Independent Study Course Released: January 2004

Sponsored by

Department of Veterans Affairs

Employee Education System

This is a Veterans Health Administration System-Wide Training Program sponsored by the Veterans Affairs Employee

Education System and the Office of Public Health and Environmental Hazards, Department of Veterans Affairs. It is

produced by the Employee Education System.
ii Traumatic Brain Injury

I commend you for choosing to take advantage of this self-study module,

“Traumatic Brain Injury.” This Veterans Health Initiative is being published at

a time when our country is engaged in military conflict. Our injured active

duty military are relying on the VA to provide them the best care possible

and some will be counting on us for this care for the rest of their lives.

Warfare is changing and as weapons have become progressively advanced,

injuries have become more complex. In VA, we are constantly preparing to

meet these challenges by educating our clinicians. Traumatic brain injury (TBI)

is a condition that requires specialized medical care and rehabilitation. Persons

with a brain injury are often referred to as the “walking wounded.” Their

greatest challenges are often invisible to those who come in contact with them.

VA and the Department of Defense recognized the need to provide specialty

care for active duty military and veterans sustaining a brain injury. Through

joint collaboration, the Defense and Veterans Brain Injury Program was

created in 1992, with 3 military and 4 VA medical centers as the core

treatment sites. Subsequently, VA established a TBI Network of Care with

designated facilities that support the 4 VA TBI Centers. 

The information in this module will assist you in your daily practice. By

increasing awareness of the varied symptoms, treatment interventions, longterm care needs and resources; you will be better able to respond to this

type of medical condition. Your commitment to continuing professional

education ensures that veterans receive the highest quality care. I encourage

all VA clinicians to take advantage of this opportunity to enhance their

knowledge of caring for persons with traumatic brain injury.
Traumatic Brain Injury iii

Introductory Materials

Message From the Under Secretary for Health . . . . . . . . . . . . . . . . .ii

Independent Study Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

Program Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Program Implementation and VA Implementation Procedure . . . . .vi

Program Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

AMA and ANCC Continuing Education Credit . . . . . . . . . . . . . . . . .xi

Disclosure Statement and American with Disabilities Act Policy . . .xiii

Content Materials

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Testimonial – The Happiest of Happy Endings . . . . . . . . . . . . . . . . .3 

Epidemiology and the Nature of Traumatic Brain Injuries . . . . . . . .5

Concussion Management: Sequelae and Treatment of Mild TBI . . .19

Rehabilitation of the Veteran with Traumatic Brain Injury . . . . . . .45

Post-acute/Chronic Sequelae: Medical and Physical Problems . . . .61

Post-acute/Chronic Sequelae: Cognitive Problems . . . . . . . . . . . . .73

Post-acute/Chronic Sequelae: 

Emotional and Behavioral Problems . . . . . . . . . . . . . . . . . . . . . .83

TBI in the Elderly and Aging with TBI . . . . . . . . . . . . . . . . . . . . . .95 

Living with TBI: Impact on the Survivor and their family . . . . . . . .99

Driving Issues after TBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

VA TBI System of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129

Appendices

Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143

TBI Referral Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145

VBA Vocational Rehabilitation and Employment (VR&E) Program .147

VBA VR&E Independent Living Eligibility and Services . . . . . . . . .149

Client Assistance, Protection, and Advocacy . . . . . . . . . . . . . . . . .151

Additional Links . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153

Independent Study Questions for CME Credit . . . . . . . . . . . . . . .155

Independent Study Program Registration/

Answer Sheet/Participation Satisfaction Form . . . . . . . . . . . . . . . . .

Table of Contents

Sect.

1

2

3

4

5

6

7

8

9

10

11

A

B

C

D

E

F
iv Traumatic Brain Injury

Target Audience

Format

Outcome

This independent study presents an overview of Traumatic Brain Injury

(TBI) issues that Primary Care practitioners may encounter when providing

care to veterans and active duty military personnel. 

This independent study module is a part of the Veterans Health Initiative

(VHI). This VHI is a comprehensive program of continuing education

designed to improve recognition and treatment of health problems related

to traumatic brain injury.

After completing this independent study, participants will be able to:

1. Identify the epidemiology and the nature of TBI;

2. Describe concussion management and treatment of mild TBI; 

3. List the rehabilitation process for a Veteran with TBI;

4. Identify medical and physical problems of Veterans with TBI;

5. Identify cognitive problems for Veterans with TBI;

6. Recognize emotional and behavioral problems for Veterans with TBI;

7. Explain TBI in the Elderly and Aging with TBI;

8. List the issues and impact on the TBI survivor and their family;

9. Describe the issues related to driving for a TBI survivor; and

10.Describe the VA TBI System of Care

As a result of this program, clinicians will have a broader base of knowledge

with which to provide effective care to patients with TBI and a better

understanding of patients who experience this condition. Drug treatments

and dosages provided in this study guide should be double-checked prior to

prescribing therapy.

This independent study is primarily designed for Department of Veterans

Affairs clinicians and interested VA staff. Other health care providers,

especially those working in veterans and military health care facilities in the

U.S., also are encouraged to complete this study module.

This program is available in booklet form and on the Web at:

http://www.va.gov. .

Independent Study Outline

Purpose

Background

Objectives

TRACE CODE: 03.VHI.TBI.P.A
Traumatic Brain Injury v

This Program Includes:

• Independent study written material

• Test for CME credits

• Program evaluation

This activity has been planned and implemented in accordance with the

Essentials and Standards of the Accreditation Council for Continuing

Medical Education (ACCME) through the joint sponsorship of VA Employee

Education System and Department of Veterans Affairs Office of Public Health

and Environmental Hazards. The VA Employee Education System is accredited

by the ACCME to provide continuing medical education for physicians.

Introductory Materials

Message from the Under Secretary for Health

Independent Study Outline 

Program Description 

Program Implementation and VA Implementation Procedure

Program Development

AMA and ANCC Continuing Education Credit

Disclosure Statement and American with Disabilities Act Policy

Content Materials

Introduction

Testimonial – The Happiest of Happy Endings 

Epidemiology and the Nature of Traumatic Brain Injuries

Concussion Management: Sequelae and Treatment of Mild TBI

Rehabilitation of the Veteran with Traumatic Brain Injury 

Post-acute/Chronic Sequelae: Medical and Physical Problems 

Post-acute/Chronic Sequelae: Cognitive Problems 

Post-acute/Chronic Sequelae: Emotional and Behavioral Problems

TBI in the Elderly and Aging with TBI 

Living with TBI: Impact on the Survivor and their family

Driving Issues after TBI

VA TBI System of Care

References

Appendices

Long-Term Care

TBI Referral Algorithm

VBA Vocational Rehabilitation and Employment (VR&E) Program

VBA VR&E Independent Living Eligibility and Services

Client Assistance, Protection, and Advocacy

Additional Links

Independent Study Questions for CME Credit

Independent Study Program Registration/Answer Sheet/Participation

Satisfaction Form

To receive credit for this course:

Program Description
vi Traumatic Brain Injury

Program Implementation and VA Application Procedure

1. Read the independent study materials.

2. Complete the CME test questions. A passing score of 70% or higher

on the CME test is required to receive credit. This test may be retaken.

3. Complete the program evaluation.

4. The estimated study time for this program is 4 hours.

If you are using the Independent Study Registration/Answer/Evaluation Form

(two sided) at the back of the independent study booklet, please send the

completed form within two weeks after reading the material to:

Employee Education Resource Center

Attn: SDU

Medical Forum, Suite 500

950 North 22nd Street

Birmingham, AL 35203-5300

NOTE: Scantron forms cannot be photocopied. For additional copies

of this independent study, Scantron forms or other VHI independent

study modules, please contact your facility education contact person.

If you have attained a passing score of 70% or higher, a certificate will be

mailed to you approximately 6-8 weeks after your test has been graded. The

test may be retaken.

The CME test and program evaluation can be completed using the VA

Internet. The address is: http://www.ees-learning.net. .

After you take the test, you will receive immediate feedback as to pass or

fail. You will be allowed to retake the test. Upon passing the test and

completing the program evaluation, you will be able to immediately print

your certificate according to instructions.

NOTE: If you experience difficulty reaching this Web site, please

contact the Help Desk via e-mail at eeslibrixhelp@lrn.va.gov, or call 1-

866-496-0463. You may also contact your local computer support staff

or librarian for assistance.

NOTE: In order to complete the CME test and Evaluation, your

computer must have Internet Explorer 4.0 or Netscape 4.0 or higher.

If you have questions or special needs concerning this independent study,

please contact:

Bob Smith, EdD, MCP

205-731-1812, Ext. 317; E-mail - bob.smith@lrn.va.gov

This program will no longer be authorized for CME credit after 

June 2005.
Traumatic Brain Injury vii

Editor

Rodney Vanderploeg, PhD

Clinical Director, Traumatic Brain

Injury Rehabilitation Program

Clinical Neuropsychologist

Psychology Service

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

Authors

Edward Brodd, RKT

Kinesiotherapist

Physical Medicine and 

Rehabilitation Service

Veterans Health Administration

Veterans Affairs Medical Center

Palo Alto, CA

Glenn Curtiss, PhD

Clinical Neuropsychologist

Psychology Service

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

Elaine S. Date, MD

Chief of Physical Medicine and 

Rehabilitation Services

Veterans Health Administration

Veterans Affairs Medical Center

Palo Alto, CA

Jennifer L. DiGrazia, MS, OTR/L

Occupational Therapist

Virginia Neurocare

Charlottesville, VA

Hsiu-Chen Huang, MD

Research Fellow

Physical Medicine and 

Rehabilitation Service

Veteran Health Administration

Veterans Affairs Medical Center

Palo Alto, CA

David Jaffe, MS

Biomedical Engineer

Veterans Health Administration

Veterans Affairs Medical Center

Palo Alto, CA

Henry L. Lew, MD, PhD

Medical Director

Traumatic Brain Injury 

Rehabilitation Program

Physical Medicine and 

Rehabilitation Service

Veterans Health Administration

Veterans Affairs Medical Center

Palo Alto, CA

Sandra Lundgren, PhD, ABPP

Clinical Neuropsychologist, 

Traumatic Brain Injury

Rehabilitation Program

Veterans Health Administration

Veterans Affairs Medical Center

Minneapolis, MN

James M. MacAulay, BA

Vocational Rehabilitation Specialist

Physical Medicine and 

Rehabilitation Services

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

Karen Moore, MHS, PT

Physical Therapist

Virginia Neurocare 

Charlottesville, VA

Rebecca Mullins, MS, LCSW

Case Manager, Traumatic Brain 

Injury Rehabilitation Program

Veterans Health Administration

James A. Haley Veteran’s Hospital 

Tampa, FL 

Rebecca Mumpower, MD

Preliminary Medicine Intern

Medical College of Virginia

Virginia Commonwealth University

Richmond, VA

Program Development
viii Traumatic Brain Injury

Program Development

F. Don Nidiffer, PhD, ABMP

Assistant Professor of Clinical 

Pediatrics and Psychiatric Medicine

University of Virginia

Charlottesville, VA

Micaela Cornis-Pop, PhD, CCSLP

TBI Associate Research Investigator, 

Speech Language Pathologist, 

Traumatic Brain Injury 

Rehabilitation Program

Veterans Health Administration

Hunter Holmes McGuire 

Veterans Affairs Medical Center

Richmond, VA

Joel Scholten, MD

Medical Director, Traumatic Brain 

Injury Rehabilitation Program

Physical Medicine and 

Rehabilitation Services

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

Ronald Seel, PhD

Neuropsychologist

Veterans Health Administration

Hunter Holmes McGuire Veterans 

Affairs Medical Center

Richmond, VA 

Barbara Sigford, MD, PhD

Department of Veterans Affairs 

Central Office

Director, Physical Medicine and

Rehabilitation Services

Director, Extended Care and 

Rehabilitation Product Service Line

Veterans Health Administration

Veterans Affairs Medical Center

Minneapolis, MN

Gretchen Stephens, MPA, OTR/L

Department of Veterans Affairs 

Central Office

Physical Medicine and

Rehabilitation Planning

Specialist/National Traumatic 

Brain Injury Coordinator

Hunter Holmes McGuire Veterans 

Affairs Medical Center

Richmond, VA 

Rodney Vanderploeg, PhD

Clinical Director, Traumatic Brain 

Injury Rehabilitation Program

Clinical Neuropsychologist

Psychology Service

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

Marina Waisman, MD

Psychiatrist, Traumatic Brain Injury 

Rehabilitation Program

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

William Walker, MD

Medical Director, Traumatic Brain 

Injury Rehabilitation Program

Physical Medicine and 

Rehabilitation Services

Veterans Health Administration

Hunter Holmes McGuire Veterans 

Affairs Medical Center

Richmond, VA

Deborah Warden, MD

National Director

Defense and Veterans Brain 

Injury Center

Walter Reed Army Medical Center

Washington, DC 

Harriet Zeiner, PhD

Neuropsychologist, Traumatic Brain 

Injury Rehabilitation Program

Psychology Service

Veterans Health Administration

Veterans Affairs Medical Center

Palo Alto, CA
Traumatic Brain Injury ix

George Zitney, PhD, CBIS-CE,

ABDA

Director

Virginia Neurocare

Charlottesville, VA

Planning Committee

Gretchen Stephens, MPA, OTR/L

Department of Veterans Affairs 

Central Office

Physical Medicine and

Rehabilitation Planning 

Specialist/National Traumatic 

Brain Injury Coordinator

Hunter Holmes McGuire 

Veterans Affairs Medical Center

Richmond, VA 

Rodney Vanderploeg, PhD

Clinical Director, Traumatic Brain 

Injury Rehabilitation Program

Clinical Neuropsychologist

Psychology Service

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

Glenn Curtiss, PhD

Clinical Neuropsychologist

Psychology Service

Veterans Health Administration

James A. Haley Veteran’s Hospital

Tampa, FL

Barbara Sigford, MD, PhD

Department of Veterans Affairs 

Central Office

Director, Physical Medicine and 

Rehabilitation Services

Director, Extended Care and

Rehabilitation Product Service Line

Veterans Health Administration

Veterans Affairs Medical Center

Minneapolis, MN

Susan Mather, MD

Chief Public Health & 

Environmental Hazards Officer

Veterans Health Administration

Department of Veterans Affairs 

Central Office

Washington, DC 

Neil Otchin, MD

Program Chief for Clinical Matters 

Public Health & Environmental

Hazards Office

Veterans Health Administration

Department of Veterans Affairs 

Central Office

Washington, DC

Micaela Cornis-Pop, PhD, CCSLP

Traumatic Brain Injury Associate

Research Investigator 

Speech Language Pathologist, 

Traumatic Brain Injury 

Rehabilitation Program

Veterans Health Administration

Hunter Holmes McGuire Veterans 

Affairs Medical Center

Richmond, VA

Deborah Warden, MD

National Director

Defense and Veterans 

Brain Injury Center

Walter Reed Army Medical Center

Washington, DC

Robert Smith, EdD, MCP

Program Manager

VA Employee Education System

Birmingham Employee Education 

Resource Center

Birmingham, AL

Nancy Donovan, MSW

Program Manager

VA Employee Education System

Minneapolis Employee Education

Resource Center

Minneapolis, MN

Program Development
x Traumatic Brain Injury

Pamela Hebert, DrPH

Program Manager

Nurse Planner

VA Employee Education System

Birmingham Employee Education 

Resource Center

Birmingham, AL

Program Manager 

Robert Smith, EdD, MCP

Program Manager

VA Employee Education System

Birmingham Employee Education 

Resource Center

Birmingham, AL

Project Support Assistant

Donna Burnett

VA Employee Education System

Birmingham Employee Education 

Resource Center

Birmingham, AL

Learning Technology and 

Media Development

Jeffrey Henry 

Media Producer

VA Employee Education System

North Chicago VA Medical Center

North Chicago, IL

Joseph Radford

Graphic Artist

VA Employee Education System

Salt Lake City Employee Education

Resource Center

Salt Lake City, UT

Program Development
Accreditation

Accreditation Council for Continuing Medical Education (ACCME)

The VA Employee Education System is accredited by the Accreditation

Council for Continuing Medical Education (ACCME) to provide continuing

medical education for physicians.

American Nurses Credentialing Education

VA Employee Education System is accredited as a provider of continuing

education in nursing education by the American Nurses Credentialing

Center’s Commission on Accreditation.

Continuing Education Credit

Accreditation Council for Continuing Medical Education (ACCME)

The VA Employee Education System designates this educational activity for a

maximum of 4.0 hours in Category 1 credit towards the American Medical

Association Physician’s Recognition Award. Each physician should claim only

those hours he/she actually spent in the educational activity.

Association of Social Work Boards (ASWB)

VA Employee Education System, Provider Number 1040, is approved as a

provider for social work continuing education by the Association of Social

Work Boards (ASWB), (1-800-225-6880) through the Approved Continuing

Education (ACE) program. VA Employee Education System maintains

responsibility for the program. Social workers will receive 4.0 continuing

education clock hours for participating in this course.

American Nurses Credentialing Education

VA Employee Education System designates this educational activity for 4.8

contact hours in continuing nursing education.

American Psychological Association

The VA Employee Education System is approved by the American

Psychological Association to offer continuing professional education for

psychologists. As an organization approved by the American Psychological

Association, the VA Employee Education System is offering this activity for

4.0 hours of continuing professional education credit. The VA Employee

Education System maintains responsibility for the program. 

American Speech-Language-Hearing Association

The Department of Veterans Affairs, Audiology and Speech Pathology Service,

is approved by the CEB of ASHA as a Provider of CE activities in speechlanguage pathology and audiology. This program is offered for 4.0 hours.

The Employee Education System maintains responsibility for the program. A

certificate of attendance will be awarded to participants and accreditation

records will be on file at the Employee Education System. In order to

receive a certificate from EES, you must read the material, complete and

pass the CME test with a 70% or higher, and complete a program evaluation.

Traumatic Brain Injury xi

AMA and ANCC Continuing Education Credits
xii Traumatic Brain Injury

Report of Training

It is the program participant’s responsibility to ensure that this training is

documented in the appropriate location according to his/her locally

prescribed process.

AMA and ANCC Continuing Education Credits
Traumatic Brain Injury xiii

The Employee Education System (EES) must insure balance, independence,

objectivity, and scientific rigor to all EES sponsored educational activities.

The intent of this disclosure is not to prevent faculty with a significant

financial or other relationship from presenting materials, but rather to

provide the participant with information on which they can make their own

judgements. It remains for the participant to determine whether the faculty

interests or relationships influence the materials presented with regard to

exposition or conclusion. When an unapproved use of a FDA approved

drug or medical device, or an investigational product not yet FDA approved

for any purpose is mentioned, EES requires disclosure to the participants. 

Faculty have provided the following information:

Glenn Curtiss, PhD

James M. MacAulay, BA

Karen Moore, MHS, PT

Rebecca Mullins, MS, LCSW

Ronald Seel, PhD

Barbara Sigford, MD, PhD

Gretchen Stephens, MPA, OTR/L

Rodney Vanderploeg, PhD

William Walker, MD

George Zitney, PhD, CBIS-CE, ABDA

No disclosable relationships or FDA issues

Joel Scholten, MD

Sources of Funding for Research/Grants - Defense and Veterans 

Brain Injury Center

Anti-seizure medications, anti-depressants, anxyolytics, and novel 

antipsychotics for treatment of post-traumatic agitation are 

discussed. This has not been approved by the FDA.

Sandra Lundgren, PhD, ABPP

The use of neuropsychological test materials is discussed. This is 

a commercial product or service.

David Jaffe, MS

Use of driving simulators

The potential of driving simulators to assess and improve driving 

performance after Traumatic Brain Injury is discussed. This has 

not been approved by the FDA.

Marina Waisman, MD

Sources of Funding for Research/Grants - Defense and Veterans 

Brain Injury Center

Anticonvulsants, anti-depressants, anxyolytics, and antipsychotics 

for treatment of post-traumatic agitation are discussed. This has 

not been approved by the FDA.

Disclosure Statement
xiv Traumatic Brain Injury

Deborah Warden, MD

Stimulants after adult traumatic brain injury are discussed. This 

has not been approved by the FDA.

Edward Brodd, RKT

Elaine S. Date, MD

Jennifer L. DiGrazia, MS, OTR/L

Hsiu-Chen Huang, MD

Henry L. Lew, MD, PhD

Rebecca Mumpower, MD

F. Don Nidiffer, PhD, ABMPP

Micaela Cornis-Pop, PhD, CCSLP

Harriet Zeiner, PhD

Did not submit disclosures or FDA issues to EES

Americans with Disabilities Act Policy

The Employee Education System wishes to ensure no individual with a

disability is excluded, denied services, segregated, or otherwise treated

differently from other individuals participating in this independent study

because of the absence of auxiliary aids and services. If you require any

special arrangements to fully participate in this independent study, please

contact Bob Smith, EdD, MCP, Program Manager, at 205-731-1812 extension

317, or e-mail bob.smith@lrn.va.gov.

Disclosure Statement
Introduction Introduction

Traumatic Brain Injury 1

Traumatic brain injury (TBI), sometimes referred to, as the “silent

epidemic,” is a condition that may result in lifetime physical, cognitive,

emotional, and behavioral impairments. The Centers for Disease Control

reports an estimated 5.3 million Americans live with disabilities associated

with a TBI. 

Providing specialized health care for active duty military and veterans

sustaining a brain injury is a high priority of VA. In peacetime, over 7,000

Americans with a diagnosis of TBI are admitted to military and veterans

hospitals each year. In times of combat TBI comprises at least 14-20% of

surviving casualties, who subsequently consume a disproportionate share of

available acute and long-term combat casualty care resources. 

The TBI Network of care for active duty military and veteran beneficiaries is

a unique partnership between the Department of Defense and the

Department of Veterans Affairs with a common purpose — to develop an

integrated disease management system and to ensure that military

personnel and veterans with brain injury receive optimal care. 

Most health care providers do not routinely see patients having a TBI. A

major aim of this Veterans Health Initiative (VHI) is to provide a knowledge

base of the epidemiology, medical treatment, and rehabilitative

interventions associated with various types and severities of injury.

Individuals having suffered a brain injury are often reluctant to reveal this

when discussing their medical history. Increasing awareness of the varied

symptoms that are a result of this condition will help providers to better

care for these veterans. 

This condition can have a profound impact on the brain injury survivor and

his or her family. There are resources available within the VA, other federal,

state and local government, and other organizations that represent persons

with brain injury. This information has also been included in this VHI to

assist with specific areas.
2 Traumatic Brain Injury
Testimonial - 

The Happiest of Happy Endings

Testimonial - 

The Happiest of Happy Endings

Traumatic Brain Injury 3

David S. Knecht

This is an account of a man’s recovery from traumatic brain injury. 

I was a soldier assigned to control and evaluate night live fire exercises for

armored forces. One dark evening, a gunner aimed his weapon at my

tracked troop carrier, thinking it was his assigned target. He squeezed off

eight rounds that battered the armored flank of my command vehicle (the

soldier earned an “A” for accuracy, but an “F” for target selection). I ducked

for cover as shards of metal and glass lacerated my face. A broken projectile

penetrated my skull. Three months and three brain surgeries later I was an

inpatient in rehabilitation at a local VA hospital.

For the past eleven years, I have been a “brain injury survivor.” Before my

brain injury, I was a soldier and a family man. Of these, my role of “family

man” supplied the motivation to recover from brain injury. I can never forget

the crushing discouragement I felt as I struggled through six months of

hospitalization. Much of what motivated me had been stripped away. Though

I had been a soldier for a decade or so, I was hurt much too badly ever to

return to soldiering. As gratifying as it had been to be the “daddy” (leader)

of my home, I could not expect ever to be more than an invalid nursed by

Mrs. Knecht and our children. Gloom gripped me as I sat in my wheelchair

and wept. I felt doomed to be a “minus” to them, and never again a “plus.”

My depression lasted only until I came to see the benefits of my traumatic

injury. Were things really so disastrous? Sure, I was certain to be hemiplegic

and half-blind. Any hope of completing a career in the Army was ruined.

Even so, “no career” could really mean “new career”! What could be more

rewarding than being a full-time dad and raising a family to maturity? Cue

“theme from Rocky”! Now I had motivation for a comeback! After some

months of rehab, I left behind a wheelchair and (later) a cane. Although I

am still half-paralyzed and half-blind, I enjoy the privilege of being a fulltime home-schooling dad. (I have even fathered four more children since

that dark night years ago.) Although the brain injury is not what I would

have chosen back then when it happened, I would choose my present life

over that past one any day.

Does my story and situation have much in common with those of others?

Everyone is unique, and I am certainly fortunate. Draw your own conclusions,

but consider this: every man needs a motivation to recover from injury. My
motivation was my home responsibilities, and mine is now a happier home

than it has ever been. “Disability” is outweighed by “ability” to devote myself

to the things of life that matter most. This is the happiest of happy endings.

4 Traumatic Brain Injury

Testimonial - The Happiest of Happy Endings
Epidemiology and the Nature of

Traumatic Brain Injuries

Epidemiology and the Nature of

Traumatic Brain Injuries

Traumatic Brain Injury 5

Section

1

Learning Objectives

1. State why traumatic brain injury is a significant health problem.

2. List three common causes of traumatic brain injury.

3. Describe three tools for classifying severity of brain injury.

4. Describe the main types of physiological changes in the brain 

resulting from trauma.

5. State common behavioral problems associated with damage to 

various areas of the brain.

6. Describe the course of cognitive recovery following traumatic 

brain injury.

Epidemiology of Brain Injury

Introduction

Traumatic brain injury is a leading cause of death and disability in the United

States. One to one and a half million Americans incur a traumatic brain

injury (TBI) each year ((http://www.cdc.gov/ncipc/factsheets/tbi.htm), CDC

Web site, March 2003; Sosin et al., 1996) and approximately 5.3 million

individuals have enduring disabilities as a direct result of a TBI (CDC Web

site, March 2003). Direct costs for hospital care, extended care, and other

medical care and services were estimated at $4.5 billion annually in 1985

(Max, MacKenzie, & Rice, 1991), with indirect costs pegged at $37.8 billion.

These figures do not include the physical, emotional, and social costs to the

injured person and their family from TBI-related disability. For the year

2001, there were 1,361 veterans who received VA inpatient hospital care for

TBI. These figures do not include veterans who may have received medical

care for TBI but who did not require hospitalization.

TBI is also a significant health problem for the uniformed services.

Ommaya, Ommaya, Dannenberg, and Salazar (1996) examined the 1992

discharge records for all military hospitals and private facilities that received

CHAMPUS reimbursement. They found that for active duty military males

aged 18-24, the hospitalization rate for TBI was 231 per 100,000. The rate

was 150 per 100,000 for active duty military females of the same age range.

Based on a military force of 1,597,000 men and 301,000 women in 1992

(Washington Headquarters Services, Directorate for Information Operations

and Reports, 2000), approximately 4,141 military personnel would be

expected to be hospitalized for TBI annually, and this number would likely

increase during wartime. These figures also do not include individuals who

received treatment for TBI but who did not require hospitalization.
Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

6

Causes of TBI

The most common means of sustaining a TBI is through motor vehiclerelated incidents. Data from the CDC indicate motor vehicle-related incidents

account for 50% of all reported TBIs (see Figure 1). These include all incidents

involving motor vehicles, bicycles, pedestrians, and recreational vehicles.

Following motor vehicle-related incidents are falls (25%). Firearms account

for 10% of all TBIs, with two-thirds of them associated with suicide attempts.

http://www.cdc.gov/ncipc/images/figure8.gif

Figure 1: Proportions of traumatic brain injury by cause - Arizona, Colorado,

Minnesota, Missouri, New York, Oklahoma, and South Carolina, 1994

Who sustains a TBI?

Given the above causes, it should not be surprising that TBI is more common in

certain groups of individuals than others. Males who sustain a TBI outnumber

females by at least 2:1 ((http://www.cdc.gov/ncipc/factsheets/tbi.htm), CDC

Web site, March 2003). Individuals between the ages of 15 to 25 and those

75 and older are at highest risk for TBI of all age groups (CDC Web site,

March 2003; Whyte & Rosenthal, 1988). As seen in Figure 2 (next page),

motor vehicle-related incidents are the most common etiology in younger

ages, while falls are the most common reason for TBI in older individuals. 

Transportation

48.9%

Falls

25.8%

Firearms

9.7%

Other 

Assaults

7.5%

Other

7.4%

Unknown 0.6%

Figure 1
Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

7

http://www.cdc.gov/ncipc/images/figure10.gif

Individuals who abuse substances represent a third group at increased risk

for TBI. About 50% of TBI cases are believed to be alcohol related (Drubach

et al., 1993; Kolakowsky-Hayner et al., 1999; Wong et al., 1993). Individuals

in the age ranges of 26-35 and 56-65 are most likely to be intoxicated at the

time of their injury. 

Severity of Brain Injury

Severity of TBI is an important determinant of outcome. The severity

grades, i.e., mild, moderate, and severe, are defined by using one of three

indexes: score on the Glasgow Coma Scale (GCS), length of loss of

consciousness (LOC), and length of post-traumatic amnesia (PTA). 

Figure 2

Traumatic brain injury rates by age group and cause of

injury - Arizona, Colorado, Minnesota, Missouri, New

York, Oklahoma, and South Carolina, 1994

Points to Remember 

The above data indicate that Primary Care providers in the VA and DoD health

care settings are very likely to encounter individuals who have sustained a 

TBI because:

• The majority of veterans and individuals on active military duty are male 

• They fall within the age ranges of greatest risk

• The frequency of substance abuse among veterans and active duty military 

personnel is high (Bray & Marsden, 2000)

• The risk of falls is increasing with the aging of the veteran population
Glasgow Coma Scale (GCS)

The GCS is a 15-point scale based upon ratings of the patient’s best eye

opening, motor, and verbal responses (see Table 1).

While the GCS is recognized as a reliable measurement tool, it is influenced

by factors unrelated to the injury itself such as intoxication and, particularly

for mild TBI (MTBI), the length of time between the injury and measurement. 

Loss of Consciousness (LOC)

LOC is the length of time the patient is non-responsive. Obviously, the longer

the LOC, the more severe the TBI. Although this may appear to be an easy

and objective measure, often patients are unaware of whether or not they

have had a period of LOC (Levin, Mattis, Ruff et al., 1987). The injury may

have been unwitnessed and the patient may have regained consciousness by

the time they are evaluated. 

Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

8

Glasgow Coma Scale

Motor Responses: Score

Obeys commands 6

Localizing responses to pain 5

Generalized withdrawal to pain 4

Flexor posturing to pain 3

Extensor posturing to pain 2

No motor response to pain 1

Verbal Responses:

Oriented 5

Confused conversation 4

Inappropriate speech 3

Incomprehensible speech 2

No speech 1

Eye opening

Spontaneous eye opening 4

Eye opening to speech 3

Eye opening to pain 2

No eye opening 1

TOTAL (Add above 3 scores) Range = 3 - 15

Table 1
Post-Traumatic Amnesia (PTA)

PTA is the time interval from when the person regains consciousness until

he or she is able to form memories for ongoing events (Whyte & Rosenthal,

1988). During PTA, the individual is not fully oriented nor able to remember

information after a period of distraction. Determination of the end of PTA in

MTBI can be difficult and the clinician may have to rely on self or family

report. Retrospectively, PTA can be assessed by asking the patient or family

member about the first event which can be remembered following the

injury, always distinguishing between what the patient actually remembers

and what they have been told (Ruff & Barth, 1999). Table 2 presents the

severity grades and defining criteria of the three indexes.

Mild TBI

Approximately 80% of patients who sustain TBIs have had a mild TBI

(Alexander, 1995). MTBI is believed to result when injury triggers the

pathologic neurochemical cascade, but is insufficient to produce widespread

neuronal dysfunction or the axonal disruption that characterizes more

severe brain injuries. The majority of these patients make excellent

neurobehavioral recovery, but many have persistent and disabling

symptoms. The formal definition of MTBI as defined by the American

Congress of Rehabilitation Medicine (Kay et al.,1993) is presented in Table 3.

Diagnostic Criteria for Mild Traumatic Brain Injury

1. Traumatically induce physiologic disruption of brain function as indicated by at 

least one of the following:

A. Any period of loss of consciousness

B. Any loss of memory for events immediately before or after the accident

C. Any alteration in mental state at the time of the accident

D. Focal neurologic deficits that may or may not be transient

2. Severity of the injury does not exceed:

A. Loss of consciousness of 30 min

B. GCS score of 13-15 after 30 min

C. Post-traumatic amnesia of 24 hr

Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

9

Table 2

Table 3

Mild (Grade 1) Moderate (Grade 2) Severe (Grade 3 & 4)

Severity Grades of TBI

Altered or LOC < 30 min

with normal CT &/or MRI

GCS 13-15

PTA < 24 hours

LOC < 6 hours with

abnormal CT &/or MRI

GCS 9-12

PTA < 7 days

LOC > 6 hours with

abnormal CT &/or MRI

GCS < 9

PTA > 7 days
10 Traumatic Brain Injury

MTBI remains a somewhat controversial classification because of the typical

negative findings on CT or MRI scans and the brief duration of altered

consciousness. Issues of MTBI are discussed more fully in Section 2.

Pathophysiology of Injury

Brain injuries also can be classified as focal, diffuse, or mixed depending on

the mechanism of injury and the host response. The degree of diffuse injury

generally determines the injury grade (mild, moderate, severe). Focal

damage, such as contusion or hematoma, can be appreciated by standard

neuroimaging studies such as CT or MRI. Widespread disruption of

neuronal circuitry or diffuse axonal injury (DAI) is difficult to appreciate

on standard neuroimaging. It is possible to have both types of injury from a

single traumatic incident. Focal lesions are usually the result of direct impact

of the brain against the cranium, most often from impact with the frontal

and temporal bones or the occipital bone. 

Primary Injuries

Diffuse Axonal Injury (DAI)

DAI results from rotational acceleration-deceleration forces. The larger focal

lesions that are easily appreciated on neuroimaging are uncommon in MTBI.

However, DAI has been observed in pathology studies following mild injuries

(Blumbergs, Scott et al., 1994). While DAI can actually be observed in

histology specimens, it is also sometimes inferred when neurological symptoms

are noted in the absence of abnormal findings or in the presence of small

white matter changes on standard neuroimaging (Warden et al., in press). 

Historically, the disconnection of axons observed after TBI was thought to

result from the direct tearing and disruption of axons at the time of injury,

referred to as primary axotomy. Recent work, however, has shown that

primary axotomy is rare, even in severe TBI (Maxwell, Povlishock et al.,

1997). Rather, axonal disconnection seems to occur several hours after

injury as a result of events in the axonal membrane and cytoskeleton

(Povlishock, Becker et al., 1983). There may be delay or change in

functional deficit over time as a result of this ongoing process. These

Epidemiology and the Nature of Traumatic Brain Injuries

Points to Remember 

• Brain injuries can vary from mild to moderate to severe

• The majority of all brain injuries are mild

• The Glasgow Coma Scale (GCS), length of loss of consciousness (LOC), 

and length of post-traumatic amnesia (PTA) are common measures of 

severity of brain injury

• A number of non-trauma-related factors (e.g., intoxication) can complicate 

assessing severity 
Traumatic Brain Injury 11

Epidemiology and the Nature of Traumatic Brain Injuries

pathophysiological changes are observed diffusely throughout the

subcortical white matter, corpus callosum, fornix, internal capsules,

cerebellum, and brain stem (Adams, Doyle et al., 1989).

Focal Lesions 

Focal lesions occur primarily in moderate to severe TBI, but should always

be a consideration in any head trauma. It should also be noted that these

injuries may not always present acutely coinciding with the actual trauma,

but may present days to months following the actual traumatic event. Focal

lesions that may be seen in TBI include subdural hematoma (SDH),

epidural hematoma (EDH), subarachnoid hemorrhage (SAH), intracerebral

hemorrhage (ICH), and cortical contusion. Subdural hematomas result when

small bridging veins between the skull and the dura are torn resulting in

bleeding into the subdural space. This can occur following motor vehicle

accidents, falls, and other types of trauma. These patients may not always be

evaluated at the time of the injury or may not be evaluated for symptomatic

complaints when they do receive early intervention. Elderly individuals are

at particular risk for this type of injury following a fall, and the primary care

physician may be the first to see and evaluate these patients for their symptoms.

Epidural hematomas result from damage to dural veins and arteries and can

result in rapid deterioration and death if not treated promptly. Subarachnoid

hemorrhage results from damage to the microvessels in the subarachnoid

space and are often associated with cerebral contusion. Intracerebral

hemorrhage results from brain laceration and typically occurs in the frontal

and temporal areas of the brain. Cortical contusions result from direct

trauma to the brain parenchyma from impact with boney prominences of

the skull. Typical areas of injury are the frontal, orbital frontal, anterior

temporal and lateral temporal areas.

Secondary Injury 

Following the initial injury to the brain, mechanisms of secondary injury,

including cellular response and neurochemical and metabolic cascades, are

set in motion. Contributing to secondary cellular injury are increased

excitatory amino acids such as glutamate, neurotoxic free radicals and

oxidants, lipases, arachadonic acid, and increased calcium (Graham, 1999).

Hypoventilation or elevated intracranial pressure (ICP) can lead to

secondary hypoxic brain injury. Secondary ischemic insults can occur in the

form of focal cerebral infarcts or diffuse watershed brain injury from

circulatory failure. Table 4 (next page) presents frequent causes and

functional correlates of various pathophysiologic changes.
Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

12

Neuroanatomy and Common Deficits Associated

with Site of Injury

Accurate prediction of deficits from TBI is difficult due to the high

complexity of the brain, the variability of injury caused by any particular

trauma, and the fact that injury sites are frequently not shown by standard

neuroimaging. However, there are generally accepted functions associated

with the major areas of the brain. Damage to these areas is often associated

with specific impairments in day-to-day function. 

Functional Correlates of Injury Pathophysiology

Injury Type Usual Cause Deficits seen

Focal Cortical Contusion

Diffuse Axonal Injury

Hypoxic/Ischemic

Ground level fall (GLF)

Assault

Gunshot wound

Motor vehicle accident

Non-ground level fall

Geriatric GLF

Anoxia

Cardiac arrest

Prolonged elevated ICP

Hemiparesis

Aphasia

Seizures

Visuoperceptual

Confused language

Amnesia

Apraxia

Hypoarousal

Quadraparesis

Spasticity

Confusion

Amnesia

Hypoarousal

Table 4

Points to Remember 

• Brain injuries can result in diffuse axonal injuries, focal lesions, or both 

depending on the mechanism of injury and the host response

• Diffuse axonal injury results from inertial (rotational accelerationdeceleration) forces and is thought to be a result of calcium influx and 

subsequent cytoskeletal damage 

• Focal injuries are typically due to a direct blow to the head and include 

subdural hematoma, epidural hematoma, subarachnoid hemorrhage, 

intracerebral hemorrhage, and cortical contusion
Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

13

Frontal Lobes

As mentioned previously, the frontal lobes are particularly susceptible to

trauma. The anterior portion of the frontal lobes is considered essential to

higher cognitive functioning, often called “executive” functions. These are

integrative functions and include the ability to focus attention to

appropriate stimuli, organize and plan, problem-solve, formulate good

decisions, and exhibit appropriate judgment. They also play a role in

behavioral control and emotion, and the ability to empathize with others.

Damage to the anterior frontal lobes often results in difficulties with

planning and carrying out activities that once were accomplished with little

effort like grocery shopping, maintaining a job, completing household

repairs, etc. There may also be more concrete thinking and decreased

mental flexibility. Damage may also result in difficulties staying on task and

completing activities. Persons with MTBI may have only vague complaints in

these areas, while individuals with moderate to severe TBI may be more

impaired. Behavioral change from injury to the frontal lobes may be quite

paradoxical, showing either an increase in disinhibition and immaturity or a

decrease in energy, motivation, and spontaneity. The posterior aspect of the

frontal lobes contains the motor strip. Damage to these areas can result in

reduced abilities to carry out motor tasks or actual hemiparesis or plegia

often associated with spasticity. Damage anterior to the motor strip near the

Sylvian fissure can produce an aphasia (Broca’s aphasia) characterized by

nonfluent, agrammatic speech consisting of mostly nouns and verbs.

Temporal Lobes

The temporal lobes, also highly susceptible to injury, are integral to memory

function and also play a role in modulating behavior. Damage to the

temporal lobes, especially the hippocampal area, can result in difficulty with

storing new memories while old memories are readily preserved. The right

temporal lobe is associated with visual memory and the left with verbal

memory. The left temporal lobe is also associated with language function

and lesions may give rise to word-finding and naming difficulties (anomic

aphasia). Behavioral problems include increased irritability and aggression. 

Parietal Lobes

The parietal lobes are instrumental in processing sensory information. The

right parietal lobe is associated with processing visual-spatial information

and damage to this area can result in difficulty with getting lost in familiar

and unfamiliar surroundings. The left parietal lobe is associated with

language function and damage here may impair an individual’s ability to

understand the spoken or written word. Again, deficits may vary from mild

to severe depending on the severity of the injury.

Occipital Lobes

The occipital lobes are primarily responsible for the reception and

processing of visual information. Damage to the occipital lobes results in

various forms of visual deficits ranging from visual field cuts to the inability

to recognize known objects to blindness.
Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

14

Cerebellum

The cerebellum has a major role in coordinated movement. Damage to the

cerebellum can make walking and the coordinated use of the upper

extremities for day-to-day tasks difficult. Nystagmus and tremors can also be

seen with cerebellar injury.

Diffuse Axonal Injury

Diffuse axonal injury, which is common in TBI, typically results in a

generalized slowing of cognitive processes. Individuals with DAI often

complain of a generalized slowness in thinking and difficulty getting things

done. There is a reduction in the number of cognitive operations that the

brain can engage in at any given time. 

Course of Recovery

Recovery is a gradual process that occurs for at least 18-36 months as the

brain recovers and regenerates. Recovery is most rapid over the first 6 months

during which the majority (80-85%) of recovery occurs. Following diffuse

axonal injury, damaged neurons may sprout ancillary axons and reestablish

disrupted connections. Other axons that have not sustained total disruption

are able to reverse the pathophysiological damage and return to function.

There is evidence from animal studies that purposeful activity may stimulate

axonal regeneration. Experimentally brain-injured rats placed in an enriched

environment with maze-reward systems and other games showed improvement

in cognitive function and, on dissection, strong growth of neuronal

pathways. This was not observed, however, in rats placed in plain cages

(Hamm et al., 1996; Passineau et al., 2001).

Points to Remember 

• There is no typical pattern of deficits associated with TBI because of the 

complexity and individual variation of the brain and variations in 

mechanisms of injury and the results of the trauma

• Specific impairments in function may be seen in behaviors that are 

strongly localized to or heavily dependent on particular areas of the brain

• Impairments in executive abilities and motor abilities are frequently seen 

with damage to the frontal lobes 

• Consolidating new information into memory may be impaired with 

damage to the temporal lobes, especially damage to the hippocampal area

• Difficulties in language comprehension or comprehension of visual stimuli 

are seen with lesions to the parietal lobes 

• Damage to the occipital lobes may produce deficits in visual abilities such 

as cuts in the visual field or cortical blindness

• Diffuse axonal injury is associated with slowed thinking and difficulty 

accomplishing tasks
Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

15

Symptoms of MTBI resolve by three months after injury in the majority of

individuals (Rutherford et al., 1989; Levin, Mattis et al., 1987). However, for a

minority of these individuals, symptoms persist for a more lengthy period of

time and sometimes for life (Binder, 1986; Rutherford, 1989; Bohnen &

Jolles, 1992). The prevalence of persistent symptoms varies from 7-8%

(Binder, 1997) to 10-20% (Alexander, 1995) to 33% (Rimel et al., 1981). A

commonly accepted estimate of prevalence is currently 20%. This group of

patients will require ongoing medical care to manage these symptoms.

There is also evidence that individuals who may appear to have recovered

in normal day-to-day function may still reveal impairments during periods

of psychological or physiological stress (Alexander, 1995). 

The recovery course of cognitive abilities after moderate to severe TBI is

highly individualized and depends on the initial distribution and degree of

injury, as well as numerous cofactors. Damage to the highly complex brain

cell bodies, axons and/or synapses can have far reaching implications for

TBI survivors and their families. Poorer outcome has been associated with

the following factors: age > 55, poorer premorbid function, lower

socioeconomic status, increased length of coma, presence of brainstem

abnormalities, lower motor score on the GCS, elevated ICP, prolonged PTA,

presence of intracranial mass lesion, and low functional abilities on

admission to rehabilitation (Sandel, Bell, & Michaud, 1998). The vast

majority of survivors of moderate to severe TBI do not return to their full

premorbid cognitive level and have troubling behavioral issues. Figure 3

illustrates three hypothetical recovery paths of cognitive functioning. 

Hypothetical Recovery Paths of Cognitive Functioning

Figure 3
In the acute phase of recovery (initial several months) rehabilitation professionals

frequently use the Rancho Los Amigos Level of Cognitive Function Scale

(Hagen, Malkmus, Durham, & Bowman, 1979) to characterize the level of

functioning and track the course of cognitive recovery over time. It is a

descriptive instrument that characterizes the level of cognitive and behavioral

deficits after moderate to severe TBI. Ratings range from Level I, indicative of

no response (comatose), to Level VIII, indicative of a person whose behavior

is purposeful and appropriate, although not necessarily functioning

independently or at premorbid levels. Table 5 presents the full range of

Rancho levels and brief descriptions of the characteristics for each level.

Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

16

Rancho Los Amigos Level of Cognitive Function Scale

Rancho Los Amigos Description

Level

I No Response Unresponsive to sound, light, touch, or pain. The individual 

appears to be in a deep sleep.

II Generalized Individual reacts inconsistently in a nonspecific manner 

Response to stimulation. May be gross body movements, unintelligible 

vocalizations, etc. Earliest response is frequently to deep pain. 

Responses to stimuli often are delayed.

III Localized Reacts to specific stimuli (e.g., eye blink to strong light, 

Response turns toward sound, etc.). Responses are often inconsistent. 

May inconsistently follow simple, direct commands (e.g., close 

your eyes, squeeze my fingers, etc.).

IV Confused - Alert and active but has severely limited ability to 

Agitated process information. Disoriented to circumstances and 

responds primarily to internal stimuli. Behavior is not 

purposeful or is bizarre and the ability to focus and sustain 

attention is extremely limited. Does not differentiate among 

people or things. Verbalizations may not be coherent or may 

be patently bizarre. Short-term memory and recall are 

impaired and may confabulate. 

V Confused - Alert and active and can respond consistently to simple 

Inappropriate commands. Disoriented to circumstances and requires 

redirection but is not responding primarily to internal stimuli. 

Short-term memory and recall are impaired and may 

confabulate. May be able to perform self-care activities with 

assistance and supervision.

VI Confused – Alert and inconsistently oriented to time and place. Follows 

Appropriate simple directions consistently and begins to show carry-over 

of new learning. Recognizes staff and has increased awareness 

of self, family, and others.

Table 5
Traumatic Brain Injury

Epidemiology and the Nature of Traumatic Brain Injuries

17

Rancho Los Amigos Description

Level

VII Automatic – Alert and oriented to person, place, and time but shows a 

Appropriate shallow awareness of medical condition. Performs self-care 

and daily routines with supervision but in a robot-like 

manner. Performance may deteriorate in unfamiliar 

circumstances. Shows carry-over of new learning but at a 

reduced rate. Judgment and problem-solving remain impaired. 

VIII Purposeful - Alert and oriented. Can recall and integrate past and current 

Appropriate events. Shows carry-over of new learning and is independent, 

within physical limitations, at home and in the community. 

Cognitive abilities may still be lower than premorbid levels.

Table 5

Table 5 (cont.)

Points to Remember 

• Recovery is a gradual process that occurs for at least 18-36 months as the 

brain recovers and regenerates

• Recovery is most rapid and greatest over the first 6 months

• Approximately 20% of all individuals who sustain a MTBI will continue to 

experience prolonged symptoms and require ongoing medical care

• Recovery of cognitive abilities after moderate to severe TBI is highly 

individualized and depends on the initial distribution and degree of injury, 

as well as numerous other factors

• Individuals who have sustained moderate to severe TBI frequently never 

recover to pre-injury functional levels and may have behavioral difficulties

• The Rancho Los Amigos scale is frequently used to track cognitive recovery 

from moderate to severe TBI

Adapted from Hagen et al., 1979.
18 Traumatic Brain Injury
Traumatic Brain Injury 19

Section

2 Concussion Management:

Sequelae and Treatment of Mild TBI

Concussion Management:

Sequelae and Treatment of Mild TBI

Learning Objectives

1. List the levels of severity for concussions. 

2. Describe the indications for an initial CT scan of the brain 

following mild TBI.

3. Describe the typical course of recovery from mild TBI.

4. List the common symptoms of post-concussion syndrome.

5. Describe factors complicating the assessment of 

post-concussion syndrome.

6. List potential interventions for treatment of 

post-concussion syndrome.

Introduction 

This section will discuss the management of the individual with mild

traumatic brain injury (MTBI) or concussion. Management will include 

both medical interventions in the emergency department or outpatient

clinic, as well as educational interventions demonstrated to be effective in

improving post-concussive symptoms. This section will be divided into 

the following sections:

• Acute Concussion Management

• Common Sequelae and Course

• Post-Acute Management of Mild Traumatic Brain Injury

• Factors complicating Assessment 

• Appropriate referrals of patients with MTBI

Acute Concussion Management

A high degree of suspicion for MTBI is required in the individual who is

being treated for other bodily injuries. With triage focused on urgency of

care, health care providers at each level of care must question whether a

concomitant brain injury may have occurred. Identification of an individual

with MTBI allows for monitoring of return of full function and educating

the individual on the natural course of MTBI recovery.
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

20

Obtaining a complete history of the injury is the first step in evaluating an

individual who has sustained a recent MTBI. Necessary information includes:

Severity of Injury

Presence and length of disturbed consciousness, from a momentary

alteration of consciousness only (i.e., having been “dinged” or having one’s

“bell rung”) to the length of a period of clear unconsciousness; length of

post-traumatic amnesia (PTA; period from injury until continuous memory

or “new learning” resumes). A rating of 13-15 on the Glasgow Coma Scale

(GCS; see Section 1) is also considered MTBI. The GCS is the most

commonly used scale to quantify initial severity of brain injury and based

upon the clinical evaluation (see below). 

The American Academy of Neurology (AAN, 1997), has published guidelines

grading the level of concussion into three categories: 

Grade I:

1. Transient confusion

2. No loss of consciousness

3. Concussion symptoms or mental status abnormalities on 

examination resolve in less than 15 minutes

Grade II:

1. Transient confusion

2. No loss of consciousness

3. Concussion symptoms or mental status abnormalities on 

examination last more than 15 minutes

Grade III:

1. Any loss of consciousness, either brief (seconds) or 

prolonged (minutes)

These categories can be found at:

http://www.aan.com/professionals/practice/pdfs/gl0013.pdf

For awake but confused patients seen in the ER or Primary Care Clinic, an

accurate determination of possible loss of consciousness (LOC) is enhanced

by interview of any bystanders, as well as review of the ambulance report (if

available). Evaluation of PTA requires review of available medical records

along with the patient and observer interviews, especially in distinguishing a

brief period of LOC from PTA. For example, an individual may report that he

was unconscious until he arrived at the hospital, yet the ambulance report

may say that he was walking around, but confused, at the scene of the

accident. The individual may believe that he was unconscious at that time

due to lack of recall of the initial events (i.e., in PTA). In cases of MTBI, PTA

is often operationally defined as the length of time until continuous

memory resumes, or when the individual scores a 75 or above on the

Galveston Orientation and Amnesia Test (GOAT; Levin, O’Donnell et al.,

1979). When the initial medical contact occurs after the resolution of PTA,

the patient is often asked when s/he began to remember events
Traumatic Brain Injury 21

Concussion Management: Sequelae and Treatment of Mild TBI

continuously after the injury. PTA technically extends from when

consciousness was regained until continuous memory resumes, but without

observer report, the distinction between brief LOC and PTA is difficult to

confirm. The length of PTA may diminish over time with events immediately

before and after the injury the least likely to resolve fully. 

Mechanism and Context of Injury

It is important to determine and document whether someone had a blow to

the head (increased likelihood of focal injury) or an accelerationdeceleration injury as in a motor vehicle accident (increased likelihood of

diffuse injury). The rare, but potentially devastating, condition of an

epidural hematoma may be suspected from a sharp blow to the side of the

head, in a patient who is alert initially, but later begins to develop decreased

level of consciousness. 

Included in the context of the injury are time and circumstances of injury,

and whether drugs or alcohol were involved. All these factors may assist in

evaluating the severity of the injury, as well as in understanding the lifestyle

of the injured person, which will be relevant to recommendations of how

treatment may fit into the individual’s routine. A tendency toward risktaking behavior is important to note, as education about decreasing risks for

a possible second injury is an important intervention. 

Sports concussion guidelines provide recommendations regarding the

timing of return to full activity (e.g., AAN, 1997;

http://www.aan.com/professionals/practice/pdfs/gl0013.pdf). Such guidelines

exist to decrease the potential for a second injury during the time period

when the individual may be functioning suboptimally from a concussion

and thus is more likely to be involved in a subsequent injury. For example,

decreased reaction time has been documented to occur up to 4 days after

injury in a group of individuals sustaining a Grade I or II concussion (no

LOC, symptoms lasting up to 24 hours) (Warden et al., 2001), and up to 35

days following ER care for an uncomplicated MTBI (McAllister et al., 1999).

Assessment of Symptoms

Careful mental status and neurologic exams are indicated in all cases of

LOC. Questions regarding recent memory (e.g., Orientation: Do you

remember the injury? What was your last memory before the injury?) and

the ability to form new memories (e.g., memory for 3 words after 1 minute

delay) are sensitive to the effects of MTBI. The Sideline Assessment of

Concussion (McCrea, Kelly et al., 1997; also

http://www.aan.com/professionals/practice/pdfs/gl0013.pdf) is an example of

a sports-based, focused mental status exam, which may be performed on

site for individuals with MTBI.

Post-concussive symptoms should be recorded, either through a clinical

history, or by the use of a standardized instrument such as the Postconcussion Symptom Checklist (Gouvier, Cubic et al., 1992) or the

Kennedy-Johnson Post-concussion Scale (Cicerone & Kalmar, 1995).

Headache is the most commonly reported symptom reported in MTBI, with
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

22

dizziness also frequently reported. Immediate post-concussive symptoms

such as nausea, vomiting, and drowsiness are typically short-lived

(Rutherford, 1989; Bohnen & Twijnstra, 1992). Other possible symptoms

include decreased concentration, difficulty maintaining attention, fatigue,

dizziness, irritability, depression, and social withdrawal. 

In terms of acute management, the available evidence supports a treatment

option (weakest level of evidence) that patients having a negative clinical

examination and negative head CT who are greater than 6 hours post-injury

may be discharged to home. Patients with responsible and informed

caregivers at home may be discharged sooner (Jagoda et al., 2002).

Neuroimaging in MTBI

A head CT is the imaging study of choice in acute brain injury because unlike

a skull x-ray, CT will demonstrate acute bleeding, either within the brain

tissue, within the ventricles, or involving the dura, i.e., epidural or subdural

hematoma. Because of availability, cost, and sensitivity to acute bleeding, CT

offers advantages over the brain MRI scan. Cervical x-rays need be considered

in all patients receiving trauma to the neck during the MTBI, and a cervical

collar should be considered prior to the x-ray being read as normal. 

The risk of intracranial pathology identified by CT varies depending on the

initial or ER GCS score (13, 14, or 15). The incidence of intracranial lesions

increases from 4% with a GCS of 15, 16% with GCS 14, and 28% with GCS

13, demonstrating that not all mild traumatic brain injuries are alike

(Culotta, Sementilli et al., 1996). 

A recent Evidence Based Guideline (Jagoda et al., 2002) group concluded

that CT scanning was not indicated for patients who did not exhibit one or

more of the following symptoms: headache, emesis, age > 60 years, drug or

alcohol intoxication, short term memory problems, seizure, or visible

trauma above the clavicle. 

However, identifying intracranial pathology is important, even in nonsurgical situations, as patients with a MTBI who have a cerebral contusion

experience a 6-month outcome more similar to patients with moderate TBI

(Williams, Levin, & Eisenberg, 1990). With this information, patients may be

assisted in planning for a more gradual return to activity.

Only relatively large abnormalities may be detected by current clinical

imaging techniques. However, the relative absence of structural

abnormalities in MTBI does not indicate that cell loss and other damage

have not occurred. Functional changes could result from a smaller degree of

cell loss due to the widespread connectivity of neurons in the brain,

especially shortly after injury before compensatory measures can take effect.

Magnetic Resonance Imaging (MRI) has greater sensitivity to the smaller

lesions seen in MTBI and may be indicated at follow-up in patients who are

experiencing persistent symptoms in the absence of findings on CT

scanning (Jenkins, Teasdale et al., 1986; Levin, Amparo et al., 1987;
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

23

Eisenberg and Levin, 1989). New and evolving MRI technologies such as

Diffusion Tensor Imaging and Magnetization Transfer Imaging also tend to

be more sensitive to structural changes following MTBI (Smith, Meaney et

al., 1995; McGowan, Yang et al., 2000; Rugg-Gunn, Symms et al., 2001), but

are currently being used more for research than clinical purposes. 

Common Sequelae and Course of MTBI

Most individuals who suffer MTBI experience few post-injury problems and

make a rapid recovery (i.e., return to normal functioning within hours or

days of their injury) and have a complete recovery within three months

(Binder, Rohling, & Larrabee, 1997). However, a significant minority

continue to report distressing symptoms for months (Alves, Macciocchi, &

Barth, 1993; Dikman, McLean, & Temkin, 1986; Powell, Collin, & Sutton,

1996); or years post-injury (Alexander, 1992; Deb, Lyons, & Koutzoukis,

1999; Hartlage, Durant-Wilson, & Patch, 2001). The size of the minority who

become chronically symptomatic varies across studies from 7-8% (Binder,

1997), to 10-20% (Alexander, 1995) to approximately one third (Rimel et

al., 1981; Vanderploeg et al., 2001).

Both the acute and chronic symptoms involve a constellation of physical,

emotional, and cognitive complaints collectively known as post-concussion

syndrome (PCS). The symptom cluster includes complaints of poor

concentration, memory difficulty, intellectual impairment, irritability,

fatigue, headache, depression, anxiety, dizziness, blurred vision, light

sensitivity. and sound sensitivity (American Psychiatric Association, 1994;

World Health Organization, 1978). This symptom complex typically occurs

without demonstrable structural changes to the brain (Eisenberg & Levin,

1989) or neuropsychological dysfunction (Dikman et al., 1986; Levin, Mattis

et al., 1987). However, the etiology of persistent PCS symptoms (greater

than several months) remains controversial. Assuming medical

complications such as subdural or epidural hematomas do not develop, the

most commonly documented persistent PCS are noted in the Table 1 (next

page). Although many of these symptoms are common in normal

individuals (e.g., difficulty concentrating, irritability, anxiety, memory

complaints, headaches), the incidence of these symptoms increases

following MTBI. Most individuals who suffer a MTBI will demonstrate only

a few of these symptoms that typically resolve over time. Those patients

Points to Remember 

• A high degree of suspicion for MTBI is required in the individual who is 

being treated for other bodily injuries. 

• An epidural hematoma should be suspected following a sharp blow to the 

side of the head, in a patient who is alert initially, but later begins to 

develop decreased level of consciousness

• Although not always necessary, a head CT scan is preferable to an MRI scan

following a mild TBI because of its sensitivity to acute bleeding
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

24

who do not make a full and rapid recovery typically report more postconcussion symptoms. 

Table adapted from: Mittenberg, W., DiGiulio, D. V., Perrin, S., & Bass, A. E.

(1992). Symptoms following mild head injury: Expectation as aetiology.

Journal of Neurology, Neurosurgery, and Psychiatry, 55, 200-204. 

Table 2 (next page) lists the formal diagnostic criteria for DSM-IV postconcussion syndrome (PCS). 

It is useful to view the symptoms of MTBI as falling four periods across time,

as the brain responds in the moments, weeks, and months following injury,

and as adjustment and psychosocial factors come into play for those who

experience ongoing difficulties. 

Acute or Immediate Symptoms

The immediate symptoms following a MTBI are either any loss of

consciousness of less than 30 minutes or any period of post-injury

disorientation, confusion, or memory problems of less than 24 hours

Frequency of PCS Symptoms following MTBI and in the General Population

MTBI PCS Frequency in the PCS Increase 

Symptom Frequency General Population after MHI

Symptom Percent of Patients Percent of People Increase over 

baserate

Poor concentration 71% 14% 57%

Irritability 66% 16% 50%

Tired a lot more 64% 13% 51%

Depression 63% 20% 43%

Memory problems 59% 20% 39%

Headaches 59% 13% 46%

Anxiety 58% 24% 34%

Trouble thinking 57% 6% 51%

Dizziness 52% 7% 45%

Blurry or 45% 8% 37%

double vision

Sensitivity to 40% 14% 26%

bright light

Table 1
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

25

(Definition of mild traumatic brain injury, (1993). Journal of Head Trauma 

Rehabilitation, 8, 86-87). Post-injury headaches are also a common

symptom. If symptoms are more severe and ongoing, patients may be

admitted overnight for observation, often because of concerns about

intracranial bleeding, which are more likely in the elderly and those on

anticoagulant medication. 

DSM-IV Symptom Criteria for Determination of PCS

1. History of a head injury with concussion

2. Following the head injury evidence of attention or memory difficulties on formal testing

3. Following the head injury presence of three or more of the following symptoms:

a. Becoming fatigued easily

b. Disordered Sleep

c. Headache

d. Dizziness or vertigo

e. Irritability or aggression with little provocation

f. Anxiety, depression, or affective lability

g. Changes in personality (e.g., social or sexual inappropriateness)

h. Apathy or lack of spontaneity

4. The PCS problems cause a significant disturbance of social or 

occupational functioning

Table 2

Figure 1

Figure 1 is a schematic representation of the stages of recovery from closed head. 
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

26

• Retrograde amnesia refers to loss of memory of events prior to 

the accident 

• Loss of consciousness or coma are interchangeable terms and 

refer to a period when the patient is non-responsive. 

• Post-traumatic amnesia (PTA) refers to the duration of time when 

the patient is unable to store continuous information (i.e., not 

fully oriented to time, place, or person with very poor memory 

for ongoing activities). PTA technically extends from when 

consciousness was regained until continuous memory resumes, 

but without observer report, the distinction between brief LOC 

and PTA is difficult to determine. Therefore, PTA is often 

operationally defined as the length of time until continuous 

memory or correct orientation resumes. A patient who has no 

recall for one hour immediately following the accident would be 

unable to recall whether or not he/she had an LOC immediately 

following the accident. This can lead to confusion in the 

determination of an LOC. One patient may actually deny an LOC 

simply because he/she has no memory for an extended period of 

time following the accident. More commonly, a patient may claim 

that he/she has a loss of consciousness for the entire time during 

which he/she had a post-traumatic amnesia. Therefore, in MTBI 

cases it is very difficult to separate PTA from LOC. 

• Anterograde memory disturbance refers to a decline in memory 

function subsequent to the TBI. Objective evidence of residual 

memory problems several weeks after a mild TBI is very unusual 

(in fact, if they persist beyond 30 minutes the injury is no longer 

considered mild). Ongoing memory complaints reported by 

individuals who sustained a mild TBI usually cannot be verified 

on formal memory testing. However, a recent study by McAllister 

et al., (1999) found that despite similar memory performance 

between MTBI patients and controls, MTBI patient activated 

more cortical regions than controls on functional MRI suggesting 

that their brains were functioning less efficiently even 6 months 

post-injury. Persisting memory problems are more typical of 

moderate to severe TBI.

Initial Several Weeks 

During the week or two following MTBI, the vast majority of patients

recover fully without any noticeable symptoms. However, having some

symptoms at this juncture is common, and is thought to be related to the

neurochemical changes or neuronal degeneration that may occur following

diffuse axonal injury. During this period, individuals often have initial

cognitive symptoms of slowed information processing speed and difficulty

with attention. 

Other than initial and ongoing headaches, some patients don’t develop many

symptoms until days or even weeks after the accident, but they can develop

Figure 1 Legend
Concussion Management: Sequelae and Treatment of Mild TBI

Traumatic Brain Injury 27

sooner. Eight out of 10 patients with a mild head injury show at least some

symptoms outlined in Table 1 (page 24) during the first several weeks or

months after the accident. These symptoms are part of the normal recovery

process and are not signs of permanent brain damage or medical complications.

Again, the majority of patients with PCS recover completely in 3 to 6 months. 

One to Six Months

People who have suffered a previous head injury are thought to be at

greater risk for developing symptoms that last beyond two weeks. At this

point, for the minority of patients who continue to exhibit symptoms, the

diagnosis of MTBI changes to that of post-concussion syndrome (PCS). If

the symptoms continue beyond six months post-injury, the diagnosis

changes again to that of chronic or persistent post-concussion syndrome.

Many individuals who fit this label continue to suffer symptoms for years.

Interestingly, persistent PCS is more common after mild head injuries than

after more severe injuries.

Chronic: Years Post-Injury

Only one study to date (Vanderploeg et al., 2001) has examined long-term

morbidities in veterans with a MTBI who are not reporting to medical

clinics. Such studies are necessary to draw conclusions regarding natural

recovery and long-term outcome from MTBI. Four groups were examined,

those who: 

1. had not been injured in a motor vehicle accident nor had a head 

injury (n = 3214);

2. had a bodily injury in an accident but did not have a head 

injury (n = 539);

3. had sustained a head injury with no alteration of consciousness 

(n = 377); and

4. had a head injury with alteration of consciousness (n = 254). 

Analyses controlled for demographic, co-morbid medical, and pre-existing

mental health factors in examining outcomes. Over a median post-injury

interval of eight years, a MTBI with loss of consciousness doubled the

likelihood of a having a current post-concussion syndrome (prevalence of

30% with MTBI). Specific subjective post-concussion symptoms were

categorized into neurological/medical, cognitive, and psychological symptoms

(Table 3, next page).
28 Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

A two- to three-fold increase in subjective PCS neurologic symptoms and

memory complaints were associated with a MTBI with loss of consciousness.

In contrast, PCS psychological symptoms and concentration complaints did

not differ across the four groups once the effects of early life psychiatric

problems and co-morbid medical conditions were controlled. Although this

symptom pattern supports a neurologic etiology for these long-term adverse

outcomes, no differences were found among groups on formal

neuropsychological evaluation in any area. Thus, although subjective

complaints are present, formal diagnostic procedures typically are negative. 

In addition to the neurological PCS symptoms, a MTBI with loss of

consciousness resulted in:

• A higher frequency of employment problems (Odds Ratio = 1.88)

• Low income (Odds Ratio = 1.91)

• Having an ongoing disability (Odds Ratio = 2.88)

• Being unmarried (Odds Ratio = 2.07)

• Having less than satisfactory social supports (Odds Ratio = 1.58) 

Neurological or Medical Cognitive Psychological

Headaches Memory Complaints Irritability

Dizziness/Vertigo Concentration Complaints Increased Aggression

Tinnitus Depression

Blurred or double vision Anxiety

Light and/or noise sensitivity

Nausea or Vomiting

Fatigue

Sleep Disturbance 

Physical Weakness 

Specific Subjective Post-Concussion Symptoms

Table 3
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Concussion Management: Sequelae and Treatment of Mild TBI

29

Post-Acute Management of MTBI

Overview

Treatment for MTBI includes education, a period of rest and observation,

and treatment of persistent or disabling symptoms (e.g., headache). A

combination of “validating” the patient’s symptoms, i.e., that postconcussive symptoms derive from the physical injury, with expectancy of

resolution of these symptoms over time, are mainstays to management of

MTBI (Salazar & Warden, 1999). 

The data from sports concussion studies demonstrating that impaired

performance follows concussion and possibly increased risk for second

injuries supports the indication for a period of rest (Macciocchi, Barth 

et al., 1996; Warden, Bleiberg et al., 2001). Additionally, when an individual

experiences two MTBIs within a brief period of time, s/he is at risk for

second impact syndrome, a rare but often deadly condition involving

cerebral edema and bleeding. Determining the necessary period of rest is

currently an area of active research. 

As described above, in general, post-acute management of MTBI consists of

closely evaluating individuals for signs of evolving injury or resolution of

symptoms following the injury (e.g., headache, dizziness, vomiting). If

further medical or surgical care is not indicated, individuals will be

observed for a period of time and sent home, with educational materials, a

period of rest and observation, and treatment of significant symptoms.

Depending on the speed of recovery, recommendations regarding return to

partial or full work are tailored to the individual. 

Pharmacological Interventions for Post-concussion Symptoms

Pharmacologic and non-pharmacologic interventions are often used to treat

specific symptoms following MTBI, especially when those symptoms, e.g.,

headache and sleep disorder, are disabling, or not improving. Post-traumatic

headache may be treated with NSAIDs, Midrin, and tryptans. Individuals

with headache and emotional dysregulation may benefit from valproate

Points to Remember 

• Most individuals with MTBI (approximately 70-80%) experience few postinjury problems and make a rapid recovery 

• In a minority, post-concussion syndrome symptoms may not appear on 

initial examination, but turn up in one to three weeks following injury 

• In MTBI, post-concussion syndrome typically occurs without demonstrable 

structural changes to the brain or measurable neuropsychological 

dysfunction

• There are significant long-term residual neurological symptoms in a small 

proportion of individuals who sustained a MTBI (about 10-30%), with 

consequent psychosocial work and relationship problems
acid. Selective Serotonin Reuptake Inhibitors (SSRIs; e.g., sertraline,

paroxetine, etc.) may improve depression and irritability following brain

injury (Fann, Uomoto, & Katon, 2001). A post-hoc analysis in a study of

sertraline for depression after TBI revealed that sertraline decreased many

post-concussion symptoms in the sample of depressed patients (Fann,

Uomoto, & Katon, 2001). Although most studies target a specific symptom,

Piracetam was effective for the spectrum of PCS in a small randomized

controlled trial (Hakkarainen & Hakamies, 1978). 

Non-Pharmacological Interventions

A crucial and often omitted component of MTBI management is the

provision of education to individuals with TBI regarding fatigue, irritability,

and mood lability that may occur during MTBI recovery. Many patients

become distressed after a concussion because they don’t realize that the

symptoms that they are experiencing are related to the MTBI. Individuals

may think they are “going crazy” due to mood lability, mental slowness, and

memory lapses that they did not realize were part of the recovery process

from their head injury. 

A standardized post-concussion program was developed by Mittenberg

(1996) based on the observation that PCS symptoms may be maintained at

least in part by psychological mechanisms (Levin et al., 1987; Luis,

Vanderploeg et al., 2003; Rutherford, 1989).

• Patients received a 10-page manual, Recovering From Head 

Injury: A Guide for Patients (Mittenberg, Zielinski, & Fichera, 

1993). The manual is intended to support the reattribution of 

symptoms to selective attention, normal transient responses to 

stress, and anxiety arousing or depressive self-statements. An 

adaptation of this manual is available in Appendix A to this section. 

• Met with a therapist who reviewed the nature and incidence of 

expected symptoms, and the cognitive-behavioral model of 

symptom maintenance and treatment (Mittenberg, DiGiulio, 

Perrin, & Bass, 1992). Base rate data for the symptoms was 

provided: 

° techniques for reducing symptoms, instructions for stopping 

bothersome thoughts, replacement of negatively biased 

thoughts, and the scheduling of reinforcing activities

° instructions for gradual resumption of premorbid activities

° interventions such as relaxation techniques, consistent diurnal 

routine, and moderation in exercise, also may be helpful. 

Following several weeks of treatment, the treatment group experienced

significantly lower symptom duration, significantly fewer symptoms and

significantly lower average symptom severity levels at 6 months follow up.

Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

30
Factors Complicating Assessment

Misdiagnosis or Missed Diagnosis

In MTBI, evidence of minor cerebral injury is typically absent from the

standard neurological examination, CT scans, and standard EEGs. But . . .

absence of evidence is not proof of absence.

On the other hand, the presence of post-MTBI neurological symptoms also

is not clear evidence of brain trauma. Post-MTBI neurologic symptoms can

include headaches, vertigo, and dizziness, but patients with whiplash neck

injuries or vestibular injuries can have similar symptoms, without any brain

dysfunction. Although many of the neurological symptoms following TBI

can be associated with structural brain injury, the association does not

prove causation. 

The same holds true for psychological symptoms such as anxiety, depression,

lability, irritability, and aggression, which can be directly related to TBI.

However, these are common complaints in healthy individuals, and increase

under stressful situations. Also, other medical patients have an increase in

anxiety or depression. Thus, whether the symptoms following a MTBI are

caused by the injury, a consequence of adjustment to the accident, secondary

to dealing with the medical-legal environment following many minor head,

or related to a combination of these factors injuries remains unresolved. 

In most first-time MTBIs, the immediate symptoms will often resolve within

three months. However, a subset of individuals (15-30%) experience

continued post-traumatic symptoms. When these are undiagnosed,

misdiagnosed, or ignored, appropriate treatment, support, and education is

not provided. Individuals with repeated MTBI also have an increased

potential for persistent symptoms. Without appropriate interventions, these

individuals are more likely to experience:

• Functional difficulties when trying to return to previous 

living patterns 

• Depression and anxiety, which has an impact on the person’s 

capacity to function 

• A tendency to isolate and significantly limit themselves to the 

comfort of familiar surroundings and routines 

Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

31

Points to Remember 

• Pharmacologic interventions can be used to treat specific symptoms 

following MTBI such as headaches, depression, irritability, or 

emotional dysregulation

• Psychoeducational intervention, combined with support and cognitivebehavioral interventions can significantly reduce the extent of 

post-concussive symptoms
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

32

• Activity avoidance

• Estrangement from his/her spouse, children, family, and 

friends — tempers flair, fears build, and the family structure may 

gradually deteriorate 

• An increased frequency of anger at “the system.” This includes 

physicians and insurance personnel who are not knowledgeable 

and, therefore, are not providing education or guidance as to 

appropriate assessment and beneficial treatment 

• Suicidal ideations and attempts 

• Problems with the law 

• A tendency for re-injury 

Self-expectations and Iatrogenic factors

Some brain injury researchers suggest that many of the symptoms following

MTBI are the result of psychological mechanisms such as expectations

following a MHI (Mittenberg, DiGiulio, Perrin, & Bass, 1992), poor coping

styles (Bohnen et al., 1992; Marsh & Smith, 1995), or emotional reactions to

an adverse event. For example, Mittenberg and colleagues (1992) found that

implicit beliefs regarding a set of symptoms anticipated following a head

injury account for attribution of the normal occurrence of these symptoms

to the MTBI. In contrast, athletes’ implicit beliefs regarding symptoms

differed such that they under-estimated the normal base rate occurrence of

PCS symptoms and attributed any PCS symptoms they experienced

following sports-related concussions to a normally occurring incidence.

This research suggests that the information provided by medical personnel

to individuals who experienced a MTBI can either amplify and increase their

symptomology and distress (iatrogenic factors), or can minimize and

normalize their symptoms. Mittenberg and colleagues demonstrated

minimization of symptoms through in a series of intervention studies.

Individuals who sustained a MTBI who were provided with basic

psychoeducational information about MTBI symptoms and their typical

course of resolution, together with psychological support and stress

management interventions, had a significant decrease in their symptoms and

complaints compared to those without such interventions. At the same time,

attribution and iatrogenic factors can’t be the entire story, because some

individuals who receive early psychoeducational interventions continue to

experience symptoms. 

Psychological factors

Individuals with poor psychological coping or increased psychological

distress have a higher rate of prolonged post-concussion symptoms

compared to those with uncomplicated recoveries (Karzmark, Hall, &

Englander, 1995). Other research suggests that persistent PCS reflects, in

part, anxiety regarding the experience of an adverse event seen as lifethreatening (i.e., post-traumatic stress response; DiGallo, Barton, & ParryJones, 1997; Bryant & Harvey, 1999). 
Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

33

Differential Diagnosis 

In those individuals reporting long-term PCS symptoms following MTBI,

their clinical presentation may be very similar to related disorders, including

post-traumatic stress disorder, major depression, disability seeking behavior,

or malingering. For instance, individuals may report sleep difficulties,

memory problems, irritability, and anxiety that fit any of these diagnoses. 

Mittenberg and Strauman (2000) suggest the following considerations in

differential diagnosis: 

• Post-concussion Syndrome versus Post-Traumatic 

Stress Disorder. PCS is not associated with persistent reexperiencing of the accident or numbing of general 

responsiveness, whereas PTSD is. In contrast, PTSD is not 

characterized by headaches, dizziness, generalized memory 

problems, or subjective intellectual impairment, while PCS is.

• Post-concussion Syndrome versus Major Depression. PCS is 

not associated with changes in appetite or weight, psychomotor 

agitation or retardation, suicidal ideation, or a history of 

depressive disorder.

• Post-concussion Syndrome versus Disability Seeking or Overt

Malingering. While a malingerer may convincingly report many 

symptoms of PCS, level and pattern of performance on formal 

neuropsychological testing can be used to differentiate between 

the two presentations, at least in cases where the medical record 

clearly indicates that the head injury was mild. However, it is 

certainly possible that individuals with legitimate post-injury 

symptoms may also amplify or exaggerate their problems. These 

cases are the most difficult to tease apart contributing etiologies, 

although a careful history, collateral interviews, and formal 

neuropsychological assessment are often useful. 

Appropriate referrals of patients with MTBI

Although a thorough physical examination and history are the initial

elements of a post-concussion clinical workup, a variety of other tools are

available to clarify examination findings. Individuals who continue to

describe difficulties with concentration, attention, and memory may be

referred for more comprehensive evaluation including cognitive assessment

by neuropsychological testing. Magnetic Resonance Imaging (MRI) may be

indicated at follow-up in patients who are experiencing persistent

Points to Remember 

• Correct diagnosis of posconcussion syndrome is complicated 

by its overlapping symptom pattern with other conditions

• Referral to a neuropsychologist for careful evaluation may be 

helpful in difficult diagnostic cases
symptoms in the absence of findings on CT scanning (Jenkins, Teasdale et

al., 1986; Levin, Amparo et al., 1987; Eisenberg & Levin 1989). Clinicallydirected appropriate referrals for additional assessment may include

consults to the following disciplines: 

Audiologist Case Manager

Kinesiotherapist Neurologist

Neuro-ophthalmologist Neuropsychologist (psychologist)

Occupational therapist Physiatrist

Physical therapist Psychiatrist

Recreation Therapist Social Worker (counselor)

Speech and Language Pathologist Vocational Rehabilitation Counselor

A more detailed description about each of these disciplines is provided

in Section 2 Appendix B.

Traumatic Brain Injury

Concussion Management: Sequelae and Treatment of Mild TBI

34
Section 2: Appendiz A

Recovering from Head Injury:

A Guide for Patients

Recovering from Head Injury:

A Guide for Patients

Traumatic Brain Injury 35

What Happens in a Head Injury?

A blow to the head can occur in a motor vehicle accident, a fall, when the

skull is struck by a blunt or heavy object, or in other ways. In most cases,

there are no lasting symptoms or ill effects from an injury to the head. This

is because the brain is surrounded by shock absorbing liquid and covered

by the skull. Often these are enough to protect the brain from any damage.

Sometimes the force of impact is more severe. This can cause the skull to

break or fracture. When the skull fractures, this absorbs some of the force of

the blow and protects the brain. This is the same way that a crash helmet

works. 

When the head is hit, the brain may be shaken around inside the skull. This

can sometimes cause the brain to be bruised if it hits the inside of the skull

hard enough. Like a black and blue mark on your arm or leg, this will

recover with time. If there are many bruises on the brain, there will be

some swelling that can take a while longer to return to normal.

The brain is made of many thousands of long, thin nerve fibers. Some of

these nerves can snap or break if a blow to the head is severe enough.

Although these nerves cannot be seen without a microscope, we know that

they can recover because many patients recover completely in time.

Like any other part of the body, the brain has blood vessels in it. If a head

injury is very serious, some of these blood vessels can tear and bleed. This

happens soon after the injury. The bleeding often stops on its own and the

blood vessels heal like any cut.

Bruises, swelling, snapped nerves and broken blood vessels are the causes

of symptoms after a head injury. Your doctors have examined you for any

signs of injury to the brain and prescribed treatment if you need it. Most

people who suffer a head injury recover completely in time because the

damage is minor and heals. 

Section 2

Appendix A
Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

36

How Serious Was the Head Injury?

One way to tell if a head injury is serious is the amount of time the patient

is unconscious afterwards. If you weren’t knocked out at all or if you were

unconscious for less than an hour, then the injury was most likely minor or

mild. Although you may have some symptoms, there was probably little

injury to the brain and complete recovery is expected. Most people who

have a head injury fall into this category.

The longer you were unconscious, the longer recovery usually takes. If you

were knocked out for more than an hour but less than a day, your injuries

were most likely moderate. Return to normal will probably take a while. 

Patients who are unconscious for more than a day, have suffered a severe

injury. Although many patients make a good recovery even after a severe

head trauma, symptoms can often last for some time. Treatment at a

rehabilitation hospital is usually recommended and can help recovery.

How Long Will the Symptoms Last?

You have probably gotten a lot better over the last few days. The most rapid

recovery occurs in the first 6 months after head injury, and most patients

will be back to normal by 3 months.

If you still have some symptoms after 6 months, these will most likely

disappear altogether or be greatly improved within a year after the injury. If

you suffered a severe injury, recovery can take as much as two years. During

the second year, improvements will be more gradual.

Not everyone recovers at the same rate. People who are under 40 recover

faster and have fewer symptoms during the time they are recovering. If you

are over 40, you won’t get better as quickly and you may have more

symptoms at first. Patients who are older or who have been hospitalized for

head injuries before should expect full recovery to take 6 to 12 months even

after a mild head injury.

Most doctors who treat head injuries agree that recovery is faster when the

patient gets enough rest during the weeks after they leave the hospital.

Work, exercise, social activities, and family responsibilities should be started

gradually, not all at once.

What Symptoms Can I Expect?

The most common symptoms after a head injury are known as the postconcussion syndrome. Eight out of 10 patients with a mild head injury show

signs of the syndrome during the first 3 months after the accident. These

symptoms are part of the normal recovery process and are not signs of brain

damage or medical complications. Like the itch of healing stitches, these

symptoms are expected as you get better. They are not a cause for concern

or worry.
Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

37

Post-concussion syndrome is more common after mild head injury. The

symptoms are less likely to trouble a patient with severe head injury. If you

have these symptoms, this is a sign that your injuries were probably mild or

minor. The majority of patients with post-concussion syndrome recover

completely in 3 to 6 months. If you are older than 40, it may take a bit

longer to return too normal.

Most patients don’t develop the symptoms until days or even weeks after

the accident, but the syndrome can begin sooner. Either way, the symptoms

often disappear without any special treatment.

A list of the symptoms that you can expect is shown in Table 1, along with

the percent of head injured patients who experience each symptom at some

point in their recovery.

What Can I Do About the Symptoms?

Post-concussion syndrome is a normal part of recovery. Most patients will

be back to normal by 3 months without any special treatment. The

symptoms are not a sign of relapse or brain damage. The syndrome is

expected even after minor head injury. Few patients will experience all of

the symptoms, but even one or two of the symptoms can be unpleasant.

Some patients find that at first, post-concussion syndrome makes it hard to

work, get along at home, or relax. The best way to deal with this is to

resume activities and responsibilities gradually, a little at a time. The time

Symptoms of Post-concussion Syndrome

Symptom Percent of Patients

Poor concentration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71%

Irritability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66%

Tired a lot more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64%

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63%

Memory problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59%

Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59%

Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58%

Trouble thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57%

Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52%

Blurry or double vision . . . . . . . . . . . . . . . . . . . . . . . . . . . .45%

Sensitivity to bright light . . . . . . . . . . . . . . . . . . . . . . . . . . .40%

Table 1
Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

38

you spend at work, getting together socially, with your family, or exercising

is determined by what you are comfortable with. You should pace yourself,

and be sure to get all the rest you need. If your symptoms get worse, or if

you notice new post-concussion symptoms, this is a sign that you are

pushing yourself too hard.

Ignoring your symptoms and trying to “tough it out” often make the

symptoms worse. Symptoms are your body’s way of giving you information.

A broken bone or a torn muscle hurts so that you won’t use it and it has

time to heal. Post-concussion syndrome is your brain’s way of telling you

that you need to rest it. Most doctors who treat head injuries agree that

recovery is faster when the patient gets enough rest and resumes

responsibilities gradually.

Thinking and worrying about your symptoms can make them seem worse.

This is partly because paying attention to a feeling seems to magnify or

increase it. If you pay attention to your heartbeat or breathing for a minute

or two, you will see that the sensations seem to become more noticeable.

Concentrating on the symptoms of post-concussion syndrome will also

make them more noticeable.

It is important to remember that the symptoms are a normal part of

recovery and will go away on their own. Of course, we all have some of

these symptoms once in a while anyway. After a head injury it can be easy to

forget that we were sometimes irritable, tired, had headaches, couldn’t

concentrate, or forgot things even before the accident. Try to deal with these

things the same way you did before.

Some of the symptoms you notice may actually have nothing to do with

your head injury. The symptoms of post-concussion syndrome are pretty

much the same as the symptoms of ordinary day-to-day stress. A list of the

symptoms is shown in Table 2 (next page), along with the percent of people

who experience each symptom even though they didn’t have a head injury.

The reason that the symptoms of post-concussion syndrome are so much

like the normal signs of daily stress is that one main cause of these

symptoms is exactly the same: everyday stress. Of course hitting your head

also has a lot to do with it. But having a head injury adds more stress to

your life, not just bumps and bruises to your head.

The accident itself, being in the hospital, and going back to work or school

are all things that add stress to most patients’ lives. Bills can pile up, time is

lost, and there may be injuries to other parts of your body. And just like a

pulled muscle or a bruised leg, your brain takes some time to recover. You

can have some trouble with work or school at first, and this is stressful also

even though it is normal. Trying to do your regular work right after a head

injury is something like trying to play baseball or swim with a pulled muscle.

You can’t see it, it isn’t really serious, but it takes some time to get better.
Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

39

Another main cause of stress after a head injury is worry about your symptoms.

Scientific studies by neurosurgeons and neuropsychologists in New Zealand

show that patients who get an information booklet like this one recover faster

and feel better during recovery than patients who don’t know what to expect.

That’s why we gave you this booklet! Doctors in the U.S. who treat head

injuries agree that the single most important factor in recovery is that you

know what to expect and what to do about the symptoms.

Of course, talking to a doctor about your symptoms is also important. Your

doctor can prescribe medication that can help you if you need it, or you can

talk to the person who gave you this booklet.

More about the Specific Symptoms

Poor Concentration 

The main cause of poor concentration is tiredness. When it becomes

difficult to concentrate on what you are doing, take a break and relax.

Between 15 to 30 minutes should be enough. If you still continue to have

problems, your workday, class schedule, or daily routine should be

temporarily shortened. Trying to “stick to it” won’t help, and usually makes

things worse.

Symptoms of Everyday Stress

Symptom Percent of Patients

Poor concentration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14%

Irritability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16%

Tired a lot more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13%

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20%

Memory problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20%

Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13%

Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24%

Trouble thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6%

Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7%

Blurry or double vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8%

Sensitivity to bright light . . . . . . . . . . . . . . . . . . . . . . . . . . .14%

Table 2
Reducing distractions can help. Turn down the radio or try to work where

it’s quiet. Don’t try to do too many things at once. Writing while you talk on

the phone or taking notes as you listen to someone talk are examples of

doing two things at the same time. It may be difficult to concentrate on

more than one thing at first. You will be able to concentrate better when

you have had enough rest.

Irritability

One of the most frequent causes of irritability is fatigue. People lose their

tempers more easily when they are tired or over worked. Adjust your

schedule and get more rest if you notice yourself becoming irritable.

Everyone gets angry from time to time, often with good reason. Being

irritable only becomes a problem when it interferes with your ability to get

along with people from day to day. If you find yourself getting into

arguments that cause trouble at home or at work, try to change the way you

think about things. Thoughts often make us angrier than what actually

happened. You can see this for yourself by imagining an irritating situation

and why it would make you angry.

There is usually a reason why irritating things happen. When something

makes you angry, ask yourself what caused it. Family, friends, or co-workers

can do things that bother us at times. Try to think of why they did whatever

it was that irritated you. What would they say the reason was? Thinking

about what caused a problem is the first step to solving it.

Problems can usually be solved better if you stay calm and explain your

point of view. The steps you need to take to solve a problem will be the

same when you are calm as they would be if you were irritated. Try to

remind yourself of this when you find yourself becoming irritable.

You can usually come up with several ways to solve a problem. Try to think

of at least 5 different ways, and then decide on which is best. Just realizing

that there are several things you can do to solve a problem will make it a lot

less irritating.

Fatigue 

It is normal to be more tired after a head injury. The only sensible treatment

for being tired is rest. Avoid wearing yourself out. Gradually increase your

activity level. Most patients have more energy in the morning than later in

the day. You may benefit from scheduled test breaks or daytime naps. If your

symptoms get worse, this means that you are pushing yourself too hard.

Depression

People become depressed when unpleasant things happen to them, and a

head injury is unpleasant. We feel good when good things happen to us. An

effective way to treat depression is to make sure that good things happen.

One way to do this is to plan to do something enjoyable for yourself every

day. Make your plan specific, and then be sure to stick to it. Decide on

something you like and exactly when you’re going to do it. That way you

Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

40
can look forward to it. Anticipating and doing enjoyable things each day will

improve your mood.

Thoughts can make us depressed. Thinking that things are bad or terrible

will do it. Bad situations are often not as terrible as they may seem at first.

Think back to an unpleasant moment in your own life and you will see that

this is so.

Chances are that if you are depressed, you are telling yourself things that

are depressing. Thinking that the situation is terrible, that there is no end to

it in sight, that you aren’t able to do anything about it, and that it is your

fault are all depressing things to tell yourself. Thinking this way can become

a habit if you do it enough.

Usually, when people tell themselves unpleasant things all the time it is out

of habit, not because those things are really true. If you find yourself

thinking depressing thoughts, stop. Simply stopping a depressing thought

can make you feel better. See if what you are telling yourself is really true.

Memory Problems 

Memory difficulties have several causes. The part of our brain that stores

memories is called the temporal lobe. This is the part of the brain that is

most likely to be bruised in a head injury. Some memory difficulties can be

caused by the bruises, which is why you may not remember the accident

very well. Like a black and blue mark on your arm or leg, these bruises will

recover with time. Your memory will most likely improve as this happens.

If you can remember the accident, chances are that your brain was not

bruised. Most of the memory problems patients notice after a head injury

are not caused by bruising. They usually come from poor concentration and

being tired. 

For you to remember something, you have to pay attention to it first. If you

don’t concentrate long enough the information is never stored in your

memory. Concentration problems are a normal part of recovering from a

head injury and some memory trouble is a normal side effect of this.

You will probably be able to concentrate and remember better, when you

get enough rest. Memory problems can be a sign that you are pushing

yourself too hard. Writing things down or using a pocket tape recorder are

other excellent ways of coping with temporary memory difficulties. They

will help recovery and not slow it down.

Of course, nobody’s memory is perfect anyway. After a head injury, it can be

easy to forget that we sometimes had trouble remembering things even

before the accident. Some of the symptoms you notice may actually have

nothing to do with your head injury. A list of common memory “problems”

is shown in Table 3 (next page), along with the percent of people who

experience each “symptom” even though they didn’t have a head injury.

Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

41
Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

42

Worrying about remembering things that you would normally forget can

make your memory seem worse to you. If you can remember your memory

problems, you probably don’t have much of a memory problem! People

with serious memory difficulties are usually not upset by their symptoms.

They don’t remember that they have any memory trouble.

If you are concerned about your memory, have it tested. Your doctor can send

you for these tests if you need them, or you can also ask the person who

gave you this booklet.

Headaches

Headaches are part of the normal recovery process, but that doesn’t make

them any less bothersome. Headaches are another cause of irritability and

concentration problems after a head injury. This guide cannot replace the

medical advice that you should get if you are bothered by headaches.

Headaches can have many causes, and your doctor will want to diagnose the

problem and prescribe medication that can help if you need it.

One of the most common causes of headaches after a head injury is stress or

tension. This is usually the cause when the headaches start for the first time

several weeks after the injury. These headaches mean that you are trying to

do too much. They will probably disappear if you take a break and relax.

Your workday, class schedule, or daily routine should be temporarily

shortened if you continue to have headaches.

Things We Normally Forget

Symptom Percent of Patients

Forgets telephone numbers . . . . . . . . . . . . . . . . . . . . . . . . .58%

Forgets people’s names . . . . . . . . . . . . . . . . . . . . . . . . . . . .48%

Forgets where car was parked . . . . . . . . . . . . . . . . . . . . . . .32%

Loses car keys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31%

Forgets groceries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28%

Forgets why they entered a room . . . . . . . . . . . . . . . . . . . .27%

Forgets directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24%

Forgets appointment dates . . . . . . . . . . . . . . . . . . . . . . . . .20%

Forgets store locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20%

Loses items around the house . . . . . . . . . . . . . . . . . . . . . . .17%

Loses wallet or pocketbook . . . . . . . . . . . . . . . . . . . . . . . . .17%

Forgets content of daily conversations . . . . . . . . . . . . . . . . .17%

Table 3
Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

43

Stress or worry cause tension headaches by increasing muscle tension in

your neck or forehead. These muscles become tense and can stay tight

without you realizing it, out of habit. They can become even tighter once a

headache starts, because muscles automatically tense in reaction to pain.

This muscle tension makes the headaches worse.

Anxiety 

Worry about symptoms and problems at work are the main cause of anxiety

for most patients. Anxiety should not be a problem for you if you

understand that your symptoms are a normal part of recovery, get enough

rest, and gradually increase your responsibilities at work.

If you are anxious, chances are that you are telling yourself things that are

making you that way. Usually, when people worry all the time it is out of

habit, not because the things that they are telling themselves are really true.

The steps you need to take to solve a problem will be the same when you

are calm as they would be if you were anxious. If you find yourself thinking

anxious thoughts, stop. Simply stopping an anxious thought can make you

feel better. See if what you are telling yourself is really true.

Trouble Thinking

This problem is usually a side effect of other symptoms. Concentration

problems, being tired, headaches, and anxiety can all make it hard to think

clearly. Like these other symptoms, trouble thinking is probably a sign that

you are doing too much too soon.

Dizziness, Visual Difficulties, and Light Sensitivity

Dizziness and visual difficulties should be checked by your doctor. These

symptoms usually go away by themselves in 3 to 6 months or less in most

patients. If you find these symptoms troublesome, your doctor may want to

prescribe medication for motion sickness or eyeglasses. Some motion

sickness medications are very effective for dizziness, but can make you

drowsy or reduce your attention span as side effects.

You may notice some increased sensitivity to bright light or loud noise,

particularly if you have headaches. Some increased sensitivity is normal after

a head injury. But scientific studies by neurosurgeons and

neuropsychologists in New Zealand show that someone’s actual sensitivity

to light and noise has nothing to do with how much light and noise bother

them. Paying attention to these symptoms makes them seem worse, because

paying attention to a feeling seems to magnify or increase it. The less you

think and worry about your symptoms, the faster they will usually go away.
Summary

The most common symptoms after a head injury are known as the postconcussion syndrome. These symptoms are part of the normal recovery

process and are not signs of brain damage or medical complications. They

are not a cause for concern or worry.

Post-concussion syndrome is more common after mild head injury. Few

patients will experience all of the symptoms. The symptoms may not

develop until days or even weeks after the accident. Most patients will be

back to normal in 3 months without any special treatment.

Most doctors who treat head injuries agree that recovery is faster when the

patient gets enough rest and resumes responsibilities gradually. If your

symptoms get worse, or if you notice new post-concussion symptoms, this is

probably a sign that you are under too much stress. Your workday, class

schedule, or daily routine should be determined by your own comfort level.

About This Guide

This guide was created by The Defense and Veterans Brain Injury Center at

Wilford Hall Medical Center, Lackland AFB, Texas. The information

presented here is based on published scientific research and clinical studies. 

Mittenberg, Zielinski, & Fichera, (1993). Psychotherapy in Private Practice,

12, 37-52.

Traumatic Brain Injury

Recovering from Head Injury: A Guide for Patients 2-A

44
Clinically-Directed 

Referral Descriptions

Traumatic Brain Injury 45

Audiologist evaluates hearing deficits and defines the type of hearing loss.

Hearing changes after MTBI may include tinnitus or loss of acuity especially

in noisy environments. Hearing aides may or may not be prescribed,

depending upon the nature and severity of the problem. 

Case Manager provides effective coordination of patient care and

appropriate utilization of resources. Whenever possible, one may consider

bringing in a case manager who specializes in brain injury, to assist in

coordinating medical care and keeping open lines of communication

between the various specialists and the patient and family. The case

manager is an advocate for, and an active participant in, the treatment

process.

Kinesiotherapist can recommend a cardiovascular conditioning program

that promotes wellness and reduces the risk of injury or further disability.

Fitness can have a positive impact upon the person’s mental and physical

stamina, reduce pain, and elevate his/her feeling of well-being. The physical

conditioning program should be initiated in the health care facility and

gradually transferred to a community gym as the person becomes more

independent.

Neurologist assesses and treats neurological sequelae, with emphasis on

physical, such as movement disorders, seizures, and pain, as well as

neurobehavioral sequelae, such as mood problems and memory complaints.

The initial primary goal of the neurological evaluation is to rule out the

presence of conditions requiring neurosurgical attention (hematomas, skull

fractures, elevated intracranial pressure, etc.) and to consider differential

diagnosis of MTBI and other neurogenic disorders with similar symptoms. 

Neuro-ophthalmologist may address double vision, blurry vision, and/or

other visual deficits following brain injury. Deficits in the visual system are

often overlooked in the MTBI patient. A common visual deficit found after

MTBI is convergence insufficiency, which is often described by the person

as “blurry” vision. The neuro-ophthalmology evaluation should rule out

potential eye damage involving the cornea, retina, vitreous fluids, as well as

occipital lobe (visual cortex) and optic nerve functioning. Therapeutic

intervention may involve prism glasses and/or eye exercises.

Neuropsychologist (psychologist) is the key player in diagnosing

cognitive impairments and may also address emotional and behavioral

Clinically-Directed 

Referral Descriptions

Section 2

Appendix B
sequelae. The neuropsychological assessment evaluates the areas of

intellectual functioning: attention and concentration; problem solving and

judgment; memory and learning; flexibility of thought and speed of

information processing. Evaluations of disorders in these areas are provided

to help patients and families understand the nature and severity of deficits

and to assist other team members when planning patient treatment

programs. Treatment services provided by neuropsychologist (psychologist)

are designed to help patients achieve maximum benefit from the

rehabilitation program and to help them manage adjustment related

problems. Counseling may be offered to patients and family members who

wish to know more about brain injury and who may be having difficulty

coping with family and/or work related stress.

Occupational therapist is the function expert who works with the braininjured person to improve everyday function in daily routines. A thorough

occupational therapy evaluation can provide a window into the ways that

concussion impacts an individual’s daily life. The occupational therapist will

assess the patient’s skills, which include visual, cognitive, and perceptual

abilities to perform tasks in complex and multi-stimuli environments.

Treatment goal is to enable patients to best manage their daily tasks, including

self-care (feeding and dressing) and managing tasks in the community

(shopping, driving, school and work activities). To be able to do these tasks,

patients may need to use special techniques, modify their physical

environment, or use equipment ranging from simple memory aids to more

advanced technology such as computers and environmental controls. 

Physiatrist is the rehabilitation specialist who treats physical, cognitive, and

behavioral sequelae and provides leadership for the rehabilitation therapies.

The physiatrist coordinates treatment to maximize the level of function and

is responsible for medical evaluations and plans of care most suitable for the

individual and his/her family. Physiatrists are actively involved with

rehabilitation therapists in planning the patient’s rehabilitation program,

including team meetings and family conferences.

Physical therapist provides assessment and treatment for balance disorders,

dizziness, functional mobility, physical problems, and pain. Physical

therapists can evaluate and address peripheral nerve and musculoskeletal

injuries related to brain trauma, along with balance issues that may be

centrally caused. Treatment goals include improving mobility, increasing

strength, decreasing joint stiffness, improving static and dynamic balance,

decreasing vertigo and dizziness, and managing pain and discomfort. The

physical therapist also evaluates a patient’s needs for equipment, such as,

canes or braces to improve safety and endurance of ambulation.

Psychiatrist can prescribe pharmacological and behavioral interventions for

the treatment of psychiatric disturbances occurring as a result of brain

injury. The range of psychiatric disturbances which may follow brain injury

is extensive and embraces most of what can be found in psychiatric

symptomatology. Premorbid personality, pre-existing psychiatric disturbance

and genetic predisposition also play a part in psychiatric complications after

Traumatic Brain Injury

Clinically-Directed Referral Descriptions 2-B

46
brain injury, but the contribution of the physical and neurochemical

disruption to the brain should not be underestimated. 

Recreation Therapist assists persons with brain injury to resume

community life by helping them participate in play and leisure activities,

which enrich life. Through leisure counseling, leisure education, leisure

skills development, aquatic education, adaptive sports, resocialization

programs and community readjustment outings, the person with brain

injury learns how to participate in community life.

Social Worker (counselor) helps patients and their families respond to

social, emotional, or financial problems resulting from physical disability or

chronic illness. Treatment modalities include individual and group

psychotherapy, crisis intervention, family counseling and family support

groups. The social worker explores community resources and entitlement

programs that are available to the patient and family.

Speech and Language Pathologist will evaluate and treat communication

and cognitive deficits that may impact a person’s everyday functioning.

Speech pathologists assist patients who have speech, language, and

cognitive problems to gain optimal communication skills. Communication

problems may include difficulty understanding complex and abstract

written or verbal information, difficulty finding words and expressing

coherent ideas, and problems with the use of language in interpersonal

relations. Cognitive problems, such as difficulty paying attention, learning

and remembering information, organizing ideas, reasoning, and solving

problems also interfere with communication skills. Academic skills may also

be assessed to rule out potential deficits that may have an impact upon the

person’s return to community interaction, work, and school. 

Vocational Rehabilitation Counselor may act as a treatment coordinator

for patients who are having difficulty returning to work after a brain injury.

This specialist may be asked to provide assistance in returning to work,

collaborating with employer, patient, and co-workers to build a successful

working relationship.

Traumatic Brain Injury

Clinically-Directed Referral Descriptions 2-B

47
48 Traumatic Brain Injury
Rehabilitation of the 

Veteran with Traumatic Brain Injury

Rehabilitation of the 

Veteran with Traumatic Brain Injury

Traumatic Brain Injury 49

Section

3

Learning Objectives

1. Describe standards of care for trauma care after TBI.

2. Identify references for consensus guidelines.

3. Describe the benefits of rehabilitation after TBI.

4. Identify what constitutes interdisciplinary “acute” rehabilitation.

5. Identify common medical complications seen in the acute 

recovery period after TBI. 

Acute Care of the Individual with Moderate to

Severe Brain Injury

Following the acute traumatic brain injury, veterans may need continued

care in a variety of settings. If the injury is of sufficient severity, they will

require acute trauma care followed by inpatient rehabilitation. Typical

medical problems associated with the brain injury must be addressed

during the inpatient period. Following a period of inpatient rehabilitation,

they may need extended services to ensure maximum return to premorbid

level of function. These services may be provided in the outpatient setting,

or in other programs specifically designed for this purpose. Some

individuals do not recover to the point of participation in rehabilitation

programs and thus need long-term care services.

Trauma Care

All regions in the U.S. should have an organized neurotrauma care system

for the initial treatment of severe TBI. Consensus guidelines for the acute

management of traumatic brain injury have been developed by The Brain

Trauma Foundation, The American Association of Neurological Surgeons,

and The Joint Section on Neurotrauma, and Critical Care, and are available

in Journal of Neurotrauma, 2000 Jun-Jul volume 17. These guidelines cover

initial management, systems of care, resuscitation of oxygenation and blood

pressure intracranial hypertension, cerebral perfusion pressure monitoring

and control, hypotension, role of steroids, role of antiseizure prophylaxis,

age, computerized tomography scan features, Glasgow coma scale, and

nutrition. Aggressive surgical intervention has been linked to better outcomes

whereas delayed surgical intervention has been linked to poorer outcomes.
50 Traumatic Brain Injury

Part 1

http://www.guideline.gov/summary/summary.aspx?doc_id=3121&nbr=2347

&string=brain+AND+injury

Part II

http://www.guideline.gov/summary/summary.aspx?doc_id=3122&nbr=2348

&string=brain+AND+injury

Acute Rehabilitation

Following acute emergency evaluation and medical stabilization, the

individual with a moderate to severe traumatic brain injury usually requires

a period of inpatient rehabilitation. These services are best provided in an

established interdisciplinary brain injury program. The focus in the early

rehabilitation phase is to restore the individual to maximal functional

independence. To be eligible for admission to an inpatient brain injury

program, the individual must be medically stable and able to participate in

rehabilitation therapies. He/she usually requires frequent contact with a

physician to monitor new or ongoing complications of the brain injury and

the services of nurses specializing in rehabilitation care. There should be a

reasonable expectation for functional improvement.

The benefits of rehabilitation after TBI have been well chronicled in the

medical literature. Outcomes are better when structured rehabilitation

interventions begin in the ICU. Early rehabilitation principles include:

1. controlled mobilization out of bed;

2. sensory regulation (avoid over- or under-stimulation);

3. avoidance of cognitively impairing medications;

4. regular pain assessment; and

5. early removal of catheter with implementation of timed voids. 

When significant pain is recognized, acetaminophen is the drug of choice,

utilizing scheduled rather than on-demand dosing.

The current standard of care dictates transfer to a formal interdisciplinary

rehabilitation unit. Physiatrists, physicians specially trained in physical

medicine and rehabilitation, are best equipped to direct interdisciplinary

programs. Inpatient interdisciplinary programs generally provide 3 or more

hours of formal therapy (physical, occupational, speech, recreational,

neuropsychology) a day. Nurses and aides participate in the treatment

process by reinforcing the skills being worked on in the therapies and

encouraging patients to carryover and apply functional improvements

during non-therapy hours. Those unable to actively engage in therapy for

several hours daily, like minimally responsive or comatose patients, would

not be appropriate to begin this level of rehabilitation. 

Interdisciplinary refers to therapists and nurses, along with the patient, their

family, and the physician communicating regularly and working toward

common goals. Better outcomes have been shown in interdisciplinary

Rehabilitation of the Veteran with Traumatic Brain Injury
compared to multidisciplinary programs, so this an important distinction.

The Commission on Accreditation of Rehabilitation Facilities (CARF) is the

leading agency to certify the quality of interdisciplinary programs. CARF

offers separate certification for brain injury rehabilitation, because brain

injured patients have unique needs for sensory regulation, behavioral

modification, cognitive retraining, and safety monitoring which are beyond

the scope and training of most acute general rehabilitation programs. Better

rehabilitation outcomes have been demonstrated in dedicated brain injury

rehabilitation programs. There are currently four CARF accredited acute TBI

programs in the VHA: Minneapolis, Palo Alto, Richmond, and Tampa.

Upon admission, the individual undergoes evaluation by the rehabilitation

team and goals for expected short- and long-term progress are set.

Therapies are established based on the current functional level and

responsiveness of the individual. This section describes common

rehabilitation interventions based on the individual’s current estimated

Rancho Los Amigos Level of functioning (Section 1, pp 16-17).

Rehabilitation at Different Stages of Recovery

1. At Rancho Level I, the patient is nonresponsive. Care is focused

on preventing complications. 

2. At Rancho Level II, the patient exhibits non-specific or

generalized responses to environmental stimulation. The

individual reacts inconsistently and non-purposefully. Responses

may be physiological (increased blood pressure or heart rate),

gross movement, or non-meaningful vocalization. Goals for this

level include increasing the level of responsiveness, increasing

initiation of responses, and increasing the localization or

specificity of responses. The treatment process is one of

controlled stimulation. Sensory stimuli utilizing all sensory

modalities are presented in a systematic fashion and elicited

responses are noted. When possible, meaningful stimuli such as

familiar music, pictures, or voices are used. Stimulation is limited

to short periods interspersed with scheduled periods of rest.

Family members may often be involved. In addition to providing

controlled stimulation, therapy at this stage focuses on

prevention of complications and managing medical issues such as

adequate nutrition, protecting the airway, etc. To prevent

complications at this level, therapists are involved in splinting,

positioning, serial casting, and range of motion. Excellent

nursing care is essential for skin care, feeding, and bowel and

bladder management.

3. Movement to Rancho Level III is marked by the emergence of

localized responses. The individual will react specifically, but

inconsistently, to stimuli that are presented. He/she may

withdraw to pain, turn to sound, or track a moving object.

Traumatic Brain Injury

Rehabilitation of the Veteran with Traumatic Brain Injury

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Traumatic Brain Injury

Rehabilitation of the Veteran with Traumatic Brain Injury

52

He/she may follow simple commands and pull at tubes. The goals

at this level are to increase the level of responsiveness, increase

the consistency of responses, and increase functional responses.

Occupational therapy (OT) will begin to work on simple activities

of daily living such as face washing using direct hands on contact

to assist the individual in performing the motions involved.

Physical therapy (PT) will work on activities related to mobility

such as upright posture and truncal stability. Speech therapy (ST)

will elicit responses to communication and swallowing. There is

an attempt to establish voice and stimulate swallowing activities.

Staff support and provide education to the family, which is critical

during these early phases as well as throughout the rehabilitation

process.

4. Rancho Level IV is marked by increasing alertness and agitation.

The individual at this stage is alert and highly active. Behavior

may be bizarre or aggressive and is usually non-purposeful. These

individuals are unable to process information and form new

memories. They tend to be confabulatory. They are often

uncooperative with therapists. The goals for this level are to

reduce agitation and increase consistency and functionality of

responses. At this stage, the individual requires a controlled

environment free of distracting stimuli and with continued

scheduled rest periods. Verbalizations to the individual are kept

simple and concrete and there should be external cues for

orientation to person, place, and time. Therapists work on

functional activities such as grooming and other activities of daily

living (ADLs), mobility, and establishing a consistent yes/no response.

5. At Rancho Level V, the individual is less agitated but remains

confused and highly distractible. Behavior is often inappropriate.

Memory impairment is severe and there is no carry over from dayto-day. He/she is able to respond to simple and basic commands.

Starting at Rancho Level V, restorative treatment of cognitive

function begins. Specific treatment modules for attention (Attention

Process Training; Sohlberg & Mateer, 1987), memory (Sohlberg &

Mateer, 1989), and executive function (Sohlberg & Mateer, 2001),

may be utilized at this level. Therapists continue to work on

functional activities at this level as well. At Rancho Level V, OTs

will assist with dressing and grooming at bedside.

6. At Rancho Level VI, the individual remains confused but

behavior begins to be more appropriate. He/she begins to show

goal directed behavior but continues to need structure and

direction. He/she begins to show carry over and may recognize

familiar staff. Ability to process information remains impaired. At

this level, the goals of therapy are to decrease confusion, improve

independence, improve cognition and information processing

speed. At Rancho Level VI, the individual may be independent in

many basic ADLs (bathing, grooming, dressing), but still require
Traumatic Brain Injury

Rehabilitation of the Veteran with Traumatic Brain Injury

53

cues or checklists to complete such tasks. Cognitive tasks are

integrated into functional tasks during therapy sessions. PT at

these levels will continue to work on mobility, utilizing special

techniques to improve walking as needed, and for those

individuals who have now become independent in ambulation,

will work on endurance, pathfinding, and general exercise

programs. ST will focus on dysarthria, aphasia, and swallowing

deficits at this level. It remains important to maintain a routine

with scheduled rest periods and external cues as needed.

Therapies may be moved to more distracting environments to

challenge emerging improvements in attention. Psychology at this

stage is important to educate staff about the individual’s cognitive

impairments and suggest best strategies for approaching

treatment. For example, some individuals may process verbally

presented stimuli better than visual. Psychologists often must

assist with behavioral issues beginning at these stages and must

be available for counseling and support to families and the

individual receiving treatment.

7. At Rancho Level VII, the individual becomes appropriate in an

automatic fashion in highly structured surroundings such as the

hospital unit. However, they still show impaired judgment and

limited insight into their deficits. They are independent in basic

ADLs, mobility, feeding, and communication. 

8. Rancho Level VIII continues this improvement with the

individual better able to function without supervision. They often

continue to show cognitive deficits in information processing and

abstract reasoning, and behavior may break down in emergency

or unfamiliar situations. The goals for therapeutic intervention at

Rancho Levels VII and VIII are to increase processing of complex

information, increase awareness of deficits, and develop

compensations for memory, communication, problem-solving

deficits, and executive functions. Treatment at this level could be

provided in the outpatient setting. Cognitive treatments continue

to focus on higher levels of attention, and memory. Exercises in

prospective memory — remembering things, which must be

completed in the future — begin at this level (Sohlberg & Mateer,

2001). In addition, individuals who have deficits in social function,

or pragmatics, may begin therapy to restore a more normal

pattern of social interaction at this level. Also, strategies to improve

problem-solving, planning, and other executive functioning will

be initiated here. OT will begin work on instrumental activities of

daily living (IADLs) including the management of money,

balancing a checkbook, shopping and cooking, etc., and will

provide an estimate for the individual’s need for supervision. A

driving evaluation prior to return to driving is advised at Rancho

Level VIII. RT at this level will provide education for safe

participation in leisure activities and provide references for

community resources. They will provide continued exposure to
54 Traumatic Brain Injury

community activities increasing the individual’s responsibility for

planning and carrying out these activities. They will also explore

alternatives to paid work for the individual who is seeking

meaningful activity but is not yet ready to return to work. 

At this point, the individual is transitioned into a community re-entry

program to continue the rehabilitation process. They no longer need or

benefit from the highly structured environment of the hospital, and medical

problems have been addressed and stabilized. Individuals are independent

in the use of medications and no longer need rehabilitation nursing care. 

Individuals who do not reach a level at which they are able to function

relatively autonomously are continued at the appropriate level of therapy

and supervision while they continue to make improvement in their

functional abilities. They can be transitioned to other treatment settings

based on their need for medical care, nursing care, and supervision. Some

individuals may require long-term care in a medical setting, not an acute

rehabilitation facility. These individuals should have rehabilitation monitoring

and evaluation available on a long-term basis to address problems and

complications that may arise as a result of their brain injury. Others may

require long-term supervision that their families are unable to provide, such

as in a group home setting or supervised apartment. Identification of such

facilities or programs can be facilitated through contact with specialized TBI

case managers. Long-term monitoring and management by rehabilitation

professionals is generally recognized as beneficial to individuals who have

sustained a moderate to severe brain injury. 

Rehabilitation of the Veteran with Traumatic Brain Injury

Points to Remember 

• Following acute emergency evaluation and medical stabilization, the 

individual with a moderate to severe traumatic brain injury usually 

requires a period of inpatient rehabilitation

• Brain injured patients have unique rehabilitation needs for sensory 

regulation, behavioral modification, cognitive retraining and safety 

monitoring that are beyond the scope and training of most acute general 

rehabilitation programs

• Rehabilitation needs and intervention of a TBI patient vary by their 

current Rancho Level
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Rehabilitation of the Veteran with Traumatic Brain Injury

55

Common Medical Complication during the 

Acute Rehabilitation Period

Seizures 

(http://www.emedicine.com/neuro/topic318.htm) 

All patients with TBI are at increased risk for new-onset seizures, termed

post-traumatic seizures (PTS). The epileptic episodes may be due to direct

damage of brain tissue which has resulted from shearing forces, infarction,

or due to secondary irritation caused by hemorrhage. Seizures may also be

triggered by secondary insults including metabolic disturbances and

hypoxic episodes. Depending on the underlying cause, a seizure can

originate from a focal or generalized area, as in cases of anoxia. It is

important to be aware that seizures arising from the frontal lobe may

resemble aggressive behavior – apparent purposeful thrashing and kicking,

with possible verbal automatisms (Yablon & Dostrow, 2001). This must be

recognized as potential seizure activity so that appropriate investigative and

treatment measures can be taken.

Most studies have failed to demonstrate the benefit of anticonvulsant

prophylaxis for late PTS. Therefore, after the first week following head

injury, seizure prophylaxis is not recommended (Liebert, 2000;

http://www.aan.com/professionals/practice/pdfs/ant_dru_pro.pdf). When late

PTS presents, investigation for possible underlying triggers should ensue

(metabolic, substance abuse, structural). If no correctable sources are

uncovered, or if a second seizure occurs, treatment with anticonvulsant

medication is warranted.

The incidence of late PTS (occurring beyond the first week post-injury) is

approximately equivalent to the incidence of early PTS (within 7 days

following TBI). New-onset of late PTS can occur at any time, but the

likelihood diminishes over time. Most patients with late PTS (75-80%)

experience onset within the first two years, 50-67% having their first seizure

by the end of the first year (Yablon & Dostrow, 2001). Patients experiencing

the onset of PTS should be referred to a neurologist for thorough

evaluation and management.

Spasticity 

(http://www.emedicine.com/pmr/topic177.htm)

TBI, like other upper motor neuron diseases, is associated with spasticity.

Spasticity is a velocity-dependent increase in tone, resulting from the loss of

inhibitory inputs from the CNS to the monosynaptic stretch reflex in the

spinal cord (Watanabe & Sant, 2001). The degree of spasticity usually

correlates with the degree of extremity motor weakness. Spasticity must be

distinguished from other causes of resistance to passive movement

including anxiety, joint pain, heterotopic ossification, and contractures. 

Spasticity, by impeding normal physiologic range of motion, can both interfere

with functional activities and lead to joint contractures. Contracture, fibrosis

of tissues resulting in fixed resistance to passive stretch of muscles, presents

a formidable obstacle to treatment once it develops. Spasticity can also lead
to pain syndromes and skin breakdown. On the other hand, spasticity can

provide benefits, as when extensor tone in the leg aids standing activities. 

Sudden worsening of spasticity warrants a search for potential triggers

including infection, ulcers, and metabolic disturbance. Whenever spasticity

develops, a stretching, positioning, and range-of-motion program should be

instituted. A myriad of further treatment options are available including

physical modalities, splinting, neurolytic, or botox injections, oral

medications, and surgical procedures

(http://www.biausa.org/word.files.to.pdf/good.pdfs/roadToRehab7.pdf). The

decision to employ them is based on careful evaluation of the severity of the

spasticity, the distribution of involved joints, the functional status, and riskbenefit analysis of each individual treatment option. Physiatrists,

occupational therapists, and physical therapists can provide important

expertise in the treatment of spasticity and resulting complications. 

Neuroendocrine Dysfunction

(http://www.emedicine.com/pmr/topic109.htm) 

Dysfunction of the endocrine system can occur anywhere along the

hypothalamic-pituitary-end-organ axis. For patients with TBI, the most likely

source of dysfunction is in the central aspects of this axis. Skull fracture,

hemorrhage, ischemia, and brain edema can all cause damage to the

hypothalamus or pituitary gland. The most common resulting endocrine

abnormalities are SIADH and diabetes insipidus (Watanabe & Sant, 2001).

Because endocrine dysfunction is so common in TBI (affecting up to 20%),

it is important to be able to determine the underlying cause of the various

electrolyte abnormalities. This will allow for the use of appropriate methods

for correction of imbalances in a given patient. 

Panhypopituitarism

Significant trauma to the head can result in problems with the

neuroendocrine axis. The pituitary gland is susceptible to injury based on its

location in the sella tursica, a bony structure at the base of the skull.

Symptoms are those of hypoadrenalcorticism, hypothyroidism, decreased

growth hormone, and/or failure to lactate after parturition.

The syndrome of panhypopituitarism may manifest an insidious onset, weeks to

months after the original closed head injury. The patient may become progressively

lethargic or anorexic and may demonstrate hypothermia, bradycardia, or

hypotension with hyponatremia. These symptoms result in a significant setback

if they occur during the acute phase of rehabilitation of the patient who has

sustained a closed head injury. Any unexplained onset of malaise and generally

decreased vital signs with associated stagnation of rehabilitation progress in

a patient following closed head injury should prompt the clinician to suspect

the presence of panhypopituitarism or anterior hypopituitarism (AH). 

The endocrine workup for panhypopituitarism includes serum hormonal

assays (e.g., cortisol, testosterone, triiodothyronine (T3), thyroxine (T4),

thyroid stimulating hormone [TSH]). Perform a complete blood count

(CBC) and serum electrolytes as well. 

Traumatic Brain Injury

Rehabilitation of the Veteran with Traumatic Brain Injury

56
Traumatic Brain Injury

Rehabilitation of the Veteran with Traumatic Brain Injury

57

Treatment involves multiple hormonal replacement therapy and monitoring

of serum levels along with the clinical response of the patient. The patient

usually responds with improved vital signs, improved constitutional

symptoms, and increased endurance for participation and progress in the

rehabilitation program. The hormonal replacement therapy usually is

required long-term.

Gastrointestinal Complications

Individuals with TBI have an increased caloric requirement in the acute

phase of recovery. This often presents an added challenge due to the fact

that patients already have difficulty consuming normal caloric requirements,

much less increasing their oral intake. Patients with TBI often have facial

trauma or dysphagia, and demonstrate a low level of arousal, all of which

present obstacles to oral consumption (Watanabe & Sant, 2001). These

individuals also may experience a decrease in their appetite as well,

resulting in little or no motivation to eat. Thus, feeding tubes are frequently

required in the acute rehabilitation phase. Another complication in the GI

tract is GI bleeding, with up to 69% of patients with TBI having gastritis or

duodenitis following their injury (Watanabe & Sant, 2001). Due to their

lower incidence of CNS side effects, proton pump inhibitors are preferred

over H2 blockers for prophylaxis during acute hospitalization. 

Hydrocephalus 

(http://www.emedicine.com/pmr/topic113.htm)

Non-obstructive hydrocephalus is a frequent complication after severe TBI.

The usual cause is disruption of the absorptive capability of the arachnoid

villae. The classic clinical signs are similar to normal pressure

hydrocephalus (imbalance, incontinence, and dementia), though a high

index of suspicion is required of the treating physician because the onset in

the severely injured is typically slow, with the earliest indication often a

vague decline or plateau in functioning and/or subtle mental status changes.

Head CT is the investigative study of choice, and when enlarged ventricles

are seen, true hydrocephalus must be distinguished from hydrocephalus 

ex-vacuo. In hydrocephalus ex-vacuo, loss of parenchymal volume allows

the ventricular system, which is under pressure, to expand giving the

appearance of hydrocephalus on imaging studies (Bigler, 2001). If the CT

findings are inconclusive, serial CT scans and sometimes CSF tapping tests

may be needed. 

Heterotopic Ossification 

(http://www.emedicine.com/pmr/topic112.htm)

The formation of new bone in non-boney tissue can be seen in the acute

recovery period following TBI occurring in 11-77% of cases (Watanabe &

Sant, 2001) Risk factors include prolonged coma (>2 weeks),

immobilization, skeletal trauma, and spasticity. The most commonly affected

joints include the hip, knee, shoulder, and elbow. Complications include

decreased range of motion, nerve and/or vascular compression,

lymphedema, and ankylosis. The early signs of HO typically presents with
pain, erythema, warmth swelling and fever, and can resemble local trauma,

fracture, cellulitis, or deep venous thrombosis (DVT). Therefore, it is

important to keep HO in the differential when a patient with TBI presents

in this manner. Heterotopic ossification typically begins within the first 2-3

weeks following injury, but onset can occur from 1 to 7 months post-TBI

(Watanabe & Sant, 2001). Treatment remains controversial, with options

including etidronate, non-steroidal anti-inflammatory drugs, range of

motion, and surgery. Referral to a physiatrist for recommendations regarding

treatment is recommended. 

Urinary Incontinence

Urinary incontinence is common acutely after TBI, and in some may

continue chronically. The usual etiology is loss of normal cerebral inhibition

and control over bladder and sphincter activity, secondary to frontal or

diffuse cognitive injury. Detrusor hyperreflexia and urinary retention can

also occur, particularly early. In the absence of hyperreflexia, retention, or

obstruction, the preferred treatment is bladder “training” with scheduled

timed voiding attempts. New incontinence in the previously continent

patient should elicit a search for inciting causes such as urinary tract

infection or a new structural insult like hydrocephalus. 

Deep venous thrombosis (DVT)/Pulmonary embolism (PE)

Virchow’s triad lists the three most significant risk factors for deep venous

thrombosis – venous stasis, trauma, and a hypercoagulable state. Individuals

with moderate and severe TBI typically meet 2 or 3 of these conditions, and

are thus prone to DVT. Published incidence rates of DVT soon after severe

TBI range from 20-54% (Watanabe & Sant, 2001). With increased risk of DVT

also comes an increased risk of pulmonary embolism and death. While early

recognition of DVT is important, most DVT’s are clinically silent. Effective

prophylaxis geared toward the appropriate risk level is paramount.

Consensus evidence-based guidelines for DVT risk stratification and

prophylaxis during hospitalization are readily available (Chest Supplement

2000; http://www.chestjournal.org/cgi/content/full/119/1_suppl/1S).

Additional Information

The following Web site contains additional potentially useful information

about post-TBI autonomic and endocrine complication, heterotopic

ossification, hydrocephalus, and epidemiology and pathophysiology of TBI:

http://www.emedicine.com/pmr/TRAUMATIC_BRAIN_INJURY.htm

Traumatic Brain Injury

Rehabilitation of the Veteran with Traumatic Brain Injury

58

Points to Remember 

• All patients with TBI are at increased risk for new-onset seizures 

• Non-obstructive hydrocephalus is a frequent complication after severe TBI
Traumatic Brain Injury 59

Rehabilitation of the Veteran with Traumatic Brain Injury

Other Resources for Rehabilitation Services

For patients who have progressed beyond, or are not appropriate for acute

inpatient rehabilitation, a variety of other services can be accessed for

specific impairments. These services include outpatient therapies,

community programs, vocational rehabilitation, and services provided in

long-term care facilities.

Often, impairments identified in the acute rehabilitation period require

continued treatment after discharge. Also, patients with history of moderate

to severe brain injury may present with new or worsened deficits in the

post-acute period. Impairments such as dizziness, spasticity, balance

disorders, falls, contractures, weakness, decreased coordination, problems

with ADLs, etc., all can be addressed through outpatient therapies. Specific

referral guidelines will be discussed later in sections devoted to

management of chronic sequelae.

Occasionally, veterans with traumatic brain injury may require continued

services in a community-based setting. Some examples of these programs include

transitional living programs, supported employment, adult day programming,

vocational rehabilitation, and specialized neurobehavioral programs. 

Some patients may never reach the level of responsiveness necessary for

participation in an acute rehabilitation program. For these individuals it is

recommended that they receive long-term coma care in a long-term care

setting. Evidence for coma stimulation programs which provide intensive

levels of stimulation with the goal of increasing level of responsiveness and

recovery is lacking in the medical literature. Care for persons in a state of

low level of consciousness, often referred to as coma care, involves

providing excellent medical care—providing adequate nutrition, pulmonary

care, bowel and bladder management—and the prevention of complications

such as contracture, skin breakdown, infection, etc.

The VA has a National Traumatic Brain Injury Coordinator, Gretchen C.

Stephens, who is available to assist with identifying resources or

appropriate placement for individuals with TBI. She can be contacted at

(804) 675-5597 or e-mail at gretchen.stephens@med.va.gov. 
60 Traumatic Brain Injury
Post-acute/Chronic Sequelae:

Medical and Physical Problems

Post-acute/Chronic Sequelae:

Medical and Physical Problems

Traumatic Brain Injury 61

Section

4

Learning Objectives

1. Describe a conceptual framework for intervening with the postacute medical complaints of individuals with TBI.

2. Describe important principals for treating individuals with postacute TBI problems.

3. Recognize the common medical problems in the post-acute 

phase of TBI.

4. List special considerations when making pharmaceutical 

interventions for TBI.

A Conceptual Framework

Given the heterogeneity of TBI, it is helpful to establish a framework for

each patient who presents for medical evaluation. Answering the following

four questions during the assessment process helps to prevent unrealistic

expectations and target those individuals needing a multidisciplinary

approach:

1. What was the medical severity of the initial injury? 

(Discussed in Section 1)

2. What is the current neurobehavioral severity of the 

patient’s “impairment”?

The assessment of the severity of the patient’s current 

impairments should not be limited to a review of systems 

and reporting of symptoms. They should include assessment 

of any personality or mood changes, new onset interpersonal 

difficulties, and the impact of the injury on academic, 

vocational, and social aspects of current functioning.

3. What brings the patient to seek services right now?

The reasons the patient provides for seeking services can 

provide important information regarding the primary factors 

at play as well as the most appropriate treatments and/or 

referrals. For example, if the patient is five months post-injury

and seeking services for the first time, it becomes critical to 

understand why the patient is presenting now versus two 

weeks ago, two months ago, or two days after the injury.
Traumatic Brain Injury

Post-acute/Chronic Sequelae: Medical and Physical Problems

62

4. Is the patient’s current neurobehavioral “impairment” driven more 

by person-centered factors (e.g., neurobehavioral symptoms, 

cognitive problems, premorbid vulnerability factors) or the 

patient’s environmental demands (family/interpersonal, work, or 

school demands)?

The amount of prior treatment and services TBI patients have received may

vary significantly. Understanding the patient’s treatment history will provide

invaluable information regarding potential first treatment steps. Persons who

seek assessment and treatment might fall into one of at least five categories:

• Never sought or received any treatment – Persons who lack

knowledge regarding the potential seriousness of TBI, who use

denial as a coping mechanism, or who lack health insurance

might be less likely to initially seek out services.

• Hospitalized for TBI, never received inpatient rehabilitation

services – Many patients hospitalized with a diagnosis of mild or

moderate brain injury are often deemed by acute care

professionals as ready for discharge home without inpatient

rehabilitation. Lack of service provision may be due to several

factors. Many rehabilitation programs are tailored to meet the

needs of persons with more severe TBI. Rehabilitation services for

TBI are often unavailable in many rural areas. Lastly, managed

care has contributed to reduced funding for rehabilitation

services, especially for persons with less severe injuries.

• Hospitalized for TBI, followed by inpatient rehabilitation

services – Patients with more severe injuries will likely have been

medically hospitalized for acute medical care and then may have

received a period of inpatient rehabilitation services (see section

3) for either a.) physical problems (Physical and Occupational

therapy), b.) cognitive problems (Speech, Cognitive, or

Occupational therapy) or c.) both (a comprehensive inpatient

brain injury program). However, they may now be presenting

months or years post-rehabilitation with newly emerging

problems secondary to environmental changes (e.g., lost job, new

vocational responsibilities, loss of social support). 

• Hidden or “Occult” TBI – Patients who are acutely hospitalized

for other medical problems (e.g., spinal cord injury, orthopedic

injury) often have their neurobehavioral problems neglected or

viewed as secondary in comparison to other medical issues. Many

of these persons have long-term difficulties that are rarely addressed

by outpatient medical and rehabilitation systems (Bohnen, Jolles,

& Twijnstra, 1992; Englander, Hall, Simpson, & Chaffin, 1992). 

• One or more unsuccessful treatments – Many patients with

mild TBI become emotionally distressed because their symptoms

fail to resolve. For some patients, treating professionals may have

misattributed the emotional reaction as the primary cause of
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Post-acute/Chronic Sequelae: Medical and Physical Problems

63

disability and might not have fully assessed the patient’s medical

condition. Conversely, for other patients, the emotional reaction

may have been untreated but plays a significant role in mild TBI

symptom chronicity.

Medical Assessment

The post-acute medical evaluation of TBI patients should include a thorough

history and physical examination. Pertinent elements are listed in Table 1.

Historical information should include accident circumstances to help gauge

severity of injury, including presence of acute alteration in consciousness,

presence, and duration of coma and amnesia, blood alcohol level, and

initial GCS. All pertinent medical records should be sought out and reviewed,

with attention to brain imaging tests. Also important is an understanding of

previous treatment interventions and their effectiveness, an understanding of

the patient’s beliefs about brain injury and long-term prognosis, whether or

not the patient has been provided with education about TBI and the typical

course, and whether or not the patient has pending litigation related to TBI.

Physical examination should focus on the neuromusculoskeletal systems,

including a careful mental status examination and cognitive assessment. 

Points to Remember 

• Try to determine whether the patients complaints are driven more by the 

medical and neurological impairments or by the demands of the patient’s 

current environment

• Carefully review prior treatment attempts and their success before initiating 

new interventions

Comprehensive Assessment of Acquired Brain Injury

History Physical Examination

Accident related facts Neurological

Initial neurologic presentation Cranial nerves 1-12

Pre-Injury information Deep tendon and pathological reflexes

Past medical and surgical history Sensory exam

Substance abuse Cerebellar exam

Developmental history Motor exam

Educational history Mental status exam

Military and legal record Behavioral assessment

Vocational history Emotional/Psychological status

Psychosocial history Musculoskeletal 

Life stressors Head

Family history Face and temporomandibular joints

Post-injury treatment interventions Extremities

Current functional status Axial structures (neck, back, pelvis)

Table 1
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Post-acute/Chronic Sequelae: Medical and Physical Problems

64

The goal of the history and physical is to define current impairments and

functional limitations and to identify all disability related factors. When

multiple symptoms, neurobehavioral impairments, and/or disability related

factors are identified, a referral to a physiatrist with brain injury expertise is

desirable. Also, a comprehensive neuropsychological assessment allows

more complete evaluation of cognitive, emotional, and behavioral

functioning. Neuropsychologists are uniquely qualified to collect data and

sort through the complexity of interactions between physiologic,

psychogenic, premorbid vulnerability, and environmental factors that lead to

the development of chronic TBI symptomatology. Head MRI should be

undertaken in those presenting with ongoing cognitive problems or postconcussive symptomatology if prior brain imaging studies were not

completed. Imaging is also recommended in those with new focal

neurologic findings or whose condition has deteriorated. The need for

further diagnostic imaging tests in those who received peri-injury brain

imaging is rare. 

Guiding Principals for Treating TBI Patients

Adopt a Multidisciplinary, Comprehensive Mindset for 

Treatment Provision

Patients who have sustained a TBI often feel misunderstood by family,

friends, and colleagues. While patients’ are keenly aware of post-injury

changes, laypersons may insist that they “look and sound normal.”

Conversely, treating professionals sometimes focus exclusively on patients’

symptoms and complaints during the course of assessment and therapy,

ignoring emotional adjustment issues. Thus, many people with brain injury

experience significant frustration and failure. 

A “dose effect” understanding of head trauma suggests that higher levels of

long-term impairment are associated with greater initial severity of trauma

(Levin, Benton, & Grossman, 1982). However, research has often found that

patients with mild TBI often report problems at equivalent or even greater

rates than patients with more severe TBI (Larrabee, 1997, 1999). As a

general rule of thumb, regardless of the severity of the initial injury those

patients with multiple sustained and more severe symptoms are likely to

require a more intensive multidisciplinary treatment approach. 

Points to Remember 

• When multiple chronic symptoms are present, a referral to a physiatrist with 

brain injury expertise is desirable 

• A comprehensive neuropsychological assessment may help identify complex 

interactions among cognitive, emotional, and behavioral sequelae to better 

focus treatment interventions
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65

TBI rehabilitation professionals have emphasized the need to take an

interdisciplinary, holistic approach to treating patients who have sustained

mild and more severe TBI (Prigatano, 1989; Ben-Yishay & Prigatano, 1990;

Prigatano, 1999). This holistic mind frame emphasizes not only the

treatment of specific physical and cognitive symptoms, but attending to the

patients’ individual needs which might include providing information,

helping to motivate, instilling hope, and taking environmental factors into

account. However, in the post-acute outpatient general medical setting, a

multidisciplinary approach is more realistic, with the overall management of

the patient’s care directed by the patient’s primary care physician. 

Developing a successful TBI treatment framework is not limited to just

attending to the patients’ cognitive and physical symptoms. Successful

treatment often will include additional interventions including educating,

advocating, counseling, and support. Providing caring attention, helping the

patient to feel understood, providing accurate information on symptoms

and outcomes, and instilling hope contribute to symptom improvement and

return to pre-injury functioning.

General Rules of Thumb for Prescribing Treatments

At the risk of oversimplifying the diagnosis and treatment of TBI sequelae, 

it is often helpful to have a general starting point from which to individualize

approaches and treatment plans. A set of general rules for conceptualizing

patients’ difficulties can provide an intervention strategy. The following 

four rules of thumb provide a general compass for directing treatment of

TBI sequelae.

1. The relationship between initial injury severity and current 

symptom presentation should guide the general approach to 

prescribing interventions.

• More severe injury with ongoing severe, diffuse symptoms 

require Multidisciplinary care

• More severe injury with few ongoing or focal symptoms 

require Symptom-specific interventions and monitor progress

• Less severe injury with more ongoing severe, diffuse symptoms 

require Psychological coping interventions

• Less severe injury with few ongoing or focal symptoms require 

Education and Monitoring 

2. Don’t prescribe what already hasn’t worked.

3. Don’t take on the “savior” role. If several other health care 

providers haven’t “fixed” the symptoms from a relatively mild 

TBI, then you won’t either.

4. If the patient has not responded to initial interventions, a 

comprehensive multidisciplinary approach to treatment 

coordinated by an experienced TBI-case manager or physiatrist is 

highly recommended 

(http://www.va.gov/health/rehab/TBI_Case_Managers.htm).
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66

Addressing Specific Medical Symptomatology 

Common Medical Problems post-TBI

TBI typically involves a complex interplay of brain injury, extracranial tissue

injury of the head and neck, and secondary or reactive symptoms. The resulting

symptomatology can have somatic, cognitive, and affective/psychological/behavioral

components. Common post-TBI medical and physical problems are

discussed below, while the common cognitive and affective/psychological

problems are discussed in Sections 5 and 6, respectively.

There are a number of common somatic medical problems that occur

following TBI. Treatment for these conditions varies minimally regardless of

severity or acuteness of the original brain injury. The following common acute

medical complications that usually present during the initial hospitalization

or acute rehabilitation phase were discussed earlier in section 3: 

• Seizures (pg 55) • Hydrocephalus (pg 57)

• Spasticity (pg 55) • Heterotopic Ossification (pg 57)

• Neuroendocrine Dysfunction (pg 56) • Urinary Incontinence (pg 58)

• Panhypopituitarism (pg 56) • DVT/PE (pg 58)

• Gastrointestinal Complications (pg 57)

This section will discuss the following symptoms or problems, which are

more likely to remain ongoing medical concerns during the post-acute or

chronic phase of recovery from TBI:

• Post-Traumatic Headaches (PTHA) • Sleep disturbances

• Pain • Spasticity, Hydrocephalus, and Seizures

• Dizziness • Visual Impairments

• Fatigue • Vestibular Impairment 

Post-Traumatic Headaches (PTHA) 

(http://www.biausa.org/word.files.to.pdf/good.pdfs/roadToRehab2.pdf)

Treatment should be based on the category of HA as determined during the

assessment and should target not only the physical pain but also the

person’s reaction to pain in daily life. Specific treatment options include

short-term use of medication, conventional physical therapy, biofeedback,

and psychotherapy for the development of coping techniques. Counseling

sessions should include gradual exposure to the cause of the anxiety,

cognitive reinterpretation, and systematic desensitization. “Habit reversal”

involves detection, interruption, and reversal of maladaptive habits. These

include jaw clenching/tension, head posture, and negative cognition or

Point to Remember 

• Adopting a multidisciplinary, comprehensive clinical mindset is important in 

dealing with the individual with chronic TBI medical problems
Traumatic Brain Injury

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67

thinking. Awareness training and deep breathing exercises are also

beneficial. Tension headache, including the cervicogenic variety, are the

most common form of post-traumatic headaches. Directed treatments

include physical therapy, relaxation techniques, medications, and myofascial

trigger point injections. Choice of analgesic medications is based on the

principle of avoiding side effects that might precipitate or exacerbate cognitive

or behavioral symptoms. Thus, the analgesic of choice is acetaminophen,

followed by non-steroidal anti-inflammatory drugs, which occasionally cause

neuropsychiatric effects. The third line of analgesic options are muscle

relaxants, tramadol, midrin and/or light narcotics (darvon, codeine). In

chronic daily tension type headaches antidepressants, including tricyclics and

the selective serotonin reuptake inhibitors, are often efficacious, particularly

when irritability and/or depression coexist. The treatment of migraine type

headaches involves prevention and abortive strategies. Preventative

medications include propanolol, amitriptyline, verapamil, and gabapentin.

Abortive agents include selective serotonin agonists (e.g., sumatriptan),

ergotamines, and the combination products of butalbital/aspirin/caffeine and

isometheptene/dichloralphenazone/acetamenophen. For post-traumatic TMJ

Syndrome, dental management is recommended with possible treatment by

a physical therapist. Neuralgic headache types including occipital neuralgia

may respond to nerve injections or neuropathic pain medications

(anticonvulsants, especially gabapentin or topiramate, and tricyclic

antidepressants). Patients who remain unresponsive to treatment may

benefit from a comprehensive chronic pain treatment program (e.g.,

http://www.vachronicpain.org). 

Pain (Acute & Chronic)

(http://www.biausa.org/word.files.to.pdf/good.pdfs/roadToRehab1.pdf)

Both acute and chronic pain can develop following traumatic brain injury.

Headache is the most common pain complaint in this patient population

but other pain sources are also frequent. Given the traumatic nature of the

brain injury, it is likely that other areas of the body are also injured.

Fractures, nerve injuries, and internal organ injury can also occur and may

not be diagnosed in the acute care setting. Treatment depends on the

etiology of the pain and should focus on interventions that are least likely to

cause cognitive side effects and abuse. Once a thorough work-up is

completed and pharmacologic management is indicated, drug choice should

include consideration of concomitant symptoms. For instance, if a patient

has neuropathic pain and mood instability then carbamazapine or

gabapentin could be considered as a means to treat both problems.

Narcotics should only be used for the treatment of acute pain and used for

the shortest duration possible. Analgesic balms, acetaminophen, and

NSAIDS should be considered as a first line treatment choice for most types

of pain. Consideration for therapy or referral to a specialized pain program

should be entertained (e.g., http://www.vachronicpain.org). 
Traumatic Brain Injury

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68

Dizziness and balance problems

Dizziness and balance problems, while common after mild TBI, most

frequently subside spontaneously. Persisting dizziness and vertigo requires

careful evaluation to find the underlying cause. This could include

hypertension/hypotension, medication effects, alcohol/drug use, visual

dysfunction, or other medical conditions. The most common cause of

dizziness following mild TBI is related to post-trauma vestibular system

dysfunction, also known as benign positional vertigo. Treatment is very

sophisticated and is discussed under separate cover (Furman & Cass, 1999).

Cervical vertigo symptoms often respond to multiple therapeutic

interventions provided by a physical therapist.

Fatigue

Fatigue can have several contributing factors, so a wide range of possible

causes should be explored including frustration, depression, vocational,

family, and social demands. For the fatigued patient who tries to maintain a

pre-injury lifestyle that included managing a staff of 40, taking three night

courses, and having a wife and four small children, a reduction in

environmental demands would make a practical first step intervention.

Chronic fatigue with related decreased attention, concentration, and

memory problems, may respond to moderate use of caffeine or short-term

trials of methylphenidate (Ritalin) or amantadine (Symmetrel). Medications

should only be used after non-pharmacologic options have been exhausted.

Sleep disturbances

Sleep difficulties are common sequelae of mild TBI. With poor sleep, the

patient often develops progressive problems with daytime fatigue that

contribute to increased irritability and reduced cognitive performance.

Treatment should begin with removal when feasible of all medications with

stimulant properties, both prescription and non-prescription (including

caffeine and alcohol). Once other confounding factors like sleep apnea,

nocturnal seizures, and pain are ruled out, behavioral strategies should be

implemented (avoiding daytime naps, avoiding caffeine after the morning,

avoiding late night snacks, avoiding use of bed for activities other than

sleep). Sleep inducing medications can be judiciously added with the

understanding that their effects can carry over into the daytime contributing

further to memory impairment, increased irritability, and depression. Some

individuals can also react with paradoxical worsening of insomnia. Low

doses of Trazodone, 50-150 mg can be highly effective in addressing posttraumatic insomnia, particularly when there is an anxiety component. Low

doses of amitryptyline, 10-50 mg at bedtime, also may be an effective

option, particularly when headache or negative affect coexist.

Anticholinergic side effects can be troublesome with amitryptyline, in which

case nortriptyline offers an alternative. 
Traumatic Brain Injury

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69

Spasticity, Hydrocephalus, and Seizures

The post-acute TBI patient, especially in cases of moderate-severe injuries,

may present post-acutely with signs or symptoms related to spasticity (pg 55),

seizure (pg 55), or hydrocephalus (pg 57). For further discussion of these

conditions, refer back to the pages next to each condition. 

Visual Impairments

Visual impairments frequently go undetected following brain injury, in part

because of the patient’s unawareness of visual changes or inability to

communicate their altered experience (Gianutsos, Ramsey, & Perlin, 1987).

The major visual impairments associated with TBI includes disorders of

accommodation, oculomotor control, and binocularity. 

• Accommodative Dysfunction: Visual accommodation is the

ability to focus on an object at various distances (Suchoff et al.,

2001). Accommodative dysfunction is one of the most common

visual impairments following brain injury (Gianutsos, Ramsey, &

Perlin, 1987), occurring in nearly 66% of patients. Individuals lose

the ability to focus automatically, and thus must consciously

attend to clearing blurred images. It may interfere with ADLs,

reading, computer use, driving, and return to work (Scheiman,

2002). There are two basic approaches to treating accommodation

problems: prism lenses and vision therapy (Suchoff et al., 2001).

Prisms can be prescribed by a neuro-optometrist. Vision therapy

is typically conducted by occupational therapists. 

• Oculomotor Dysfunction: Specific oculomotor skills include

fixation, saccades, and pursuits. Post-injury deficits may include

problems with scanning, tracking, saccadic dysfunction, and

nystagmus (Scheiman, 2002). Nearly 40% to 50% of individuals

with brain injuries have some form of oculomotor dysfunction

(Gianutsos, Ramsey, & Perlin, 1987; Suchoff et al., 1999). Patients

may report dizziness, nausea, losing their place while reading, or

eyestrain. Again, treatment includes use of prisms and/or vision

therapy (Scheiman, 2002). 

• Binocular Dysfunction: Binocular vision is dependent on the

ability to align the two eyes so that they focus on the same point

in space. Suchoff et al., (1999) found that more than half of

patients with brain injuries had binocular disorders of which the

overwhelming majority were exo-deviations. Symptoms include

double vision, eyestrain, and headaches. Persons with diplopia

often recover spontaneously within the first six months. If not, a

patching regimen, Fresnel (stick-on prisms), vision therapy,

corrective surgery, or any combination of these may be necessary

(Falk & Aksionoff, 1992). 

Vestibular Impairment

Vestibular injuries manifest as complex complaints including dizziness,

vertigo, balance problems, disorientation, or visual disturbances. Fitzgerald
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Post-acute/Chronic Sequelae: Medical and Physical Problems

70

(1996) reported that between 15 to 78% of all individuals with mild brain

injury have dizziness as a clinical symptom, and vertigo is clinically seen in

as many as 75% of mild brain injuries and almost all of the patients with

moderate brain injuries (Gizzi, 1995). However, that does not mean these

symptoms necessarily indicate underlying vestibular impairment. A formal

vestibular function evaluation may be indicated for patients reporting

sustained symptoms, and might consist of caloric and rotary tests,

electronystagmography (ENG), and post-urography of dynamic balance.

Vestibular, visual, and proprioceptive systems are challenged in an effort to

isolate the malfunctioning sensory modality. Audiometry and a thorough

neuro-ontologic evaluation may also be indicated. Benign paroxysmal

positioning vertigo (BPPV) is a condition commonly identified following TBI

(Furman & Cass, 1999). Those with a bilateral complete loss of function may

benefit from an exercise program that focuses upon compensatory strategies

for postural control (Cohen, 1994; Gizzi, 1995; Herdman, 1990; ShumwayCook, 1992). Emphasis upon the remaining visual and proprioceptive

systems and balance control may optimize therapeutic outcome. Those with

unilateral lesions often respond to a program of habituation exercises,

patient education, and postural/balance retraining (Godbout, 1997). 

Special Considerations when Making Pharmaceutical Interventions for TBI

It is critical for the treating physician to identify potential drug interaction

effects with TBI symptomatology. In particular, medications for headaches,

musculoskeletal pain, or depression/anxiety must be carefully reviewed to

avoid sedation, which can have an impact upon a person’s attention,

cognition, and motor performance. The rule universally applied to the

elderly of “start low and go slow” applies to the TBI population as well. In

addition polypharmacy should be minimized. 

Precautionary Steps

(http://www.biausa.org/word.files.to.pdf/good.pdfs/roadToRehab6.pdf)

• Provide appropriate therapeutic drug trials and allow adequate time for 

one drug to clear out of the person’s system before changing to 

another medication 

• Allow adequate time for any drug trials 

• Rule out other causes of symptoms/behaviors; know the person’s history 

• Know all the medications the person takes and their possible interactions 

• Evaluate the person’s potential for addictions 

• Check for non-compliance in taking medications that could be either 

intentional or due to poor memory 

• Inform all those who are treating the person of his/her current medications 

and any medication changes 
Traumatic Brain Injury

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71

Role of the Primary Care Physician 

in the Management of Medical Symptomatology

In the post-acute or chronic phase, the primary care physician is the

individual most likely to manage the ongoing care of the survivors of

moderate to severe TBI. A careful medical history and examination will help

identify any residual problems, and the likelihood that they require

additional intervention. The primary care physician may well want to

consult with other specialists, or enlist the aid of a TBI case manager if

available (http://www.va.gov/health/rehab/TBI_Case_Managers.htm).

Clinically directed appropriate referrals for additional assessment may

include consults to the following disciplines:

See page 45-47 for a description of the care provided by each discipline.

Audiologist

Case Manager

Kinesiotherapist

Neurologist

Neuro-ophthalmologist

Neuropsychologist (psychologist)

Occupational therapist

Physiatrist

Physical therapist

Psychiatrist

Recreation Therapist

Social Worker (counselor)

Speech and Language Pathologist

Vocational Rehabilitation Counselor
72 Traumatic Brain Injury
Post-acute/Chronic Sequelae:

Cognitive Problems

Post-acute/Chronic Sequelae:

Cognitive Problems

Traumatic Brain Injury 73

Section

5

Learning Objectives

1. List the common chronic cognitive problems affecting individuals 

with moderate to severe TBI.

2. Describe pharmacological agents that have shown some promise 

in improving cognitive functioning in some individuals with TBI.

3. Describe the indications for cognitive therapy in the chronic 

phase of recovery from TBI.

Common Chronic Cognitive Problems Affecting

Individuals with Moderate to Severe Brain Injuries

While TBI is characterized by substantial heterogeneity in its

pathophysiology, long-term cognitive deficits from moderate to severe TBI

can be viewed as generally resulting from frontal-temporal damage

superimposed on more diffuse pathology. Orbitofrontal and anterior

temporal regions are particularly susceptible to damage. In keeping with

these characteristics, the following symptoms have been seen as the most

prominent cognitive sequelae following moderate to severe TBI:

• Attention and concentration problems

• New learning and memory deficits

• Executive control dysfunction

A variety of other problems also may be present at various stages of recovery

depending on injury differences. The predominant symptoms, their

assessment, and recovery course will be summarized next.

Attention problems are common following moderate to severe brain injury,

particularly among those, which occurred under conditions of rapid

deceleration. Several subdivisions of attention have been considered

(Sohlberg & Mateer, 1987, 2001):

• Focused attention: the basic ability to respond to stimuli.

• Sustained attention: vigilance or the ability to maintain attention 

over time during a continuous activity. Working memory is a 

similar concept and refers to the ability to actively hold and 

manipulate information.

• Selective attention: reflects the ability to maintain an attentional 

focus in the face of environmental distractions.
Traumatic Brain Injury

Post-acute/Chronic Sequelae: Cognitive Problems

74

• Alternating attention: the capacity for mental flexibility, 

appropriately shifting one’s attention between two or more 

ongoing activities.

• Divided attention: the ability to respond to two 

tasks simultaneously.

Attention problems after TBI are seen particularly on novel and speeded

tasks, and in part are due to slowed information processing speed

associated with diffuse axonal injury. However, the dorsolateral aspects of

the frontal lobes are also responsible for directing and controlling

attentional resources. 

New learning and memory problems are among the most commonly

reported deficits after brain injury and typically are associated with medial

inferior temporal lobe damage. Such deficits are a major reason for failure

to return to work or school, or for difficulty performing complex activities of

daily living. Memory span (e.g., short-term memory as reflected in digit span

forwards) and remote memory for events that happened long before the

injury usually are relatively unaffected. Psychomotor skill learning also may

be preserved. Difficulty learning new information, retaining it, and

subsequently retrieving it are the most common memory impairments.

Following TBI, alcoholics, particularly those intoxicated at the time of injury,

are likely to have greater memory impairments than persons with no

alcoholic history.

Executive control dysfunction often is associated with frontal damage and

is common after brain injury. Examples of executive control functions include:

• Abstraction

• Reasoning, problem solving, and conceptualizing

• Planning and organization

• Foresight (anticipation)

• Flexibility/adaptability

• Initiative and drive

• Response inhibition

• Task persistence

• Generative thinking

Patients with executive control dysfunction typically show symptoms

including loss of spontaneity, increased impulsivity, difficulty moving flexibly

from task-to-task, or perseverating in a non-productive manner. When

injuries are predominantly frontal, the patient may perform well on familiar,

highly structured tasks but is likely to have difficulty functioning

independently. Diminished awareness of deficits also can occur with frontal

injury. Without such awareness, patients are not motivated for retraining

and do not monitor their performance properly. Deficits associated with

frontal lobe injury often are the most handicapping as they interfere with

the ability to use otherwise intact skills adaptively.

Other prominent cognitive sequelae of moderate to severe TBI can

include impairment in orientation, mental and behavioral slowing,

communication problems, visual-perceptual changes, and psychomotor

problems. Although aphasia is relatively rare following traumatic brain
Traumatic Brain Injury

Post-acute/Chronic Sequelae: Cognitive Problems

75

injury, a tendency for breakdown in linguistic competence has been

associated with more severe damage. Word finding, misnaming, and poor

conversational fluency are common problems. Communication-relevant

skills, including pragmatics, also often are impaired. Communication

pragmatics include the social and non-verbal aspects of communication such

as social appropriateness, voice volume, rate, and tone, gestures and body

posture, and interpersonal style.

Deficits in general intelligence are not characteristic after TBI. Lower scores

on intellectual tests have been related to severity, but recovery is seen over

time. For example, long after the acute stages have passed, TBI adults

achieved score patterns on the Wechsler Adult Intelligence Scales that

tended to approximate the population average. Abstract reasoning skills are

more affected than knowledge of more over-learned information.

Assessment of Cognitive Problems Affecting

Rehabilitation and Community Re-entry

In the acute and early post-acute stages, patients often are not capable of

meaningful cooperation or valid responding on psychometric cognitive

tests. The following assessment instruments typically are used to track

improvement in responsiveness and orientation in the early stages after

moderate to severe brain injury:

• Rancho Los Amigos (RLA) Scale: Levels of Cognitive Function

• Galveston Orientation and Amnesia Test

In the late post-acute or chronic recovery period (3 or more months postinjury), a referral to a neuropsychologist may be useful in helping determine

the nature and extent of relatively permanent cognitive problems and the

effect these are likely to have on daily functioning. Neuropsychological

evaluations generally take 2-5 hours to complete, and include measures of

general intelligence, attention and concentration, learning and memory,

language, visuospatial abilities, and executive functions. Often an evaluation

of psychological and personality functioning is conducted as well to help

assess issues of depression, anxiety, and adjustment to the brain injury. If a

neuropsychologist is not available within one’s facility, speech pathologists

often can complete similar cognitive evaluations of attention, memory,

language, and thinking abilities. 

Points to Remember 

• The three most common areas of cognitive difficulty in chronic moderate to 

severe TBI are: a) Attention and concentration problems, b) New learning 

and memory difficulties, and c) Executive control dysfunction

• Executive control dysfunction often is associated with frontal damage, and 

includes impairment in higher-order reasoning, problem-solving, and 

cognitive flexibility
Traumatic Brain Injury

Post-acute/Chronic Sequelae: Cognitive Problems

76

Recovery from Cognitive Problems

In the weeks to months after return to consciousness many aspects of

cognition improve, some quite rapidly. In fact, in the first few months rapid

change is considered the rule. The most typical sequence of reorientation is

for person, place, and time in that order. Early after the injury, the period of

retrograde amnesia (loss of memories immediately prior to the accident)

may range from hours to months. Retrograde amnesia for early life events

typically is considered to reflect psychological rather than neurological

factors. As the individual recovers, the length of retrograde amnesia typically

shrinks to a few hours or a couple of days prior to the accident. 

Recovery in performance on intellectual tests is seen over time. Activities

that have a large attentional component tend to improve quickly and reach a

plateau within the first year after injury. Activities, such as new learning and

memory tend to improve over time, but often do not reach normal levels.

Many patients with moderate injuries can and, for the most part do,

function independently. Many return to work or resume their usual

responsibilities. Yet, they tend to differ from neurologically intact persons

and from what they were prior to injury, in that most continue to

experience cognitive and emotional/personality (see section 6) problems

associated with frontal and/or temporal damage. Frontal lobe problems, in

particular, tend to show up in subtle ways. Patients display diminished

initiative and spontaneity and no longer plan for non-routine activities. 

Few patients with severe injuries return to work or even to fully

independent living. Particularly common, persistent long-term cognitive

problems include cognitive and motor slowness, poor memory, and

executive control dysfunction. Fluctuations in performance are common in

patients with impaired executive functions, which is considered to represent

these patients’ lack of internal stability and self-regulation. Quality of life as

reflected in patient and family satisfaction and distress also tends to be

increasingly compromised with increased severity of injury. Severely head

injured patients have been found to have a four to five time greater

likelihood than that of the general population of developing dementia.

After the first year post-injury, improvement in cognitive performance

becomes increasingly gradual and more reflective of compensatory strategies

than recovery of function. Common cognitive problems noted after

moderate to severe TBI persist with no consistent, significant change after a

two-year period. Such difficulties contribute more than physical changes to

eventual level of disability.
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77

Medication Management of Cognitive Deficits

To date, there is no proven pharmacologic intervention to treat and

potentially improve post-TBI cognitive deficits. Different mechanisms

causing brain injury (diffuse axonal injury, focal or multifocal

frontotemporal lobe damage, or anoxic injuries) can cause varied

neurochemical imbalances. These imbalances occur in various

neurotransmitter systems. Cholinergic, noradrenergic, dopaminergic,

serotonergic, and gabaminergic neurotransmitter pathways ascend and

descend between the frontal cortex and subcortical structures, including the

brainstem. In individuals with TBI a number of medications have been

studied which adjust neurotransmitter imbalances. Many agents are still

being studied in the animal model, although some have been tried in case

studies or even groups of patients with various medical diagnoses. This

section will review the literature in the following categories: 

1. neurostimulants,

2. antidepressants; 

3. dopaminergic agents; 

4. acetylcholinesterase inhibitors; and

5. other agents.

Neurostimulants

(Methylphenidate (Ritalin), dextroamphetamine, pemoline) 

Methylphenidate (MPH), now used primarily in attentiondeficit/hyperactivity disorder (ADHD), is a central nervous system stimulant,

which binds to dopamine transporters in the pre-synaptic cell membrane. It

blocks the reuptake of dopamine, causing increased extracellular dopamine

levels. It also has effects on norepinephirine reuptake, and binds to

serotonin transporters. 

One of the initial reports of the use of methylphenidate in brain injury was a

case report of a severely brain injured individual who had a marked

cognitive improvement with methylphenidate (Weinberg, Auerbach, &

Moore, 1987). The patient was then placed on lecithin, which did not have

any effect on the patient’s status, and subsequently physostigmine. The

patient did have improvement with physostigmine, which was lost after the

medication was discontinued. 

Points to Remember 

• Cognitive functioning improves, but usually reaches a plateau within the 

first year after injury, at which time some ongoing problems typically 

remain in the individual with a moderate to severe TBI

• Many patients with moderate injuries can and, for the most part do, 

function independently

• Few patients with severe injuries return to work, or even to fully

independent living
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Post-acute/Chronic Sequelae: Cognitive Problems

78

Since then, there have been mixed reports addressing the effects of

methylphenidate on memory and attention after TBI. Two review articles

have been published (Challman & Lipsky, 2000; Kraus, 1995), reviewing 11

studies. These studies were primarily uncontrolled, but the authors

concluded that neurostimulants have some utility for certain types of mood,

behavior, and cognitive symptoms following brain injury. Promising studies

include one subacute administration study of MPH in 23 moderate brain

injured patients (Plenger et al., 1996). Disability Rating Scale, tests of

attention, memory, and vigilance were performed at 30 and 90 days after

discontinuation of the MPH or placebo. MPH affected the rate of recovery

(with improvement at 30 days) but not the ultimate level of recovery (at 90

days). Kaelin et al., (1996) studied the effects of MPH on attention and

functional outcome in acutely injured TBI patients and found improvement

in digit span, mental control, and symbol search when on MPH as compared

to the scores pre-MPH administration. Benefits were sustained 1 week after

discontinuation of the medication. In a double-blind, placebo-controlled

TBI study, MPH improved mental processing, but had no effect on orienting

to distractions or sustaining attention (Whyte et al., 1997). Finally, in an

animal model, rats have shown improvement in water maze performance

after TBI after treatment with MPH for 18 days (Kline, Yan, Bao, Marion, &

Dixon, 2000).

Antidepressants 

(Tricyclic antidepressants (TCA’s))

The tricyclic antidepressants, which seem to have the best potential for the

brain injury population, are those with a stimulant effects, due to their

adrenergic profile such as protriptyline, nortriptyline, and desipramine.

Wroblewski et al., (1993) reported that protriptyline was effective in a series

of 8 case reports as an activating/stimulant medication in patients with head

injury. More recently, at least in part due to their more limited side effects,

attention has been focused on the use of SSRI’s in head injury deficits.

SSRI’s

(Sertraline (Zoloft) and Fluoxetine (Prozac))

Fann et al., (2001) reported improvements with sertraline in recent verbal

memory, recent visual memory, and general cognitive efficiency in patients

with depression after mild TBI. However, Meythaler et al., (2001) failed to

show any significant improvement in arousal and alertness in 11 individuals

with severe TBI.

Dopaminergic Agents

(Amantadine (Symmetrel), Seligiline/Deprenyl (Eldepryl), Bromocriptine

(Parlodel), Pergolide (Permax), L-Dopa/Carbidopa (Sinemet), Ropinirole,

and Pramipexole) 

Amantadine (Symmetrel) is a dopamine agonist that has suspected presynaptic and post-synaptic actions. Nickels and colleagues (1994)

retrospectively reviewed 12 TBI patients treated with amantadine; of these,

10 exhibited cognitive and/or physical improvement while on amantadine.

In contrast, in a double-blinded, placebo controlled study of amantadine in
Traumatic Brain Injury

Post-acute/Chronic Sequelae: Cognitive Problems

79

acute TBI patients there were no significant improvements on cognitive

measures (Schneider et al., 1999). 

Selegiline or L-Deprenyl (Eldepryl) is a selective MAO-B inhibitor that has

antioxidant and cellular protective mechanisms as well. It is commonly used

to treat the symptoms of Parkinson’s Disease. In a rat TBI model, selegiline

resulted in improved cognitive performance, but not motor improvement

(Zhu et al., 2000). 

Bromocriptine (Parlodel) is a directly acting dopamine agonist, which has

been demonstrated to improve performance on tasks of executive function

and dual-task performance in a double-blind, placebo-controlled study with

24 TBI subjects (McDowell et al., 1998). Similarly, it has been shown to

improve working memory (water maze performance) in rats with TBI (Kline

et al., 2002). 

The effects of L-Dopa/carbidopa have been studied in 12 patients with

diffuse brain damage (Lal et al., 1988). All subjects had reached their plateau

in their rehabilitation programs for at least 2 weeks before the medication

was started, but after treatment showed some cognitive and behavioral

improvement of varying degrees. 

Cholinesterase Inhibitors

(Physostigmine, Donepezil (Aricept), Rivastigmine (Exelon), and

Galanthamine (Reminyl))

Although a number of case studies have reported potential benefits of

Donepezil (Aricept) following TBI (Taverni et al., 1998; Masanic et al., 2001;

Bourgeois et al., 2002), no controlled studies exist to date. 

Other Pharmacological Agents 

There are a number of other agents, which are actively being studied for

potential recovery post-brain injury; many are still in the stages of being

studied in the animal model. The nootropics (nefiracetam, piracetam,

pramirecetam) potentially increase the glucose and oxygen consumption in

the ischemic nervous tissue and increases blood flow through cerebral

terminal vessels. McLean (1991) reported that pramirecetam improved

memory in young males with head injury or anoxic injury. 

In conclusion, there are a number of pharmacologic agents that show

potential to improve cognitive sequelae post-brain injury. However, the

number of clinical trials for these agents in head injury has been limited to

date. With the newer, more specific neuronal agents now available, there is

potential for targeted use of such agents in both acute and possibly

subacute stages of brain injury. 

Point to Remember 

• To date, there is no proven pharmacologic intervention to treat and 

potentially improve post-TBI cognitive deficits
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80

Rehabilitation/Cognitive Therapy/Environmental

Management of Cognitive Deficits

Most individuals with moderate to severe brain injury will have completed

an inpatient rehabilitation program, during which they will have received

cognitive therapies either from speech therapists or occupational therapists.

These therapies help individuals learn and practice various compensation

strategies to deal with residual cognitive problems. However, if a patient has

not received inpatient rehabilitation, they may not have been provided the

education and compensatory training necessary to help them achieve their

maximal level of cognitive and functional independence. In addition, if their

environmental or social situation has changed (moved to a new residence,

divorced, death of a caregiver), individuals may well benefit from a trial of

additional cognitive therapy. In addition, there are patient-centered

educational materials, which may be useful (e.g.,

http://www.biausa.org/word.files.to.pdf/good.pdfs/roadToRehab3.pdf). 

Impaired attention/concentration 

In the post-acute or more chronic phase of recovery, ongoing problems with

attention and concentration are best addressed through education and the

development of compensatory strategies. Patients often report problems in

high demand situations where they must process several different ongoing

aspects of the environment (answering the telephone and taking a message,

while working on paperwork). They can benefit from education that their

ongoing problems in attention and concentration may well result in

difficulty following tasks through to completion and frequent errors,

especially in a stressful work environment. Useful management tips include:

• pace yourself

• perhaps work more slowly

• frequently check work for errors

• work on one task at a time 

• clear away materials from one task before beginning work 

on another 

• take regular breaks to refocus attention 

• work in a quiet environment with minimal noise and 

few interruptions 

• when reading, allow time to re-read or re-study sections

• if problems persist, outpatient cognitive rehabilitation 

may be beneficial

Learning and memory difficulties 

The impact of learning and memory difficulties on daily functioning, school,

and work performance can also be reduced through the use of compensatory

strategies. Examples of memory strategies that are often useful include:

• using a daily organizer/calendar to record appointments, daily 

tasks, important telephone numbers, etc.

• allowing extra time to learn material

• breaking material to be learned into smaller portions
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81

• repeatedly rehearsing material to be learned

• designating specific places for frequently misplaced items (e.g., 

keys, purse/wallet, etc.)

• using a pill box to organize medication schedules or a timer to 

signal medication times

• making “to do” lists and posting them in a designated place 

where they can be easily seen

• making checklists of tasks to be accomplished everyday and 

marking them off as they are completed

• making a checklist of procedures used on the job

• writing down important information (e.g., phone messages)

• taking careful notes and/or making outlines when reading

• if visual memory is substantially better than verbal memory, using 

visual imagery and symbols may aid in learning new material

• tape recording class lectures and replaying them slowly to allow 

for effective note taking at a later time

If a patient has not had a course of cognitive rehabilitation during the more

acute phase of treatment, for persisting and more severe learning and

memory problems, outpatient cognitive rehabilitation should be considered.

Cognitive retraining has been shown to be beneficial, particularly in higherlevel patients. Depression and anxiety can also impact learning and memory

performance. Clarifying the precipitating causes of impairments can help

determine the most appropriate intervention — referral to speech pathology

for cognitive rehabilitation or referral to psychology or psychiatry for

treatment of depression, anxiety, or adjustment issues. 

Executive control dysfunction 

Many of the same tips and compensatory strategies that assist with attention

and memory problems are also useful in managing executive difficulties.

These include using strategies and extra time to manage complex tasks. 

• working on one task at a time 

• working more slowly and carefully 

• checking work for errors 

• breaking tasks down into small steps, and then working through 

each small step to complete the larger task

• making checklists of tasks to be accomplished everyday and 

marking them off as they are completed

• using a pocket organizer of some kind to keep track of what 

needs to be done

• making “to do” lists and post them in a designated place where 

they can be easily seen

Communication problems 

For patients with slowed communication and/or word-finding difficulties,

patients should be encouraged to speak slowly and allow time to formulate

their thoughts before speaking. The pressure to speak in a social situation

can be reduced by allowing more time for listening to others’ conversations

and developing active listening skills.
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When referring patients for cognitive rehabilitation, the following

considerations should be taken: 

• Many third party payors will not reimburse for cognitive 

rehabilitation; referrals may need to be made for speech therapy 

services in which cognitive therapies are embedded

• Cognitive remediation should be embedded into tasks that are 

directly relevant for the particular patient

• Case management 

(http://www.va.gov/health/rehab/TBI_Case_Managers.htm; 

(Section 10 Case Management)) is absolutely essential to be 

able to tease out what is overkill, and determine what 

treatments are efficacious 

• Given that most patients’ ultimate goal is to return to work or 

return to effective performance, outpatient rehabilitation 

programs with a vocational track might be most beneficial

• Lastly, if a patient with a TBI expects to be able to return to preinjury functioning levels at the end of cognitive treatment, then the

entire endeavor of cognitive remediation may be set up for failure 

Role of the Primary Care Physician in the

Management of Cognitive Deficits

In the post-acute or chronic phase, the primary care physician is most likely

to coordinate the ongoing care of the individual with a TBI. Common symptom

complaints are likely to be memory problems, behavioral changes including

irritability and perhaps increased aggression, and difficulty modulating affective

responsiveness. Initial consults to neuropsychology for evaluation of the cognitive

complaints if they have not previously been evaluated and to psychiatry for

medication management are appropriate. Other referrals may be indicated as

discussed above, depending on prior medical workups and previous rehabilitation

interventions. Providing patients and families with education material (e.g.,

Guidelines on TBI http://www.guideline.gov/search/searchresults.aspx?Type=

3&txtSearch=brain+injury&num=20) and supportive listening are also

likely to be useful interventions.

Points to Remember 

• Most individuals with moderate to severe brain injury will have completed 

an inpatient rehabilitation program, during which they will have received 

cognitive therapy

• In the chronic phase of moderate to severe TBI, a new trial of 

compensatory cognitive training may be helpful if the environmental or 

social situation has changed resulting in a decrement in 

functional independence

• In the post-acute or more chronic phase of recovery, ongoing cognitive 

problems are best addressed through education and the development of 

compensatory strategies
Post-acute/Chronic Sequelae:

Emotional and Behavioral Problems

Post-acute/Chronic Sequelae:

Emotional and Behavioral Problems

Traumatic Brain Injury 83

Section

6

Learning Objectives

1. Recognize common neuropsychiatric sequelae of TBI.

2. Describe the interplay of cognitive and emotional problems 

following TBI.

3. Distinguish between similarly presenting neurological versus 

psychological symptoms and problems.

4. Describe the assessment data needed to prescribe efficacious 

treatments for TBI.

5. Describe symptoms and problems that may require referral to 

mental health professionals.

6. Describe basic pharmacological treatment for these emotional 

and behavioral sequelae.

Introduction

Emotional difficulties and behavioral problems are common following brain

injury (Morton & Wehman, 1995; Sohlberg & Mateer, 2001). Furthermore,

premorbid psychiatric problems, such as impulse control difficulties,

substance abuse, and family problems increase the risk for head injury

(Bennett & Raymond, 1997; Hanks, Temkin, Machamer, & Dikmen, 1999;

Kersel, Marsh, Havill, & Sleigh, 2001; McCauley, Boake, Levin, Contant, &

Song, 2001; Sarapata, Herrmann, Johnson, & Aycock, 1998), and are

unlikely to improve following head injury. Therefore, following a brain

injury one has to deal with both pre-injury emotional/behavioral problems,

typically compounded by the emergence of new post-injury behavioral problems.

Damage to the frontal lobes are common in motor vehicle accidents and

can cause specific behavioral problems including difficulty tolerating

frustration or higher levels of stimulation. This in turn can lead to agitation,

cursing, aggression, and potentially destructive behavior. In addition,

behavior problems can be the result of an impaired ability to process

information or understand situations accurately. Finally, post-TBI behavior

problems also can occur because individuals become fatigued much more

easily, increasing irritability and poor frustration tolerance. Emotional

sequelae following a brain injury include increased anger, lowered

frustration tolerance, increased anxiety, depression, and low self-esteem. 

Behavioral and emotional problems may be long-lasting and take a

tremendous toll on family members, caregivers, and friends. In addition,
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84

they tend to lead to social problems including over-dependency; loud,

tangential, or incessant talking; immature behavior; inappropriate use of

humor; obsessive eating; inappropriate sexual behavior; poorly controlled

spending; self-centeredness; and general difficulty appropriately

reciprocating in social interactions. Divorce is very common and frequently

accompanied by a loss of social group membership for the injured person,

further resulting in long-term obstacles for a successful recovery.

For persons with mild brain injuries (also referred to as post-concussive

disorder), many emotional problems may go unreported, either altogether

or not until the symptoms have produced a significant negative impact on

the person’s life. Sleep disturbance following concussions is particularly

unappreciated as an event following mild injuries (Kelly, 2002). These sleep

problems can worsen other problems that frequently occur in mild head

injuries such as inattention, poor concentration, depression, relationship

difficulties, and decreased problem solving abilities. People with mild

injuries frequently have been found to change or lose their jobs within six

months of the injury (Gasquoine, 1997) and particularly are at risk for not

understanding why they now are having problems in their life (Prigatano &

Schacter, 1991).

Denial of problems by injured persons and/or their families often lead to

difficulties with getting services and maintaining the injured person’s

involvement or willingness to participate in the rehabilitation process.

Often, problems are discovered beyond the time when health care providers

can effectively prevent major social losses of family and friends, thus losing

the “window of opportunity” for remediation of some problems.

When mildly injured persons are identified in a timely fashion, their

rehabilitation often will eventually approximate their premorbid status.

Indeed, simply being identified has the effect of anxiety relief that comes

from being able to attribute one’s problems to the appropriate source (i.e.,

the brain injury). Treatment for anxiety and depression are frequently

needed in addition to the rehabilitation process that addresses their deficits.

Resources (e.g., emotional, physical, financial, social, etc.) are much more

likely to be exhausted in the recovery of someone with a more severe injury.

The family burden can be too much for many families, resulting in family

disintegration and the loss of this important resource that plays a major role

in obtaining a successful outcome for the injured person.

The information contained in this section is intended to provide health care

providers with sufficient information to understand when a referral might

be useful to psychology or psychiatry. 

Points to Remember 

• Damage to the frontal lobes are common in motor vehicle accidents and can 

cause specific behavioral problems or changes in personality

• Behavioral and emotional problems may be long-lasting and take a 

tremendous toll on the family system
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85

Interplay of Cognitive and Emotional Problems

Cognitive deficits (e.g., mental slowness, memory problems, inattention,

poor concentration, impaired problem-solving skills, etc.) clearly impact

emotional reactions. Impaired self-awareness (i.e., difficulty seeing one’s

strengths and deficits) is common in moderate to severe injuries and

typically results in the person’s having unrealistic goals and expectations for

him/herself. Difficulty arises when the injured person cannot see how

socially inappropriate their goals or behaviors are. The continued lack of

successful social interactions, in part due to the interplay of cognitive deficits

with emotions, results in ongoing issues with anxiety, depression, guilt,

shame, anger, fear, decreased self-esteem, and an erosion of self-confidence.

Sometimes, emotional symptoms are the direct result of neurological damage

rather than psychological reactions secondary to having a brain injury, despite

similar clinical appearance. Judd (1986) has illustrated this point well in the

list of psychogenic vs. neurologic etiologies listed below in Table 1.

Psychogenic/Psychiatric Symptoms

Denial

Anger and irritability

Depression

Rigid compulsive/hypervigilant

Emotional lability

Social withdrawal

Sense of futurelessness

Thought disorder

Personality or conduct disorder

Neurogenic Symptoms

Anosognosia (lack of awareness of

impairment)

Frustration, catastrophic reaction, reduced

information

Lack of initiative, impaired emotional

expressiveness, lowered crying threshold,

fatigue

Distractibility, inability to deal with more

than one task at a time, dependence on

external controls

Lability of emotional expressiveness (not

the underlying feeling state)

Lack of initiative

Impaired planning

Aphasia, anomia, or confusion

Impulsivity, social disinhibition

Table 1
Predictors of Outcome/Adjustment to Disability

Predicting eventual outcomes and overall adjustment to living with a

chronic disability involves a complex interplay of multiple factors. These

factors include premorbid status, severity of brain injury, the ability to return

to work or school, and the amount of available resources from which to call

upon (including financial, emotional stability, level of family support,

stability of social relationships, specific deficits, etc.). 

Assessment

Obtaining collateral information from family or caregiver is essential due to

the frequent lack of self-awareness, denial of impairments, or

language/communication disorders common following TBI. 

Sample structured interview questions to get at these issues include:

• How has your injury changed your life? 

• Have you experienced changes in your mood such as sadness, 

depression, or anxiety?

• During the times you have felt sad, do you ever feel like harming 

yourself or anyone else? (If yes to suicidal question, assess current 

feeling and thoughts regarding active suicidality. Do you have a 

plan; do you feel like killing yourself right now?) 

• Have you experienced changes in frustration level or anger control?

• Have you experienced increased difficulties in interpersonal 

relationships with your spouse or friends?

• What resources (e.g., family, friends, doctors) have been the most 

helpful for you? 

Consider a referral to psychology if a more detailed diagnostic interview,

psychological testing, and/or psychotherapy appear to be warranted.

Consider a referral to psychiatry for a diagnostic interview, medication

management of emotional or behavioral difficulties, and/or psychotherapy. If

it is uncertain whether the emotional/behavioral problems are neurologic

versus psychogenic in origin, then an additional referral to a neuropsychologist

or neurologist may be indicated. The more information provided to

consultants about the problems for which one is seeking analysis and

recommendations, the more likely the referral would provide useful

information and a targeted answer that will assist future decision-making. 

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86

Points to Remember 

• Impaired self-awareness is common in moderate to severe injuries and often 

results in the person’s having unrealistic goals and expectations

• Similar appearing emotional and behavioral problems can be the result of 

either neurological damage or psychological reactions secondary to having 

a brain injury
Therapies to Address Emotional and 

Behavioral Issues

The main goal of this section is to increase understanding of the common

neurobehavioral disorders affecting TBI patients and the current

recommended treatment strategies. General principles apply to the

management of all psychiatric sequelae and these include:

• Interdisciplinary approach 

• Psychotherapy/behavioral management 

• Pharmacotherapy

• Caregiver education/support 

Common non-pharmacological behavioral interventions 

Cognitive-behavioral interventions

Cognitive-Behavior therapy includes teaching self-monitoring, selfinstruction, and relaxation techniques. Patients are often encouraged to

track emotions and use reminders such as “keep cool” or “chill out” before

reacting to a frustrating situation. Evaluating the situation before

responding is also recommended. This self-evaluation can be assisted by

teaching a series of questions to ask oneself before acting:

1. What is the problem?

2. What would I typically do?

3. What would happen if . . .?

4. What should I do? 

5. What will result from a different course of action? 

Behavior or cognitive-behavior therapy may be particularly useful for

specific behavior problems such as:

• Irritability and low frustration tolerance

• Anger management

• Adjustment difficulties

• Depression 

• Anxiety

• Inappropriate or disinhibited behaviors

• Social skills deficits (including socially inappropriate behaviors 

such as loud talking, “overly friendly” touching, invasion of 

personal space of others, reading social/emotional cues in 

conversations, conflict resolution skills, etc.) 

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87

Point to Remember 

• Obtaining collateral information from family is essential due to the frequent 

lack of self-awareness or denial of impairments common following TBI
Supportive Psychotherapy

Supportive therapy helps address issues of poor self-esteem, confusion, loss

of relationships, unrealistic goal setting, and grief responses to impairments

from the brain injury (including physical, emotional, social, personal, and

family). 

Group Therapy

Group therapy can be effective in addressing:

• Social/emotional interactions 

• Support and education regarding brain injury related problems

Family or Marital Therapy

Family or marital therapy would help families deal with the common postinjury issues such as change in family roles, burden of care of the individual,

relationship conflicts such as hypersexuality of injured member, loss of

family independence, expenditure of family resources for the injured

person, etc.

Spiritual guidance 

Is based upon their specific belief systems to provide hope, comfort,

support, etc.

Education

Providing education regarding brain injury, what to expect, and how to

handle difficult circumstances is a potentially powerful intervention. For the

achievement-oriented patient, providing education that impairments are

related to the injury, and that pushing oneself harder may not result in

success. Pushing oneself too hard can result in stress and increased fatigue,

which can further intensify impairments. Patients can be encouraged to

allow time for recovery and to break goals into smaller, more manageable

steps. Specific information about available resources is also helpful:

• Contact information for state and national brain 

injury organizations

• Information about local self-help and support groups

To secure these types of services for brain injured clients referrals can be

made to psychology, psychiatry, or various mental health service

organizations. 

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88

Points to Remember 

• There are multiple psychological interventions that can be helpful in 

dealing with the emotional and behavioral problems following TBI

• Information and education to patients and families are potentially 

powerful interventions
Psychopharmalogical Treatment -

Post-Acute Symptom Management

Despite the lack of randomized controlled trials to guide pharmalogical

treatment of the psychiatric sequelae of TBI, the use of pharmacologic

agents has become standard practice in the rehabilitation community. The

psychiatric disturbances associated with TBI do not fit easily into DSM-IV

diagnostic categories. Therefore, medication management is typically

symptom-based, not diagnosis-based (Silver, Yudofsky, & Hales, 1994). 

The pharmacologic approach is based on the severity and acuity of the

predominant symptoms while taking into account other factors. These

include other medical and/or psychiatric conditions, the hypothesis

regarding the pathophysiology of the symptoms, and medication side effect

profiles. The rule universally applied to the elderly of “start low and go

slow” applies to the TBI population as well. In addition, polypharmacy

should be minimized. Table 2 (next page) adapted from Arciniegas,

Topkoff, & Silver, (2000) provides useful information about medications

potentially useful in treating various symptom profiles. 

Traumatic Brain Injury

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89
Traumatic Brain Injury

Post-acute/Chronic Sequelae: Emotional and Behavioral Problems

90 Risk of

Affective lability Agitation or Adverse

Medication Depression Or Irritability Mania Psychosis Aggression Anxiety Apathy Cognition Event

Nortriptyline ++ + - - +Desipramine ++ + - - +Amitriptyline + - +++ - - - +++Protriptyline + + - ++ - +Fluoxetine +++ +++ - ++ ++Sertraline +++ +++ - ++ +Paroxetine +++ +++ - ++ +Lithium + ++ - +++Carbamazepine ++ +++ - - ++Valproate ++ +++ +++ +Benzodiazepines + - - - +++Buspirone + ++ + + +Typical antipsychotics ++ + - - +++Atypical antipsychotics +++ + - +Methylphenidate ++ ++ ++ ++ ++Dextroamphetamine ++ ++ ++Amantadine + ++ ++ +Bromocriptine - - ++ + +L-dopa/carbidopa - - + + +Beta blockers - - +++ - - -Donepezil ++ +

Only medications for which there are reports in the literature are listed here. Additional adverse events include increased likelihood of seizures(antidepressants), neurotoxicity (lithium), impaired cognition (mood stabilizers and benzodiazepines), and psychosis (bromocriptine and L-dopa/carbidopa).+ Indicates potential benefit; - indicates potential adverse effects. Table 2
Acute Agitation/Aggression

This problem is seen most commonly during the early phase of recovery

from moderate to severe brain injury during Rancho Level IV and can

severely affect the patient’s ability to participate in therapy. Post-traumatic

agitation is a diagnosis of exclusion. This means that provoking or

aggravating medical (infection, pain, drug withdrawal), neurological

(seizure, hydrocephalus, etc.), or pharmacological factors should be

investigated and treated. 

Medications that should be used with caution in TBI patients include

benzodiazepines, antispasticity drugs, typical antipsychotics, narcotics, H2

blockers, certain anticonvulsants, anti-hypertensives, clonidine, and steroids

as they can all contribute to agitation or restlessness. Nevertheless,

benzodiazepines and antipsychotic medications may be useful for the rapid

resolution of acute agitation. However, they should be used for the shortest

period of time at the lowest possible dose. Benzodiazepines are known to

impair memory/attention, prolong post-traumatic amnesia, and can result in

a paradoxical reaction while typical antipsychotics (haldol, thorazine) can

lower the seizure threshold, delay motor recovery, and impair cognitive

recovery. Valproate, carbamazepine, and beta-blockers are the medications

of choice for acute agitation, followed by amantadine and the SSRIs. 

Chronic Agitation/Aggression

Treatment of chronic agitation includes using atypical antipsychotics,

anticonvulsants, serotoninergic/noradrenergic antidepressants, buspirone,

and beta-blockers (Yudofsky & Hales, 2002). 

Atypical antipsychotics (i.e., risperidone and quetiapine) are used for

agitation as they have a much lower incidence of extrapyramidal side effects

and tardive dyskinesia as compared to typical antipsychotics and are the

drugs of choice for treatment of agitation that presents with psychotic

symptoms. Side effects include weight gain, hyperglycemia, hypotension,

and QTc prolongation.

Commonly used anticonvulsants for the treatment of agitation include

carbamazepine, (Tegretol) and Valproate sodium (Depakote). 

Antidepressants can also be used for the treatment of chronic agitation.

Trazodone can help normalize sleep-wake cycles and has side effects

including sedation, orthostatic hypotension, and priapism (incidence < 1%).

SSRIs and SNRIs are helpful in treating agitation associated with affective

lability and sexually inappropriate behavior. These medications are well

tolerated but have delayed benefits. Tricyclic antidepressants (i.e., Elavil &

imipramine) are generally avoided due to anti-cholinergic properties and

lowering of the seizure threshold. Beta-blockers are useful in the treatment

of agitation but use is limited by cardiac side effects. Less lipophilic betablockers (nadolol) are preferable due to fewer CNS side effects (Brooke,

Patterson, Questad, Cardenas, & Farrel-Roberts, 1992). Buspar, a novel

anxiolytic, is non-addicting and does not affect cognitive function. Psychostimulant medications (i.e., Methylphenidate) have also been used for the

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91
Traumatic Brain Injury

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92

treatment of agitation as they can improve level of arousal and cognitive

function.

To date there is no FDA approved drug for agitation or aggression. Most of

current treatment practice has been modified from psychiatric research with

non-TBI patients.

Mood Disorders/Apathy

Depression occurs in 25-50% of TBI patients and risk factors include prior

psychiatric history, prolonged PCS, left hemisphere damage, and

psychosocial factors (loss of social support, work, etc.; Jorge, Robinson,

Arndt, Starkstein, Forrester, & Geisler, 1993). Studies report an increased

risk of suicide following TBI (Yudofsky & Hales, 2002). Treatment for

depression following TBI includes supportive psychotherapy and

pharmacologic treatment. Drug choice is guided by side effect profiles but

dictated by clinical presentation and history. SSRIs and SNRIs are most

frequently used. Mania and emotional lability are treated similarly. Mania

occurs in 4-10% of TBI patients and risk factors include right hemisphere

damage and family history of mood disorders. The treatment of choice for

mania in the TBI population are the anticonvulsants. 

Apathy presents as a lack of initiation, motivation, and pleasure. Depressed

mood, feelings of hopelessness or worthlessness, identifiable stressor, and

changes in sleep are generally not present (Rao & Lyketsos, 2000).

Treatment of choice is use of dopaminergic agents such as amantadine and

neurostimulants. 

Anxiety Disorders

TBI often impairs the ability to understand or adapt to external and internal

stimuli. Approximately 29% of TBI patient have measurable levels of anxiety

(Yudofsky & Hales, 2002). This occurs most commonly with lesions

involving the right orbital-frontal region. Treatment should include a review

of all factors that might possibly play a role in provoking or maintaining

symptomatology such as work, family dynamics, and environment.

Medications that can be effective include SSRIs, buspar, SNRIs, and

propranolol. 

Disinhibited Behavioral Control Disorders

Personality changes frequently occur following TBI and empirically we see

this as one of the most difficult adjustment issues. These are frequently a

consequence of frontal and temporal lobe damage and treatment depends

on the subtype of the personality change. DSM-IV classifies the following

personality change subtypes: labile, disinhibited, aggressive, apathetic,

paranoid, combined, and unspecified. The disinhibited personality subtype

may respond to anticonvulsant or SSRI medications, whereas the apathetic

type may respond to psychostimulant medication.
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93

Psychotic Disorders

The incidence of post-traumatic psychosis ranges for 0.7 to 20% (Ahmed &

Fujii, 1998). Risk factors include left hemisphere injury, specifically left

temporal lobe damage, and can occur early (during PTA) or after a long

latency. Interestingly, there is a higher incidence of head trauma in

schizophrenic patients. Treatment includes the use of atypical antipsychotics

or anticonvulsants.

Role of the Primary Care Physician

In the post-acute phase, TBI patients and their families are most likely to

present to their primary care physician with various complaint. The family

may well report problems with irritability, anger control, and disinhibition,

while the patient is more likely to report general life dissatisfaction, poor

mood, or low self-esteem. Once the history of TBI has been clarified and

the onset of the reported symptoms dated to the TBI, the primary care

physician may well consider referrals to psychiatry, psychology, or

neuropsychology for further evaluations and treatment intervention.

However, the primary care physician is likely to remain the primary

provider and is likely to follow the patient on their medication regimen

once an effective regimen is determined with psychiatry. 

Points to Remember 

• To effectively treat neuropsychiatric disorders following TBI, one must be 

sure to rule out confounding medical and neurological factors as well as 

alcohol or drug induced symptoms 

• Polypharmacy should be minimized. An attempt to minimize unnecessary 

medications should occur prior to initiating new medications to treat 

symptoms. Familiarity with side effects is crucial, and helps guide 

selection of medication 

• Family/Caregiver education and support are key for the effective treatment 

and management of neuropsychiatric disturbances following TBI
94 Traumatic Brain Injury
TBI in the Elderly and aging with TBI TBI in the Elderly and aging with TBI

Traumatic Brain Injury 95

Section

7

Learning Objectives

1. Describe the unique aspects of traumatic brain injury (TBI) 

epidemiology in the elderly.

2. Describe strategies to prevent falls (and TBI) in the elderly.

3. Explain the influence of age on outcome after TBI.

4. Identify indications for head CT after TBI in the elderly.

5. Describe the relationship between physiological changes in the 

elderly and adverse cognitive medication side effects.

6. Describe the link between TBI and Alzheimer’s Disease (AD).

Epidemiology of TBI in the Elderly

Rates of ambulatory care visits for TBI to physician offices, outpatient

departments, and emergency departments are higher in the elderly,

especially in those greater than 75 years old (Englander & Cifu, 1999).

Given current demographic and longevity trends in the United States, the

number of older adults with TBI should increase over the next several

decades. Individuals between the ages of 15 to 25 and those 75 and older

are at highest risk for TBI of all age groups. Whereas motor vehicle collision

is the leading cause of TBI in adults, falls are the leading cause of TBI in the

elderly (Kraus & Nourjah, 1988; Thurman et al., 1999). Being struck as a

pedestrian is also a more common etiology in the elderly compared with

other adults. Men account for a higher percentage of TBI in the young

elderly group. Whereas in those, over 80 years old, greater female longevity

leads to a female preponderance for a TBI. (Englander & Cifu, 1999). 

Prevention of TBI in the Elderly

Despite the fact that falls is the most important cause of TBI among the

elderly, relatively little research has been done on fall prevention.

Approximately 30% of persons over 65 fall each year and may sustain

injuries requiring hospitalization (Englander & Cifu, 1999). The cause is

usually multifactorial, with weakness, poor balance and medication side

effects frequently contributing. A recent controlled trial of a multiple risk

factor intervention strategy showed a reduction of falls and head trauma in

subjects compared with controls using gait training by physical therapist,

assistive devices, and balance and resistive exercises (Tinetti et al., 1994).
Traumatic Brain Injury

TBI in the Elderly and aging with TBI

96

Another randomized study of elderly persons living in the community who

presented to the emergency department after a fall found that a program of

patient evaluation, referrals, and home visit by occupational therapists (n =

183) resulted in significant improvements in outcome at 12 month followup compared to usual treatment (n = 213). The risk of falling was

significantly reduced; odds of hospital admission lowered; and the Barthel

score declined less (Close et al., 1999).

Prognosis

Age is an important factor in functional and cognitive outcomes after TBI. In

short, the probability of poor outcome increases with advanced age

(Braakman et al., 1980; Jennet et al., 1979; Stablein et al., 1980; Chestnut et

al., 2000). Possible explanations include reduced reserves with which to

tolerate brain injury or a more fragile physiologic status in the elderly

resulting in a more destructive injury (Rothweiler et al., 1998). Despite

slower recovery rates and longer lengths of stay, the majority of elderly TBI

survivors undergoing rehabilitation achieve functional improvement and

community discharges (Cifu et al., 1996).

When assessing the impact of TBI on the older adult, one must take into

account significant accumulated chronic comorbidities (e.g., arthritis,

cardiopulmonary, diabetes, atherosclerosis, renal failure, cancer). In

addition, one needs to consider chronic premorbid conditions that could

reduce cerebral functional reserve at baseline (cerebrovascular disease,

chronic alcoholism, advanced liver or renal disease, dementia) and

potentially impede or prolong the recovery process. Another impediment to

rehabilitation is higher levels of psychosocial limitation seen with advanced

age (Rothweiler et al., 1998). 

Assessment of TBI in the Elderly

Severe trauma in individuals over 70 is 6 times more likely to cause

intracerebral lesions than severe chest, abdominal, or pelvic injury. Older

individuals are more likely to have “complicated” mild TBI, a term used for

patients meeting clinical criteria for mild TBI and who also have abnormal

findings on head CT. Thus, when an individual with mild TBI presents to

the clinic or emergency department (ED), age should be considered in the

decision whether to obtain a head CT. Based on retrospective review of

1448 patients seen in ED with mild TBI, Borczuk (1995) recommends CT

scan for patients after TBI when age is greater than 60 years, or if any of the

following is present: focal neurologic deficit, evidence of basilar skull

fracture, or cranial soft tissue injury.

For the elderly TBI survivor with significant functional limitations, a full

medical rehabilitation evaluation by a physiatrist is strongly recommended

when available. Lower physiologic reserves make the recovery process more

challenging in the elderly. An estimation of physiological reserve allows
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97

more specific structuring of the rehabilitation program, and is made

possible by delineating preinjury activity level and pertinent acute and

chronic medical issues. Impairments (e.g., hemiparesis, dysphagia,

incontinence, and cognitive deficits) and functional deficits (mobility status,

activities of daily living) should likewise be fully delineated. The evaluation

should also seek to identify any of the potential medical complications after

TBI, which will be discussed further below.

Management: Behavior and Cognition

Due to the physiological and pathological changes that accompany aging,

older adults experience more frequent and more severe cognitive

impairment when compared to younger adults with similar severity of TBI

(Rosenthal, Kreutzer, Griffith, & Pentland, 1999). This is primarily due to

lower cognitive reserve capacity and a higher incidence of premorbid

dementia. Significant premorbid memory deficits are present in nearly 10%

of community-dwelling older adults (Beard et al., 1995), and greater than

20% of those over 85 (Skoog et al., 1993).

Older individuals with TBI also have slower rates of drug metabolism and

excretion, which creates a greater propensity for cognitive side effects from

medications including agitation, somnolence, and increased confusion. To

complicate matters, most elderly are chronically on regular prescription

medications, with more than 90% of the entire population over age 65

taking at least one prescription medication daily, and most taking two or

more (Chutka et al., 1995). After TBI, thorough review of both prescription

and non-prescription medications is imperative, and all non-essential

medications should be stopped or tapered. General principles for TBI

pharmacology should be applied. For example, acetaminophen is the

preferred medication for pain syndromes; proton-pump inhibitors are

favored over H2 blockers for peptic ulcer disease or reflux; beta-blockers

that cross the blood-brain barrier should be avoided; benzodiazepines and

metoclopromide should especially be avoided; and low-dose trazodone is

the preferred medication for insomnia. 

Although major depression is less common, depressive symptoms are more

common in elderly TBI patients compared to younger adults (Rosenthal et

al., 1999). When pharmacological treatment of depression is indicated,

SSRIs are the recommended first line in elderly patients with TBI. In elderly

patients with mild TBI, the development of a significant post-traumatic

dementia with transient psychotic symptoms at night can be seen in

association with increased nighttime agitation and disorientation (Goldberg,

2001). This can be viewed as stemming from a disorganized circadian sleepwake cycle and an exaggeration of the effects of aging on circadian

physiology. The use of low doses of risperidone, olanzapine, or quetiapine

at bedtime can be helpful in reducing these disturbing symptoms and reestablishing a normal circadian rhythm.
Chronic Complications

Common medical complications after TBI are discussed in sections 3 and 4.

Compared to younger individuals with TBI, the elderly have a higher risk for

DVT and a higher risk for urinary retention and incontinence. Those who

remain sedentary will continue to be at risk for complications of immobility

such as decubitus ulcers, DVT, pneumonia, and deconditioning weakness. As

previously mentioned, polypharmacy should be avoided, and non-essential

medications should be eliminated. 

Motor and balance functions tend to recover more slowly in the older adult

with TBI because of premorbid limitations in cognition, sensation, strength

and balance, along with decreased tolerance for intensive therapy sessions,

and increased levels of joint and musculoskeletal pain. Special mobility

considerations in the older adult with TBI include alterations in vision,

decreased peripheral sensation, imbalance, decreased strength, and limited

physical endurance. Many elders have a difficult time comprehending and

adjusting to these limitations and therefore pose a significant risk in safety,

judgment, and fall propensity. Comprehensive caregiver education and

training are paramount. A home evaluation by the rehabilitation team can

optimize household level mobility.

TBI/Alzheimer’s Disease (AD) Link

Evidence is accumulating that links TBI to the onset and progression of AD

(Graham, 1999). Beta-amyloid peptides, which are associated with both AD

and Parkinson’s Disease, and increased amyloid precursor protein

immunoreactivity, which represents plaque-like formation, are demonstrated

in post-mortem evaluations after severe TBI and may be an early maker for

axonal injury. Among individuals diagnosed with AD, a prior history of TBI is

associated with a significantly earlier onset of the dementia. Furthermore,

the presence of Apolipoprotein E gene with E 4 allele is associated both

with onset of AD and poorer outcome in TBI. It seems that ApoE is critically

important to the process of protecting against oxidative insults to the brain.

At least in the case of ApoE genotype, the clinical effects of head injury are

significantly influenced by the genotype of the affected individual, and there

is a close neuropathologic link between the reaction to brain trauma and

the process involved in the development of AD (Graham, 1999). 

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Points to Remember 

• Falls are the leading cause of TBI in the elderly

• Gait training, the use of assistive devices, and balance and resistive 

exercises can decrease the rate of falls and therefore TBIs in the elderly

• For the same type of injury, the elderly are more likely to have intracranial 

findings (e.g., bleeds) than younger individuals

• In the elderly, a relatively mild TBI can disrupt the normal circadian sleepwake cycle and result in a reversible post-traumatic dementia accompanied 

by transient psychotic symptoms at night 

• There is an increased risk for Alzheimer’s disease in those with a history 

of prior TBI
Living with TBI:

Impact on the Survivor and their Family

Living with TBI: 

Impact on the Survivor and their Family

Traumatic Brain Injury 99

Section

8

Learning Objectives

1. List common questions posed by the family member of 

someone with a TBI.

2. Describe potential responses to common questions posed 

by family members.

3. Describe why TBI family members often present to health care 

professionals in an angry manner.

Introduction

One of the major difficulties confronting the health care professionals

assessing and treating TBI patients is that symptoms of TBI are not

pathognomonic, and are often confused with psychiatric symptoms.

Treating symptoms of TBI individually, without considering the etiology of

the complaint, can have several negative effects:

• The patient may be placed on inappropriate medications that do 

not treat the symptomatology

• The patient can be inappropriately labeled with a 

psychiatric diagnosis

• Most importantly, the physician will not serve as the patient’s 

and family’s primary source of understanding about the nature 

and course of the cognitive and emotional changes that 

have occurred

The purpose of this section is to present the explanation and treatment

suggestions that the primary care physicians can give to TBI patients and

their families for the most common complaints regarding changes in

behavior, function, and personality.

Family members often complain of vague “personality” changes in the

patient. When questioned specifically, they mention fatigue, anger,

emotional outbursts, social insensitivity, lack of organization, memory

problems, loss of motivation, and changes in family roles. 

Although these have been mentioned in previous sections, they will be

addressed here in order to provide the health care professional with

educational information to provide to family members as well as the

patient. The goals in giving this information are:
• To reduce the family stress level

• To give the family a framework for tolerating TBI symptomatology

• To start the process of treatment of the patient’s symptoms by 

using the family to provide daily structure

The organizing principle is that most of the perceived personality changes

are secondary to reduced cognitions from the TBI. 

Eight Frequently Asked Questions by Family

Members, and How to Answer Them

1. Why is my family member with TBI so tired all the time?

Family members, particularly spouses, often state that the individual with a

TBI has no energy, naps at all times of the day, and wakes up tired and

unrefreshed. They sleep late or have a chaotic day/night schedule that does

not match the rest of the family, nor the normal work-a-day world.

The explanation helpful for family members is two-fold.

Explanation 1. The natural day/night cycle, regulated by the

chronobiological clock in the suprachiasmatic nucleus, is

permanently disturbed in many TBI patients. Stage three sleep,

during which body repairs occur and that is highly correlated with

“feeling refreshed”, may be permanently reduced. Patients often

wake up many times in the night, rather than going through the

normal six 90-minute sleep cycles. This sleep disruption is often

mistaken for a vegetative sign of depression. 

Additionally, fatigue exacerbates all the symptoms of head injury.

When fatigued, patients will be more memory impaired, obtunded,

confused, clumsy, and irritable.

Management Strategy Disturbed Sleep/Wake Cycle. In addition to

medication, the treatment for this sleep cycle disruption is to artificially

impose a rigid bedtime and rise time on the patient. Choose a total

sleep time, which is 1 to 1.5 hours longer than the patient’s premorbid

length of sleep at night. Patients must go to bed at a set bedtime,

whether or not they fall asleep. They need to rise at a set rise time

and not nap during the next day, even if very tired. It takes about 3

weeks to establish a new artificial day/night cycle. It must be applied

7 days/week. After the three weeks, patients can be allowed afternoon

naps, but the schedule must be maintained. If the artificial pattern is

broken, it always takes about three weeks to re-establish again. 

This is the first intervention that physicians can make as both the

family and the patient will come back with statements that the

patient has more energy available during the day. It’s an easy, highly

reinforcing intervention.

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Explanation 2. Many of the cognitive functions, which are

automatic and reflexive for people without brain injury, require 2-3

times the mental effort to accomplish for people with TBI. This is

due to the fact that people with TBI often have to think about, and

do with conscious effort, what the rest of the world does

automatically, without thinking. 

All thinking requires some expenditure of mental energy. Cognitions

such as paying attention, switching attentional focus to a new person,

keeping up with the topic of conversation, organizing an answer to a

question, making a decision, trying to decide what to do next,

organizing your day’s activities in the morning – all cost mental energy.

If each of us wakes up with 100 units of mental energy to spend

each day, patients with TBI spend more of their energy budget on

simply paying attention to casual conversation, activities of daily

living, and making choices, than does the rest of the world. They

“use up” their energy budget by mid afternoon, and have to wait for

a good night’s sleep to recharge the next day and start over with 100

more mental energy units. This is why they are tired “without having

done anything exhausting”. Making choices, having to think

spontaneously or flexibly or conditionally (“if A happens, I will

do...”, but “if B happens, I will do...”) — all of these are high-energy

expenditures. 

Treatment recommendations:

• Make important decisions when the patient has the greatest

amount of mental energy, usually in the morning.

• Make as many activities as possible into a routine to minimize

choice. This saves mental energy.

• Do not fill up the days with scheduled activities, do one

important thing/day.

• The use of an organizer, either paper or electronic is essential.

Premorbid “blithe spirits” who premorbidly made decisions

based on how they felt at the moment, have the greatest difficulty

adjusting to life by familiar routine. Patients often need help in

how to use these. Often speech and language pathologists can

help in the organizer training. 

2. Why is my family member angry all the time?

Explanation. Cognitive deficits — slowed rate of information

processing, reduced span of attention, loss of the ability to multitask

(“Now I’m a one-trick pony.”), memory problems for new

information, visuospatial difficulty in perceiving the environment —

all serve to make the world seem a more difficult place for the

patient to comprehend. The anger expressed by patients is often a

symptom of stimulus overload.

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“Catastrophic reactions” are emotional responses of neurologically

impaired patients when the environment is too complex for them

cognitively. There are four variants:

• Laughing hysterically when overwhelmed, the patient appears 

“silly” to family.

• Bolting, running away when overwhelmed, “I’m out of here!”

• Crying when cognitively overwhelmed. This is often mistaken 

for depression. The condition does not respond to 

antidepressants. The treatment is to simplify the situation, the 

patient immediately stops crying.

• Anger outbursts when overwhelmed. This is the most 

maladaptive of responses, as people go away, the situation 

simplifies, then the patient calms down. The method the 

patient learns is maladaptive as it breaks psychosocial bonds.

Patients can show all four, but usually evidence one consistent

response to being overwhelmed, anger and tears are the most common

responses. Patients are not aware of the connection between the

environment being too complex and their anger or tears. If asked

why they are angry, they cannot explain, and simply get angrier.

Treatment recommendations:

• First, the family can point out the irritability, frustration, or 

anger when it occurs, and suggest to the patient that too much 

is coming at them too fast.

• Family members can be taught to speak with pauses (Speak as 

if you threw a handful of commas into your speech.) When 

you pause in parts of the sentence, the patient can “catch up”

in information processing. 

• The patient can be asked to talk to people one-on-one rather 

than in groups (two or more people places a strain on 

attentional mechanisms). 

• Patients can ask for verbal slowing, repetition of information, 

or writing down steps.

• Patients can ask if they can audiotape important information to 

review later. All physician sessions should be recorded by 

patients so they can retain the information for a later review.

3. Why is my family member more emotional?

Explanation. Emotions come from the limbic system in the core of

the brain, but whether or not they are behaviorally expressed is

controlled by inhibitory neurons in the frontal cortex. These frontal

inhibitory neurons are at high risk in TBI. Patients are having the

same emotions they experienced premorbidly, but their control of

emotional expression is lessened. Families experience this as “a

personality change”.

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Treatment recommendations:

• Explain this phenomenon to patients and their families. A 

poker analogy may be useful to explain the difference 

between emotions and emotional control. “If I were playing 

poker with you right now, and I had a royal flush, I would be 

experiencing great joy. But I wouldn’t want to show it to you, 

or I couldn’t sucker you into betting. My emotion is the 

feeling inside, the joy, but my expression is bland — that’s 

what’s meant by a poker face, it’s my ability to control what 

emotions I let out.”

• Intensity of emotion is often expressed as tears — either 

happiness or sadness, or the feeling of being emotionally 

connected. This is often misinterpreted as depression, and 

families try to avoid topics, which brings on tears. A better way 

to handle patient tears is to:

o Ask permission to bring up topics which induce tears “to 

desensitize” patients.

o During the tears, have the patient breathe deeply to dissipate

the energy — they often hold their breath in an attempt to 

inhibit the tears.

4. Why does my family member seem so insensitive and hurtful 

since the injury?

Patients with TBI appear to be insensitive to partners, children, and friends

due to 4 possible cognitive deficits. The first three deficits are related to

frontal lobe injury, the fourth to right parietal lobe damage. 

Explanation 1: Difficulty with Inhibitory Control. The primary

source of social difficulty is a moving of the line, which distinguishes

private thoughts (those which should remain unspoken) from

thoughts, which are expressed as public statements. Patients

describe this as “things just spill out of my mouth, my stop sign has

been moved.” “Gumballing” is a better term — thoughts occur, they

drop like a gumball onto the patient’s tongue and just roll right out

with no mental processing at all. Families need to know that they

are hearing the patient’s thoughts, that the barrier between private

and public thoughts has been damaged.

Treatment recommendation. After the physician’s explanation,

family members need to tell the patient ”That’s an inside thought,

not an outside one.” This allows feedback without criticism or

humiliation (e.g., “that’s inappropriate”).

Explanation 2: Difficulty with Multitasking. A second source of

social difficulty is the inability to do two things at once, the loss of

the ability to multitask, the reduction of thinking to one channel at a

time. In everyday life, most of us are doing at least two things

simultaneously when we function socially. We respond, and, at the

same time, we monitor ourselves, we watch ourselves responding in

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103
order to self-correct any errors or problems. Some patients with TBI

can only do one thing at a time. This means they can either respond,

or they can self-monitor, but they can’t do both. Adding additional

people in the social situation makes this worse. Channel capacity

cannot be modified.

Explanation 3: Brain-damage Related Egocentricity. The third

source of social difficulty is the inability of the patient with TBI to

step outside his or her own view and see someone else’s point of

view. Spouses in particular find this frustrating. 

Treatment recommendation. Patients can be taught a basic form of

negotiation with their partners. Asking the spouse to a.) State their

point simply, b.) Have the patient state the spouse’s point, c.) Have

the patient state their own point, and d.) Have the patient state a

position that includes half their own and half their spouses position. 

Explanation 4: Difficulty Reading Facial Expressions. The fourth

source of social difficulty is difficulty reading facial expressions. All

human adults are able to distinguish the following emotions on

other people’s faces, regardless of culture: happy, sad, fearful, anger,

surprise, disgust, and contempt. Of the emotions listed, most are

discernible by a single part of the face — except for anger. Anger

requires accurately reading three parts of the face, with two possible

variations in each part. This makes anger a harder task visuospatially.

Patients with visuospatial difficulty due to parietal lobe injury may

interpret anger as surprise or confusion, and miss significant facial

feedback from their spouse. 

Treatment recommendation. Having spouses verbalize their feeling

(“that makes me angry”) often helps. 

5. My family member used to be a real go-getter, the source of energy 

and ideas. Why is he/she so passive now, just sitting around unless 

I tell him/her what to do?

Explanation. We exhibit two types of behavior: spontaneously

emitted behavior or behavior elicited in response to a certain stimulus.

For patients with TBI, spontaneously emitted behavior can be reduced.

This problem with behavioral completion fall into two categories:

1. Difficulty with inertia, with starting up a behavior. Often this is 

the result of both frontal dysfunction and low mental energy. In 

addition, when presented with too many choices, individuals with 

TBI have difficulty deciding what to do and may make no choice.

2. Interruption of an ongoing behavior before completion. This is a 

loss of internal focus, resulting in tangentiality in speech, or 

unfinished tasks at home. An activity is normally defined by a 

beginning, middle, and an end of response. Patients with TBI 

often drop off the end of the response and start another action. 

This results in tasks that are incomplete, or just sitting in 

distracted confusion.

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105

Treatment recommendation. Initiation difficulties can be partially

remediated with a daily routine; temporal conditioning replaces

spontaneous choice and reduces the dilemma of decision-making. If

the problem is too much initiation (i.e., impulsivity), slowing them

down by requiring mental counting before acting is recommended.

If they are easily distractible, this gives family members an

opportunity to distract them from an unwise course of action. Verbal

distractibility (tangentiality) is best treated by asking the patient to

announce when he/she is changing topic. This may appear

conversationally awkward, but will focus the survivor’s attention on

the problem.

6. What can I do, I feel as if I no longer have a spouse, but another 

child in the family?

Explanation. The partner of the patient with TBI often feels as if

their role in the marriage and family has changed. This is a real

perception; their roles and responsibilities have changed, they have

grown enormously. It is best to give spouses several premises about

brain injury, so they can perform their increased role without anger. 

Treatment recommendation.

• Think of the patient’s brain as Swiss cheese. There is plenty of

good cheese — intact circuits that were unaffected by the injury.

But now there are a few “holes” where cells were injured or

destroyed. Whatever these injured circuits did before, will now

be a problem for the patient. It is important that spouses loan

the patient only those abilities that the patient has holes in

— only those areas where the patient needs help. It is

important that patients with TBI be permitted to practice

behaviors that are deficits, which they are poor at — so they can

improve with practice.

This accomplishes three things:

1. Family members (and patients) stop thinking globally, that all 

abilities are lost.

2. Family members will stop doing everything for the patient in the 

name of “efficiency” and can tolerate slow, inaccurate, messy 

performance, if it results in “brain rewiring.”

3. Patients need to be given family tasks, which are within the 

“good cheese” portion of their abilities — practical tasks that are 

their contribution. Again, structure to the day and reducing 

choices allow maximum function. 

• The following is an example of saving energy with routine that

can reduce a spouse’s sense of caretaking load with a

neurologically injured partner who has slowed speed of dressing

or getting started in the morning. The patient is to have clothes

for the next day arranged in complete outfits, including

underwear, socks, shoes, etc. The pile of clothes can be arranged
in the order of dressing the body. Routines save time and help the

patient feel more independent.

• Return to compensated work is often impossible for patients with

TBI. Cognitive functions necessary for most jobs are speed and

memory — these effect production rate and independence of

action, necessary from an employer’s point of view. The two areas

most affected in TBI are slowed information processing and

memory difficulties. Often an individual with TBI is on social

security disability, medical pension or some compensation for

injury. This can be viewed as “income” brought into the family —

the individual may not be able to work at a salaried job, but they

provide means for families to economically survive.

• TBI can be thought of as “premature aging” of the brain. What

were the couples’ intentions as they aged, and grew towards

retirement? Unfortunately, many Americans have a poor model of

aging — physical decline, leading to social irrelevance, followed

by death. Other cultures recognize that there is a developmental

task for each age. A potential developmental task for those who

are older is to become a sage or a mentor, rather than compete in

the work-a-day-world. The patient with TBI now has unique

experiences — he/she knows what it is like to deal with adversity,

to have a chronic condition, to fight their way through each day

spending more energy than most to function. They understand

handicap and disability. It is strongly recommended that husband

and wife attend a TBI survivor/caretaker group as a couple. These

groups often break into two meetings, TBI survivors, and

spouses/family members. Knowing that others have coped and

having a place where both get their needs met is crucial.

• Caretaking spouses need to have some respite/alone time. This is

not meant to be time to do errands, but to replenish their energy,

doing something fun and joyful. Spouses often feel guilty about

taking time off. Remind them that the same logic of putting on

the adult oxygen mask first before putting on a child’s in an

airplane emergency holds true. If the spouse breaks down, both

the patient and the spouse will falter.

• Caretaking spouses often feel unappreciated for their

extraordinary efforts. Writing a couple of phrases of appreciation

“You are such a wonderful partner, I’m so lucky to have you”. Or

“Have I told you I love you?” in the patient’s memory book or

electronic organizer every few days, (which the patient reviews

after each meal) can make a spouse feel that their efforts are noticed.

7. There seem to be so many problems, new ones keep cropping up. 

Will our lives ever get back to normal?

Explanation. In TBI, all impairments are present at the moment of

damage — at the initial impact. All difficulties may not show up at

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once, but they are all present at the moment of injury. It is only an

illusion that new problems are emerging over time. The expression

of some impairment is initially masked by larger functional

problems, but the masked impairments have been present all along.

For example, if the TBI survivor cannot scan visually in an effective

way, if their gaze is random rather than orderly, he/she cannot read.

Training to scan from left to right, top to bottom, can give survivors

back their ability to see the printed words in sentences in an orderly

sequential manner. Now that the survivor can see the words, it may

be discovered that his/her reading comprehension is only 60%; that

is, they don’t comprehend 40% of what they are reading. To the family,

this appears to be a discovery of another problem, a new one, but

the reading comprehension difficulty was present all along. It could

only be exposed if the patient can see words on an orderly manner.

Treatment recommendation. It is helpful to explain the emergence

of masked cognitive problems (or finer and finer difficulties) as

peeling an onion. Fixing problems at one level allows the survivor to

emit more complex behavior, which permits subtle impairments,

which have been present the whole time, to emerge.

8. How long is the psychological recovery going to take?

Explanation. The standard answer to “How long does it take for the

brain to heal?” is usually 18-24 months (the period of spontaneous

healing, based on age and metabolism, with younger patients

requiring 18 months, older ones requiring 24 months). The answer

to the question, “How long before he/she is as good as they’re going

to get?” is harder to answer. There is evidence that language and

intellectual recovery are still occurring at 5 years post-injury, albeit at

a slowed rate. It is best to think of the TBI survivor’s

psychological/cognitive problems in the following manner:

• Some problems are primary: They are due to alterations in the

nervous system as a result of physical damage. Examples are

memory problems, spatial difficulties, emotional lability, and

attentional difficulty. These primary lesion effects are best

handled by environmental modification, psychoeducation,

(explanations) and cognitive retraining.

• Some problems are secondary: They are emotional reactions

due to changes in functional ability, role, and status. These

emotional reactions to existential changes are best dealt with by

short-term psychotherapy.

• Some problems are tertiary: That is, they are long-standing in

nature, either developmental and/or characterlogical. They are

determined either by the personality defensive structure of the

individual, or, their developmental stage in life. Here’s an

example of the effect of developmental stage on the TBI

survivor’s concerns and willingness to work on issues. Two

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identical cases of TBI, both with left upper extremity hemiplegia,

a tendency to drool (secondary to reduced swallowing and

pooling of saliva), and moderate memory problems. One is 18,

the other 43 years of age. The 18 year old will be most concerned

about his left arm hemiplegia and drooling, and will consider the

memory difficulty as the least important to him. This is because

his developmental task at this stage in life is to find a partner.

Being considered “dating material” will be his primary concern,

drooling and physical impairment will be highest on his list of

what needs remediation, memory less so. For the 43 year old who

is concerned with earning a living for himself and his family and

working up the ladder of success (his developmental task), the

drooling and hemiplegia are of concern, but not nearly as much

as the memory problem, which interferes with his ability to be

economically successful. Paying attention to the age of your

patient and the developmental life task they are most concerned

with will tell you what your patient will be most concerned about.

Treatment of characterlogical tertiary problems is long-term psychotherapy;

treatment of developmental stage problems is short-term psychotherapy.

Other Important Family Issues Facing the Health

Care Provider

1. Human Sexuality: Ask patients about changes in their sex life 

after TBI.

Changes in sexual functioning often occur in a couple after one has

had TBI. Physicians should ask both the husband and wife

(separately) about their sexual functioning. Here is a suggested way

to bring the issue up. First tell the patient that you are going to ask a

personal question which he/she may choose not to answer.

“I always ask whether patients are having any sexual problems. 

Your sexual health is one important part of your life. Sometimes 

an illness, accident, or a medication can affect sexuality too. 

How has your sexual relationship been going lately?”

Other problem areas and potential solutions:

• For patients who are now disinterested in sexual activity — a

laboratory test for gonadal hormones, particularly testosterone,

may be in order. 

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Points to Remember 

• Listening to family members and providing them with education about TBI 

is a powerful intervention supporting the family system

• Helping family members understand the cause for various problems and 

ways of handling them gives them a sense of control over a very 

difficult situation
• Difficulties with achieving or maintaining an erection may be

resolved with medication (Viagra) or mechanical devices (ErecAid, a plexiglas tube into which the penis is placed, which creates

a vacuum, the penis is engorged and a penile ring at the base

maintains an erection for up to 30 minutes). Referral to a

urologist or human sexual dysfunction clinic (within the VA, the

andrology clinic) can result in more treatment suggestions.

• Reduced vaginal lubrication — replacement with gels.

• Altered sensation after neurological injury — numbness,

hypersensitivity, tingling, painful. A good neurological

examination can alert the partner to these changes, especially

areas to avoid. Other recommendations, approach from the

“good side” of sensory intactness, emphasize intact senses, more

talking, more touching, use of perfume (although patients with

frontal injury are frequently anosmic).

• Awareness of position of affected body parts, for example, a

numb arm. Suggested treatment is a change in intercourse

position with the “good” side up. 

• If spasticity or hypertonicity is a problem, a warm bath before

intercourse can relax the tone.

• Fatigue effects sexual functioning. Naps before sex or switching

sex to the morning when the patient is more awake, can reduce

brain injury effects.

• Other neurological symptoms of altered communication

(incorporate more touching, physically guiding the hand of the

person affected), difficulty reading facial expression (use more

verbal descriptions of how you feel), keep dialogue simple, use a

familiar routine.

• If bowel or bladder incontinence is a problem, reduce the chance

of accidents during sex by recommending:

° Routine bowel program — use of suppository at specific, 

convenient time of day.

° Routine bladder program (timed voids every two hours).

° Limit fluid intake prior to sex.

° Empty bladder just before sex.

° Have a urinal, soap, washcloth, water, and towel nearby for 

urgency problems.

• Inappropriate sexual comments or touching to individuals not

their partner. It helps to understand why brain injured patients

may make unwanted sexual comments. A change in physical

functioning often brings fear of loss of sexual/physical

competence. It’s on their minds. Cortical control of emotion is

often lessened, lability and impulsivity result. Patients with TBI

often misperceive or misinterpret the social situation. They may

Traumatic Brain Injury

Living with TBI: Impact on the Survivor and their Family

109
have difficulty understanding consequences. They often want

nurturance, support, affection, friendship, or company, but

sexualize it instead.

° Recommendation. Direct confrontation to the patient. Ascribe 

positive motivation to the patient’s action, but redirect with 

what’s appropriate. Reflecting back reality is the physician’s 

role; there are social consequences to sexual 

inappropriateness.

° Example of a possible response: “I know that you are grateful 

for the care and understanding you get from me (ascribing 

positive motivation to the patient’s action, even if not 

apparent), we are not in a social situation, but in a 

professional one. You need me to work with you, and I can 

work with you only if you speak to me with courtesy and 

respect. We are not in a social situation.”

2. Why are the family members, particularly spouses of patients, so

complaining and angry?

Family members project negative emotions onto physicians for many

different reasons:

• Family members feel they need energy to cope with a crisis, and 

anger activates people.

• The family member is in danger of collapsing in despair, so they 

get angry to activate themselves.

• Anger is often delayed from the acute setting, when coping with 

disaster, emotional suppression is paramount. These suppressed 

feelings come out in outpatient settings because “now it’s safe to 

express how overwhelmed we feel”.

• TBI often challenges families assumptions about how the world 

works. We all hold some false beliefs about the world, such as:

° Life’s fair. This is untrue. In dealing with unfairness, it helps to 

change the frame of reference of the family member. For 

example: Everyone who is alive today has beaten the odds. The 

odds are 100,000,000 to 1 that a particular sperm would 

fertilize the egg, which resulted in a particular individual. 

Those are the odds we all win at conception. After we are 

born, everything else is gratis, icing on the cake. This is offered 

as an alternative viewpoint to family members who feel 

cheated that the patient didn’t get his/her fair share of good 

health and long life with any untoward events.

° Spiritual beliefs that bad things that happen to us are 

punishment for sin. Families will state, “But he’s good, why 

did this happen?” It is helpful to point out that suffering is not 

a punishment, surely innocent infant/children suffer and are 

not to blame.

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Living with TBI: Impact on the Survivor and their Family

110
° Displaced anger at the patient for bringing on the TBI, “I told 

him not to drink and drive”. Often this anger cannot be 

expressed at the patient who is too vulnerable, so it is often 

displaced onto the nearest authority figure, the physician.

° The belief that causal events are simple. If I can control A, 

then B will surely happen. If I can make you give him the right 

drug, his memory will return. This is a belief in simple, one 

factor causality.

How to respond to angry family members:

• Never respond in anger, not even in clipped tones. 

• Give lots of information to the family member about TBI, it binds 

anxiety. Have them record the information, to review at a later time.

• Determine what is fair for the patient — and stick to it. Being a 

broken record is often helpful, this means repeating your 

position, not in anger.

• Playing dumb can be a useful stance, “ I’m confused, at first I 

understood you to say that he’s impulsive and can’t be 

controlled, then you said he’s unable to self-start, can you give 

me some examples of what you mean?”

• Always ask for specific examples. Family members don’t speak in 

medical terminology and they may mean something quite 

different than you do when they say, “he’s depressed”.

• If a family member is constantly attacking you verbally, 

demanding predictions and prognoses to questions that cannot 

be answered, recognize that they have difficulty with ambiguity. 

Acknowledge that not having clear answers is hard, but you have 

given them all that you can. If they continue to question you, 

answer questions with a question. This stops the placing of 

blame on the physician, and places the tolerance of ambiguity 

where it belongs, back with the family.

• When pressured by a family’s anger, delay by taking time to 

answer. ”I can understand why you might think that. I’ll have to 

think about that, I’ll get back with you later.” This allows you not 

to answer in anger.

• Consider suggesting that the spouse seek counseling. 

Acknowledging that care giving is an incredible load for anyone 

to bear, that anyone would need some stress reduction and 

support. Have the names of some professionals that are familiar 

with head injury. The BIA maintains such a list, as does the 

National Caregivers Alliance. Definitely have literature available 

on local support groups for family members.

Traumatic Brain Injury

Living with TBI: Impact on the Survivor and their Family

111

Point to Remember 

• Dealing with angry and frustrated family members is stressful; listen and 

provide educational information in a direct, matter-of-fact, consistent manner
112 Traumatic Brain Injury
Driving Issues after TBI Driving Issues after TBI

Traumatic Brain Injury 113

Section

9

Learning Objectives 

1. Describe the effects of physical, cognitive, and neurobehavioral 

TBI sequelae on driving abilities.

2. State how medications can affect driving abilities. 

3. Describe the components of a pre-driving assessment.

Introduction

Driving is an essential activity of daily living for many individuals and is one

determinant of level of independence. Individuals lacking this mobility are

deprived of meaningful educational and vocational opportunities and

reduced ability to participate in recreational, social, cultural, and

community events. They are also deprived of full and independent

completion of basic survival skills and self-sufficiency. 

Driving requires a complex set of skills and abilities, including mobility,

vision, and visual-motor coordination, as well as multiple cognitive and

neurobehavioral abilities and functions. It is well known that individuals

with TBI have varying degrees of physical impairments, cognitive dysfunctions,

and neurobehavioral problems that can impede the integrated operation of

neuropsychological and physical capacities for driving. However, disabled

veterans, including those undergoing rehabilitation, are entitled by Public

Law 93-538 to have the opportunity to pursue a return to driving. 

It has been estimated that 38% to 78% of individuals with traumatic brain

injury seek and obtain driving privileges after their injury (Katz et al., 1990;

Oliver et al., 1996; Priddy et al., 1990). A more recent study suggests that

individuals with TBI who successfully pass a driving evaluation and

complete a comprehensive driving program are able to reintegrate into the

driving community with minimal difficulty (Schultheis et al., 2002). Thus, it

is the physician’s responsibility to determine when and how to return the

individual to driving. Only after an understanding of the impact of the

individual’s physical, cognitive, and neurobehavioral factors on driving has

been attained can a plan for training and treatment be developed that will

result in safe driving.
Effects of Physical Impairments

Occulomotor dysfunction including diplopia, hemianopsia, and reduced

vision can impact driving capabilities following TBI. Therefore, it is essential

to perform a visual acuity test and visual field evaluation periodically during

the recovery stage. Some individuals are also known to have auditory or

vestibular dysfunction, causing hearing impairment and vertigo/dizziness,

which might also interfere with driving performance. Refer to Section 4 for

details about visual and vestibular dysfunction.

Motor disturbances, such as paresis of the limbs, spasticity, and ataxia can

obviously interfere with the visual-motor coordination and motor skills

requisite for driving. It is thus essential to evaluate the person’s motor

performance and range of motion prior to a driving evaluation. Upper

extremity steering strength and range of motion are frequently included in

pre-driving evaluations. 

Primary care physicians may wish to consult ophthalmology or physical

medicine and rehabilitation to assist with evaluation of these dysfunctions.

Effects of Cognitive Impairments

Because driving places high demands on the brain’s ability to integrate a

number of cognitive functions, possession of driving knowledge and driving

skills are insufficient to guarantee safe driving performance. Cognitive

impairments commonly seen after TBI can influence driving performance in

several ways.

Arousal and Attention 

Following TBI, individuals often suffer from inattention. Inattention

includes impaired sustained attention and divided attention, hemispatial

neglect, and slowed information processing speed — all of which can

compromise driving capabilities. 

Executive Abilities 

Changes in executive abilities as a result of TBI were presented in Section 5.

Dysfunction in mental flexibility, sequencing ability, monitoring, and

allocation of cognitive resources, and problem solving can impede the

individual’s driving performance. These dysfunctions may be expressed as

difficulties in navigation planning, the ability to handle unexpected road

conditions, the ability to consider multiple decision alternatives and their

consequences, and the ability to perform multiple simultaneous tasks.

Visuo-spatial Perception and Skilled Motor Abilities

The ability to see accurately, to judge depths and speed, and to perceive

changes in the environment are important for safe driving. Impairments in

Traumatic Brain Injury

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114
Traumatic Brain Injury

Driving Issues after TBI

115

visuo-spatial perception, visual scanning ability, perception of focus, spatial

relations, color perception, and perceiving figure-ground relationships can

obviously interfere with driving performance and safety. 

Effects of Neurobehavioral Dysfunction

Neurobehavioral changes frequently include impulsivity, aggression, lack of

insight, and substance abuse. These behaviors can lead to risky driving

behaviors, which may endanger the safety of the driver, passengers,

pedestrians, and other vehicles and property. 

Other Factors Affecting Driving Capabilities

Seizures 

The overall incidence of epilepsy among individuals with severe TBI is

estimated to be 17.2% (Annegers & Cohen, 2000). A seizure during driving

can impose a great threat to public safety. Some investigators have shown a

40% increased risk in serious injuries due to automobile accidents in this

population (Taylor et al., 1996). However, there is no common nation-wide

law that restricts driving for patients with epilepsy. Most states require

people with epilepsy to be seizure-free for a certain period, ranging from 3

to 12 months. Other states have more flexible restrictions, basing the

required seizure-free period on clinical factors (Krauss et al., 2001). Thus, it

is the responsibility of the physician to help determine when their patients

may drive, with the intent being to protect the public and patient safety

optimally while permitting patients with controlled seizures to drive. 

Medications 

Psychotropic medications, commonly prescribed for individuals who have

sustained a TBI, include benzodiazepine, neuroleptics, narcotics, hypnotic

sedatives and barbiturates, and antidepressant medications such as SSRIs

and tricyclics (see Section 6 for more details on pharmacological

treatments). The medications can influence driving capabilities by: affecting

visual abilities; causing fatigue, drowsiness, and slowed reaction time; and

decreasing attention and multitasking abilities (Hopewell, 2002). Other

agents, frequently prescribed in the TBI population to treat general medical

problems, may also affect the above driving abilities (e.g., b-blockers, anticonvulsants, sedating antihistamines, etc.) or interact with the primarily

“psychotropic” medications. As always, physicians should be aware of

potential interactions and the effects of multiple prescribed medications

and monitor or assess side effects.
Traumatic Brain Injury

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116

Pre-driving assessment

There is no universally accepted standardized driving evaluation for

individuals who have sustained a TBI. Current pre-driving assessment and

training methods typically include neuropsychological evaluation, behindthe-wheel evaluations, reaction time measures, and assessment of visual

abilities including acuity, night vision, and depth perception (Schultheis,

2000). However, neuropsychological test performance has been found to

have highly variable predictive power 0.20 to 0.95 (Schultheis, 2000).

Computer-based driving simulators create a safe means of replicating actual

driving conditions including hazardous situations (emergency vehicles,

surprise pedestrians), and poor weather and lighting conditions (rain, glare)

that would be difficult to achieve otherwise. But further research is needed

to verify a driving simulator’s reliability and validity in predicting driving

capabilities. 

Driver Rehabilitation Programs

A driver rehabilitation program for individuals who have cognitive and/or

physical deficits secondary to brain injury should include a pre-driving

assessment, a behind-the-wheel assessment, education, and training. These

components are necessary to ensure that individuals are safe to operate a

motor vehicle on public roads. This multi-faceted rehabilitation approach is

initiated by referral from a physician, who has determined that the patient is

medically stable and able to receive this comprehensive evaluation. 

VA has 39 Driver Rehabilitation Centers nationwide. Information on the

program and location of centers is available at http://www1.va.gov/health/

rehab/dvrcnters.html.
VA TBI System of Care VA TBI System of Care

Traumatic Brain Injury 117

Section

10

Learning Objectives

1. Describe the TBI continuum of care within the VA.

2. Identify the VA Brain Injury Network of Care and its components.

3. Describe the unique benefits available to veterans within the VA 

as well as within other federal, state, and community agencies.

4. Identify the exceptional, life long issues that impact the brain 

injured veteran and caregiver.

Introduction

The Department of Veterans Affairs (VA) recognizes traumatic brain injury as

a priority condition for health care services. It is one of the Special

Disability Populations subject to VA’s congressionally mandated Capacity

Report. The VA is required to maintain its capacity to provide specialized

care for veterans sustaining a brain injury. TBI is also designated as one of

its’ Special Emphasis Programs for which national performance measures

are in place. A long-standing national agreement between the Department

of Defense (DoD) and VA provides for transfer of active duty personnel who

have incurred a brain injury to VA medical centers (VAMCs) for care.

The VA established a system of care with the goal of assisting active duty

military and veterans sustaining a brain injury in progressing along the

continuum of care (Table 1, next page) toward achieving optimal clinical

outcomes. This section provides an overview of the different levels of care

that may be needed when providing for individuals with a TBI. It includes a

brief history of the development of the TBI Network of Care, the structure,

management of referrals, and the roles and functions of the designated

sites. Due to the catastrophic nature of brain injury, maximizing available

resources can be crucial. Sources of assistance within VA as well as state and

local entities are provided to assist health care providers, survivors, and families.
Providing a Continuum of Care

Persons having sustained a traumatic brain injury may require different

levels of TBI-specific and other supportive care throughout their lives.

Ideally, patients follow a typical treatment course in which they initially

receive acute medical, proceed to the acute level of rehabilitation, and

progress to more independent settings such as home with an outpatient

program. However, some patients due to the severity of their brain injury

and/or other medical issues would not benefit from acute rehabilitation or

cannot tolerate such an intensive approach. Unfortunately, some patients do

not progress and will not benefit from intensive rehabilitation. These

patients will likely require long-term care (see Appendix A) that is offered in

the least restrictive setting possible. 

Ongoing follow-up assessment of the TBI survivor is key to managing sequelae

and preventing development of secondary conditions. A TBI survivor is

vulnerable to life events that typically occur and effect general health status.

Something that may seem relatively insignificant can potentially result in a

dramatic change in the ability to care for oneself. Quite likely, it is the primary

care professionals that will be following the TBI survivor for the long-term.

Consulting with TBI specialists will assist in providing appropriate ongoing care.

Traumatic Brain Injury

VA TBI System of Care

118

Trauma Care • Emergency Room/Trauma Center

• ICU

Specialized Acute Inpatient Rehabilitation • High Intensity Rehabilitation (3-5 

hours per day)

• Patient actively participates

Sub-Acute Rehabilitation • Lower Intensity Rehabilitation 

(< 3 hours per day)

• Ventilator Care

• Coma Care

Post-Acute Rehabilitation • Outpatient

• Day Treatment

• Home Care

Community Re-entry • Transitional Living

• Independent Living

• Vocational Rehabilitation

• Supportive Employment

Extended Care • Skilled Nursing Facility

• Neurobehavioral Management

• Assisted Living

• Adult Day Care

• Respite Care

Components of a Continuum of Care for TBI

Table 1
Development of a VA/DoD TBI Network of Care

Prior to 1992, the VA used multiple approaches to provide specialty care

across the continuum for veterans and active duty members having

sustained a traumatic brain injury. Physical Medicine and Rehabilitation

Services with a special interest in this condition acquired additional

knowledge and skill to enhance their capability of providing TBI-specific

medical care and rehabilitation. However, this specialized care was not

integrated throughout the VA’s health care system. 

In February 1992 the Defense and Veterans Head Injury Program (DVHIP)

was established and funded by Congressional appropriation. The mission

charge to the program was:

“The purpose of this project is to seek to define optimal care

and rehabilitation utilization for patients with TBI...It is

intended that this effort facilitate the referral of TBI patients

among DoD and DVA facilities.” (E. Mendez, ASD, DoD Health

Affairs, Dec. 1991)

In 2002, DVHIP was restructured as The Defense and Veterans Brain Injury

Center (DVBIC). DVBIC has become proactive since it’s inception,

developing multiple new programs that will enable patients evaluated in the

DVBIC to have multiple treatment options at each site. The program helps

to ensure that all military and veterans personnel with traumatic brain

injury receive TBI-specific evaluation, treatment, and follow-up. Clinical

care and research is conducted at both military and VA sites that allow

DVBIC to complete innovative single and multi-center trials to inform future

clinical care and treatment strategies. Research conducted by the DVBIC has

helped define optimal care for survivors of TBI.

The DVBIC is currently comprised of DoD, VA, and civilian specialized brain

injury sites:

• Walter Reed Army Medical Center - Washington, 

DC Center Headquarters

• Naval Medical Center San Diego - San Diego, CA

• Wilford Hall Medical Center - Lackland Air Force Base, TX

• James A. Haley Veterans Hospital - Tampa, FL

• Minneapolis Veterans Affairs Medical Center - Minneapolis, MN

• Veterans Affairs Palo Alto Health Care System - Palo Alto, CA

• Hunter McGuire Veterans Affairs Medical Center - Richmond, VA

• Virginia Neurocare, Charlottesville, VA 

For additional information contact the DVBIC Headquarters 1-

800-870-9244 or visit their Web site at http://www.dvbic.org.

Traumatic Brain Injury

VA TBI System of Care

119

Point to remember: 

• The needs of survivors are unique and may require intensive long-term 

management and support beyond acute rehabilitation
Traumatic Brain Injury

VA TBI System of Care

120

The DVHIP formed the nidus for further development of TBI services within

the VA. Additional VAMCs were identified who were willing to support and

provide components of the TBI continuum of care. They became known as

Network TBI Centers. The original four VA DVHIP sites became known as

Lead Centers because they provide the full spectrum of TBI care. VA Under

Secretary for Health officially recognized this system of care in an

Information Letter issued in February 1997.

Each of the participating medical centers has a designated TBI coordinator

who facilitates patient care, expedites facility transfers, and community

placement. A National TBI Coordinator position was established within the

Rehabilitation Strategic Healthcare Group to monitor and maintain this

system of care.

VA TBI Network of Care: Major Roles and Functions

VHA Brain Injury Rehabilitation Sites

TBI Lead Centers (4)

• Located in tertiary care medical centers 

• Accredited in Brain Injury Medical Rehabilitation by the 

Commission on Accreditation of Rehabilitation Facilities (CARF)

• Dedicated TBI Interdisciplinary Treatment Teams 

• Provide the full spectrum of rehabilitation services

• Accept admissions nationwide, including active duty military 

• Focus is on rehabilitation in the acute and early post-acute phase

• Assist other health care providers with assessment and treatment 

planning

• Identify federal, state, and community resources

TBI Network Centers (18)

• CARF accredited in Comprehensive Inpatient 

Medical Rehabilitation 

• Provide components of specialized care 

• Staff have an interest in TBI rehabilitation

• Usually located closer to the patient’s home

• Coordinate continued rehabilitation after discharge

• Follow the patient in their catchment area for the long-term 

duration of service needs

• Provide care coordination

• Identify federal, state, and community resources

Point to remember: 

• DVHIP (now DVBIC) established the original structure for a coordinated 

system of Brain Injury Care for the VA and DoD.
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121

TBI Associate Network Centers (5) 

• Provide TBI-specific case management

• Assist with coordination of care

• Identify federal, state, and community resources

• Provide education to survivors and families

• Outsource services as needed

• Follow the patient in their catchment area for the long-term 

duration of service needs

Consultation and Referrals

To facilitate management of referrals and coordination of care across the

system, the TBI Network of Care is organized regionally (Table 2). The TBI

Lead Centers, having the most expertise and experience, consult and guide

other programs in their region to best meet the needs of the survivor and

family:

Point to remember:

• All VA TBI Lead centers offer specific comprehensive acute Brain Injury 

Rehabilitation. The scope of care at the Network and Associate Network 

Centers varies from site to site.

1, 2, 3, 4, 5, and 6 Richmond VAMC (804) 675-5332

7, 8, 9, 16, and 17 Tampa VAMC (813) 972-2000, ext. 6185

10, 11, 12, 15, and 23 Minneapolis VAMC (612) 725-2000, ext. 3562

18, 19, 20, 21, and 22 Palo Alto HCS (650) 493-5000, ext. 66150

For VISN’s TBI Lead Center Phone Contact

Table 2
For additional assistance, contact Gretchen C. Stephens, VA National

Traumatic Brain Injury Coordinator at (804) 675-5597 or e-mail at

gretchen.stephens@med.va.gov. National program information and points

of contact are updated and available at http://www1.va.gov/health/rehab/

index.htm.

To facilitate decision making for referrals and coordination of care across the

system, a TBI Referral Algorithm (Appendix B) was developed and

implemented by the TBI Network case managers and coordinators.

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122

Point to remember:

• Contact a TBI Lead Center for assistance with TBI care planning. TBI Case 

Management helps ensure continuity of care

VHA TBI Network

Lead Centers

James A. Haley Veterans Hospital – Tampa, FL

Minneapolis VAMC – Minneapolis, MN

Veterans Affairs Palo Alto Health Care System – Palo Alto, CA

Hunter Holmes McGuire VAMC – Richmond, VA

Network Centers

VAMC Albuquerque, NM VAMC Augusta, GA VAMC Bay Pines, FL

VAMC Boston, MA VAMC Denver, CO VAMC Hines, IL

VAMC Houston, TX VAMC Indianapolis, IN VAMC Knoxville, IA

VAMC Little Rock, AR VAMC Long Beach, CA VAMC Martinsburg, WV

VAMC Northport, NY VAMC San Juan, CA VAMC Seattle, WA

VAMC Tuscaloosa, AL VAMC Tuskegee, AL VAMC West Los Angeles, CA

Associate Centers

VAMC Albany, NY VAMC Cincinnati, OH VAMC Pittsburgh, PA

VAMC Temple, TX VAMC Wichita, KS
Traumatic Brain Injury

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Resources and Outreach

It is important to be aware of all resources that may be available to veterans

and their families dealing with the impact of traumatic brain injury. These

programs and services may be a valuable source of assistance. 

Health Care Benefits: Maximizing Resources

Upon enrollment, veterans are placed in one of VA’s Enrollment Priority

Groups (http://www.va.gov/elig/Priority%20Groups.htm) 1 through 8, with 1

being the highest priority group. Veterans in enrollment group 5 or higher,

having sustained a brain injury may qualify for the Priority 4 group through

a formal Catastrophic Disability Evaluation. The provider, the veteran, or

his/her representative may request the evaluation. Contact the Enrollment

Office at a local VA health care facility for information on how to request an

evaluation. Moving to Priority 4 enrollment group does not eliminate

responsibility for co-payments as a result of means testing. 

Active duty, retired service members, and retired reservists may be eligible

for health care under the military health system. Information regarding

eligibility and benefits under TRICARE can be found at:

http://www.tricare.osd.mil/. 

Veterans covered under other insurance providers may be able to obtain

TBI-specific services closer to their home. 

Veterans Benefits Administration (VBA)

Vocational Rehabilitation and Employment (VR&E) Program

Veterans who have a service-connected disability that was incurred or

aggravated in service are potentially eligible for vocational rehabilitation

services. VR&E Vocational Rehabilitation Counselors in the VBA Regional

Offices will determine if a veteran is entitled and demonstartes a need for

vocational rehabilitation services in order to prepare for employment.

(Appendix C). Information on location of VBA Regional offices is available

at: http://www.vba.va.gov/bln/vre/regional_offices.htm. (The printable

Vocational Rehabilitation application form (VA-1900) is located at

http://www.vba.va.gov/bln/vre/self_serv.htm).

Point to remember:

• Identifying a veteran as catastrophically disabled may help to maximize VA 

health care benefits.
Independent Living Program

Independent living generally refers to the empowering of individuals to take

control of their own lives, live autonomously, and participate fully in society.

Independent living services (Appendix D) are provided through the

Department of Veterans Affairs Vocational Rehabilitation and Employment

Program. These services are intended to improve the ability of a veteran to

function more independently within his/her family and/or community.

Independent living services do not require a program goal of return to

work. The printable application form (VA-1900) is located at

http://www.vba.va.gov/bln/vre/self_serv.htm. Additional information is

available at http://www.vba.va.gov/bln/vre/ilp.htm.

Other VA Programs 

VA has a number of special needs programs that in some instances may be

appropriate for persons with brain injuries. These programs are not geared

specifically for the individual who sustained a TBI; therefore, the individual

may need to be functioning at a fairly high level, e.g., independent in

activities of daily living and does not require close supervision.

Homeless Veterans Program

The VA’s specialized homeless veterans treatment programs offer a variety of

programs and services such as:

• Domiciliary Care for Homeless Veterans

• Supported Housing Program

• Comprehensive Homeless Centers

Additional information about these programs and others is available at

http://www.va.gov/homeless. 

Veterans Industry

Veterans Industries is a vocational rehabilitation program of the Department

of Veteran Affairs that subcontracts with many and diverse industries. They

provide temporary and permanent staffing for information technology,

manufacturing, warehousing, construction, office support, retail, and the

services delivery industry. They also provide outsource support in assembly,

packaging, sorting, grading, reclaiming, and recycling.

Traumatic Brain Injury

VA TBI System of Care

124

Point to remember:

• Service-connected veterans with TBI should apply for Chapter 31 benefits 

through VR&E for Independent Living Services
Traumatic Brain Injury

VA TBI System of Care

125

Veterans Industries programs develop an individual rehabilitation plan for

each veteran. And, depending on the specific program location, Veterans

Industries provides a wide range of support services to the veteran. These

include: 

1. Transitional work experience 

2. Sheltered work therapy 

3. Career development/job placement and follow-along services 

4. Employment education and job readiness training 

5. Vocational assessment (situational) 

6. Transitional residence (residential rehabilitation) 

7. Vocational counseling and case management 

Additional information is available at http://www.va.gov/vetind. 

Other non-VA Resources and Programs 

The Brain Injury Association (BIA)

The BIA partners with many federal, state, and other agencies to promote

awareness, education, prevention, public policy, and research related to

brain injury. BIA is an excellent resource for health care providers, families,

and survivors. Their Web site (http://www.biausa.org) contains educational

materials, links to state chapters, support groups, and many other

resources. They also maintain a toll-free Family Help line 1-800-444-6443. 

TBI State Grant Programs

A number of states across the country have received federal grants from the

Health Resources and Services Administration (HRSA) in conjunction with

the 1996 Traumatic Brain Injury Act. These grants are specifically for

providing access and development of programs and services for survivors

and families. The Web site contains information about these funded

programs: http://www.tbitac.org. 

State Vocational Rehabilitation Departments

Every state offers vocational rehabilitation services for individuals with

disabilities. Vocational Rehabilitation is a joint federal-state program that is

administered by each state, so the available services vary from state to state.

Services may include assessment/evaluation, job training, and assistance

with job placement, supported employment services, and independent

living services. In some cases, Vocational Rehabilitation agencies also may

Point to remember:

• There are other programs within VA that are not specifically geared to persons 

with Brain Injury, but may be a viable resource depending on the needs and 

abilities of the veteran
pay for rehabilitative services at private programs, technical/vocational

training (at technical schools), or post-secondary education.

Life Care Management Considerations

In addition to medical care for their brain injury, veterans and their

caregivers may need assistance with a variety of non-medical issues that can

significantly impact their functioning and managing in the community

setting. These may include but are not limited to:

Guardianship

When a patient is felt to lack the capacity and or judgment to make

decisions regarding themselves or personal affairs the state may assign a

guardian. The guardian can be a family member, other interested party or

professional guardian chosen by the family or state. States differ on

mechanisms of determination and assignment. Court fees may apply.

Fiduciary

In instances where a veteran is felt to lack the capacity or judgment to

handle their VA monies, a fiduciary may be assigned through the local VA

Regional Office. The fiduciary may be a family member or professional

fiduciary. The fiduciary only manages VA monies such as compensation or

pension benefits.

Representative Payee

In instances where it is felt that a person lacks the capacity to manage their

Social Security benefits, the Social Security Administration (SSA) may assign

someone as their representative payee. This can be a family member, other

interested party or a guardian. For further information visit the SSA Web site

at http://www.ssa.gov.

Advance Directives

Legal documents such as a Living Will, Durable Power of Attorney for Health

Care, and Health Care Surrogate are collectively known as Advance

Directives. Advance Directives can only be completed by an individual who

at that time has the capacity to understand the content and consequences.

Advance directives only go into effect when a person cannot communicate

their wishes. If advance directives do not exist, the legal next of kin or

guardian will be asked to make health care and end of life decisions for a

patient.

Traumatic Brain Injury

VA TBI System of Care

126

Point to remember:

• There are Federal, State, and local organizations outside of VA that can provide 

a variety of resources to persons with brain injury 
Life Care Planning

A Life Care Plan is a tool to help manage the individual with a brain injury,

over his/her life expectancy and to manage resources and finances. A Life

Care Plan should be prepared by a person who is a Certified Life Care

Planner with advanced life care planning, training and experience in

traumatic brain injury, case management, or a medical care expert. The

International Academy of Life Care Planners offers credentialing. 

Veteran Service Organizations

AMVETS - http://www.amvets.org

Provides information and counseling to veterans on matters such as

education, disability compensation, employment, hospitalization, pension,

and other benefits.

VETERANS OF FOREIGN WARS (VFW) - http://www.vfw.org

Advocates for and with veterans of foreign wars. Provides counseling

services and educational programs to veterans.

DISABLED AMERICAN VETERANS (DAV) - http://www.dav.org

Provides counseling services to veterans with disabilities and advocates on

behalf of the veterans.

PARALYZED VETERANS OF AMERICA (PVA) - http://www.pva.org

Provides services to veterans with disabilities on matters such as serviceconnected disability compensation, loan guarantees, medical care,

educational benefits, government insurance, and benefit claims and appeals.

Client Assistance, Protection, and Advocacy 

Each state offers Client Assistance Programs (CAP) and Protection and

Advocacy (P & A) Systems. (Appendix E). These programs offer valuable

resources to people with traumatic brain injury and their families who meet

eligibility criteria. In the event an individual is not found eligible for services,

the CAP or P & A System will provide assistance to locate other resources.

Traumatic Brain Injury

VA TBI System of Care

127

Point to remember: 

• Non-medical issues such as financial and legal concerns may be brought up 

by a patient/care giver in the ambulatory care setting and may impact the 

patient’s overall health. It is important for the primary care provider to be 

aware of these issues and of the resources that can help.
128 Traumatic Brain Injury
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144 Traumatic Brain Injury
Traumatic Brain Injury 145

Appendix A:

Long-Term Care

Appendix A: A Long-Term Care

Long-Term Care

Long-term care is no longer an automatic referral to a nursing home. Today,

long-term care has come to mean living with a brain injury in the least

restrictive environment best suited to meet the individuals’ needs. The

individuals’ physical, emotional, and behavioral needs, along with severity

of injury (both physical and cognitive) determine which option is best.

There are many options available for long-term living. Ideally, a placement

facility will be familiar with the complexities of brain injury. If it is not

possible to locate a facility familiar with brain injury, staff will need to

educate the facility staff to help ensure a successful placement. Here are

some alternative options:

a. Living in an independent apartment or private home — This

option allows the individual to remain in familiar surroundings

and to live as independently as possible. The key to success is

finding the right people to serve as supportive help or

companion caregivers. If families are unable to provide this care

there may be agencies in the community that can provide this

service, or make recommendations, or contact the State

Department of Vocational Services or Human Services. Funding is

usually through private funds or community resources. Respite

Care is an invaluable resource to caregivers and patients, offering

a break from each other and allowing the caregiver time to

themselves. A companion or sitter may provide respite in home.

It may be provided outside of the home in an adult day care or

assisted living or nursing facility, depending on the individuals

needs. Respite care is time limited, ranging from a few hours per

day, a week, or short-term placements. Funding is usually

through private funds, but may also be provided through some

private insurance plans or community resources. Day Programs

may also be utilized to help patients remain in the home by

giving them meaningful, engaging, structured activities during

the day while the caregiver is at work. Many VA Medical Centers

offer respite care and day programs.

b. Cooperative supported apartments are available in some

communities by local agencies. These apartments are for persons

with brain injury who can live without much supervision. Usually
Traumatic Brain Injury

Appendix A: Long-Term Care

146

a caseworker or case manager monitors the individual. Local

Centers for Independent Living should have information on these

facilities. Funding is usually through private funds or community

resources.

c. Group homes are another option for long-term living. These

homes are usually licensed by the State Department of Health or

Social Services. In group homes, the person engages in social and

some leisure activities. Funding is usually through private funds

or community resources.

d. Community-based residential treatment centers – these are

larger community based facilities that provide rehabilitation and

other therapeutic activities. They are staffed around the clock

with trained staff and the facilities are licensed by the appropriate

state agency. Funding during rehabilitation may be through

private funding, insurance benefits, or community resources.

Funding beyond the rehabilitation phase is usually covered by

private funds.

e. Assisted living facilities – these are facilities that provide 24-

hour supervision and are licensed by the state. Services vary but

may include assistance with daily living activities, meal

preparation, medication monitoring, transportation, and leisure

activities. Therapy and nursing services are not usually provided

but may be contracted or obtained through community, Medicaid,

or insurance benefits.

f. Skilled nursing facilities – these state licensed facilities provide

round the clock nursing care and supervision for persons with

complex health and medical needs including vent care. They may

provide subacute care or long-term (custodial) care. Cost for

subacute care is usually covered through insurance or Medicare

benefits or private funds. Long-term (custodial care) is usually

funded through private funds or Medicaid. 
Traumatic Brain Injury 147

Appendix B:

TBI Referral Algorithm

Appendix B: B TBI Referral Algorithm

The TBI Referral Algorithm original is also located at the following Web site:

http://www.va.gov/health/rehab/tbi_referral_algorithm.doc

See Page 148 for full view of Algorithm 
Traumatic Brain Injury

Appendix B: TBI Referal Algorithm

148
Traumatic Brain Injury 149

Appendix C:

VBA Vocational Rehabilitation

and Education Program

Appendix C:

VBA Vocational Rehabilitation

and Employment (VR&E) 

Program

C

Eligible veterans with disabilities may receive rehabilitation services through

VBA’s VR&E program, which may include an extended evaluation,

independent living services, educational or vocational training, employment

services, or a combination of any of these. If neccessary, training may take

place in a college or university, technical school, on-the-job training or in a

specialized rehabilitation program (for individuals with severe disabilities).

VA pays for the costs of tuition, books, supplies, and equipment and may

pay for other special services (e.g., transportation, tutorial assistance,

adaptive equipment, services). The VA may supply a monthly stipend in

addition to compensation benefits received by the veteran. Throughout the

program, the veteran will receive assistance in locating and obtaining a

suitable job.

Veterans who are rated unemployable by the VA due to a service-connected

disability may request an evaluation by VR&E, and if entitled, may

participate in a program of rehabilitation services and receive assistance in

securing employment under the VR&E program. Should the veteran then

secure employment; his/her unemployability rating is protected from

reduction until he/she has worked continuously for 12 months. 

Additional information on VR&E is available at

http://www.vba.va.gov/bln/vre/index.htm.
150 Traumatic Brain Injury
Traumatic Brain Injury 151

Appendix D:

VBA VR&E Independent Living Eligibility

and Services

Appendix D:

VBA VR&E Independent Living Eligibility

and Services

D

The VR&E Program offers Independent Living (IL) services for veterans who

meet the eligibiliity and entitlement requirements for the VR&E program,

who demonstrate an IL need and who do not currently have employment as

a goal.

Eligibility

• Must have a discharge other than dishonorable.

• Must have a compensable service-connected disability.

Entitlement

An evaluation by VBA’s Vocational Rehabilitation and Employment (VR&E)

Program will determine entitlement to Vocational Rehabilitation services

which may include Independent Living services.

Program Services

The services, which may be provided to program participants and their

families, include but are not limited to:

1. Evaluation of independent living potential;

2. Training in independent living skills;

3. Attendant care;

4. Health maintenance programs;

5. Identification of appropriate housing accommodations;

6. Reader services for those with visual impairments;

7. Interpreter services for those with hearing impairments; and

8. Special transportation assistance.
152 Traumatic Brain Injury
Traumatic Brain Injury 153

Appendix E:

Client Assistance,

Protection and Advocacy

Appendix E:

Client Assistance,

Protection and Advocacy

E

Client Assistance Programs and Protection and Advocacy Systems

investigate, negotiate, and mediate solutions to problems expressed by

persons with developmental disabilities or mental illness, or

applicants/clients of programs funded under the Rehabilitation Act, their

families or agency representatives.

These programs also offer technical assistance to attorneys, government

representatives, and service providers. They also provide legal counsel and

litigation services to eligible individuals who are unable to attain adequate

legal services in their communities. Training for advocates, consumers,

volunteers, professionals, and others is also provided.

Client Assistance Programs and Protection and Advocacy Systems are listed

in the Brain Injury Association’s National Directory of Brain Injury

Rehabilitation Services in the state resources section. For more

information, contact the National Association of Protection and Advocacy

Systems at (202) 408-9514. You can also search on the Internet using key

words “Client Assistance Program.”

Client Assistance Program

Client Assistance Programs (CAP) provides services to individuals seeking or

receiving services under the Rehabilitation Act, (including federally funded

vocational rehabilitation and independent living services).

The goal of CAP services is to help people with disabilities obtain

information and access to the array of services available through programs,

projects, and facilities funded under the Rehabilitation Act. CAP is

administered by the U.S. Department of Education, Office of Special

Education and Rehabilitation Services, Rehabilitation Services

Administration.

Protection and Advocacy for Persons with 

Developmental Disabilities (PADD) 

Protection and Advocacy Systems for Persons with Developmental

Disabilities (PADD) were established to provide advocacy services to people
Traumatic Brain Injury

Appendix E: Client Assistance, Protection and Advocacy

154

with developmental disabilities. Developmental disabilities are defined by

the federal government as chronic and attributable to mental and/or

physical impairment, which is evident prior to age 22. Such disabilities tend

to be life-long and result in substantial limitations in three or more of the

following major life activities: self-care, receptive and expressive language,

learning, mobility, self-direction, and the capacity for independent living

and/or economic self-sufficiency. An interagency project, PADD is

administered by the Administration on Developmental Disabilities, the

Center for Mental Health Services, Rehabilitation Services Administration,

and the National Institute on Disability and Rehabilitation Research.

Protection and Advocacy for Individuals with Mental Illness (PAIMI)

The Protection and Advocacy for Individual persons with Mental Illness

(PAIMI) was established to protect the rights of persons with mental illness

under federal and state statutes, and investigate allegations of abuse and

neglect of individuals residing in facilities. Individuals eligible for services

must reside in facilities that provide 24-hour care and treatment, or have

been discharged from such a facility within the previous 90 days. Programs

represent individuals in certain situations involving prisons and jails, and

transportation to and from facilities. The PAIMI system is administered by

the U.S. Department of Health and Human Services, Center for Mental

Health Services.

Protection and Advocacy for Individual Rights (PAIR)

The Protection and Advocacy Program for Individual Rights (PAIR) was

established as a national program under the Rehabilitation Act in 1993.

Through the PAIR programs, P & A systems nationwide protect and advocate

for services to persons with disabilities who are not eligible for PADD or

PAIMI programs, or whose issues do not fall within the jurisdiction of the

Client Assistance Program. PAIR is administered by the U.S. Department of

Education, Office of Special Education and Rehabilitative Services,

Rehabilitation Services Administration (RSA).
Traumatic Brain Injury 155

Appendix F:

Additional Links

Appendix F: F Additional Links

http://www.va.gov/health/rehab/TBI_Case_Managers.htm

http://www.va.gov/health/rehab/SpecPrograms.htm

http://www.va.gov/health/rehab/TBI_REFERRAL_ALGORITHM.doc

http://www.driver-ed.org

http://www.guideline.gov/summary/summary.aspx?doc_id=3121&nbr=2347

&string=brain+AND+injury

http://www.guideline.gov/summary/summary.aspx?doc_id=3122&nbr=2348

&string=brain+AND+injury

http://www.cdc.gov/ncipc/pub-res/tbi_toolkit/physicians/mtbi/index.htm
156 Traumatic Brain Injury
CME Exam CME Exam

Traumatic Brain Injury 157

1 The single most common cause of TBI is:

a. Falls

b. Firearms

c. Motor vehicle accidents

d. Sports injuries

2. Which of the following is NOT a defining characteristic of mild TBI?

a, Any alteration in mental state at the time of the accident

b. Glasgow Coma Scale score of 13-15

c. Indication that a physically traumatic event occurred 

d. Positive CT or MRI findings

3. Individuals with a moderate to severe traumatic brain injury who are

having trouble with attention, completing projects they start, and

thinking as efficiently and effectively as before may have sustained

damage to the:

a. Frontal lobes

b. Hypothalamic-pituitary axis

c. Occipital lobes

d. Parietal lobes

4. The most commonly used scale to quantify initial severity of brain 

injury is the:

a. American Academy of Neurology guidelines for grading level 

of concussion

b. Glasgow Coma Scale (GCS)

c. Post-concussion Symptom Checklist 

d. Rancho Los Amigos Scales of Functioning

5. Which of the following is NOT a potential indication for an initial CT

scan of the head following a mild TBI? 

a. Age < 50 years

b. Drug or alcohol intoxication at time of injury 

c. Emesis

d. Headache 
6. What percentage of individuals who suffer MTBI experience significant

ongoing symptoms or problems after 3 months?

a. Less than 5%

b. 10% to 30%

c. 50%

d. 75%

7. Which of the following is NOT true about “second impact syndrome”?

a. It can occur if individual suffers a second concussion, even 3 years 

after a previous concussion

b. It is a rare but often deadly condition

c. It may occur if an individual experiences two or more mild TBIs 

within a brief period of time

d. The length of period of rest following a first concussion necessary to 

avoid a “second impact syndrome” is currently unknown

8. Which of the following is NOT true?

a. At Rancho Levels I and II, rehabilitation goals include increasing 

the level of responsiveness and avoiding complications such 

as contractures

b. At Rancho Level IV and above, patients can actively participate to 

some degree in various rehabilitation therapies 

c. Patients at Rancho Levels VI and below remain either somewhat 

confused or unresponsive

d. By Rancho Level VIII patients are entirely back to normal 

9. Which of the following is NOT true about post-TBI Spasticity?

a. Spasticity can also lead to pain syndromes and skin breakdown 

b. Spasticity is best treated on an outpatient basis through primary 

care clinics

c. Spasticity must be distinguished from other causes of resistance to 

passive movement including anxiety, joint pain, heterotopic 

ossification, and contractures

d. Whenever spasticity develops, a stretching, positioning, and range-ofmotion program should be instituted 

10. Initial medical assessment in the post-acute or chronic phase of TBI

should include all of the following EXCEPT:

a. A CT or MRI scan of the head 

b. An assessment of what education the patient has received about 

TBI and recovery 

c. An understanding of the patient’s beliefs about brain injury and 

their beliefs about their long-term prognosis

d. Whether or not the patient has pending litigation related to TBI

Traumatic Brain Injury

CME Exam

158
Traumatic Brain Injury

CME Exam

159

11. Which of the following is NOT true about a neuropsychological

evaluation?

a. It can assess current cognitive functioning and identify any potential 

cognitive problems

b. It can assess potential emotional and psychological factors that might 

be affecting current functioning

c. It can evaluate limb range of motion, mobility, and balance issues

d. It can help assess the impact of secondary factors, such as litigation, 

on current functioning

12. Which of the following is NOT a common medical symptom or problem

in the individual with a moderate to severe TBI?

a. Dizziness and balance problems, while common after mild TBI, most 

frequently subside spontaneously

b. Headache is the most common pain complaint in this patient 

population but other pain sources are also frequent

c. Post-injury fatigue can have several contributing factors, so a wide 

range of possible causes should be explored including frustration, 

depression, and environmental demands

d. Spasticity usually emerges for the first time in the post-acute 

phase of TBI

13. What are the three most common cognitive problems following

moderate to severe TBI?

a. a) attention/concentration, b) learning and memory, 

c) executive dysfunction

b. a) attention/concentration, b) speech/language, 

c) executive dysfunction

c. a) reasoning, b) abstraction, c) problem-solving 

d. a) speech/language, b) visuospatial functioning, c) abstraction

14. Which of the following is true about cognitive ability recovery following

moderate to severe TBI?

a. Although some chronic problems typically remain, in the first few 

months rapid cognitive improvement is the rule

b. Memory almost always recovers to pre-injury levels

c. Minor cognitive recovery may happen over the course of 

years and decades

d. Once brain injury has occurred, there is no recovery
15. Which of the following is true regarding cognitive rehabilitation in the

individual with a chronic TBI?

a. A new trial of compensatory cognitive training may be helpful if the 

environmental or social situation has changed resulting in a 

decrement in functional independence

b. A trial of cognitive therapy is usually indicated

c. Cognitive therapy is useful for learning and memory difficulties, but 

otherwise has no utility

d. In the chronic phase of recovery, cognitive therapy is effective in 

re-establishing lost cognitive abilities

16. The consequences of long-lasting post-TBI behavioral and emotional

problems can include all of the following EXCEPT:

a. Exhaustion of financial resources

b. Higher degree of sociability

c. Increase likelihood of divorce

d. Increased isolation over time

17. Principles guiding pharmacotherapy of emotional and behavior

problems following TBI include all the following EXCEPT:

a. Familiarity with side effects is crucial, and should help guide selection 

of medication

b. Higher levels of medications are likely needed to control symptoms in 

those with TBI

c. Medication selection should be symptom-based, not diagnostic 

category-based

d. Medication should be guided by hypothesis regarding the 

pathophysiology of the symptoms

18. Which of the following statements is true?

a. Anticonvulsant medications such as carbamazepine (Tegretol) and 

Valproate sodium (Depakote) are not effective for the treatment of 

chronic agitation following TBI

b. Atypical antipsychotics (i.e., risperidone and quetiapine) are very 

useful for the treatment of chronic agitation following TBI

c. Benzodiazepines are a safe and effective medication for agitation in 

TBI and have few adverse side effects

d. Medication management of acute and chronic Agitation/Aggression in 

TBI is identical

19. All of the following are true EXCEPT:

a. A TBI secondary to being struck as a pedestrian is more in the elderly 

than in younger adults

b. Falls are the leading cause of TBI in the elderly

c. Individuals over the age of 75 are at a higher risk for TBI than all 

other adults over the age of 25

d. Men generally account for a higher percentage of TBI than women 

do, except in individuals over the age of 65

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20. In terms of prognosis or outcomes, all the following are true for the

elderly EXCEPT:

a. Chronic premorbid conditions such as cerebrovascular disease, 

alcoholism, advanced liver or renal disease, or diabetes potentially 

impede or prolong the recovery process in the elderly

b. The elderly have a more fragile physiologic status, which can result in 

a more destructive injury

c. The majority of elderly TBI survivors undergoing rehabilitation do 

not achieve functional improvements

d. The probability of poor outcome increases with advanced age 

21. Which of the following explains why many individuals with TBI have

limited energy or complain of feeling fatigued?

a. Following TBI one’s rate of metabolism often slows down, resultingin 

low energy

b. Their natural day/night cycle is disturbed following TBI resulting in 

less restful sleep

c. They have difficulty reading facial expressions and hence 

misperceive social cues

d. They have inhibitory control problems secondary to frontal 

lobe damage 

22 All of the following help explain why many individuals with TBI seem

more insensitive, egocentric, or irritable, EXCEPT:

a. Often they have language impairment in comprehension, 

such as an aphasia 

b. They have difficulty reading facial expressions and hence 

misperceive social cues

c. They have difficulty with multitasking and hence have trouble 

keeping up with normal social interchanges

d. They have frontal lobe impairment inhibitory control difficulties

23. Why is apathy, difficulty in moving forward on tasks, or passivity so

common following TBI?

a. Following TBI, many individuals become lazy and just want others to 

take care of them

b. Following TBI, one rate of metabolism often slows down, resulting in 

low energy

c. TBI commonly results in language comprehension problems, so they 

don’t know what others are asking of them

d. The apathy following TBI is a result of both frontal lobe dysfunction 

and low mental energy

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CME Exam

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24. All of the following are helpful ways of dealing with anger in family

members of those with TBI EXCEPT:

a. Acknowledge that they are in a difficult situation and that not having 

clear answers is hard

b. Never respond in anger, not even in clipped tones

c. Respond in a direct, matter-of-fact, consistent manner

d. Try to spend as little time with them as possible to avoid their anger

25. Which of the following is NOT a factor in the ability to safely 

drive post-TBI?

a. Impairments in arousal and attention

b. Impairments in executive abilities

c. Impairments in visuospatial abilities

d. Speech/language impairments such as dysarthria or Broca’s aphasia

26. All of the following are true about post-TBI seizure problems 

and driving EXCPET:

a. A seizure during driving can impose a great threat to public safety

b. Most states require people with epilepsy to be seizure-free for a 

certain period, ranging from 3 to 12 months

c. The incidence of a post-TBI seizure disorder is estimated to 

be around 17% 

d. There is a nation-wide law that restricts driving for patients 

with epilepsy

27. All of the following are true about post-TBI driving assessment EXCEPT:

a. Computer-based driving simulators create a safe means of replicating 

actual driving conditions

b. There are no VAMCs with the capacity to perform driving evaluations

c. There is a listing of VAMCs able to perform both driving evaluations 

and driving rehabilitation listed on the VA Intranet

d. There is no universally accepted standardized driving evaluation for 

individuals who have sustained a TBI

28. Which best describes the needs of a TBI patient within the 

continuum of care?

a. All brain injury patients needing long-term care require 

nursing home placement

b. All brain injury patients require acute rehabilitation

c. Brain injury patients have no further needs beyond 

acute rehabilitation.

d. TBI patients may vary in their progression throughout the continuum 

and require ongoing, coordinated disease management 

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29. To help maintain or gain independence the VA offers independent living

services. To receive these benefits a veteran:

a. Is automatically eligible for this VBA program by virtue of their 

status as a veteran

b. Must be service-connected and submit application for benefits 

(VA-1900) 

c. Need not apply, the military makes veterans aware of all possible VA 

benefits at discharge 

d. Need not apply, they are eligible by virtue of his, or her serviceconnected status

30. When the primary care provider sees a veteran with a brain injury

it is important to:

a. Be aware of the impact of common non-medical issues on 

overall health

b. Discourage the patient from contacting organizations involved in 

advocacy for the brain injured

c. Focus only on the immediate medical complaints of the patient

d. Minimize the patient’s anxiety by encouraging them to focus 

on other issues

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