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BIAA HOME : LIVING WITH BRAIN INJURY : TREATMENT

Treatment

Treatment Continuum
Facility and Program Types
Medications
Alternative Medicine
Healthcare Professionals
Scales and Measurement of Functioning
Helpful Resources

Just as no two people are exactly alike, no two brain injuries are exactly alike. For some, brain injury is the start of a lifelong disease process. The injury requires access to a full continuum of medically necessary treatment and community-based supports furnished by interdisciplinary teams of qualified and specialized clinicians working in accredited programs and appropriate settings.

The individual who sustains a brain injury and his or her family are the most important members of the treatment team. Their choices, goals and cultural, religious, social and economic backgrounds must always be taken into consideration in treatment planning.

The Brain Injury Association of America endorses the Brain Trauma Foundation's Guidelines for the Management of Severe Brain Injury and the Colorado Traumatic Brain Injury Medical Treatment Guidelines

Treatment Continuum

The diagram below depicts brain injury treatment in an orderly progression from trauma care to community integration. But very little about brain injury is orderly. Individuals who sustain brain injuries may enter, exit and re-enter treatment at any point along the continuum. Treatment may be needed continuously or on an intermittent basis throughout the individual's lifespan. 

image of traumatic brain injury continuum of care

Facility and Program Types

Intensive Care Unit (ICU)
After receiving emergency medical treatment, persons with a moderate to severe brain injury may be admitted to a hospital’s Inpatient Intensive Care Unit. The goals in the ICU include achieving medical stability, medical management, and prevention of medical crisis. Some preventive rehabilitation may be initiated in the Intensive Care Unit such as body positioning, splinting, and range of motion (a therapist moves the person’s limbs).

Persons treated in the ICU may be unconscious, in a coma, and medically unstable. Many tubes, wires, and pieces of medical equipment may be attached to the patient to provide life sustaining medical care. Medical equipment frequently used in the ICU includes:

A Ventilator (also called a Respirator) is a machine that helps a person breathe.

  • A person who has sustained a brain injury may be unable to breathe on his or her own.To use a ventilator, a tube is placed through the person’s mouth to the breathing passage, (trachea, “windpipe”). This procedure is called intubation.
  • Intubation with the use of a ventilator allows a person to breathe and receive oxygen, which is necessary for life.
  • Intravenous lines (IVs) are tubes placed in a person’s veins to deliver medications and fluids to the person’s body.
  • Arterial lines are tubes placed in a person’s arteries to measure blood pressure.

A Foley Catheter is used to collect and monitor a person’s urine output.

  • A person who has sustained a brain injury may be unable to control bladder functions.
  • A rubber tube is inserted into the person’s bladder. This allows urine to move from the bladder, through the tube, and to a container at the end of the tube.

A Nasogastric Tube (NG Tube) is used to deliver medication and nutrients directly to a person’s stomach.

  • A person who has sustained a brain injury may be unable to swallow.
  • A tube is placed through a person’s nose or mouth and ran through the swallowing passage (the esophagus), to the stomach.

An EKG machine monitors a person’s heart.

  • Wires with sticky ends are placed on the body.
  • An Intracranial Pressure (ICP) Monitor is a device attached to a person’s head with a monitor that indicates the amount of pressure in the brain.
  • When the brain is injured it may swell.
  • When the brain swells, the brain has no place to expand. This can cause an increase in intracranial pressure (the pressure within the skull).
  • If the brain swells and has no place to expand, this can cause brain tissues to compress, causing further injury.

A Pulse Oximeter is a small, clamp-like device placed on a person’s finger, toe or earlobe. The Pulse oximeter measures the amount of oxygen in the blood stream.

Acute Rehabilitation
As early as possible in the recovery process, individuals who sustain brain injuries will begin acute rehabilitation. The treatment is provided in a special unit of the trauma hospital, a rehabilitation hospital or another inpatient setting. During acute rehabilitation, a team of health professionals with experience and training in brain injury work with the patient to regain as many activities of daily living as possible. Activities of daily living including dressing, eating, toileting, walking, speaking and more. 

Postacute Rehabilitation
When patients are well enough to participate in more intensive therapy, they may be transferred to a postacute rehabilitation setting, such as a residential rehabilitation facility. The goal of postacute rehabilitation is to help the patient regain the most independent level of functioning possible. Rehabilitation channels the body's natural healing abilities and the brain's relearning processes so an individual may recover as quickly and efficiently as possible. Rehabilitation also involves learning new ways to compensate for abilities that have permanently changed due to brain injury. There is much that is still unknown about the brain and about brain injury rehabilitation. Treatment methods and technologies are rapidly advancing as knowledge of the brain and its function increases.

Subacute Rehabilitation 
Patients who cannot tolerate intensive therapy may be transferred to a subacute rehabilitation facility. Subacute rehabilitation programs are designed for persons with brain injury who need a less intensive level of rehabilitation services over a longer period of time. Subacute programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing but are not making rapid functional gains. Subacute rehabilitation may be provided in a variety of settings, often a skilled nursing facility or nursing home.

Day Treatment (Day Rehab or Day Hospital)
Day treatment provides rehabilitation in a structured group setting during the day and allows the person with a brain injury to return home at night.

Outpatient Therapy
Following acute, postacute or subacute rehabilitation, a person with a brain injury may continue to receive outpatient therapies to maintain and/or enhance their recovery. Individuals whose injuries were not severe enough to require hospitalization or who were not diagnosed as having a brain injury when the incident occurred may attend outpatient therapies to address functional impairments.

Home Health Services
Some hospitals and rehabilitation companies provide rehabilitation therapies within the home for persons with brain injury. 

Community Re-entry
Community re-entry programs generally focus on developing higher level motor, social, and cognitive skills in order to prepare the person with a brain injury to return to independent living and potentially to work. Treatment may focus on safety in the community, interacting with others, initiation and goal setting and money management skills. Vocational evaluation and training may also be a component of this type of program. Persons who participate in the program typically live at home.

Independent Living Programs
Independent living programs provide housing for persons with brain injury with the goal of regaining the ability to live as independently as possible. Usually, independent living programs will have several different levels to meet the needs of people requiring more assistance and therapies as well as those who are living independently and being monitored.

Medications 

Medications for persons with brain injury are carefully selected, prescribed, and monitored by the physician on an individual basis. The physician or pharmacist can explain a medication’s purpose, side effects and precautions to you. A general explanation of medication groups is described below.

  • Analgesics may be used for pain relief and pain management.
  • Anti-Anxiety Agents may lesson feelings of uncertainty, nervousness, and fear.
  • Anti-Coagulants may be used to prevent blood clots.
  • Anti-Convulsants may be used to prevent seizures.
  • Anti-Depressants may be used to treat symptoms of depression.
  • Anti-Psychotics may be used to target psychotic symptoms of combativeness, hostility, hallucinations, and sleep disorders.
  • Muscle Relaxants may be used to reduce muscle spasms or spasticity.
  • Sedative-Hypnotic Agents may be used to induce sleep or depress the central nervous system in areas of mental and physical response, awareness, sleep, and pain.
  • Stimulants may be used to increase levels of alertness and attention.

Alternative Medicine and Brain Injury

Alternative medicines, including alternative therapies, are an under-researched area of brain injury treatment. The National Center for Complementary and Alternative Medicine (part of the National Institutes of Health) offers a Guide to Complementary and Alternative Medicines. The Brain Injury Association also published an issue of the Challenge! newsletter about alternative medicine and brain injury.

Healthcare Professionals

A Physiatrist is a doctor of physical medicine rehabilitation. The physiatrist typically serves as the leader for the rehabilitation treatment team and makes referrals to the various therapies and medical specialists as needed. The physiatrist works with the rehabilitation team, the person with a brain injury, and the family to develop the best possible treatment plan.

Physical Therapists evaluate and treat a person’s ability to move the body. The physical therapist focuses on improving physical function by addressing muscle strength, flexibility, endurance, balance, and coordination. Functional goals include increasing independent ability with walking, getting in and out of bed, on and off a toilet, or in and out of a bathtub. Physical therapists provide training with assistive devices such as canes or walkers for ambulation. Physical therapists can also use physical modalities, treatments of heat, cold, and water to assist with pain relief and muscle movement.

Occupational Therapists use purposeful activities as a means of preventing, reducing, or overcoming physical and emotional challenges to ensure the highest level of independent functioning in meaningful daily living. Areas addressed by occupational therapists include: feeding; swallowing; grooming; bathing; dressing; toileting; mobilizing the body on and off the toilet, bed, chair, bathtub; thinking skills; vision; sensation; driving; homemaking; money management; fine motor (movement of small body muscles, such as in the hands); wheelchair positioning and mobility; home evaluation; durable medical equipment assessment and training (such as, use of a raised toilet seat to assist with getting on and off the toilet easier). The occupational therapist also fabricates splints and casts to reduce deformities and optimize muscle functioning.

Speech/Language Pathologists evaluates a person’s ability to express oneself (speech, written, or otherwise expressed) and comprehend what is seen or heard. A speech/language pathologist trains a person to use assistive technology as an alternative form of communication if the person is unable to verbalize. The speech/language pathologist focuses on the muscles in the face, mouth, and throat. They also address swallowing issues.

Rehabilitation Nurses monitor all body systems. A rehabilitation nurse attempts to maintain the person’s medical status, anticipate potential complications, and work on goals to restore a person's functioning. A rehabilitation nurse is responsible for the assessment, implementation, and evaluation of each individual patient's nursing care and educational needs based on specific problems as well as coordinating with physicians and other team members to move the patient from a dependent to an independent role.

Case Managers/Social Workers are responsible for assuring appropriate and cost-effective treatment and the facilitation of discharge planning. Maintains regular contact with the patient's insurance carrier, family, and referring physician to assure that treatment goals are understood and achieved.

Recreational Therapists provide activities to improve and enhance self-esteem, social skills, motor skills, coordination, endurance, cognitive skills, and leisure skills. Recreational therapists plan community outings to allow the person to directly apply learned skills in the community. Additional programs provided by recreational therapists may include pet therapy, leisure education, wheelchair sports, gardening, special social functions or holiday functions for persons and their family.

Neuropsychologists focus on thinking skills, behavior, and emotional processing. Neuropsychologists provide services to reduce the impact of setbacks and to help the person return to a full productive life. The neuropsychologist’s evaluations provide valuable information to assist with school, community, or employment re-entry.

Aquatic Therapists are occupational therapists, physical therapists, or recreational therapists with specialized training to provide therapy in a heated water pool. Aquatic therapists assist a person to increase strength, coordination, ambulation skills, endurance, muscle movement, and reduce pain. The ultimate goal is to increase the person’s functional ability with activities of daily living.

Scales and Measurements of Functioning

Several scales and measures are used to rate and record the progress a person makes in rehabilitation following a brain injury. The most common ones are described below.

Disability Rating Scale (DRS)

The Disability Rating Scale (DRS) measures an individual’s general functional change over the course of recovery and rates an individual’s level of disability from None to Extreme. This scale considers cognitive and physical function, impairment, disability and handicap to present a global depiction of the individual’s disability. The DRS can track an individual’s progress from "coma to community."

Functional Independent Measure (FIM)

The Functional Independent Measure (FIM) is a scale that rates an individual’s independence level with activities of daily living. Areas of activities of daily living include self-care, bowel and bladder management, locomotion, transfers, communication, and social cognition. FIM scores range from 1-complete dependence to 7-complete independence.

Functional Assessment Measure (FAM)

The Functional Assessment Measure (FAM) is used in conjunction with the Functional Independent Measure (FIM). The FAM was developed specifically for people with brain injury and consists of 12 items added to the 18 items of the Functional Independence Measure (FIM).

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale is used to determine the initial severity of a brain injury. It is often used at the emergency scene or emergency room. Motor, verbal, and eye responses are solicited and rated. A score of 15 is normal/near normal and a score of 3 indicates the worst possible neurological status.

Glasgow Outcome Scale

This is NOT the same as the Glasgow Coma Scale The Glasgow Outcome Scale is a very broad scale and has been shown to have very little functional value for people in rehabilitation.
5 = Good Recovery - normal or near normal recovery
4 = Moderate Disability - disabled but independent
3 = Severe Disability - dependant with physical or psychological disabilities or both
2 = Persistent Vegetative State
1 = Dead

Rancho Los Amigos (Revised) - 10 Level Scale of Cognitive Functioning

Level I - No Response: Total Assistance • Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular or painful stimuli.

Level II - Generalized Response: Total Assistance
• Demonstrates generalized reflex response to painful stimuli.
• Responds to repeated auditory stimuli with increased or decreased activity.
• Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization.
• Responses noted above may be same regardless of type and location of stimulation.
• Responses may be significantly delayed.

Level III - Localized Response: Total Assistance
• Demonstrates withdrawal or vocalization to painful stimuli.
• Turns toward or away from auditory stimuli.
• Blinks when strong light crosses visual field.
• Follows moving object passed within visual field.
• Responds to discomfort by pulling tubes or restraints.
• Responds inconsistently to simple commands.
• Responses directly related to type of stimulus.
• May respond to some persons (especially family and friends) but not to others.

Level IV - Confused/Agitated: Maximal Assistance
• Alert and in heightened state of activity.
• Purposeful attempts to remove restraints or tubes or crawl out of bed.
• May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another's request.
• Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
• Absent short-term memory.
• May cry out or scream out of proportion to stimulus even after its removal.
• May exhibit aggressive or flight behavior.
• Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
• Unable to cooperate with treatment efforts.
• Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance
• Alert, not agitated but may wander randomly or with a vague intention of going home.
• May become agitated in response to external stimulation, and/or lack of environmental structure.
• Not oriented to person, place or time.
• Frequent brief periods, non-purposeful sustained attention.
• Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
• Absent goal directed, problem solving, self-monitoring behavior.
• Often demonstrates inappropriate use of objects without external direction.
• May be able to perform previously learned tasks when structured and cues provided.
• Unable to learn new information.
• Able to respond appropriately to simple commands fairly consistently with external structures and cues.
• Responses to simple commands without external structure are random and non-purposeful in relation to command.
• Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.
• Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.

Level VI - Confused, Appropriate: Moderate Assistance
• Inconsistently oriented to person, time and place.
• Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.
• Remote memory has more depth and detail than recent memory.
• Vague recognition of some staff.
• Able to use assistive memory aide with maximum assistance.
• Emerging awareness of appropriate response to self, family and basic needs.
• Moderate assist to problem solve barriers to task completion.
• Supervised for old learning (e.g. self care).
• Shows carry over for relearned familiar tasks (e.g. self care).
• Maximum assistance for new learning with little or nor carry over.
• Unaware of impairments, disabilities and safety risks.
• Consistently follows simple directions.
• Verbal expressions are appropriate in highly familiar and structured situations.

Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills
• Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time.
• Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks.
• Minimal supervision for new learning.
• Demonstrates carry over of new learning.
• Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing.
• Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance.
• Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs.
• Minimal supervision for safety in routine home and community activities.
• Unrealistic planning for the future.
• Unable to think about consequences of a decision or action.
• Overestimates abilities.
• Unaware of others' needs and feelings.
• Oppositional/uncooperative.
• Unable to recognize inappropriate social interaction behavior.

Level VIII - Purposeful, Appropriate: Stand-By Assistance
• Consistently oriented to person, place and time.
• Independently attends to and completes familiar tasks for 1 hour in distracting environments.
• Able to recall and integrate past and recent events.
• Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with stand-by assistance.
• Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.
• Requires no assistance once new tasks/activities are learned.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.
• Thinks about consequences of a decision or action with minimal assistance.
• Overestimates or underestimates abilities.
• Acknowledges others' needs and feelings and responds appropriately with minimal assistance.
• Depressed.
• Irritable.
• Low frustration tolerance/easily angered.
• Argumentative.
• Self-centered.
• Uncharacteristically dependent/independent.
• Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.

Level IX - Purposeful, Appropriate: Stand-By Assistance on Request
• Independently shifts back and forth between tasks and completes them accurately for at least two consecutive hours.
• Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with assistance when requested.
• Initiates and carries out steps to complete familiar personal, household, work and leisure tasks independently and unfamiliar personal, household, work and leisure tasks with assistance when requested.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assist to anticipate a problem before it occurs and take action to avoid it.
• Able to think about consequences of decisions or actions with assistance when requested.
• Accurately estimates abilities but requires stand-by assistance to adjust to task demands.
• Acknowledges others' needs and feelings and responds appropriately with stand-by assistance.
• Depression may continue.
• May be easily irritable.
• May have low frustration tolerance.
• Able to self monitor appropriateness of social interaction with stand-by assistance.

Level X - Purposeful, Appropriate: Modified Independent
• Able to handle multiple tasks simultaneously in all environments but may require periodic breaks.
• Able to independently procure, create and maintain own assistive memory devices.
• Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them.
• Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies.
• Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or comepensatory strategies to select the appropriate decision or action.
• Accurately estimates abilities and independently adjusts to task demands.
• Able to recognize the needs and feelings of others and automatically respond in appropriate manner.
• Periodic periods of depression may occur.
• Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress.
• Social interaction behavior is consistently appropriate.

Rancho Los Amigos (Original) - 8 Level Scale of Cognitive Functioning

Level I - No ResponsePatient appears to be in a deep sleep and is completely unresponsive to any stimuli presented to him.

Level II - Generalized Response
Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. Responses are limited in nature and are often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalization. Often, the earliest response is to deep pain. Responses are likely to be delayed.

Level III - Localized Response
Patient reacts specifically, but inconsistently, to stimuli. Responses are directly related to the type of stimulus presented as in turning head toward a sound or focusing on an object presented. The patient may withdraw an extremity and/or vocalize when presented with a painful stimulus. He may follow simple commands in an inconsistent, delayed manner such as closing his eyes, squeezing or extending an extremity. Once external stimuli is removed, he may lie quietly. He may also show a vague awareness of self and body by responding to discomfort by pulling at nasogastric tube or catheter or resisting restraints. He may show a bias toward responding to some persons (especially family, friends) but not to others.

Level IV - Confused/Agitated
Patient is in a heightened state of activity with severely decreased ability to process information. He is detached from the present and responds primarily to his own internal confusion. Behavior is frequently bizarre and non-purposeful relative to his immediate environment. He may cry out or scream out of proportion to stimuli even after removal, show aggressive behavior, attempt to remove restraints or tubes, or crawl out of bed in a purposeful manner. He does not, however, discriminate among persons or objects and is unable to cooperate directly with treatment efforts. Verbalization is frequently incoherent and/or inappropriate to the environment. Confabulation may be present; he may be euphoric or hostile. Thus, gross attention to environment is very short and selective attention is often nonexistent.Being unaware of present events, patient lacks short-term recall and may be reacting to past events. He is unable to perform self-care (feeding, dressing) without maximum assistance. If not disabled physically, he may perform motor activities such as sitting, reaching, and ambulating, but as part of his agitated state and not as a purposeful act or on request, necessarily.

Level V - Confused, Inappropriate Non-Agitated
Patient appears alert and is able to respond to simple commands fairly consistently; however, with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or, at best, fragmented toward any desired goal. He may show agitated behavior, but not on an internal basis (as in Level IV), but rather as a result of external stimuli, and usually out of proportion to the stimulus. He has gross attention to the environment, but is highly distractible and lacks ability to focus attention to a specific task without frequent re-direction back to it. With structure, he may be able to converse on a social-automatic level for short periods of time.Verbalization is often inappropriate; confabulation may be triggered by present events. His memory is severely impaired, with confusion of past and present in his reaction to ongoing activity. Patient lacks initiation of functional tasks and often shows inappropriate use of objects without external direction. He may be able to perform previously-learned tasks when structured for him, but is unable to learn new information. He responds best to self, body, comfort, and, often, family members. The patient can usually perform self-care activities, with assistance, and may accomplish feeding with maximum supervision. Management on the ward is often a problem if the patient is physically mobile, as he may wander off, either randomly or with vague intentions of "going home".

Level VI - Confused, Appropriate
Patient shows goal-directed behavior, but is dependent on external input for direction. Response to discomfort is appropriate and he is able to tolerate unpleasant stimuli (as NG tube) when need is explained. He follows simple directions consistently and shows carry-over for tasks he has relearned (as self-care). He is at least supervised with old learning; unable to maximally be assisted for new learning with little or no carry-over. Responses may be incorrect due to memory problem, but they are appropriate to the situation. They may be delayed to immediate and he shows decreased ability to process information with little or no anticipation or prediction of events. Past memories show more depth and detail than recent memory. The patient may show beginning immediate awareness of situation by realizing he doesn't know an answer. He no longer wanders and is inconsistently oriented to time and place. Selective attention to task may be impaired, especially with difficult tasks and in unstructured settings, but is now functional for common daily activities (30 min. with structure). He may show a vague recognition of some staff, has increased awareness of self, family and basic needs (as food), again, in an appropriate manner as in contrast to Level V.

Level VII - Automatic, Appropriate
Patient appears appropriate and oriented within hospital and home settings, goes through daily routine automatically, but frequently robot-like, with minimal-to-absent confusion, but has shallow recall of what he has been doing. He shows increased awareness of self, body, family, foods, people, and interaction in the environment. He has superficial awareness of, but lacks insight into, his condition, decreased judgment and problem-solving and lacks realistic planning for his future. He shows carry-over for new learning, but at a decreased rate. He requires at least minimal supervision for learning and for safety purposes. He is independent in self-care activities and supervised in home and community skills for safety. With structure, he is able to initiate tasks as social or recreational activities in which he now has interest. His judgment remains impaired; such that he is unable to drive a car. Prevocational or avocational evaluation and counseling may be indicated.

Level VIII - Purposeful, Appropriate
Patient is alert and oriented, is able to recall and integrate past and recent events, and is aware of, and responsive to, his culture. He shows carry-over for new learning if acceptable to him and his life role, and needs no supervision once activities are learned. Within his physical capabilities, he is independent in home and community skills, including driving. Vocational rehabilitation, to determine ability to return as contributor to society (perhaps in a new capacity) is indicated. He may continue to show a decreased ability, relative to premorbid abilities, in abstract reasoning, tolerance for stress, judgement in emergencies or unusual circumstances. His social, emotional, and intellectual capacities may continue to be at a decreased level for him, but functional in society.

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

Helpful Resources

State Brain Injury Associations

BIAA has chartered affiliates that provide provide information and resource services, linkage to support groups, awareness and prevention programs, education, advocacy and more. Contact one of our chartered state affiliates today.

Brain Injury Support Groups

Support groups can help individuals with brain injury increase their knowledge about brain injury and cope with the issues they face. Support group members can provide valuable emotional support because of their experiences and understanding of the impact of brain injury. Brain injury support groups are also a good place to network and learn what others have done in similar situations. Support group types, locations and times can be obtained from BIAA's National Directory of Brain Injury Services or chartered affiliates

 
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