Brain Injury Information

Below you will find resources and information on brain injury in a variety of areas that may help and/or guide you through recovery.

Educating the head injured child

Educating the Head Injured Child

By: Murray Wall Murray Wall is Administrator and Teacher at the Niagara Peninsula Children’s Centre.

The Centre, apediatric rehabilitation facility operates a school. (Pre?kindergarten through high school levels) forstudents requiring extensive physical therapies.

In the past few years there has been an increase in the number of head injured children andadolescents admitted to the Niagara Peninsula Children’s Centre for treatment and education.Although the staff was used to dealing with a population having diverse needs, theirexperiences with head injured students have reinforced two ideas.

OBIA Article

  1. Each head injured child is unique in his physical, educational, behavioural, emotional,and social requirements, as well as his rate of recovery. Although there are many similar deficits among the head injured, the approach to recovery must, by the nature of thedamage, be treated very individually.
  2. The very fact that the head injured child has so many areas where intervention must be given necessitates a coordinated interdisciplinary approach. No single person has the skills to provide all that is required. An integrated program is needed to treat the physical, cognitive and psychosocial fragmentation that results from a severe headinjury.

The five hour school day is a busy one with the possible involvement of occupational, physioand speech therapy, social work, augmentative communication, and recreation, as well aseducation. On a less frequent basis the student may be seen by psychology, seating or orthotic clinics.

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Serving the education needs of the traumatically brain injured student at moderate cost

Servicing The Education Needs of the Traumatically Brain Injured Student at Moderate Cost

Each year 30,000 to 45,000 Canadian people sustain a traumatic brain injury. The majority of these people are under the age of 30. Until the mid-1980’s there was no single existing federal, provincial, or private agency concerned exclusively with the unique problems facing persons who live with the effects of head injury. This population was inappropriately placed in psychiatric institutions, schools for the retarded, or nursing homes. Unfortunately, even today, the educational needs of most children who have suffered a head injury are not being adequately met, not because of intent, but due to lack of knowledge. In the U.S., the medical and rehabilitational phases of head injury have made significant gains in the past years. More and more physicians and rehabilitation specialists are becoming involved in research and program planning. In comparison, relatively few educators have become aware of this growing dilemma, with even fewer numbers becoming involved with research and program planning.

Brain injury is a very complex phenomenon. Research has shown that in virtually all forms of traumatic brain injury, thinking and behaviour may be altered. The areas which are most affected include cognition, communication, psychosocial, academics, and psychomotor.

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Due to the perceived low incidence of traumatic brain injury, it is a financial necessity for school districts to place these students in special education classrooms on the basis of their secondary disability, such as learning disability, behaviour disorder, mental handicap, or physical disability. Additionally, there is no teacher certification for Traumatic Brain Injury as there is for other disabilities. These facts are further complicated by the lack of awareness or education about Traumatic Brain Injury by personnel of most school districts or special education cooperatives. Therefore, professionals concerned about the educational welfare of children with traumatic brain injury must work within the framework of traditional special education or regular education classrooms. It is of the utmost importance, however, that the unique educational needs of this population be considered when these students are placed in classrooms whose primary concern is that of other disabilities. Both the financial needs of the school district as well as the educational needs of the students can be satisfied by instituting support services …

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The re-entry of traumatically brain injured students into rural school systems

The Re-entry of the Traumatically Brain Injured Students Into Rural School Systems

Special education services across the country have gone through some radical changes since Public Law 94-142 was implemented in 1975 (Helge, 1980). This federal law mandated that schools provide all handicapped students with a fee and appropriate public education. PL94-142 also delineated that the services be provided in the” Least Restrictive Environment”. This stipulated that “…to the maximum extent possible, handicapped students must be educated in the company of their non-handicapped peers” (Carter & Savage, 1985).

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This law was intended for ALL school systems across the country and for ALL handicapped students, regardless of the degree or nature of their handicapping condition. However, school districts in many rural communities have experienced problems when striving to implement the services mandated in PL94-142 (Helge, 1980, 1984a, 1984b). “A district is considered rural when the number of inhabitants is fewer than 150 per square mile or when located in counties with 60% or more of the populations living in communities no larger than 5,000 inhabitants” (Helge, 19845b).

Additionally, there have been students with certain handicapping conditions who, despite guarantees with the law, have experienced problems receiving appropriate educational services. One such group of students are children with traumatic brain injury (TBI). Traumatic brain injury occurs when an individual incurs “…a serious blow or jar to the brain which may unfortunately cause disruption to his/her cognitive, social, and physical well-being” (Pollack & Savage, 1985). There are specific characteristics of persons with traumatic brain injury (TBI) that differ significantly from any other disability category.

Educating any student with special needs is a challenge for any school system. Educating a traumatically brain injured student presents a unique set of challenges. The unique needs of a TBI student combined with the weakness that a rural school systems special education program may exhibit, compound the obstacles that a TBI student may encounter in his/her pursuit of education.

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Developing a Low-Cost Rehabilitation Program - Guidelines for Family Members

Developing a Low-Cost Rehabilitation Program – Guidelines for Family Members

Reprinted by permission of Judith Falconer, Ph.D., 8343 Currant Way, Parker, CO 80134 www.brain?

OBIA Article

The day you waited for with such mixed feelings finally arrived: your family member wasdischarged from rehabilitation after sustaining a head injury. Contrary to the predictions youmay have heard the night of the accident, he did survive; he woke up; he began to talk, to eat,and maybe even to walk. Each time you met with members of the rehabilitation team, they toldyou about his progress over the past several days. You saw his progress each time you visitedand when he was home on weekend passes. Family members and friends visited in the hospital,the rehabilitation setting, and even during trips home on weekends; they all offered to helponce he was home for good. You knew things would work out, that he would continue toimprove, that you could handle it all. But now that he’s been home for several weeks, months ormaybe even years, the situation is very different from what you saw in the rehab setting andvery different from what you expected. He didn’t continue to improve; in fact, his skills andbehaviours may even have deteriorated. He did less and less each day and demanded more andmore from you. No one comes to visit him or you, including family members. It breaks yourheart to see him struggling to accomplish simple tasks. But at the same time you get angrywhen he behaves inappropriately. You realize that unless the situation changes, he may survivebut you won’t.

At this point, you’re ready to try anything which might make things better. Unfortunately,insurance benefits have usually been totally exhausted; if local head injury programs exist, youhave already discovered that he is not eligible or that the programs cannot meet his specialneeds. You may decide to design a program for him using free or low?cost resources which existin your community. The steps listed below may serve as a guide if you wish to develop aprogram to continue rehabilitation after discharge to the community.

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Family Adjustment To The Long Term Effects Of Traumatic Brain Injury Of Husbands

Family Adjustment To The Long Term Effects Of Traumatic Brain Injury Of Husbands

This paper represents the first summary report of a weekend retreat for families affected by brain injury tohusbands. The intention of this paper is to describe the experiences of these families from the perspective ofthe husbands with disabilities and their wives. Extensive data was gathered on each family and, once thisdata has been analyzed, the results may very well differ from the perspectives of these wives or husbands.However, we feel that their own accounts of the problems and helpful aids arrived at by their familiesshould be presented on their own.

The authors of the paper include Barry Willer, Ph.D., who is co-director of the Research and Training Center on Community Integration of Persons with Traumatic Brain Injury. Dr. Willer is a psychologistand associate professor in the Departments of Psychiatry and Rehabilitation Medicine at the Universityat Buffalo. Second authors are Marcia Liss & Miriam Arrigali, who are graduate students at theUniversity of Buffalo.(Tech. Report 89-2)

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It has often been stated that when one member of the family becomes disabled, all members ofthe family experience the disability in one form or another and all members of the family mustcope with the effects. The literature on families of individuals disabled by traumatic brain injuryhas demonstrated this fact time and again. Lezak (1988) describes the emotional and practicalburden felt by the primary caretaker. Usually caretakers are family members who may even beforced to give up their jobs or other pursuits so that the disabled family member receives thebest care and treatment in the home or elsewhere. Lezak cites previous research, which hasfound that caretakers (most often wives and mothers) are likely to experience significantdepression within the first year after injury.

The burden and stress felt by family members is strongly related to the behavioural andcharacterological alterations which are often displayed by individuals with traumatic braininjury (Brooks & McKinlay, 1983; McKinlay, Brooks, Bond, Martinage, and Marshall, 1981). Instrumental burden associated with providing assistance because of the individual’s physicallimitations appears to be less debilitating than the emotional burden associated with…

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Head injuries happen to families

Head Injuries Happen to Families

Perhaps it was a phone call that changed your life so dramatically. Although you didn’t know it then, many strangers would soon enter your life; most of them would be speaking “medicalese” and offering confusing and conflicting messages. One of the first things these strangers might have told you was that a person very close to you had sustained a head injury, was in a coma, and might never awaken.

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Raised with the belief that medical skill and technology could repair damaged bodies, you assume that the injured individual will recover and resume life with few, if any impairments. Maybe there will be a limp or some scars, but the person will be the same person you always knew. After all, doctors cure people, don’t they? While the injured person appears to sleep, untroubled by the social, emotional and financial problems which the head injury has caused, you make decisions, meet obligations, and survive the acute crisis. Ready or not, willing or not, able or not, you assume new roles and responsibilities. Nothing can prepare you for any of this, but you know it’s only temporary. Soon things will be back to normal.

Unfortunately, head injury is unlike other illnesses and injuries. You discover that little is known about recovery and that the few available treatment programs are incredibly expensive and located hundreds of miles away. Physicians providing treatment may simultaneously relay prognoses which range from total recovery to little hope. Or may relay information you neither understand or accept. You don’t even know what questions to ask so you don’t get answers. You know that the person who existed before the injury has changed but you’re not sure how or for how long.

Somehow, you survive the acute period and follow your loved one to a rehabilitation setting staffed by three shifts of professionals, none of whom are related to or knew the patients before they were injured. Compliance with “orders” from white cloaked professionals is usually expected and given by both patients and family members. Everyone sees (or imagines) daily progress in walking, speaking, eating, dressing—all the activities which used to be routine and taken for granted. It all looks easy, even though garbed in words like apraxia, ataxia, and hemiparesis. Everything will soon be OK.

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Religious Wellness & Trauma: One Family's Experience

Religious Wellness & Trauma: One Family’s Experience

At some time in their life, every person is faced with trauma. What form the trauma takes is not the issue. When it occurs it is an awful experience.

Generally these people are not adequately prepared to handle the trauma in such a way as to minimize the devastation inherent within the very nature of the experience. The Meaning of Wholeness: Disability and Spiritual Dignity was the title of a weekend theology seminar at Conrad Grebel College, University of Waterloo in Waterloo, Ontario, Canada. The seminar focused on issues relating to persons with physical disabilities and was sponsored by the Mennonite Central Committee, (Handicap Ministries Section). It attracted theologians and other interested church people from across North America. The accompanying three presentations formed the initial discussion for the weekend deliberations. The papers, as a unit, are published not to promote or negate any particular religious attitude or spiritual issue, rather to demonstrate the impact of religion upon the lives of individuals and their families.

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Raymond Rempel, B.A., M.S.

Throughout his lifetime Ray has been an active member of the Mennonite faith community. After their son, Jeremy’s accident, along with his wife Elsie, they co-founded the Head Injury Association of Niagara. In 1986 he left a successful career as an insurance broker and was the co-founder and executive director of the Ontario Brain Injury Association. He has also been a leader in the ongoing development of a national head injury association in Canada and more recently has taken a leading role in the organization of an international symposium designed to study the status of support for persons who live with the effects of traumatic brain injury. Ray has become a leading advocate and spokesperson for Canadians who live with the effects of Traumatic Brain Injury.

Jeremy Rempel, Age 16

Jeremy was traumatically brain-injured in a bicycle/automobile accident at age nine. Following a lengthy period of coma he has gradually re-learned and recaptured much of what he once knew and could do. With the support of …

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The Family: Planned Adjustment to Head Injury

The Family: Planned Adjustment to Head Injury

Good morning. It’s a real pleasure for me to be here with you. I’ve met a few of your people over a number of years. I’ve met Ray Rempel and Bev Mantell on the telephone in my position with the National Head Injury Foundation, and tried to assists them in their efforts; but they were also helpful in sharing information with me. When Ray spoke with me earlier in the summer, he suggested we talk about day to day, practical advice. The kinds of adjustments that you need to make, the kinds of things families needed to know to survive.

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Many times we rely on Mother Nature to solve our problems. Or we say, time will cure our ills or heal our minds, and time will mend our broken hearts. Our expectation is that there’s a natural order to life. Traumatic head injury doesn’t fit that picture, I don’t think, for either the family or the head injured people. It’s my feeling that head injury rehabilitation and adjustment requires intervention. We have to really, actively get involved in changing the catastrophe that has befallen us. This is a crisis for which you have no preparation and no experience. So, in order to overcome those obstacles, families need information and support to help the head injured person and to help themselves gain some segment of control in their lives.

The goal of my presentation is to help provide some new information and new insights on the adjustment process; to suggest some new options for managing your life; and I want to encourage you to be risk takers to get your needs met. Over the years I’ve spoken to many families and professionals, and mostly it was on the telephone when they called the National Head Injury Foundation for information. Sometimes the callers knew what they wanted. They wanted names of physicians, or rehab facilities, or lawyers, or whatever. But other times callers would call, and they really didn’t know what they wanted, and they’d end up saying, “What do you do?” meaning the National Head Injury Foundation. And it wasn’t that they didn’t know what to ask. They had so MANY questions; they didn’t know where to start. So the families need to start their head injury education in the emergency room, and you need to be informed every step of the way; you need to know what’s happening. Typically, families would say nobody talked to them, or they just got little pieces of information which weren’t helpful, I don’t think that’s always the case. I think that people usually try to talk to you.

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Adolescents with Brain Injury: Issues of Sexuality

Adolescents with Brain Injury: Issues of Sexuality

By Leslie Kahn, ACSW

This article is reprinted from i.e. Magazine, Volume 2, Issue 3, 1994.

Sexuality can be a difficult issue for adults; it becomes even more difficult to deal with whenadolescents have incurred a brain injury. Many therapists shy away from this often emotionaland certainly controversial subject. However, kids have a strong need to learn the skills theyrequire to deal with the problems they will encounter. Addressing sexual behaviour orquestions of sexuality is not meant to usurp parental values or control. Parents should beinvolved with all aspects of therapy, including education of changes in behaviour. Astherapists, health care providers and parents, we must approach sexuality at age?appropriatelevels, through individual and group counselling, sex education, and/or behaviour modification.

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Often, the focus of staff concern is impulsive actions and the inability to monitor oneself,resulting in inappropriate sexual behaviour. For those dealing with the person who is sexuallyacting out, it is important to orient the individual toward appropriate behaviours, alwaysremembering that the person is a sexually functioning individual. With children andadolescents, one must discriminate between acting out behaviours and typical developmentand acceptable experimentation.

Frequently, “sexual” behaviours start early in recovery. It may be that while still functioning ata low level a person may begin to touch or rub him or herself. The person may not discriminatebetween being alone in his room or in the middle of the therapy area. Before we label the actionas “inappropriate behaviour” we should check for rashes or catheter problems. If the touchingis self?stimulation then we should view this action as a developmental stage. Just as a youngchild learns that touch is pleasurable, we also teach when and where this action is appropriate.Keep in mind that lower level patients may be less aware of their surroundings.

It is important to help staff understand that we do not assign consequences for such behaviour,but we do need to provide redirection. Redirection may include handing the patient somethingto hold, engaging him in an activity, giving verbal or physical directions where to put hishands. If the actions are happening while the patient is alone in his room, all that is necessary isto close the door and give a little private time. Individual dignity and respect are required atevery level of recovery. Staff need to talk openly with parents and assure them that this …

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Cognitive Emotional & Behavioural Changes Following TBI: Mechanisms & Management

Cognitive Emotional & Behavioural Changes Following TBI: Mechanisms & Management

The current article presents an overview of rehabilitation following traumatic brain injury. It begins with a description of the types of brain damage which occur following head injury and the brain structures which are most often involved. The implication of damage to these structures is then discussed. Specified problems in cognitive abilities, emotional disturbance and social difficulties are described. A number of rehabilitation interventions are then described.

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First, a case example of a behavioural program designed to contain a problem behaviour is discussed. Then, research demonstrating the specifics of social skills deficits is described and the potential of social skills retraining is discussed. A memory retraining package designed to facilitate educational reintegration is discussed and its effectiveness documented in a single case research design. The type of client who will not benefit from such an approach is also described and methods of identifying and rehabilitating such clients are discussed.

Finally, the generalization of the techniques described is addressed. An adolescent with a traumatic brain injury with frontal lobe damage and cognitive impairment upon neuropsychological assessment as well as deterioration of academic performance was dramatically assisted in returning to his premorbid level of aspirations through an intensive cognitive rehabilitation program.

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Memory Disorders Following Traumatic Brain Injury: All May Not Be As It Seems

Memory Disorders Following Traumatic Brain Injury: All May Not Be As It Seems

I have the distinct honour of coming to Ottawa to give people having the last session of the day. First of all, I didn’t expect so many people here. It’s very exhilarating to see how many people have come to this meeting. The talk I am about to give will be geared towards professionals working in the field. It is going to be somewhat academic in nature, and there will be some technical terminology that I’ll use, but I’ll try my best to define it as I go.

In addition, the presentation won’t be quite exactly what was advertised in the brochure. I wanted to spend more time talking about how memory functioning breaks down rather than propose a “cure-all” for the problem. Over the course of the last several years, a number of people in the field have presented soled clinical data with regard to the rehabilitation of those with acquired disorders of memory. What seems to be missing, however, are presentations which characterize in adequate detail how the process of learning and remembering, memory functioning, might actually break down.

With that in mind. I decided it would not be the best use of time to come to Ottawa to give people several hours of ways to improve “memory”; take those ways back to your family or rehabilitation center; and, hopefully, employ them with “astounding” results. Presuming to be able to do this would be, I believe, a great disservice. I propose that it would be better, perhaps, to try to spend the time “walking” you through related neuropsychological concepts involving cognitive information processing, in order to show you where, along the way, that learning and remembering of new information can break down. Additionally, I’ll give you some examples demonstrating the above notion and, then, quite possibly, lead you to discover that many who have trouble remembering don’t have a true disorder of memory, but, rather, something else. When trying to improve memory functioning, head injury rehabilitation professionals frequently encounter problems when trying to apply successfully their techniques. Often, the patient is declared to have a problem more serious than previously believed or that he or she is not trying hard enough. Sometimes, the therapist will assume the responsibility for problems and will redouble his or her efforts in an attempt to improve performance.

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Post-Traumatic Headaches: A Pain in the Brain

Post-Traumatic Headaches: A Pain in the Brain

Headache and neck pain are the most common physical complaints following concussion (mild brain injury) and are experienced early after injury by up to 70% of persons with these types of injuries. Headache also occurs after more severe brain injury; however, for some reason, as yet unidentified, it tends to be a much less common phenomenon. Post-concussive headaches may be quite persistent; however, they cannot be positively correlated with severity of injury. Often, injured persons will seek medical care following concussion and/or cervical whiplash injury only to be diagnosed with “post-traumatic headache” (also termed PTHA). This article will provide the reader with an overview of issues related to diagnosis, treatment and outcome of post-traumatic headache.

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Although the majority of headache conditions following mild brain injury are benign, there are, on occasion, complications that occur that may require surgical intervention. Specifically, certain more serious complications may occur after closed head injury that results in persistent headache including subdural and epidural hematomas (blood collecting between the brain and the skull), abscesses, and carotid cavernous fistulas (abnormal communication between the venous blood flow and arterial blood flow). Through appropriate clinical examination and potentially additional diagnostic tests, these types of conditions can be ruled out.

There are multiple sources of head and neck pain, both inside and outside of the head. The brain itself, interest-ingly, is not a source of pain. Inside the skull the major structures responsible for pain are the thin coating over the brain at its base (dura), the venous sinuses, blood vessels and certain cranial nerves (specifically II, III, V, XI and X). Out¬side of the skull the major structures that may produce pain after trauma include the skin, muscles, arteries, joint capsules, cavities within the head such as the sinuses, eyes, ears, nose and oral cavity, cervical nerves (1st through 3rd), and the thin layer of pain sensitive tissue coating bones in the head and neck (periosteum).

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A Guide to Selecting & Retaining an Attorney

A Guide to Selecting and Retaining an Attorney

The following is a reprint of an article that first appeared in Volume 3?2 of i.e. Magazine(1995).Charles N. (Nick) Simkins is a Northville, Michigan attorney who specializes in representing personswith brain injury and their families. He currently serves on the Board of Directors of the Brain InjuryAssociation in the United States.


It is a sad fact of life that many persons with brain injury do not receive, or will not receive,adequate compensation for their injury and losses. Unfortunately, an inadequate result may bedirectly traceable to the fact that the patient’s attorney did not have an adequate understandingof the injury or its long?term consequences. Sometimes, lawyers do not have enough education,knowledge or experience to be able to analyze, understand, prepare, and present a legitimateclaim for compensation on behalf of a person with brain injury. What is worse for the personrelying on the lawyer for help is that many lawyers do not really appreciate or believe in the reality or the significance of so?called mild traumatic brain injury.

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Just as a person sustaining a traumatic brain injury needs specialized medical care, treatment,and therapy, so also do they need specialized legal representation. In our society, no one wouldlet their podiatrist perform heart surgery on them, and no one would let a five year old fly anairplane and yet, many persons who have sustained traumatic brain injury obtain legalrepresentation from the same lawyer who did their real estate closing or a friend’s divorce,without realizing that there are lawyers who specialize in this type of injury litigationthroughout North America.

Our system of justice is an adversarial system, and the amount of money paid out bydefendants or insurance companies for injuries is usually more in tune with the quality of legalrepresentation than it is with the seriousness of the injuries. The results of your lawsuit willhave an important and long?term impact on some aspects of quality of life and the morequalified and experienced the lawyer is the better that result is likely to be.

The purpose of this article is to assist and empower persons and families affected by traumaticbrain injury to be able to select and hire the most qualified attorney possible for these types ofcases. In most states, claimants have the ability to retain an attorney by the use of what is called …

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Law: The Paediatric Perspective

Law: The Paediatric Perspective

More than one million Canadian and American children sustain traumatic brain injuries (TBI) each year. Many of these injuries occur in traumatic events—e.g., motor vehicle, pedestrian, bicycling, falls or sports—which may become the subject of personal injury claims or litigation. For this reason, it is important for the parents or guardians of these children to become aware of how the civil justice system works and how this system may be of value. (For the remainder of this article I shall refer to the adults who are looking after the interests of the injured child as parents, while readers recognize that sometimes the responsible person may actually be a court-appointed guardian.) This article explores the legal aspects of paediatric brain injury. First, we shall look at the typical elements of a personal injury (“tort”) case. Second, we shall review the personal qualities which parents seek in attorneys who represent children with brain injury. Finally, we shall consider the notion of “structured settlements“—a legal device often used to ensure long-term financial protection for the injured child.

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The typical personal injury (PI) case involves three primary elements:

• Liability on the part of another (defendant)

• Injury to the child (plaintiff)

• Ability to recover damages

Trial lawyers often refer to these elements as the “three-legged stool.” As we shall see, each of these items must be present in a particular case if the child with brain injury is to be successful in recovering monetary damages for compensation. Absence of one or more of these elements in a case causes the “stool” to collapse and likely will result in the child obtaining little or no compensatory damages. Let’s now look at each of these items individually.


In every personal injury case, it is necessary for another person or entity (defendant) to be liable or legally responsible for causing the injury in question. Since most brain injuries occur in traumatic events, the typical basis of legal responsibility is the negligent conduct of the defendant. (Occasionally, however, liability may be based upon some other legal theory, e.g., product liability when a defective product is responsible for causing the injury.)

NeuroLaw: Medico-Legal Aspects of Acquired Brain Injury

NeuroLaw: Medico-Legal Aspects of ABI

Neurolaw is the new area of medical jurisprudence which deals specifically with acquired brain injury (ABI), as well as spinal cord injury. In the majority of instances, ABI results from a traumatic event. Because ABI is caused by trauma, this condition is also commonly referred to as traumatic brain injury (TBI). For purposes of this article, ABI and TBI are considered synonyms. Events which produce neurotrauma—e.g., motor vehicle crashes, falls, violence or sports activities—often become the subject of personal injury (tort), workers’ compensation or insurance litigation. Legal proceedings in ABI cases are called neurolitigation. Attorneys who represent individuals affected by ABI are designated neurolawyers. By virtue of their education, training and experience, neurolawyers have developed special expertise in the medico-legal aspects of neurological injury.

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In a previous issue of this magazine, we reviewed neurolaw from the paediatric perspective. There we looked at the typical elements of a tort case—i.e., liability on the part of another (defendant), the extent of injury to the claimant with acquired brain injury in a legal case, and the ability of the defendant to pay for the injury resulting from tortious conduct. We also discussed structured settlements which are legal mechanisms for securing long-term financial benefits in brain injury cases. Now we shall expand upon that prior discussion and I shall provide further insight into the philosophical underpinnings of neurolaw and explore the practical implications of this field for people with ABI and their families.

First, we shall examine the historical development of neurolaw. Second, we shall consider the central thesis of neurolegal practice. Finally, we shall discuss the primary principles which support that thesis.

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The High Cost of a Bump on the Head

The High Cost of a Bump on the Head

OBIA Article

We all know that the results of a “bump on the head” may range anywhere from a slight headache to major alterations in the physical, cognitive, emotional, and vocational status of an individual. Likewise, the cost in terms of dollars and cents may range from the price of a bottle of Tylenol to literally millions of dollars. To adequately address the topic “The High Cost of a Bump on the Head”, one might spend as little as three minutes or as much as a lifetime for the issues to be understood. I have, therefore, chosen to narrow the topic to include three major issues: 1) First, I will review cost in terms of the loss experienced by the family and the person with a head injury; 2) Second, I will review cost in terms of replacing or restoring that which was lost; 3) Third, I will review how economics defines and drives the rehabilitation process—for better or for worse. Through examining these three issues, I hope that we will better understand the difficulty in assigning a monetary value to intrinsic needs, such as the need for self?esteem, the need to be loved, and the need to be productive. I also hope that we will have a better understanding of why rehabilitation should emphasize an individual’s residual strengths as well as their deficits. Ultimately, it is my goal that each of us will leave this presentation with the awareness that as consumers and/or providers of rehabilitation, we are not buying or selling products. Rather, we are united in a process that incorporates a whole person, their past, present, and future, into a rehabilitation plan that minimizes the barriers and creates possibilities for a quality of life after head injury. I will conclude my talk by showing you a videotape of a conversation I had with a gentleman who is twelve (12) years post?head injury. The gentleman, whose name is Tom, will tell you what it has been like to live with a head injury and about the high cost of a bump on the head to him personally. I think his experience will touch you and will help bring this topic, “The High Cost Of A Bump On The Head”, home for all of us.


At this time, let’s examine the first two issues: 1) cost in terms of loss; and 2) cost in terms of how much money is required to restore the loss. In order for you to have an appreciation of the issues, I will ask you to do an exercise. This exercise has two components. First, I would like for you to think about the skills you possess, and quickly identify one skill that is most important to you. Please identify this skill by name and write it on a piece of paper. Examples might include, writing skills, accounting skills, skills for successfully working with people, public speaking…

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Awareness - Do I Know What I Can Do?

Awareness: Do I know What I Can Do?

Irwin M Altman, Ph.D., MBA, is the Executive Director of Rehab Without Walls®, in Phoenix, AZ

The following is a re?print of an article that first appeared in Volume 4?1 of i.e. MAGAZINE (1996)


Each day when we awaken, we make a near immediate, though not necessarily conscious,decision what our capabilities are at that moment for the task at hand. For example, can we seeclearly or do we need to don our glasses before attempting to get out of bed? Can we get out ofbed independently or do we need assistance? What assistance do we need? As the dayprogresses, we come across hundreds of such decisions with each instance requiring anassessment of our capabilities. We are compelled to make many of these self?assessmentsinstantaneously and accurately if we are to succeed and avoid possible dangerous situations.

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Now imagine for a moment, that we are rendered unable to discern accurately what we arecapable of doing. That is, we are not capable of determining what we can and cannot do.Furthermore, we are incapable of determining that we are incapable of this determination. Thiscircuitous predicament is encountered by many individuals with brain injuries and theirrespective family members, caregivers, and rehabilitation professionals who are providing themwith treatment. These individuals’ self?awareness has been affected, most often to the point ofbeing unaware that their self?awareness itself has been altered.

During the acute stage of some neurological conditions (e.g., traumatic brain injury,cerebrovascular accidents, etc.), individuals may demonstrate remarkable instances of thisdeficit. I once observed an individual with a significant right hemisphere injury who was quite angry with his aunt. When I questioned him regarding this matter, he indicated that his aunt’sarm was in bed with him all the time and would give him no peace. When I asked him to showme, he pointed to his own left paretic arm. Upon further examination, he raised his unimpairedright arm when I asked him to raise his right arm and again raised his right arm when I askedhim to raise his left arm. No form of reasoning on my part could dissuade him from hisconclusion that his aunt’s arm was in bed with him. This lack of recognition of his limb abatedand finally ceased as the individual proceeded through the acute phase of his recovery.

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Because I am Involved in Mankind

Because I am Involved in Mankind

A speech presented to The New Beginnings Conference St. Catharines, Ont. Canada

By: Frederick Russell Linge, Psychologist

My friends, I am very honoured to be talking with you today. I spoke at the New BeginningsConference in Calgary in 1982, and the intervening years have been exciting, for ourorganization and for me personally, as a survivor of traumatic brain injury.

The title of my talk today is: “Because I am involved in mankind.” This is a quotation from thepoet John Donne’s Seventeenth Meditation. It may sound odd to be addressing a group such asthis with a line of 360?year old poetry as my theme, but after all, it is precisely because we are allinvolved in mankind that we are here today. We have brought many different viewpoints andexperiences to this conference, but the one thing that unites all of us is our vigorous rejection ofan apartheid approach that would separate brain damaged people from the rest of mankindand rob us of our dignity and our humanity.

Most of us have read Alice’s Adventures in Wonderland and perhaps also the sequel, Alice’sAdventures Through the Looking Glass. In the second book, Alice steps through the minor intoanother world, a world eerily like the familiar one except that everything is reversed.

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Almost ten years ago, I was involved in a head?on automobile collision that left me with severebrain damage and thereby changed my life entirely in the space of a split second. When I cameback to consciousness, it was as if I had suddenly found myself in Alice’s minor world…. aworld that was familiar and yet was strange. It seemed as if my family and other people werestanding on the other side of a minor, waving and calling out and trying to reach through theglass to me. I remember my rage and despair and the futile questions I asked in those earlyyears: “Why me?” I remember also the grief at what I had lost and the desperate desire to goback and be my old self again in my old familiar world.

I realize that for many of us who have suffered brain damage, there will be no turning back, nopassing again through the minor into the “ordinary” world, no closing of the book and puttingit back on the shelf if the story isn’t happy. I have discovered one thing, though. In this “other”world just as in the “ordinary” one, we, to a large extent, each write our own script. Whetherthere is a “happy ending” or not also depends largely on us.

I am in the unusual position of being a clinical psychologist who suffered brain damage andwho has slowly returned to almost full functioning. I have been on the outside looking out.

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Beginnings of a Change in Direction

Beginnings of a Change in Direction

Comments by Gerald W. Bush, Ph.D.

Mr. Bush is Past Chairman of the Board ? NHIF Director, Employee Benefits Program Heller School, Brandeis University Waltham, MA 12254,/p>

Mr. Bush is the father of Patrick Bush who is a young man who sustained severe head injuries. Presented at: HEAD INJURY FRONTIERS, NHIF, 6th Annual Symposium, San Diego,CA


Samuel Gridley Howe quoted in Wolf Wolfensberger: Normalization p. 59

I thank you for having me here today to address you. As many of you know, I have announcedthat I will not seek a fourth term as its volunteer Chairman of the Board of NHIF.

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The mission of the National Head Injury Foundation and, I hope, everyone associated withhead injury is: to improve the quality of life for persons with head injury and their families, and todevelop and support programs to prevent head injury. This statement seems simple enough, but itcan be profound in its implications. All of us ? individually and collectively ? have a deepethical, family and professional responsibility to think through its implications for our personalbehaviour and for our institutional behaviour.

We must all ask the question: What is rehabilitation? and Rehabilitation for what role in society?

Roger L.I. Wood has written: an unintentional shaping procedure can develop which allows a patient,whilst still in a disoriented, confused or partially conscious state, to gradually associate disruptivebehaviour with attention from nursing staff (an experience which can have rewarding qualities). Slightly …

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Empowerment: The Next Challenge

Empowerment: The Next Challenge

A speech delivered to the Ontario Brain Injury Association, “New Beginnings” Conference, Toronto,June 1988.

By: Al Condeluci, MSW, Ph.D.

Dr. Condeluci has been an advocate and catalyst for innovative community based services for severelydisabled people in Western Pennsylvania since 1970. He is Program Director for Independent Livingwith United Cerebral Palsy and is administratively and programmatically responsible for all programsoffered through United Cerebral Palsy. Al is also associated with the University of Pittsburgh,Community College of Allegheny County, and does private organizational consulting.

This is such a nice sized audience. What a great turnout for the Ontario Brain Injury Association. I really salute Ray Rempel, President Bev Mantell and the staff here at the OntarioBrain Injury Association, for getting together, not only an exciting conference, but one that Iunderstand is standing room only. I certainly also salute you, the participants. I know howvaluable your time is and how difficult it is to get time away from your busy schedules to come here today to talk, to learn, to dialogue, to share and compare. Essentially, that’s what I’m herefor as well. I don’t come before you as any kind of an expert, as much as I come before you as aperson who has a passion about injustice. A passion about what’s happened to people whohave disabilities in this country, not just with head injuries but with disabilities in general.

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I see that a lot of the issues that are occurring in the head injury movement today are related tothe kinds of things that have happened in the past to other disability groups. They are thereasons why we see people with disabilities as second class citizens throughout Canada, theUnited States, and in fact the world. In this spirit I’m going to share with you some ideas andthoughts I have about this issue of devaluation. I’ll share conclusions I’ve come to as I’ve lookedaround for the last seventeen years or so that I’ve been involved in the disability movement. I’llattempt to articulate some of the reasons why I think we’re at the place we’re at. Along with thenegative aspects of this kind of analysis, I’m going to also share with you why I think we canmove forward and why I think tomorrow is so much brighter for people with disabilitiesthroughout North America. Consequently, I’m going to share with you some ideas, conceptsand thoughts that I’ve generated, some that are certainly viable concepts from other strugglesand other minority movements that cause a “gestalt” in my thinking as to where we need to go.So, without further ado, let’s talk about the issues.

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From the Patient's Point of View

From the Patient’s Point of View

LEIR, Lake Erie Institute of Rehabilitation, a rehabilitation hospital for patients with brain injuries, located in Erie, PA had a group that meet weekdays from 8:30 to 9:30. This group is called SDL. SDL means Strategies for Daily Living.

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As a result of our head injuries every one of us has suffered some type of limitation of cognitive abilities. The limitations range from very slight to severe, but it is something we all share. Limitations can be in memory skills, or speech impediments, lack of organizational skills, difficulty in forming questions, lack of social skills, writing difficulties and a change in problem solving skills.

The SDL group has a big effect on the patients who participate in the group. One of the biggest effects that the SDL group has on members is that it promotes independence through the use of strategies. Some strategies we practice include: finger pacing (tapping simultaneously for each syllable) on a board, table, or in one’s head; logbooks where daily schedules, calendars and general information is kept; planning outlines, worksheets, stop/ think/do, note taking, visual reminders, verbal mediation, role playing and monthly calendars with important dates and deadlines recorded. Our group uses the mark-off system, marking off completed items on a list and the days on the calendar.

Before strategies can be developed, every group member is subject to an initial evaluation. During this evaluation, problem areas are discovered, understood and ultimately accepted. We must show a willingness to change the problem through the practice of specific strategies. Strategies are then developed through trial and error. We experiment with what works and what doesn’t work, after which we begin to use the ones that work and disregard the ones that don’t. During this period, we are able to see how these strategies help to make things easier.

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Supported Employment as an Option for Return to Competitive Employment

Supported Employment as an Option for Return to Competitive Employment

With varying degrees of success, people with brain injury often struggle for years to resume their former lives. Despite progress in rehabilitation program development, return to work remains a formidable challenge, especially for persons with severe injury. In many societies, employment is the basis of an adult’s personal identity, with higher paying and more prestigious occupations affording higher levels of social recognition. Consequently, many unemployed persons with brain injury view their recovery as incomplete or insignificant.


Research in Europe has suggested that fewer than one-third of persons with severe brain injury are able to return to work within the first seven years post-injury. Similar unemployment levels were reported by American researchers who surveyed patients between seven and ten years following injury.

Using standardized tests, researchers have identified the following problems as primary contributors to unemployment: (a) problems with attention, concentration, and memory; (b) interpersonal, behaviour, and executive skill difficulties; (c) slowness and reduced productivity; and (d) limited self-awareness regarding ability and suitability for different occupations. Vocational rehabilitation professionals have developed a variety of programs to address the diversity of brain injury sequelae. Program models are often classified as “traditional” or “supported.”

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Early on, clinicians attempted to adapt traditional vocational rehabilitation models to serve persons with brain injury. Characteristics of traditional programs include: …

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Acute Rehabilitation Progress Through a Team Approach

Acute Rehabilitation Progress Through a Team Approach

On behalf of the panel, I’d like to thank the Conference Committee, especially Fran Houle and Ray Rempel, for asking us to participate this year. I had the pleasure of being at the Conference in St. Catharines last year and am pleased to be with you again here in Ottawa. I’d like to introduce the individuals who will participate in today’s presentation. While they come from different disciplines, they represent the Interdisciplinary Team and an approach to rehabilitation that removes the limiting boundaries of multidisciplinary focus and allows for interaction, cooperation and integration of individual skills.

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Dr. Robert F. Sawicki, a Neuropsychologist, is Director of Neuropsychology at our facility. Dr. Sawicki will be presenting a contextual framework by which to understand brain function and how this relates to the rehabilitation of TBI survivors. Linda Sproat, RN, CRRN, Director of Nursing and a Certified Rehabilitation Nurse will discuss certain aspects of rehabilitation that pertain to the nursing staff but more importantly, how that nurse interacts with other team members in respect to the rehabilitation goals of the patient. Our third member of the panel is Nannette Crawford, MA, CCC-SLP, Director of Speech Language Pathology at LEIR. Nannette will share some ideas relating to early intervention through sensory stimulation as well as those specific team goals relating to speech and communication. Goals of feeding, including stimulation feeding will also be addressed.

To quote Dr. Mike Howard, a noted Psychologist in the field of Head Injury Rehabilitation: “It’s not so much what we do but how we do it.” This really points to the importance of the Team. The fact is that in recent years there have been no major breakthroughs in the technology of head trauma rehabilitation. However, the team can be the one tool that can be a key element to successful rehabilitation.

Today we hope to show through our presentation how this team approach encourages the sharing of information and interventions. It is this divergence from the typical discipline-oriented focus toward a person-oriented one that makes the integrated functioning of the Team ideally suited to the needs of the Head Injured.

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Cognitive Behavioural Brain Injury Rehabilitation

Family Adjustment To The Long Term Effects Of Traumatic Brain Injury Of Husbands

This paper represents the first summary report of a weekend retreat for families affected by brain injury tohusbands. The intention of this paper is to describe the experiences of these families from the perspective ofthe husbands with disabilities and their wives. Extensive data was gathered on each family and, once thisdata has been analyzed, the results may very well differ from the perspectives of these wives or husbands.However, we feel that their own accounts of the problems and helpful aids arrived at by their familiesshould be presented on their own.

The authors of the paper include Barry Willer, Ph.D., who is co-director of the Research and Training Center on Community Integration of Persons with Traumatic Brain Injury. Dr. Willer is a psychologistand associate professor in the Departments of Psychiatry and Rehabilitation Medicine at the Universityat Buffalo. Second authors are Marcia Liss & Miriam Arrigali, who are graduate students at theUniversity of Buffalo.(Tech. Report 89-2)

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It has often been stated that when one member of the family becomes disabled, all members ofthe family experience the disability in one form or another and all members of the family mustcope with the effects. The literature on families of individuals disabled by traumatic brain injuryhas demonstrated this fact time and again. Lezak (1988) describes the emotional and practicalburden felt by the primary caretaker. Usually caretakers are family members who may even beforced to give up their jobs or other pursuits so that the disabled family member receives thebest care and treatment in the home or elsewhere. Lezak cites previous research, which hasfound that caretakers (most often wives and mothers) are likely to experience significantdepression within the first year after injury.

The burden and stress felt by family members is strongly related to the behavioural andcharacterological alterations which are often displayed by individuals with traumatic braininjury (Brooks & McKinlay, 1983; McKinlay, Brooks, Bond, Martinage, and Marshall, 1981). Instrumental burden associated with providing assistance because of the individual’s physicallimitations appears to be less debilitating than the emotional burden associated with…

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Living With Brain Injury: Post-Rehabilitation Recovery

Living With Brain Injury: Post-Rehabilitation Recovery

You survived the physician telling you he would not live through the night. You survived waiting for him to wake up from a coma (and maybe being told that if he did, he would be a vegetable). In the rehab center, you watched him struggle to re-learn the simple things we all take for granted: sitting up, walking, eating, bathing, talking. When he was discharged from the rehab center, you re-arranged your schedule to take him to therapy and all those medical appointments. You noticed that his rate of progress was slowing down but you could wait; you’d do whatever it took to make him like he was before.

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But no more therapy is scheduled and there doesn’t seem to be any progress; maybe he’s even lost some of the skills he learned during rehabilitation. There are times when you see a glimmer of the person you used to know: that wry sense of humour, the winning smile, maybe he even remembers an incident from before the accident. Other times he is an unlikeable stranger masquerading in the body of the person you knew: he has angry outbursts, messes up the house, repeats the same stories, asks the same questions, forgets things from one moment to the next, and never gets things done unless you’re there every minute.

You ride an emotional roller coaster: guilt, depression, anger, frustration, regret, and hope. It dawns on you that your whole family has been injured, not just one person. You’ve all had to change your lives. You can’t even remember what it used to be like. You wonder if things will ever return to normal, if there’s anything you can do to change the way things are now. You’re willing to try anything but don’t know where to start. You’re afraid to “rock the boat,” fearing anything you try might make things worse. If only there were a magic wand you could wave, a miracle pill you could take. Where’s that fairy godmother when you need her?

When you reach that point, you may be ready to start your own program to make things better. The following information may help guide you in your quest for a more normal life for you and all members of your family, including the injured individual:

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Making Treatment Work

Making Treatment Work

Alcohol abuse has been associated with the acquisition of traumatic brain injury in over half of all occurrences. Traumatic brain injury appears to be correlated with lifestyles where alcohol and other drug abuse and risk taking are common. When alcohol and other drug use predates the disability, the chances are greater that the substance abuse problems will continue following rehabilitation. The continued abuse of alcohol and other drugs can negate attempts at physical, social, and cognitive rehabilitation. In fact, many individuals with brain injury are unaware of the impact that their use of alcohol and other drugs has on their lives. Even when the consumer recognizes and accepts a problem with substance abuse, adequate services are not always available.

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Substance abuse services are most often designed for a population of adults who can function in group settings and can benefit from models of drug education that are cognitively based and didactic. In addition, most substance abuse services offered today focus on a traditional disease model which espouses chemical dependency as a primary disease. Although the disease model is a viable method for substance abuse treatment, it may be less successful with people who understandably argue that their injury is far more “primary” than the abuse of substances. Also, traditional disease model treatment is highly cognitive in its approach; whereas, people with brain injury require a more behavioural and situation-specific orientation.


People with brain injury should have individualized services, even when the problems experienced are similar to the problems of others. Traditional chemical dependency treatment settings find it difficult to provide truly individualized treatment services. A number of factors should be considered when determining which alternative is best for a certain consumer with brain injury. These include current and past drug use patterns, specific risk factors, physical health, prescribed medications, severity of cognitive impairment, family or other support, and motivation, Some individuals with traumatic brain injuries may benefit more from one-on-one counselling, family counselling, or disability-specific support groups than traditional chemical dependency treatment.

In every case, it should be taken as a matter of course that substance abuse services will need to be adjusted for some people with traumatic brain injuries. It is especially important to engage and actively involve this person in …

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Rehabilitation Following a Mild Traumatic Injury: A Team Approach

Rehabilitation Following a Mild Traumatic Injury: A Team Approach

Neuropsychologists frequently conduct neuropsychological evaluations to determine the neurobehavioural status of persons following minor injuries to the head with mild traumatic brain injury. Typically these persons experience some type of injury to the head with either brief or no loss of consciousness. They report changes in physical and mental functioning adversely affecting their normal adaptation. The neuropsychologist is asked to evaluate these patients and address several questions: Is there evidence of neurobehavioral dysfunction? If so, what are the causes of the dysfunction? What are the practical effects of impairments upon real-world functioning? What treatments and rehabilitation are indicated?

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Well trained clinical neuropsychologists knowledgeable in the relevant research and clinically experienced with mild traumatic brain injury are uniquely qualified to tackle these questions, and play a key role in diagnosis and management. The neuropsychologist’s knowledge of brain functions, neurobehavioral problems associated with neurologic and psychiatric disorders, mild traumatic brain injury, as well as neuropsychological assessment methods provide special contributions. A major strength is neuropsychological testing. Neuropsychological tests allow a quantification of brain functioning not found in other clinical disciplines. The work of the neuropsychologist often leads to a quantified understanding of the person and provides direction for treatments.

This role is however fraught with pitfalls potentially leading to misdiagnosis, misunderstanding of the person, and mismanagement. A number of challenges confront the neuropsychologist working with patients having mild traumatic brain injury. Those challenges include: A limited knowledge base, misconceptions, biases, overlapping disorders, overlapping symptoms, limited technology, and motivation. This article discusses these challenges and suggests ways to avoid these diagnostic pitfalls.

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Restorative Techniques in Cognitive Rehabilitation: Program Design & Clinical Benefits

Restorative Techniques in Cognitive Rehabilitation: Program Design & Clinical Benefits

In the treatment of traumatic brain injury, cognitive rehabilitation is an intervention that seeks to improve cognitive abilities and day to day functioning. Cognitive rehabilitation programs may involve training in the use of assistive memory devices, instruction in the use of strategies to aid learning and memory, and the direct re-training of impaired abilities. The efficacy of cognitive rehabilitation techniques has been the subject of numerous articles but practical and theoretical issues related to program design have not received much attention as yet, despite the widespread use of re-training methods.

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The techniques of cognitive rehabilitation are primarily compensatory or restorative. Compensatory techniques are designed to circumvent deficits through the use of external memory aids, such as appointment books and electronic devices; restorative techniques are designed to remediate impaired abilities through regular exposure to material in the area of deficit. The use of compensatory techniques appears to have gained acceptance without further scrutiny, whereas restorative techniques have been viewed with scepticism. Progress in the area of program design has been seriously hindered by the prevailing distrust of cognitive restoration efforts, but recent publications on the topic suggest that much of the criticism of restorative methods has been too simplistic. Ironically, program design issues are pivotal to the efficacy debate.

The present article discusses issues related to the design of cognitive restoration programs for people with brain injury. Aspects of program design, such as selecting a therapeutic starting point and measuring progress, are briefly reviewed. The role of repetition or “practice” within the context of a re-training program is reviewed and comments are made on the psychosocial and emotional benefits that may result from participation in a well-designed program. The article also suggests guidelines for choosing and evaluating cognitive rehabilitation programs.

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The Therapeutic Use of Guided Imagery in the Brain Injured

The Therapeutic Use of Guided Imagery in the Brain Injured

Ten years ago the study of the mind-body connection was considered on the fringe of science; today it is in the mainstream of scientific investigation. Though the science of mind-body healing is relatively new in technological medicine; in the art of healing, the mind-body connection has always been recognized. In traditional tribal medicine and in Western practice, beginning with the work of Hippocrates, the need to work through the patient’s mind has been considered a vital part of the healing process.

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When we consider healing from this larger historical perspective, we are actually rediscovering something that we have always known, that the mind and body are inseparable, and that when you influence one, you influence the other. Paracelsus, a 15th century physician and the founder of modern chemistry, stated that “man has a visible and an invisible workshop. The visible is his body, the invisible is his imagination. The spirit is the master, the imagination is the tool, and the body is the plastic material.”

Given this intimate link, the question then becomes how can we utilize this connection to assist in the healing and recovery process of the brain injured individual. Guided imagery is emerging in many fields as a very powerful tool for engaging the mind to positively influence the body, from Cancer research to the study of peak performance in athletes.

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