Brain Injury: Severity Levels and the Recovery Process

Prognosis

People often want to know when their loved one will get better and how much the person will recover. These are very difficult questions to answer because of many uncertainties about brain injuries. Your health care team will do their best to provide you with the most accurate estimation of recovery that they can. Sometimes, however, the most honest response will be a frustrating one: “We’ll just have to wait and see.”

Many factors affect the rate and extent of recovery after brain injury. Your loved one’s physicians will be collecting and integrating all the information available as they make their assessments. Some of these factors include pre-existing features:
the medical history of the person, age, history of previous neurological problems,
the injury itself (the type and location of the injury, the depth and duration of coma, the presence of low blood pressure or oxygen levels after the injury) and
current findings (results of physical examinations, radiological studies of the brain, etc.)

The Recovery Process

The fact that the brain recovers at all is remarkable in many ways. A brain injury causes the death of brain cells (neurons). Unfortunately, the brain is one of the few places in the body that cells do not seem to regenerate. Yet, people with brain injuries often make tremendous gains.

Scientists are still unsure about all of the mechanisms that allow for brain recovery. Possibilities include: some of the neurons are just bruised or swollen and not permanently damaged. As the bruising and swelling improve, the neurons start to function again;
other parts of the brain take over the functions of the damaged areas and new connections between the remaining brain cells may form.

Regardless of the reasons, people can get better after a brain injury. However, for the reasons mentioned, predicting the degree and pace of recovery is very difficult.
A person’s recovery after a brain injury goes through a series of stages. After severe brain injury, the sequence is:coma, coma emergence, post-traumatic amnesia and
resolution of post-traumatic amnesia.

More information about these terms follows, but keep these points in mind as you read it.
These stages represent only general categories. Sometimes, recovery can stop at one of these stages and not progress to the next stage. The transition between stages is rarely abrupt; it is usually very gradual. Every person recovers at an individual pace, so it is difficult to compare the experience of one person to another.

Much of the recovery after a brain injury occurs early after the injury – usually within the first six months. Most experts agree that the brain can continue to heal for up to two years after an injury. Even after two years, people can continue to slowly improve. The reason for this continued progress is that many of the gains after the first year or two do not depend so much on the healing of the brain, as on the learning of new skills. Although difficulties, such as muscle weakness or poor memory, may not change at this point, people who are recovering are learning ways to compensate and become more functional. The recovery process at this point is more like being back in school than recuperating from a surgery.

After a severe brain injury, the person is in a coma. This means that they are unaware and unresponsive. It is a state of unconsciousness. The person can not be described as asleep or awake; there are no sleep-wake cycles. They do not speak, follow commands or open their eyes. There are, however, stages of coma, such as lighter or deeper, and these are usually measured by the Glasgow Coma Scale (GCS), see Table 1. The higher the score is, the lighter the coma stage. A person with a score between three (which is the lowest possible score) and eight is considered in a coma.

As a person’s score improves, he or she is considered to be emerging from coma. These changes usually take place gradually. For instance, people may start to open their eyes or show evidence that they have sleep cycles, but they may still be unable to speak or follow commands. As these abilities appear, the GCS no longer applies. Most rehabilitation centers now use the Rancho Levels of Cognitive Functioning to describe the progress of the person at this point (refer to Table 2.).

The term minimally conscious state refers to people who demonstrate some (but very little) awareness and responsiveness to their surroundings. Their responses are typically inconsistent. Thus, they are not considered comatose or vegetative. As the name suggests, a person is considered conscious in this state. Occasionally, physicians may prescribe medicines that help stimulate the brain, especially if a person is not becoming more responsive with time. Some people do not progress beyond this stage in their recovery process.

Most people move beyond this stage and enter what is often referred to as post-traumatic amnesia. As the name suggests, this is a stage in which the person has serious memory problems. However, it does not refer to all problems with memory after a brain injury. Post-traumatic amnesia is a technical term that refers to the stage that people are in after emerging from coma. Its main feature is the inability to remember any information from day to day. As a result, the person with a brain injury is disoriented and confused (they do not know where they are or what has happened to them). This does not mean that a person is unable to benefit from therapies, however. Evidence exists that people are able to retain basic skills that they are taught without remembering that they learned them! This is sometimes referred to as procedural or implicit memory.

In addition to having memory problems, people in post-traumatic amnesia are often agitated. Some of this agitation is a result of the brain injury itself, and some is simply a response to the confusion a person feels at this stage. It can be a frightening experience to see a loved one during this time. It is important to remember that the behavior you see is not under the control of the person. The physicians may sometimes order medicines to help relieve some of the agitation. In addition, they may order some sort of physical restraint to prevent persons in this stage from hurting themselves or others, such as a special bed or mitts. Just as important are the other steps that the whole team will take.

Post-traumatic amnesia is thought to resolve when these people are able to consistently remember basic information from day to day. Most likely, however, they will never recover any memories from a short time before their accident through the resolution of their post-traumatic amnesia. It is also important to realize that these persons can still have significant problems with their memory even though the post-traumatic amnesia has resolved. After the resolution of post-traumatic amnesia, further recovery continues. Again, it is extremely difficult to predict just how quickly and how much recovery to expect.

If you are interested in the TABLES ( Glasgow Coma Scale and Rancho Levels Of Cognitive Functioning) please go to the following link:

http://lifecenter.ric.org/content/2162/index.html?topic=1&subtopic=271