If you have had a brain injury, or know someone who has, these are some of the natural reactions that the
body exhibits behaviorally, emotionally, cognitively, physically, and with their personality. This information is
provided so you can know what to expect when helping to care for a loved one, or if you are experiencing
these symptoms.
Behavioral Issues Physical Issues
• Wanders off/runs away • Fatigue and/or weakness
• Impulsive (acts without thinking) • Spasticity and tremors
• Reduced self-esteem • Motor coordination
• Repeated invasion of personal space • Speech difficulties
• Short fuse – unable to control outbursts • Seizures
• Difficulty maintaining relationships • Balance
• Mobility
Cognitive Issues • Sense of taste or smell changes
• Easily distracted
• Seems to “space out” Social Issues
• Difficulty understanding • Inappropriate social interaction (overly
• Difficulty with reality formal or overly friendly)
• Seems confused • Interrupts conversations
• Poor memory • Fabricates stories/lies
• Decreased safety awareness • Inappropriate conversation (sex, drugs,
• Slow to answer questions alcohol abuse, etc.)
• Difficulty organizing (time, etc.) • Poor eye contact
• Goes off on tangents
Personality Issues
• Denies deficits Verbal Issues
• Irritable • Poor speech
• Egotistical • Speaks in a monotone
• Doesn’t listen • Vulgarity/swearing
• Asks a lot of questions • Talks too loud or too soft
• Argumentative • Has difficulty “finding” words
• Manipulative • Broken speech
• Appears unmotivated
• Moody – laughs or cries easily
• Depressed
• Face shows little or no emotion
4 Resource Guide l Arkansas Trauma Rehabilitation Program
[GLASGOW COMA SCALE]
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is an assessment tool that helps medical professionals to determine the severity of
the brain injury. The Glasgow Coma Scale measures motor response, eye opening, and verbal response on a scale
between 3 and 15. GCS scores between 3 and 8 indicate a severe brain injury.
Most severe brain injuries occur from open head injuries. Such injuries can cause a wide range of functional short
or long-term changes that affect thinking, sensation, language, and emotion.
Moderate brain injuries have a GCS between 9 and 12. Moderate brain injuries occur when a person experiences
changes in brain function for longer than a few minutes following trauma.
Mild brain injuries have a GCS between 13 and 15. These injuries occur when an individual sustains a blunt trauma
or acceleration force to the head. The individual can experience disorientation, dizziness, and irritability.
EYE OPENING Points BEST VERBAL RESPONSE Points BEST MOTOR RESPONSE Points
Spontaneous: 4 Oriented: 5 Obeys Commands: 6
Indicates arousal Patient knows who and Note: a gasp reflex or a
mechanisms in brain stem where he or she is, the year, change in posture does not
are active. the season and month. count as a response.
To Sound: 3 Confused: 4 Localized: 5
Eyes open to any sound Responses to questions Moves a limb to attempt to
stimulus. indicate varying degrees of remove a painful stimulus.
confusion and
disorientation.
To Pain: 2 Inappropriate: 3 Flexion: Normal 4
Apply stimulus to limbs, Speech is intelligible, but Entire shoulder or arm is
not face. sustained conversation is flexed in response to
not possible. painful stimuli.
No Response 1 Incomprehensible: 2 Flexion: Abnormal: 3
Unintelligible sounds such The patient is rigidly still
as moans and groans are with arms flexed, fists
made. clenched, and legs
extended
No Response 1 Extension: 2
Select one number above
Abnormal turning and
that best describes patient’s
rotation of the arms and
response.
shoulders.
Select one number above that best No Response 1
ENTER HERE:
describes patient’s response.
Select one number above that best
ENTER HERE:
describes patient’s response.
The Patient’s Glasgow Score ENTER HERE:
is the total of the numbers ENTER TOTAL:
selected per Column
Resource Guide l Arkansas Trauma Rehabilitation Program 5
[RANCHO LOS AMIGOS SCALE]
Rancho Los Amigos Scale
The Rancho Los Amigos Scale is an assessment tool that provides a description of various behavioral stages of an
individual with a brain injury. Medical professionals use the Rancho Los Amigos Scale to monitor a patient’s
behavior while he or she progresses through rehabilitation. The Rancho Los Amigos Scale is most useful during the
first few weeks or months following a brain injury.
Level I:
Patient has no response to pain, touch, sound or sight.
Level II:
Generalized Response—regardless of type and location of stimuli.
Level III:
Localized Response. Blinks to strong light, turns toward or away from sound, and responds to physical
discomfort, inconsistent response to commands.
Level IV:
Confused/Agitated. Alert, very active, aggressive or bizarre behavior, non-purposeful motor movement,
short attention span, inappropriate verbalization.
Level V:
Confused/Inappropriate/Non-agitated. Gross attention to environment, distractible, requires continual
redirection, agitated by too much stimuli, inappropriate social interactions.
Level VI:
Confused/Appropriate. Inconsistent orientation, recent memory attention impaired, follows simple
directions, goal-directed with assistance, begins to recall past, emerging awareness of self.
Level VII:
Automatic/Appropriate. Performs daily routine in robot-like manner, skills deteriorate in unfamiliar
environment, unrealistic planning. Superficial awareness.
Level VIII:
Purposeful/Appropriate. Stand-by assist. Uses memory device with intermittent assist, over or under
estimates abilities, irritable, self-centered, acknowledges other's feelings with minimal assist, low
frustration tolerance, carries out familiar tasks with intermittent assist.
Level IX:
Purposeful/Appropriate. Stand-by assist on request. Completes familiar tasks independently,
independently shifts between tasks, self-monitors and anticipates problems with stand-by assist, uses
assistive memory devices to recall schedule.
Level X:
Purposeful/Appropriate. Modified independence. Handles multiple tasks simultaneously, independently
initiates and carries out unfamiliar routines, anticipates impact of impairments, independently thinks
about consequences of decisions, social interaction is consistently appropriate.
6 Resource Guide l Arkansas Trauma Rehabilitation Program
[CONTINUUM OF CARE: TBI Recovery Stages]
CONTINUUM OF CARE: TBI Recovery Stages
Each patient’s experience will be different, and the Rehabilitation is an important component of
care they receive will be tailored to their needs. healing after a brain injury. It is here that patients
Not all patients will need each treatment option relearn basic skills for everyday living and move
listed. We’ve included a description of the type of toward re-integration into their community.
patients who are treated on the different phases, Lengths of stay are variable.
as well as the goals that are worked towards for
Sub-Acute Rehabilitation
each.
Sub-acute rehabilitation is a hospital-based or
Our resource section provides tools and skilled nursing-based program for brain injury
information that you can use, depending on where patients who are still medically dependent after
you are on the road to healing and coping. given acute care, or for those who have complex
nursing needs. The average stay is 2-3 months,
Emergency Care and Critical Care
and patients are given 1-3 hours of therapy per
Emergency care is the first medical treatment
day. The goal of this care is to help each person
administered after a traumatic brain injury. Some
reach their highest level of functioning, and to
patients are treated by emergency medical
help recreate the safest, most active lifestyle
technicians (EMT) at the scene of their injury.
possible when they return home.
Others are treated in the emergency room (ER)
at the nearest hospital. Patients with a brain injury are sent to sub-acute
rehabilitation if they need help mastering a
The goal of critical care is to ensure that the
particular task, even if they have met their main
patient is stabilized, and to prevent further
goals, and if their muscles are not yet strong
neurological damage. EMT and ER staff makes sure
enough for more intense therapies.
that the patient has enough oxygen to the brain,
and they reestablish blood pressure to the body Neurobehavioral Unit
and to the brain. Patients with a brain injury receive treatment at
the neurobehavioral unit if they have difficulty
Acute Care
controlling behaviors and impulses. The goal of
Acute care is administered to patients with a brain
this highly specialized treatment is to assist
injury in the hospital after their initial emergency
patients to ultimately live independently. It is also
care is complete. Acute care is active, short-term
important for patients to be able to adapt to a less
treatment for severe brain injury, typically
structured environment in terms of their
provided in the hospital’s intensive care unit.
behavioral and cognitive stability.
Medical and surgical specialists care for patients in
acute care and work to optimize a person’s Community
medical condition. Diagnostics, surgery, and The community is a term that signifies where you
follow-up with coordinating teams help to ensure live—whether that is with a family, or in a
the stability of the patient. The goal of acute care common location, as well as the group of people
is to stabilize the patient’s condition, and direct that surrounds and supports you. Patients with a
the patient to another unit for further treatment. brain injury at this stage begin living at home while
receiving support services from a variety of
Acute Rehabilitation
agencies and medical professionals. The goal for
Acute rehabilitation is for patients with a brain
patients living in their community is to receive
injury that need ongoing therapy to improve
ongoing support needed to thrive at the greatest
his/her functional abilities. Therapy focuses on
possible level of independence.
improving bowel and bladder control,
communication, mobility, basic hygiene,
orientation, and learning.
Resource Guide l Arkansas Trauma Rehabilitation Program 7
[CONTINUUM OF CARE: TBI Recovery Stages]
All levels of care may not be available in your area.
8 Resource Guide l Arkansas Trauma Rehabilitation Program
Description:A Family Guide to Understanding Traumatic Brain Injury and the Early Recovery
Glasgow Coma Scale/Rancho Los Amigos Scale. • Continuum of Care: TBI
