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Where There is Life, There Is Hope

This is the one piece of advice every person visiting this site should take to heart.  There is always hope.  Do not let anyone take that away from you.  Unless and until the person has passed away, there is always hope.  
We have met with too many people that have been told that they will never do this or never do that again, yet they are doing all of those things.  I spoke with a lady that was pronounced dead at the scene and the ambulance was on the way to the morgue when one of the paramedics noticed she was still alive.  We know another young woman who was told she would never walk again who danced at her wedding.  
Our daughter is another example.  At one point we were told she had an hour, maybe two to live.  We were told she would not get off of the ventilator and never be able to remove her feeding tube.  While we are still a long way off from where we hope we end up, we are thrilled that she has proven the doctor’s wrong so far.

They Tend To Be Pessimistic

 A trait that seems to be common is that doctors often present a very negative picture to the family early in the process.  My hypothesis as to why the doctor’s seem to be so pessimistic is that it is their attempt to prepare you for the worst in case the worst happens.  After all, if the doctor tells you your loved one will never walk again and six months later they do walk, you are not going to be upset with your doctor.  However, if they say the patient will walk and then they don’t, you will be upset.  The better doctors are able to prepare you for the worst while still leaving your hope and not breaking your spirit. 
Another reason may be that it is a natural reaction for the family to resist the bad news they have been given.  The doctors may come across very blunt, and somewhat pessimistic, in order to break through that defense mechanism from the family.   

We Still Know Very Little About the Brain

A factor that makes projecting the long-term outcome more difficult is that we still really know very little about the brain.  It is the least understood organ in the body.  A doctor explained it well to us when he said that he can tell us with the CAT scans and MRI’s where the brain has been damaged but he can not tell if other areas of the brain will be able to take over some of the tasks previously performed by the damaged area.  Recent studies have shown that the brain does indeed exhibit more plasticity than previously thought.

You Only Have One Choice

We think you have to act as if you only have one choice.  That choice is to believe and act as if your loved one is going to be completely healed.  You need to make sure they get aggressive treatment all along the way and get every opportunity to recover.  This way if the person can do better than the doctor’s have said, you have given them every chance to prove it.  But, if they don’t progress as much as you would like, at least you will have no regrets.  Think of the other side - what if you find that they could do better but you haven’t been trying because someone told you it wouldn’t matter.
I will give you an example from our experience.  We transferred our daughter to a new facility after we left the hospital.  This facility was going to try to wean her off of the ventilator.  A physical therapist came in to do an evaluation and said he was going to get Ashleigh sitting up on the edge of the bed.  I said I thought that was a fine goal to shoot for and he said no, I mean tomorrow.  Here was our daughter on a ventilator, unable to move, we were unsure she if she was even aware of anything going on and he is going to sit her up on the edge of the bed?  Well he did, and before long they were standing her with a tilt table.   My point is we would have never thought she was ready for that kind of activity.  So keep challenging yourself and your loved one to move forward as aggressively as possible.  Challenge your medical and therapy staff to keep pushing you as well.

The Path

This is the path many patients take on their road to recovery.  The main consideration is that each head injury is different and so each recovery is different.  Below are the general steps:

  • ER – First, the Emergency Room where they work to stabilize the patient.

  • ICU – Next comes the Intensive Care Unit.  Your loved one will stay in the ICU until they move past the immediate danger.

  • Neuro ICU - This is sometimes called a step-down unit.  It offers care by neuro-trained nurses who evaluate whether the patient is ready to move to the general neurological floor.

  • Neuro floor - The general Neurological floor is staffed by specially trained staff to help your patient recover and prepare to go home.

  • Rehab Unit -  Intensive therapy to help the patients maximize their abilities and develop compensation techniques for any remaining deficiencies.

  • Home – Back home where they will continue on the long hard road to recovery.



Overview of Brain Injuries

Below is an overview from the National Institute of Neurological Disorders and Stroke.
What is Traumatic Brain Injury?
Traumatic brain injury (TBI) occurs when a sudden physical assault on the head causes damage to the brain. The damage can be focal, confined to one area of the brain, or diffuse, involving more than one area of the brain. TBI can result from a closed head injury or a penetrating head injury. A closed head injury occurs when the head suddenly and violently hits an object, but the object does not break through the skull. A penetrating head injury occurs when an object pierces the skull and enters the brain tissue. 
Several types of traumatic injuries can affect the head and brain. A skull fracture occurs when the bone of the skull cracks or breaks. A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain. This can cause bruising of the brain tissue, called a contusion. A contusion can also occur in response to shaking of the brain within the confines of the skull, an injury called "countrecoup." Shaken baby syndrome is a severe form of head injury that occurs when a baby is shaken forcibly enough to cause extreme countrecoup injury. Damage to a major blood vessel within the head can cause a hematoma, or heavy bleeding into or around the brain. The severity of a TBI can range from a mild concussion to the extremes of coma or even death. A coma is a profound or deep state of unconsciousness. 
Symptoms of a TBI may include headache, nausea, confusion or other cognitive problems, a change in personality, depression, irritability, and other emotional and behavioral problems. Some people may have seizures as a result of a TBI.
Is there any treatment?
Immediate treatment for TBI involves surgery to control bleeding in and around the brain, monitoring and controlling intracranial pressure, insuring adequate blood flow to the brain, and treating the body for other injuries and infection.
What is the prognosis?
The outcome of TBI depends on the cause of the injury and on the location, severity, and extent of neurological damage: outcomes range from good recovery to death. Doctors often use the Glasgow Coma Scale to rate the extent of injury and chances of recovery. The scale (3-15) involves testing for three patient responses: eye opening, best verbal response, and best motor response. A high score indicates a good prognosis and a low score indicates a poor prognosis.
What research is being done?
The NINDS conducts and supports research on trauma-related disorders, including traumatic brain injuries. Much of this research focuses on increasing scientific understanding of these disorders and finding ways to prevent and treat them.
Source:  The National Institute of Neurological Disorders and Stroke, National Institutes of Health Bethesda, MD 20892

Classifications of Brain Injuries

Brain injuries can come from a number of causes.  Motor vehicle accidents, falls, sport injuries, near drownings as well as medical causes such as a strokes, brain tumors, aneurisms, seizure activity, or infectious diseases.
Brain injuries or head injuries are often classified into three categories; mild, moderate or severe.  The categorization is based on the Glasgow Coma Scale (GCS) rating, listed below. 
Mild Traumatic Brain Injury
Definition: A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following: 

  • any period of loss of consciousness;
  • any loss of memory for events immediately before or after the accident;
  • any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); and  
  • focal neurological deficit(s) that may or may not be transient but where the severity of the injury does not exceed the following:
  • loss of consciousness of approximately 30 minutes or less;
    after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and
     posttraumatic amnesia (PTA) not greater than 24 hours.
  • style="margin-left: 40px">Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8(3), 86-87.
    Be sure to have your loved one checked out by a doctor if they have any of the symptoms above.  Err on the side of caution. 
    Most individuals with a mild brain injury will not have any major functional deficits.  There may be some long term impacts but they are typically more subtle such as headaches or cognitive or memory problems.  Sometimes the cognitive symptoms are not readily identified at the time of the injury.  Instead, the cognitive symptoms may show up as the person returns to school or work.
    Moderate Brain Injury
    Brain injuries are classified as Moderate when the GCS score is between 9 -12 and with a loss of consciousness and/or post-traumatic amnesia of greater than 30 minutes but less than 24 hours and/or a skull fracture. 
    There may be long-term physical or cognitive deficits as a result of a moderate brain injury.  Much will depend on the type and location of the specific insults to the brain.  Rehabilitation will help to overcome some deficits and help provide skills to cope with any remaining deficits.
    Severe Brain Injury
    A severe brain injury will present with a Glasgow Coma Scale score lower than 9 and accompanied by a loss of consciousness or post-traumatic amnesia lasting more than 24 hours.  Severe brain injuries are very life-threatening.  If the person lives, they will typically be faced with long-term physical and cognitive impairments.  The range of the deficits can vary widely from a vegetative state to more minor impairments that may allow the person to still function independently.   The patient will require extensive rehabilitation to try to overcome some of the deficits and learn strategies to cope with others.     

    Glasgow Coma Scale

    GCS Scale – The Glasgow Coma Scale (GCS) is the first assessment done with the brain injured patient.  It attempts to give the medical team an initial idea of the severity of the injury.  The assessment is widely used because it is easily observable and can be pretty consistent.  A score of 13 or higher is categorized as a mild brain injury, 9-12 moderate, and 8 or below severe.

    Chose one response in each category


    Eye Opening Response



       To Speech

       To Pain




    Best Motor Response

       Obeys Command Localizes Pain

       Flexor Withdrawal to Pain

       Abnormal Spastic Stereotypes

       Flexion Posture  

       Extensor Response at Elbow

       No Movement


    Verbal Response

        Oriented Conversation

       Confused Conversation

       Inappropriate Words

       Incomprehensible Sounds

       No Vocalization



    Total Score Possible

    3 to 15

    Teasdale, C., & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2, 81-84.

    Other Terms You May Hear

    Closed Head Injury
    A Closed Head Injury is an injury where the skull stays intact.  The rapid movement of the head can be enough to significantly injure the brain.  The brain can be slammed into the inside of the skull and there may also be rotational forces which cause shearing in the brain (see diffuse axonal injury).  There may be bleeding in the brain and swelling in the brain will follow. 
    Open Head Injury
    An Open Head Injury may be the result of some object penetrating into the brain or the skull being fractured by an impact. In the case of a penetrating wound the injury is usually located at a focal point in the brain so very specific identifiable problems will result.  Gunshot wounds can cause more extensive damage as they move within the skull and cause shock waves inside the brain.  Open head injuries leave the brain susceptible for infection in addition to the damage to the brain itself.
    Coup Contrecoup
    This is a French term that describes the impact forces that can happen inside the brain.  For example, in a car accident the momentum of the vehicle when it hits something may cause the brain to slam forward into the skull, the coup, then the momentum shifts and the brain may be then slammed again against the opposite side of the skull, the contrecoup.  Both sites of impact may cause damage to the brain.
    Diffuse Axonal Injury
    This term describes the injuries are to axons located throughout the brain.  Axons are long thin nerve fibers that may extend across different layers of the brain.  As the head moves violently, as in a motor vehicle accident, the brain may experience rotational forces and the axons may become sheared.  The shearing is made worse by the fact that the different layers of the brain have different densities and react at different speeds to the rotational force.  The injured axons may also release chemicals which can factor into increased swelling in the brain.
    The resulting impacts may be widespread and encompass a number of body systems and functions.  It is more difficult for doctors to initially assess the impacts of a diffuse axonal injury than a focal injury. 
    A hematoma is a collection of blood that has pooled.  Surgery may be necessary to remove the blood.  Below are a few types of hematomas related to brain injuries.
    -          Subdural Hematoma  - The brain is surrounded by a tough, leathery outer covering called the dura.  When the brain is injured and blood accumulates within the space between the brain and the dura it is called a subdural hematoma, or blood clot in the brain.
    -          Epidural Hematoma  - An epidural hematoma is when blood accumulates within the space between the dura and the skull.

    Possible Impacts

    Disabilities resulting from a brain injury depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).  (Source: National Institute of Neurological Disorders and Stroke)

    Communication Deficits

    Brain injuries can commonly cause a number of communication related deficits.  Some are transient while others are permanent.  Some of the deficits may be as a result of the damage to particular communication centers in the brain causing one or more forms of aphasia.  Other problems may be a result of motor problems or weaknesses caused by other complications.  Some people may have difficulty with the more subtle aspects of communication, such as body language and emotional, non-verbal signals.  Communication disorders are complex and need to be identified and treated by speech pathologists. 
    I can tell you from our personal experience that our daughter’s loss of speech has been one of the cruelest parts of this ordeal.  A bubbly, outgoing 18 year-old girl who I used to kid all the time about having the phone becoming physically attached to her ear has now been silent for over four years.  In addition to the fact that we miss her being able to talk with us terribly, it also adds a lot more danger to the situation in that she cannot tell us when anything is wrong.  There have been medical problems that have been made much worse because she could not tell us something was wrong.
     Aphasia -  Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write.  There are many types of aphasia and a person with a brain injury or stroke may have one or more impacting their ability to communicate.  Some of the types of aphasia are described below.  A Speech therapist can help assess your loved one’s particular deficits and work to overcome them.  
      Global Aphasia – Patients suffering with global aphasia can produce few recognizable words, understand little spoken language, and can neither read nor write. In the less severe cases the patient may have symptoms initially and then improve as they recover.
      Broca's Aphasia -  With Broca's aphasia speech is very limited to short utterances that are very halting and difficult.  May be able to understand speech and read, but limited in writing. Sometimes referred to as non-fluent aphasia.  Most patients are aware of these deficits and may become extremely frustrated.
      Wernicke's Aphasia -  People with Wernicke's Aphasia or fluent aphasia may speak in flowing gibberish, drawing out their sentences with non-essential and invented words.  Many are unaware that they make little sense.  Often have trouble reading and writing. 
      Anomic Aphasia  -  People with this form of aphasia have trouble finding words in both speech and writing.  They understand speech well, and in most cases, read adequately.

     Apraxia -  Apraxia related to speech describes problems a person may have producing speech particularly with articulation and prosody.  There is difficulty  coordinating mouth and speech movements.  The errors are inconsistent.
     Dysarthria -  Dysarthria refers to a disorder where the patient can think of the appropriate language, but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds because of the neurological damage. Speech is often slow, slurred, and garbled.  May involve some or all of the basic speech processes: respiration, phonation, resonance, articulation, and prosody.
    Swallowing Disorders – Swallowing seems like such an easy, natural thing but it is actually very complex involving coordination of a number of muscle groups.  Problems with swallowing may be more motor related but we have included it here because the Speech Pathologist will be the therapist working to alleviate it.  The Speech Pathologist may recommend a fluoroscopic swallow study to identify exactly where the problem lies.  The therapist will then develop a plan to overcome the deficits. It can be a very slow process but very necessary in order to come off of the feeding tube.

    Movement Disorders

    Brain injuries can cause a number of movement disorders.  In addition since so many brain injuries happen as a result of accidents there may be other injuries contributing to the movement disorder. 
    Paralysis -   You are probably familiar with Quadriplegia and Paraplegia.  Another form of paralysis that is common with brain injury survivors is Hemipelegia which is paralysis to one side of the body.  
    Spasticity -  Spasticity is a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles and may interfere with movement, speech, and manner of walking. Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement.  Treatment may include stretching, medications, and in some cases surgery. 
    Apraxia -  Apraxia is a movement disorder characterized by the inability to perform skilled or purposeful voluntary movements, generally caused by damage to the areas of the brain responsible for voluntary movement.
    Ataxia - Damage to a lower part of the brain, the cerebellum, can affect the body's ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

    Cognitive Deficits

    Many brain injury survivors suffer from cognitive disabilities which may include the loss of higher level mental skills. People may be easily confused or distracted and have problems with concentration and attention.  
    ·Memory -  The most common cognitive impairment among brain injured patients is memory loss and the partial inability to form or store new ones.  
    Executive Function -  There may also be problems with higher level, so-called executive functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments, which may make it difficult to resume work or school related activities.

    Emotional Deficits

    Emotional problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings. Problem behaviors may include aggression and violence, impulsivity, disinhibition, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired self-awareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. 
    Many TBI patients who show psychiatric or behavioral problems can be helped with medication and psychotherapy.  Family members of TBI patients often find that personality changes and behavioral problems are the most difficult disabilities to handle.    (Source: National Institute of Neurological Disorders and Stroke)

    Sensory Deficits

    Many TBI patients have sensory problems, especially problems with vision. Patients may not be able to register what they are seeing or may be slow to recognize objects. Also, TBI patients often have difficulty with hand-eye coordination. Because of this, TBI patients may be prone to bumping into or dropping objects, or may seem generally unsteady. TBI patients may have difficulty driving a car, working complex machinery, or playing sports. Other sensory deficits may include problems with hearing, smell, taste, or touch. Some TBI patients develop tinnitus, a ringing or roaring in the ears. A person with damage to the part of the brain that processes taste or smell may develop a persistent bitter taste in the mouth or perceive a persistent noxious smell. Damage to the part of the brain that controls the sense of touch may cause a TBI patient to develop persistent skin tingling, itching, or pain. Although rare, these conditions are hard to treat. (Source: National Institute of Neurological Disorders and Stroke)
    The Rancho Los Amigos National Rehabilitation Center created the scale below to describe the progression a brain injury survivor may take on the path to recovery.  Keep in mind not everyone displays all of these behaviors.  Some people may move through some of the phases very quickly while others may spend longer periods at each level.  

    Levels of Cognitive Functioning 

    Level I - No Response: Total Assistance 

    -          Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular or painful stimuli.  

    Level II - Generalized Response: Total Assistance 

    -          Demonstrates generalized reflex response to painful stimuli.

    -          Responds to repeated auditory stimuli with increased or decreased activity.

    -          Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization.

    -          Responses noted above may be same regardless of type and location of stimulation.

    -          Responses may be significantly delayed. 

    Level III - Localized Response: Total Assistance 

    -          Demonstrates withdrawal or vocalization to painful stimuli.

    -          Turns toward or away from auditory stimuli.

    -          Blinks when strong light crosses visual field.

    -          Follows moving object passed within visual field.

    -          Responds to discomfort by pulling tubes or restraints.

    -          Responds inconsistently to simple commands.

    -          Responses directly related to type of stimulus.

    -          May respond to some persons (especially family and friends) but not to others.  

    Level IV - Confused/Agitated: Maximal Assistance 

    -          Alert and in heightened state of activity.

    -          Purposeful attempts to remove restraints or tubes or crawl out of bed.

    -          May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another's request.

    -          Very brief and usually non-purposeful moments of sustained alternatives and divided attention.

    -          Absent short-term memory.

    -          May cry out or scream out of proportion to stimulus even after its removal.

    -          May exhibit aggressive or flight behavior.

    -          Mood may swing from euphoric to hostile with no apparent relationship to environmental events.

    -          Unable to cooperate with treatment efforts.

    -          Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

     Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance 

    -          Alert, not agitated but may wander randomly or with a vague intention of going home.

    -          May become agitated in response to external stimulation, and/or lack of environmental structure.

    -          Not oriented to person, place or time.

    -          Frequent brief periods, non-purposeful sustained attention.

    -          Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.

    -          Absent goal directed, problem solving, self-monitoring behavior.

    -          Often demonstrates inappropriate use of objects without external direction.

    -          May be able to perform previously learned tasks when structured and cues provided.

    -          Unable to learn new information.

    -          Able to respond appropriately to simple commands fairly consistently with external structures and cues.

    -          Responses to simple commands without external structure are random and non-purposeful in relation to command.

    -          Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.

    -          Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.

     Level VI - Confused, Appropriate: Moderate Assistance 

    -          Inconsistently oriented to person, time and place.

    -          Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.

    -          Remote memory has more depth and detail than recent memory.

    -          Vague recognition of some staff.

    -          Able to use assistive memory aide with maximum assistance.

    -          Emerging awareness of appropriate response to self, family and basic needs.

    -          Moderate assist to problem solve barriers to task completion.

    -          Supervised for old learning (e.g. self care).

    -          Shows carry over for relearned familiar tasks (e.g. self care).

    -          Maximum assistance for new learning with little or nor carry over.

    -          Unaware of impairments, disabilities and safety risks.

    -          Consistently follows simple directions.

    -          Verbal expressions are appropriate in highly familiar and structured situations.

     Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills 

    -          Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time.

    -          Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks.

    -          Minimal supervision for new learning.

    -          Demonstrates carry over of new learning.

    -          Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing.

    -          Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance.

    -          Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs.

    -          Minimal supervision for safety in routine home and community activities.

    -          Unrealistic planning for the future.

    -          Unable to think about consequences of a decision or action.

    -          Overestimates abilities.

    -          Unaware of others' needs and feelings.

    -          Oppositional/uncooperative.

    -          Unable to recognize inappropriate social interaction behavior.

     Level VIII - Purposeful, Appropriate: Stand-By Assistance 

    -          Consistently oriented to person, place and time.

    -          Independently attends to and completes familiar tasks for 1 hour in distracting environments.

    -          Able to recall and integrate past and recent events.

    -          Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with stand-by assistance.

    -          Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.

    -          Requires no assistance once new tasks/activities are learned.

    -          Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.

    -          Thinks about consequences of a decision or action with minimal assistance.

    -          Overestimates or underestimates abilities.

    -          Acknowledges others' needs and feelings and responds appropriately with minimal assistance.

    -          Depressed.

    -          Irritable.

    -          Low frustration tolerance/easily angered.

    -          Argumentative.

    -          Self-centered.

    -          Uncharacteristically dependent/independent.

    -          Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.

     Level IX - Purposeful, Appropriate: Stand-By Assistance on Request 

    -          Independently shifts back and forth between tasks and completes them accurately for at least two consecutive hours.

    -          Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with assistance when requested.

    -          Initiates and carries out steps to complete familiar personal, household, work and leisure tasks independently and unfamiliar personal, household, work and leisure tasks with assistance when requested.

    -          Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assist to anticipate a problem before it occurs and take action to avoid it.

    -          Able to think about consequences of decisions or actions with assistance when requested.

    -          Accurately estimates abilities but requires stand-by assistance to adjust to task demands.

    -          Acknowledges others' needs and feelings and responds appropriately with stand-by assistance.

    -          Depression may continue.

    -          May be easily irritable.

    -          May have low frustration tolerance.

    -          Able to self monitor appropriateness of social interaction with stand-by assistance.


    Level X - Purposeful, Appropriate: Modified Independent 

    -          Able to handle multiple tasks simultaneously in all environments but may require periodic breaks.

    -          Able to independently procure, create and maintain own assistive memory devices.

    -          Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them.

    -          Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies.

    -          Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action.

    -          Accurately estimates abilities and independently adjusts to task demands.

    -          Able to recognize the needs and feelings of others and automatically respond in appropriate manner.

    -          Periodic periods of depression may occur.

    -          Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress.

    -          Social interaction behavior is consistently appropriate.


    Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R.

    There are other measurement scales used by the professionals.  To read more about them you can visit the Center on Outcome Measurement in Brain Injury Web site at:



    Traumatic Brain Injury (TBI) is a leading cause of death and disability among children and young adults in the United States. Each year, an estimated 1.5 million Americans sustain a TBI. That's 8 times the number of people diagnosed with breast cancer and 34 times the number of new cases of HIV/AIDS each year. (1)    As a consequence:

    -          50,000 people die each year. (2)

    -          230,000 people are hospitalized annually and survive. (2)

    -          80,000 to 90,000 people experience the onset of long-term disability each year. (2) 

    -          The cumulative result is that today an estimated 5.3 million people - 2% of the U.S. population - are living with a permanent TBI-related disability. (1)


    The risk is highest among adolescents, young adults, and persons older than 75 years. The risk to males is twice the risk among females. (2)  The major causes of TBI are:

    -          Motor vehicle crashes are a leading cause, accounting for 50% of all TBIs and the leading cause of TBI resulting in hospitalization. (2) 

    -          Violence, especially suicidal behavior and assaults that involve firearms--the leading cause of TBI-related death. (2)

    -          Falls--the leading cause of TBI among the elderly. (2)  


    These injuries have both short-term and long-term effects on individuals, their families, and society and the financial cost is enormous. TBIs requiring hospitalization cost the nation about $56.3 billion each year. Approximately 1 in 4 adults with TBI is unable to return to work one year after injury.  The financial cost is only part of the burden. The long-term impairments and disabilities associated with TBI are grave and the full human cost is incalculable. (1) 

    (1)  Source: CDC - The Injury Fact Book 2001–2002. A publication of the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. November 2001. 

    (2)  Source: Traumatic Brain Injury in the United States: A Report to Congress.  Prepared by:  Division of Acute Care, Rehabilitation Research, and Disability Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.  December 1999 


    For more information there are numerous sites on the Web including the following from the National Institute of Neurological Disorders and Stroke.


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