Synapse - reconnecting lives

Predictions of recovery are difficult in the months following a brain injury, with individuals and their families often frustrated by the lack of knowledge about the future.

This uncertainty is common along the spectrum of brain injury. With a severe injury, doctors can make vague guesses on the degree of recovery expected, yet they will have seen exceptions to the rule, with some never emerging from a coma despite good prospects, and others who defied all odds and returned to work, albeit with cognitive problems to deal with.

Doctors also realise that in very mild traumatic brain injuries and concussions, they can once again make general statements about expected recovery yet some individuals with a brain injury may have lifelong problems that result in a major disability.

Why Predictions are Difficult

Physical injuries do not give an accurate picture of the degree of brain injury sustained. The victim of a terrible car accident may have numerous fractures yet there can be less brain trauma than someone who fell over in the bath tub.

The CT and MRI scans used to detect brain injury are good at detecting bleeding in the brain, yet fail to accurately show trauma at the microscopic level. Brain trauma can sever the connections between brain neurons over areas of the brain yet this will not show in many tests. It is only recently that a technique called diffusion tensor imaging has been shown to be effective at finding these injuries. Unfortunately, the cost of the scan is a big handicap to its usage in public hospitals.

The brain does have a limited ability to heal itself. This process tends to occur over two years, with the most rapid improvement in the first six months as swelling and bruising of the brain subside. This pace of healing usually tapers off to the two year mark. This is only a guideline as some will find improvement stops after a year, others may find gradual improvements two years afterwards. Generally, a slow rate of initial improvement is associated with a greater chance of permanent disability.

Proper rehabilitation is very important once a patient has emerged from coma and post-traumatic amnesia, and has a significant effect on the final outcome. It should be noted that discharge from rehabilitation does not mean that recovery has finished. The individual with a brain injury has hopefully learned the tools to continue with their own recovery.

Personal factors make a significant difference to the degree of recovery expected. For example, people who did well in the educational system and those with very determined, motivated personalities usually perform very well in rehabilitation. Those who had drinking or drug problems before the brain injury do not do as well in recovery, particularly if they continue their habit after the injury. Other personal factors that contribute to a good outcome are a tendency to be 'giving' and think of others, an optimistic and humorous approach to life, and religious faith.

 
How Predictions are Made

Physicians look at several indicators to predict the level of a patient's recovery during the first few weeks and months after injury:

• Duration of coma
• Severity of coma in the first few hours after the injury (as measured by the Glasgow Coma Score)
• Duration of post-traumatic amnesia (PTA)
• Location and size of contusions and haemorrhages in the brain

Severity of injuries to other body systems sustained at the time of the TBIPrecise predictions are difficult with TBI, but some generalizations can be made:

• The more severe the injury, the longer the recovery period, and the more impairment a survivor will have once recovery has plateaued.
• Recovery from diffuse axonal injury takes longer than recovery from focal contusions.
• Recovery from TBI with hypoxic (lack of oxygen) injury (e.g. near drowning, strangulation or carbon monoxide poisoning) is less complete than without significant hypoxic injury.
• The need for surgery does not necessarily indicate a worse outcome. For example, a patient requiring the removal of a blood clot may recover as completely as one who never needs surgery.The Glasgow Coma Scale is used to determine the depth of coma.

The length of time a patient spends in a coma correlates to both post-traumatic amnesia (PTA) and recovery times:

• Coma lasting seconds to minutes results in PTA that lasts hours to days; recovery plateau occurs over days to weeks.
• Coma that lasts hours to days results in PTA lasting days to weeks; recovery plateau occurs over months.
• Coma lasting weeks results in PTA that lasts months; recovery plateau occurs over months to years. Post Traumatic Amnesia (PTA) is the gradual process of regaining consciousness after coma.
• Individuals in PTA are partially or fully awake, but are confused about the day and time, where they are, what is happening, possibly who they are and they will have problems with memory. Length of PTA is frequently used as a guide to the severity of brain injury. A commonly used interpretation of the scale involves the following:

General Guide

A general finding is that if the PTA stage lasts for more than one week, ongoing cognitive problems can be expected.

It is important for the person and the family to be optimistic but realistic about recovery and to develop a better understanding of what is or isn't possible. Some families with a loved one in hospital have likened this to hoping for the best while preparing for the worst.

Factors Influencing Long Term Outcome

An injury to the brain results in a number of impairments that may create serious problems for the injured person. The ability of an individual to cope with these effects is influenced by four factors:

• Personal assets and limitations of the person before the injury
• The nature and severity of the injury
• The person's reaction to the injury
• The support of significant others.Of these four factors, it is the person's reaction to his or her acquired brain injury that is recognised as the one that can most likely be changed to improve future enjoyment and success in life. Self-awareness, motivation, goal setting, coping strategies (use of memory aids etc.) and management of emotions are important reactions which influence long-term outcome following an acquired brain injury.

Hard Work and Hope

A brain injury is very different from other conditions where full recovery is the norm. The reality is that even a mild brain injury will usually leave lifelong cognitive effects.

The brain is the most highly organised system in the universe and the bad news is that a complete recovery is usually not possible. The good news is that faith, hope, hard work and a systematic approach can dramatically impact upon the recovery process and life afterwards. Like a marathon, you have to pace yourself for the long race and keep a positive attitude on the way.