Neuro International

If there is just one thing learned over the past 20 years with regard to TBI including MBI, it’s that traumatic brain injuries do not discriminate.  Any person can sustain a brain injury at any time and from many causes.

The geriatric population is the most “at-risk” population for injuries as the result of a fall.  Statistics show us that this is the highest age population for cognitive decline which includes short-term memory loss, general forgetfulness, and confusion.  With these deficits, frustration from not being able to recall simple information can turn to anger as well as aggression including blaming others.  Some behavioral changes can include paranoia, which can stem from another individual sharing or correcting information with the older person who can perceive he or she is being fooled or purposely mislead.

Over the past 30 years, the work force in America has increased in age.  The oldest baby-boomers, historically raised by parents with a strong work ethic, continue to work into their 60’s and 70’s.  Many individuals in their 80’s go back to work part time, seeking jobs with flexible and sometimes shared hours such as crossing guards and school bus drivers.  Both of these positions are risk positions for falls and car accidents.  One would believe that employers recognize there can be a significant risk placing the geriatric population in these positions.  However, informal observation of crossing guards and school bus drivers reveals a high number of individuals 65 and older driving school buses and crossing children at crosswalks.

Examining the separate cases of two 75+ years of age individuals who were working part-time in high-risk positions, it is evident balance is a basic issue related to falls as is the risk of a car accidents. Following each injury, each employer indicated verbally, and almost identically, to the workers’ compensation carriers in each case that the employee was “part-time,” “having difficulties keeping up” at work, was “reprimanded recently,” and was “close to being terminated.”  There was no documentation in either individual’s employee file indicating there were any performance problems.  Attendance during the last performance review for one was “outstanding” and “excellent” for the other.

Each individual was initially treated in a hospital.  Both underwent acute rehabilitation for several weeks and each was discharged home with 24/7 attendant care primarily due to cognitive deficits and secondarily due to ambulatory and balance deficits.  Each workers’ compensation carrier referred each claimant to a residential post-acute neurological rehabilitation program for a comprehensive evaluation, including neuropsychological evaluation, cognitive evaluation, occupational therapy, physical and vestibular therapy, community assessment, and observation in all environments. General health improved significantly in the residential post-acute programs due to lack of medical management and regular follow-up prior to each injury.  In a structured and supervised environment and under the direct care of a physician, each individual was medically managed holistically while undergoing neurorehabilitation (non work-related medical issues were not the responsibility of the workers’ compensation carriers).  It appeared that and it was opined that recovery from  brain injury was enhanced once each individual was placed on general health protocols, prescribed medications for specific health diagnoses, and maintained a well-balanced and nutritious diet while in the residential post-acute neurorehab program.

Through each neurorehabilitation course, neuropsychological evaluation identified specific areas of cognitive deficits.  More specialized testing became necessary over time to help determine the “normal” age-related cognitive decline versus the extent of the cognitive decline as a result of the brain injury.  Breaking down the percentage of accident-related (TBI/MBI) decline versus age-related decline is important to workers’ compensation carriers when costing out the financial resources.  Given the normal aging process combined with the TBI/MBI diagnosis, it is anticipated that the injured worker will require any one of the following:  care and treatment in a supported living program; or specialized assisted living facility; or supported apartment program; or close supervision and specialized services being cared for by a loved one in a home environment; or services from a home health agency specializing in neurological care.

In each of the two cases, the specialized methods of testing and evaluation within the residential post-acute neurorehabilitation program were successful in determining the percentage split of injury-related versus age-related cognitive decline which was beneficial to each of the workers’ compensations carriers.  This resulted in each injured worker receiving appropriate and clinically relevant support and care with medical management of their pre-existing medical issues in an environment that met their individualized needs and wants for the best possible life following TBI/MBI.

To the layperson, a Traumatic Brain Injury is a brain injury, but to the person with Mild Brain Injury as a diagnosis it can be a curse that remains forever and the person with the injury may never know what’s wrong.

“Fall” and “car accident” are the most common causes of brain injury in the country.  These causes of injury are also common work-related injuries.  However, workers’ compensation carriers can have a very difficult time understanding how a slip-and-fall could cause cognitive and behavioral deficits in an individual who is reported to have had no injury at all following release from a hospital or a walk-in clinic.  The severity of reported behaviors resulting from a mild brain injury can include aggression and anger as well as substance abuse where the person had none of these behaviors prior to the injury or accident and never used illegal substances.

Imagine if you were to slip and fall on a wet floor, through no fault of your own, in front of co-workers.  You’re not sure what happened or why you’re lying on your back for a few seconds, but as soon as you realize you fell, embarrassment is often the first thing you feel.  Your co-workers have immediate concern but you quickly laugh and tell them you’re okay.  Even if you have some discomfort, you get up and continue on your way, hoping everyone will forget that you looked silly when you fell.  No one even thinks you should go to the emergency room.  It never crosses your mind.

That night when you get home you’re not sure if you pulled something in your leg when you fell but it hurts.  Maybe it’s just a strain.  Over the next few days you notice a little soreness overall but you know it’s nothing serious.  Someone tells you at work that you have been writing the word Michigan instead of the word Florida and that they’ve answered your same question twice regarding lunch.  The soreness is gone in a few days but over the following weeks you feel increasingly “off” and can’t really describe the feeling.  You notice you’ve been unusually agitated and angry and what’s with those headaches.  Your co-workers seem to be very picky which is aggravating you, and your boss has corrected your work several times.  Your spouse is getting on your nerves much more than usual too.  The “fuzzy” feeling in your head is increasing but you don’t want to tell anyone as they will think you’re going crazy and losing it.  Maybe that is what’s happening but who do you talk with to find out?

These are some of the signs and symptoms of a mild brain injury which may not be detected or diagnosed for months or more.  Over time the symptoms can increase mildly or significantly and the person decompensates, can lose his or her job, and friends may fall away due to the personality change that can take place.  Diagnostic testing, including CT scans and MRI’s, cannot always detect when a Mild Brain Injury has occurred.  This is one of the reasons the diagnosis of Mild Brain Injury has been so controversial for many years.  A neuropsychological evaluation remains the best and most accurate method of testing individuals to determine their cognitive and behavioral status as well as observing and continuously evaluating and individual thought to have a Mild Brain Injury.

In some cases, individuals are referred to specialized residential post-acute neurological programs where professionals with expertise in mild to severe brain injury provide a comprehensive evaluation covering all areas of function over an extended period of time, typically up to one month.  Over a consistent period of time, these experts can observe, interact, and continuously evaluate individuals thought to have cognitive and/or behavioral deficits in normal everyday environments doing a variety of activities.  Combined with cognitive testing, and a behavioral analysis, a definitive diagnosis is possible.  This same process of evaluation holds true when determining an individual does not have a Mild Brain Injury and is suffering from some other diagnosis or cause of symptoms.

For the individual suffering a Mild Brain Injury, learning there is a diagnosis and that there are treatment and rehabilitation options available provides hope and relief.

Neuro Behavioral Approaches – Praise versus Punishment?

Have you ever noticed when discussing childhood memories, most of those memories revolve around some type of punishment inflicted by a parental figure? We remember the time we were spanked for going into the street as we didn’t understand what a car accident would do to us. When older, we recall being grounded for three weeks for not coming right home from school after practice (and really for hanging with the wrong crowd). What is it that makes these events prominent and as if they happened yesterday? Through no fault on the part of our parents, it would appear being punished had a negative impact on us as children and as teenagers. Do we have the same recall when it comes to the times our parents praised us, congratulated us or rewarded us?

Now apply this to a person who has sustained a traumatic brain injury and has residual ongoing behavioral difficulties including aggression, anger, and substance abuse issues. Neurobehavioral rehabilitation programs that use a “punishment” approach may be re-enforcing unwanted and, specifically, aggressive behaviors. As an example, review of a graph recording the behavioral incidents of one individual residing in a group home reveals 13 “punishment” consequences in one month compared to one positive “praise” re-enforcement by program staff. The second month in a residential supported living/assisted living program reveals 15 “punishment” consequences which included the gradual removal of electronic devices from the individual’s room (CD player, TV and DVD). Another “punishment” consequence was employing a “room-based protocol” for three days where the individual was not able to leave his room or participate in any therapeutic groups, outings, activities, or eat meals in the dining room with other clients and staff. Review revealed after another behavioral incident, the “room-based protocol” was repeated. Both times this protocol was instituted after the electronics were taken away. The downward behavioral spiral or fall continued. There was no “praise” re-enforcement recorded for the second recorded month. Given a rehab outcome goal of “living with support services in an apartment,” this individual was going the in the wrong direction.

When a neurobehavioral program is so focused on the negative behaviors it can’t find positive events where an individual can be praised, its approach should be seriously examined and alternative methods explored. It is very difficult, takes more time, and requires patience from all staff when utilizing a “gentle” behavioral approach to reduce unwanted and aggressive behaviors. The “glass is half full” mentality is much more optimistic and all individuals want to be recognized for positive acts. By reversing the re-enforcement and praising an individual, even if actions seem minor considering our own “normal,” the individual learns gradually that attention and reward is good and that good things happen when appropriate social skills are demonstrated.

It can be shocking to family members when a loved one diagnosed with traumatic brain injury as the result of a car accident, fall, or other cause of injury starts exhibiting signs of unwanted behaviors including agitation, aggression, and uncontrolled anger shortly after discharge from a rehabilitation facility.  Discounting the phase of recovery at Ranchos Los Amigos Level IV, signs and symptoms of underlying behavioral issues may not be apparent during the early stages of acute rehabilitation.  It is safe to say that the hospital and acute rehabilitation stages following TBI are where the highest number of medications are prescribed. These can include seizure and anxiety medications which are prescribed to prevent seizures and prevent agitation which can impact rehabilitation efforts.  It is up to the primary physician managing the care of the patient to determine if these medications should continue following discharge home with family members.

In the most typical cases of TBI where anti-anxiety medications are discontinued at the time of discharge from the hospital or from acute rehabilitation, it can take some time for unwanted behaviors to surface.  Family members are happy that all is well and their loved one is home so things can go well for a period of time.  Without a regular routine or structured day, however, combined with the lack of stimulation and preferred activities, it is not uncommon for the individual diagnosed with TBI to become frustrated, restless, and easily agitated.  Family members may find they are living with a very different person than the person they lived with prior to the TBI diagnosis.  Driving, working, socializing, and living alone in an apartment has changed for the person with TBI – through no fault of his or her own – to not being able to drive or work, and living with family members now.  Frustration with the inability to do “normal” activities and boredom from not being able to “do anything” can lead to inappropriate relationships.  Substance abuse and drinking alcohol (whether or not these were habits before the injury) are all too common occurrences and can exacerbate anger, leading to more aggressive and even violent behaviors if neurobehavioral rehabilitation is not provided.

A highly specialized residential post-acute neurobehavioral rehabilitation program will have a multidisciplinary team in place consisting of (and not limited to) the following specialties: neuropsychiatrist, neuropsychologist, certified behavior analyst, psychologist, neurologist, nurse.  Supported living and assisted living services will be provided in such programs where individuals with TBI – and some with multiple or repetitive MBI – are encouraged to do as much as possible as independently as possible.  A positive and gentle neurobehavioral philosophy will prove over time to have the best results and successful long-term outcome, which is the overall goal in any rehabilitation program.

Behavioral signs and symptoms can be caught early.

March is “Brain Injury Awareness Month” and today is the 8^th yet it does not appear that any of the national media programs and newspapers or local news programs and local newspapers (Florida) are aware of this. There’s nothing mentioning “Brain Injury Awareness Month” in the lobby or halls of the trauma center visited this week and nothing in the neuro ICU or the trauma ICU waiting areas.  How do we bring traumatic brain injury and mild brain injury awareness to the public the same way breast cancer awareness is brought to the public?  Statistically, there are more brain injuries diagnosed (and undiagnosed) than there are individuals diagnosed with breast cancer (CDC).

The Brain Injury Association of Michigan (www.biami.org) is extremely active in its quest to educate families as well as the public. With car accidents as a leading cause of brain injury, the auto manufacturers in Michigan have a strong force to assist them with regard to safety and prevention. Providing statistical information is critical to everyone who drives, is a passenger, or is a pedestrian on any road in America.

Other groups and organizations that can provide information on an almost “firsthand” basis with regard to brain injury awareness are residential post-acute rehabilitation facilities such as assisted living programs, supported living programs, specialized group homes, and apartment programs.  These organizations provide specialized neurological rehabilitation as well as long term residences for individuals who are not able to live independently as they had before they suffered a traumatic brain injury.  There are brain injury groups and associations that have annual injury statistics recording new injuries, but there is no national group reporting the number of individuals who have an entirely different life than anyone can imagine while living with a brain injury.

The majority of individuals residing or participating in supported living programs have ongoing behavioral difficulties as a result of a traumatic brain injury.  Barriers to living independently or with family members include aggressive behaviors, issues with uncontrolled anger, and some have a history of substance abuse, or substance abuse is a newly acquired habit.  Those individuals with brain injury who are unable to work or maintain an active daily schedule on their own, or while living with family members, are at risk of significant decline when left alone and without some type of coaching or supervision. Exploring options and activities of interest that can be incorporated into a daily schedule is most important no matter the environment in which an individual with brain injury resides.  Everyone wants to have and deserves a good life doing things they enjoy.  This can be realized in independent settings as well as in specialized residential post-acute supported living environments.

Input from individuals residing in supported living programs would be beneficial to educating the public with regard to brain injury awareness and what it’s like to live with a brain injury over an extended period of time.

March is “Brain Injury Awareness Month.”  Hopefully those living in Florida, New York, Michigan, New Jersey, Colorado, and California, as well as those in workers’ compensation and in the no-fault auto industry, are much more aware than the general public.  How much more does the public know now than 20 years ago?  It would be interesting to set up a table at the local supermarket for a day to ask people going in and coming out to share their knowledge or understand of traumatic brain injury.  Unless you are related to a person or living with a person who sustained a brain injury, or you work with individuals diagnosed with brain injury, it is likely the average person is unaware of the realities of brain injury.

Individuals living with traumatic brain injury who have behavioral issues, such as aggression, anger, and inappropriate social skills, are often mistaken by the public as being drunk or on drugs.  This is magnified when the individual has slurred or impaired speech as a residual of brain injury.  While we don’t want to believe this is still quite common, it is.  Even among seasoned police officers who arrive on the scene of a car accident and trained paramedics who respond when a person is injured in a fall, a mild brain injury and even a traumatic brain injury can be completely overlooked.

Famous people who have sustained a brain injury could help tremendously in the area of brain injury awareness.  However, it appears when a famous person suffers a brain injury, what that person actually endures is often downplayed by the media and the word “recovered” or “recovery” is used very loosely.  The public sees how well the famous person looks and interacts on television.  Often there is no sound in the media coverage of the famous person, and the newscast is providing its own voice overlay.  It would be truly beneficial to see a recurring educational program on mainstream television filming a “regular” person going through the medical stages in the trauma center all the way through residential post-acute rehabilitation, an apartment program, receiving assisted living or supported living services, and, if able, going home if that is the true outcome.

Showing the positive outcome of an individual diagnosed with a traumatic brain injury going home with family and back to work is most often what we see in the media.  The person with the brain injury is surrounded by a loving family and everyone is happy and smiling.  What about the case of the “regular” person who does not have the benefit of being famous, having a “glamorous” story, a loving and close family, or being able to participate in the rehabilitation program he or she needs.

“Brain Injury Awareness” includes all examples of signs and symptoms of mild brain injury, how to assess if a brain injury may have occurred, how to prevent brain injury, and what individuals encounter following the diagnosis of traumatic or mild brain injury.  In all cases, information should be geared toward educating the public on the long-term aftereffects of brain injury, meaning years post-injury as that is the true reality.  More will follow in our blog.

It’s no surprise that the top two causes of TBI are falls and car accidents, and these statistics hold true for Florida and Michigan. Falls have always been an injury statistic held by the elderly, but considering the do-it-yourself aging baby boomers taking care of their residential homes or apartments, this cause of TBI is expected to increase. The statistics of falls does include the elder population including falls within elder assisted living and elder supported living facilities, elder group homes, and skilled nursing facilities. Ladders come with all sorts of safety recommendations that most often aren’t heeded. This is a concern for those working on personal projects and for those who make a living working on ladders or scaffolds. As workers continue to use ladders, their behavior becomes increasingly confident. They mistakenly believe they can run up and down ladders quickly, without holding onto the ladder, and without precautions. A fall from a ladder can result in an extremely severe TBI, even from the lowest rung of the ladder. When reviewing medical records and the workers’ compensation Notice of Injury, the words “fall of three feet” do not accurately reflect the significance of the fall. In actuality, a person diagnosed with a TBI fall of three feet suffered a blow to his or her head from nine feet if he or she is six feet tall. Through no fault of the hospital, the distance of the fall is not clearly reflected in medical records as the hospital is using the same information in its report that the paramedics used to describe the injury. Another consideration of the severity of the blow to the head is if the head is the only part of the body that sustained an injury. The implication is that the person’s head hit the ground with the full force of the fall, without any means of breaking the fall. When a person loses balance on a ladder, his or her equilibrium is off and it can become impossible to determine the direction of up and down. Even putting one’s hands out does not necessarily break the fall. Individuals using a ladder at work or for a residential project should not drink alcohol, engage in substance abuse, work when angry, and never work aggressively when trying to meet a deadline. These behaviors can lead to more serious injuries. Caution should always be used not only when climbing and descending the ladder but while working on the ladder.

Family members have a number of responsibilities with regard to supporting a loved one with TBI who is receiving neurorehabilitation in a residential program or specialized assisted living facility, or support services in a supported living program or group home. Whether located in Florida or Michigan, families can find themselves in unchartered territory when a loved one demonstrates inappropriate behaviors, such as aggression, anger, and substance abuse as the result of the TBI. Understanding and supporting the neurobehavioral plan while encouraging goals toward increased independence is a big responsibility for families. It can create a conflict of emotions for some families as the need to protect a loved one is so primary in familial relationships.

Finding a balance is key. Individuals who progress from a residential program or group home to a supported apartment program or to an apartment with wrap-around support services are on their way to total independence. It is up to the rehab team working with the workers’ compensation (workman’s compensation) or no-fault professionals to help educate and support the families throughout the entire process and beyond.

Cross William Flannery

Helmet Awareness: Prevent TBI, Wear a Helmet

With driver distractions at an all time high, safety outside the vehicle is more important than ever.

Statistics show that 85% of bike-related injuries and 75% of fatalities are preventable if riders wear a helmet. With those staggering statistics people still choose to not wear helmets. We encourage riders to wear helmets with the goal of preventing Traumatic Brain Injuries (TBI’s) from motorcycle, biking, skateboarding and other recreational and work activities.

Help prevent Serious Brain Injuries, buy a helmet and wear it.

Christine O’Donnell at the “National Work Comp Convention in Vegas”

Christine O’Donnell and Neal Flannery at the “National Work Comp Convention in Vegas”

National Work Comp Convention in Vegas