To Drive or Not to Drive? Getting Behind the Wheel after a Traumatic Brain Injury

Driving is the ultimate symbol of independence and control. Losing the ability to drive after a traumatic brain injury (TBI) may feel devastating and can greatly affect a person’s quality of life during recovery. But considering that driving is one of the most dangerous activities we do on a daily basis, the decision of if and when to return to driving can be complex. Safe driving requires a number of skills which may be altered after a TBI including:
  • Visual acuity and perception
  • Memory to recall directions or destination
  • Hand-eye coordination
  • Reaction time
  • Safety awareness and judgment
  • Sustained and alternating attention
  • Range of motion and strength of arms, legs and neck
  • Confidence behind the wheel
  • Anxiety level
Research indicates that 50-70% of people with moderate to severe TBI will return to driving regardless of recommendations from their healthcare team or safety concerns (Schultheis & Whipple, 2014) (Classen, 2009). That’s why it’s important for TBI survivors to discuss and address return to driving with their healthcare team openly and honestly. As a first step in the path towards returning to drive, therapists are able to incorporate pre-driving skills into therapy sessions. These pre-driving therapy sessions focus on remediating, refining and strengthening any of the above skills that may impact driving ability or safety. Many rehabilitation providers offer pre-driving screenings or programming to jumpstart the process. After pre-driving skills are mastered, TBI survivors can benefit from working with a Certified Driving Rehabilitation Specialists (CDRS) for on-the-road training. These experts also assist in obtaining and practicing the use of adaptive equipment. Various types of equipment such as hand controls and adaptive steering wheels can be used if traditional foot pedals or wheels are not optimal. A CDRS can even help coordinate securing an adaptive vehicle with ramp access and modified seating if necessary. Safe return to driving after a traumatic brain injury is possible with the right training and resources. The first step toward safely getting behind the wheel after a traumatic brain injury is starting a conversation with the rehabilitation team.

References:

  • Classen, S. e. (2009). Traumatic brain injury and driving assessment; and evidence-based literature review. American Journal of Occupational Therapy, 580-591.
  • Schultheis, M. T., & Whipple, E. (2014). Driving after traumatic brain injury:evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Reports, 176-183.
Angela West, MSOT, OTRL
Occupational Therapist + Therapy Best Practices Coordinator
Special Tree Rehabilitation System

What Is A Concussion and How Do We Treat It?

One of the hot topics right now in the world of brain injury is Concussion Prevention and Treatment. In order to fully be able to discuss this topic, we first have to understand and answer this question: What is a Concussion? Newer research has shown that a concussion happens from acceleration or deceleration of the brain inside of the skull. This can happen from activities such as a hit directly to the head or body as in contact sports, falls, military activity, or motor vehicle accidents. This acceleration/deceleration of the brain causes stretching of the brain tissue and creates an excitatory response that places the brain in an energy deficit resulting in any of the below symptoms. Symptoms are typically temporary and usually dissipate by 8-10 days. What are some signs and symptoms of a concussion?
  • Loss of Consciousness (only occurs in ~10% of all concussions!)
  • Seizures
  • Delayed verbal/motor responses
  • Confusion/Disorientation/Memory deficits
  • Lack of focus/Concentration
  • Speech disturbances such as slurred speech
  • Balance/Incoordination
Sports are one of the leading causes of concussion resulting in approximately 3.8 million concussions per year in the United States. Rugby, ice hockey, football, and soccer are the top high-risk sports for both men and women due to the amount of contact. The large number of concussions sustained from sports has led to a push for prevention measures such as advancements to helmets. Research has shown that the use of a properly fitting helmet may reduce the risk of the severity of the symptoms of a concussion; however, there is lack of evidence supporting the use actually reducing the number of concussions sustained. Since concussions cannot be completely prevented, we now need to look at treatment! Due to the wide variation of symptoms that can present following a concussion, a comprehensive treatment plan should be utilized. The brain accounts for approximately 2% of our body weight and it takes approximately 20% of our blood supply! Why is this important? A concussion can temporarily reduce blood flow to the brain by up to 50%! This makes exercise one of the most crucial treatment options for an individual following a concussion. Treatment will be based on the presentation of symptoms and following Return-to-School and Return-to-Play guidelines and only moving to the next stage if they are symptom-free for 24 hours. What kind of treatments should be used?
  • Rest
  • Nutrition
  • Physical Exercise
  • Visual and Vestibular Retraining
  • Cervical Spine-Alignment and Musculature Issues
  • Balance Retraining
What does the Return-to-School and Return-to-Play Guideline look like?
  • Rest Initially 24 hours
  • Light Cognitive Activity
  • Half Day of School
  • Full Day of School
  • Clearance for Physical Activity
  • Light Non-Contact Sport Specific Activity
  • Higher Intensity Non-Contact Sport Specific Activity
  • Full Contact Sport
  • Return to Competition
An important fact to remember is that typical concussion symptoms dissipate in 8-10 days; however, the brain metabolic state (no longer being in an energy deficit) does not return to its own baseline until 22-30 days after an injury. Why is this important? Three words: Second Impact Syndrome. If there were to be another concussion prior to the brain reaching its metabolic baseline, the effects of the first concussion can now be compounded, thus placing the individual at an increased risk for permanent deficits or even death. Comprehensive Baseline Testing can assist with not only making sure all aspects of the individual's brain function, including both physical and cognitive aspects, have returned to their baseline. The testing also significantly assist clinicians in the Return-to-Play decision. Early comprehensive treatment of concussion can also decrease the time that symptoms are experienced thus reducing the likelihood of Post-Concussion Syndrome (where the concussive symptoms last greater than 2 weeks). In summary, a concussion can and should be treated with a comprehensive approach and in a collaborative effort between the individual and their family, a trained rehabilitation professional, a physician, school administrators, and coaches. This collaborative approach will help minimize the possible long-term effects of a concussion.

References:

  • Prien, Et al. “Epidemiology of Head Injuries Focusing on Concussions in Team Contact Sports: A Systematic Review” Sports Med. 2018 Apr:48(4):953-969.
  • Langlois Et al. “The epidemiology and Impact of Traumatic Brain Injury: A Brief Overview” Journal of Head Trauma Rehabilitation: September-October 2006: Vol21. Issue 5. Pg 375-378.
  • Patel, Et Al. “Aerobic vs anaerobic exercise training effects of the cardiovascular system” World J Cardiol. 2017 Feb 26:9(2):1324-138.
  • Viano Et al. “Concussion in professional football: biomechanics of the struck player part 14” Neurosurgery. 2007 Aug:61(2):313-327.
Karley Glashauser, PT, DPT, CBIS, CF-L1 Physical Therapist, The Lighthouse Neurological Rehabilitation Center

Karley graduated with her Doctorate of Physical Therapy from Central Michigan University in May of 2009. She has been employed at The Lighthouse Neurological Rehabilitation Center, Caro location, since July of 2009. Karley has continued education in the areas of Hippotherapy, NDT, and Concussion Management. Karley is also a CrossFit Level 1 Trainer at Davison CrossFit and Flint CrossFit with a special certification in Adaptive CrossFit.

Triangulation – What Is It and How Does It Apply to the Role of Caregiver

As caregivers, we are each drawn to the work we do for a reason. It may be because we simply like to help, have someone in our lives suffering from a disease or an injury, or are just stopping along the way to get to another spot. Whatever the reason, our jobs involve helping people. This can be very rewarding and enriching – it can also be troubling, stressful and distressing. One tactic we come across in the world of therapy is triangulation – a form of manipulation where a person will not communicate directly with another person, instead they use a third person to relay the information to the second person – thus forming a triangle. Triangulation is a concept primarily used in trauma-based therapy, taught to mental health professionals specifically trained to work with individuals who have experienced a traumatic incident, such as a car accident, fire, death of a loved one, etc. The way these individuals perceive life and relationships can be drastically influenced by that experience.
This has much to do with how the brain is wired, through social and emotional experience, and how social experiences have affected the individual. The act of triangulation can be intentional or unintentional – a very complicated cycle that negatively impacts everyone involved. Triangulation can be common in many aspects of our lives, but as a psychologist in the world of brain injury rehabilitation, I see it quite often. To have a triangle, you must have three people: a victim, a persecutor, and a rescuer.
Victim: “The good guy”. No voice, no power. In this frame of mind, the victim does have power and a voice but are afraid to use them. Persecutor: “The bad guy”. The attacker, the one who bothers the victim. It could include allowing the victim to experience the natural consequences of their choices or behaviors. Rescuer: “The hero”. Swoops in and takes care of the victim’s problem – but at the same time ensures the victim never finds their own voice or personal power. Let’s use the characters in the movie The Wizard of Oz as an example... Dorothy – the victim. Riding in a house which drops and kills the Wicked Witch; obtains the Ruby Slippers. Wicked Witch of the West – the persecutor. Unhappy about sister’s death, but more importantly – wants the Ruby Slippers. Glenda the “Good Witch” – Dorothy’s potential first rescuer. Glenda is good, and tells Dorothy how to solve her problem but doesn’t do it for her. In the movie, Dorothy picks up potential rescuers along the way – the Tin Man, the Cowardly Lion and the Scarecrow – all victims of their own life circumstances. Each of them do their best to rescue one another from their fears. We also see several persecutors for the victims, each of whom are looking for help/rescuing from the Wizard of Oz.
“When we cast ourselves in the victim role, we often feel helpless, hopeless, powerless, inept, etc. Sometimes, we may think “I can’t do it, I need you to do it.”
Fast forward to the Emerald City, where the best rescuer is believed to reside – the Wizard. Dorothy asks the Wizard for help, but is denied. [Oh, no, that isn’t supposed to happen – the Wizard (rescuer) is supposed to help me.] For the Wizard, his role quickly transitions from rescuer to persecutor.
“Now the victim has to find a new rescuer.”
In the case of the Wizard of Oz, that person becomes Glenda. Glenda helps Dorothy rescue herself by finding her voice and enacting her power to dissolve the witch with a bucket of water, and with three taps of the shoes, we see Dorothy back home.
“Rescuers, understand: if you are not able to rescue your victim, the victim doesn’t like how you rescued them, or other reasons – you – the rescuer is now becomes the persecutor.”
So, how do we break out of the triangle?
  • Support, don’t rescue. If someone comes to you to rescue them, assist them in figuring out how to solve the problem themselves.
  • Refer the victim back to the person with whom they are having the problem.
  • Help the victim find their voice. Role play what they could say by using the “I” message concept:
When your [insert description of behavior], I feel [insert name the emotion], I want [insert description of replacement behavior]. Example:
“When you act like a jerk, you make me angry, I want you to stop” will serve to incite more conflict versus help resolve. A different approach might be “when you keep your headphones on when I am trying to talk to you, I feel frustrated. I would like you to take the headphones off.”
We can also use this method to communicate positives. “When you take off your headphones when I’m trying to talk to you, I feel appreciative, please keep it up!” Some helpful reminders:
  • When we say “I feel,” we’ve taken responsibility for our own emotions, versus when we say “you make me feel,” we give all the power to the other person.
  • Make sure the description of the behavior is without opinion or judgement.

References:

Kimberly McGowan, MA, LLP, CBIS
Limited License Psychologist
Hope Network Neuro Rehabilitation

Celebrating Brain Injury Awareness Month

Brain injury is often referred to as an “invisible” injury or disability since the effects of the injury are not always visible or immediately evident. However, to anyone who has suffered a brain injury, or to those that care about someone who has, the effects of brain injury are complex and can pervade many aspects of the individual’s life. Brain injury can be difficult to understand, the symptoms can be significant, and the rehabilitation process can be extensive. We are proud to join brain injury survivors, caregivers, and supporters in celebrating Brain Injury Awareness Month. For decades, the Brain Injury Association of America (BIAA) has led a nationwide public awareness campaign during the month of March to de-stigmatize brain injury through outreach and education.
According to the Brain Injury Association of Michigan (BIAMI), in Michigan alone, 58,500 people sustain a brain injury each year. The truth is that no one plans for a brain injury, but brain injuries can happen to anyone, at any time. Please join us this month as we spread awareness and educate others on the definition of brain injury, its causes, and where to seek proper rehabilitative care.

What is a Brain Injury?

Just as there are no two people alike, no two brain injuries are the same. An acquired brain injury is an injury to the brain that has occurred after birth; these injuries are not a result of heredity, nor are they congenital or degenerative. There are two types of acquired brain injuries, non-traumatic and traumatic. A non-traumatic brain injury is caused by damage to the brain by internal factors, such as lack of oxygen, exposure to toxins, pressure from a tumor, and so on. A traumatic brain injury is an injury to the brain that is caused by an outside force or impact that is sudden and damaging.

Common Causes of Brain Injury

  • Stroke
  • Anoxia/hypoxia (lack of oxygen to the brain)
  • Neurotoxic poisoning (ingestion of insecticides, solvents, lead)
  • Tumors
  • Virus/infection
  • Seizures
  • Falls
  • Motor vehicle accidents
  • Struck by an object
  • Sports
  • Improvised Explosive Device (IED)
  • Assault

Brain Injury Recovery

Following a brain injury, it is imperative to receive the proper rehabilitative care. Brain injury survivors can experience an array of cognitive, physical, and emotional/behavioral challenges. These symptoms can often concur feelings of hopelessness in survivors and caregivers, but there is hope. The goal of brain injury rehabilitation is to maximize function and encourage survivors to achieve their fullest potential. Origami Brain Injury Rehabilitation Center brings together a team of experts from the following disciplines including physiatry, psychiatry, psychology, physical therapy, occupational therapy, speech-language pathology, recreational therapy, rehabilitation nursing, vocational, and more in order to tailor a care plan to the needs of each survivor. The rehabilitation journey begins with a thorough assessment to identify the individual’s exact needs and goals. At Origami, survivors and their support systems are an essential part of the interdisciplinary team and the rehabilitation journey. It is important brain injury survivors and caregivers know they are not alone on this journey. If you have a question about brain injury or if you are interested in learning more about brain injury rehabilitation, please visit our website at origamirehab.org or call us at 517-336-6060. For those looking for support, visit BIAMI's Support Group page or call them at (800) 444-6443. Origami Brain Injury Rehabilitation Center is a 501(c)(3) non-profit organization located in Lansing, Michigan. Origami provides comprehensive rehabilitation care for survivors of brain injuries and their families. Through their compassionate and innovative services, Origami creates opportunities and transforms lives.

How to Decrease Your Risk of Falling Following a Brain Injury

Along with ringing in the New Year, January is sure to bring plenty of snow and ice! The onset of slippery conditions can cause an increase in incidences of falls. Though the majority of falls only result in mild injuries such as muscle soreness or bruising, approximately 10% of falls result in a trip to the emergency department. Some falls may be unavoidable, but being informed of the risks and actively making changes can reduce the risk of falling. With 30-65% of people with brain injuries reporting balance deficits at some point during recover, it is especially important for survivors to be aware of the facts that make them more susceptible to falling. Factors to Consider: Are you over 65 years old? Approximately 1 out of 4 people over the age of 65 experience a fall every year, with falls being the leading cause of injuries in this population. Do you take multiple medications? Individual medications or interactions between multiple medications may cause an increase in risk of falling. Researchers have found that certain classes of medications including sedatives and antidepressants may contribute to increased falls risk. If you notice an increase in falls with the start of a new medication, be sure to contact your physician. Have you fallen more than once in the last year? Previous falls are an indicator of an increased likelihood for subsequent falls. If you have previously fallen it is very important to take preventative measures to avoid reoccurring falls. Do you have vision deficits? Vision is an important component of balance, and having vision deficits significantly increase the risk of falls. Blurred vision, double vision, and other visual impairments are common after a brain injury; therefore, it is important to follow up with your optometrist or ophthalmologist if you suspect any changes in your vision. They may make changes to your eye glasses or refer you to an occupational therapist for vision therapy. Do you have impaired sensation in your legs? It is common to experience decreased sensation or proprioception, the perception of movement and positioning of our body, following a brain injury or due to other chronic conditions such as diabetes and peripheral neuropathy. This can cause individuals to trip on objects or lose their balance. Are you depressed? Studies have shown a correlation in increased falls with depression likely due to cognitive, sensory, and motor changes that may occur with brain injuries. Consider talking to your physician, social worker, or counselor if you believe you are experiencing depression. Do you experience dizziness? Dizziness can be a symptom of many conditions including damage to the vestibular system, changes in vision, medication symptoms, or other medical conditions. If you are experiencing dizziness it is advised to consult with your physician. They may refer you to an Ear Nose and Throat Specialist, ophthalmologist or to a vestibular physical therapist depending on the cause. Are you mostly inactive? A decrease in activity can lead to poor cardiovascular endurance and flexibility, as well as weakened muscles, which can increase your risk for falls. Ask your physician if you are able to participate in a regular exercise program, and consider consulting a physical therapist or another expert for a custom exercise program to meet your needs and goals. Do you experience incontinence?Incontinence is associated with an increase in falls due to impulsive and unsafe behavior occurring when a sudden urge to urinate occurs. Depending on the type of incontinence and the severity, different techniques such as utilizing caregiver assistance, bed pans, pads, or Kegels may be appropriate. A pelvic floor specialist can aid with decreasing episodes of incontinence. If you answered yes to any of these questions, you might be at an increased risk for falling. Many brain injury survivors may have answered yes to many of the above questions; because of this, individuals who have experienced a brain injury have a significant increased risk of falling. Although some risk factors such as age are out of our control, many others may be modified to reduce your risk. If you believe you or a loved one is at an increased risk for falling, there are some simple modifications that can be made to decrease the risk:
  • Remove tripping hazards such as rugs or uneven thresholds in your home
  • If you use an assistive device, make sure you are using it correctly
  • Wear supportive shoes with a rubber sole to prevent shuffling feet and slipping.
  • Use night lights in order to increase visibility at night. Alert systems can be used for individuals requiring more assistance.
  • Shovel snow and apply salt to reduce the risk of slippery sidewalks
These tips can reduce your likelihood of falling and incurring an injury. If you have notice any recent changes or have questions regarding your balance, please contact your physician.

Emily Wolf, PT, DPT

Physical Therapist, The Lighthouse Neurological Rehabilitation Center

References

  • Kallin, Kristina, et al. "Predisposing and precipitating factors for falls among older people in residential care." Public health 116.5 (2002): 263-271.
  • Lord, Stephen R., Hylton B. Menz, and Catherine Sherrington. "Home environment risk factors for falls in older people and the efficacy of home modifications." Age and ageing 35.suppl_2 (2006): ii55-ii59.
  • Peterson, Michelle, and Brian D. Greenwald. "Balance problems after traumatic brain injury." Archives of physical medicine and rehabilitation 96.2 (2015): 379-380.
  • Thurman, David J., Judy A. Stevens, and Jaya K. Rao. "Practice parameter: assessing patients in a neurology practice for risk of falls (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology." Neurology 70.6 (2008): 473-479.
  • Woolcott, John C., et al. "Meta-analysis of the impact of 9 medication classes on falls in elderly persons." Archives of internal medicine 169.21 (2009): 1952-1960.

Emily graduated from Arcadia University with a Doctorate of Physical Therapy. Her academic focus was primarily on treatment of adolescents and adults post-concussion. She has been practicing as a physical therapist at The Lighthouse Neurological Rehabilitation Center in Kingsley, Michigan since 2017.

It’s the most wonderful time of the year…or is it?

Some helpful tips for holiday cheer following a TBI

The holidays are fast approaching and are typically associated with excitement, family gatherings, music, delicious food and lights! While all of these aspects of the holidays are wonderful, they can be incredibly challenging for someone with a traumatic brain injury (TBI) to navigate and manage. Various symptoms of TBI can impact how one perceives the holidays: experience of sensitivity to light and sound, increased headaches or migraines, issues with processing information, challenges with energy levels, struggles with accurately interpreting social cues, trouble with controlling emotions, and difficulty with planning or initiation.
There is hope! Many steps can be taken to ensure the holidays are enjoyable for individuals with TBI and their family members. Here are a few identified by Brainline.org’s online community:
  1. Identify in advance - a quiet place to go at gatherings if you are feeling overwhelmed. This gives you a chance to take a break, and lets your loved ones stay involved in the festivities.
  2. Avoid crowded stores and order gifts online instead.
  3. If you are shopping in stores, remember to make a list in advance and plan your trips on week days - either early in the morning or late at night when there are fewer crowds.
  4. Wear a cap with a brim or lightly tinted sunglasses to minimize the glare of bright lights in stores or flashing lights on a tree.
  5. Wear noise-reducing headphones or ear buds. These are also great gift ideas for loved ones with TBI if they don’t already have them.
  6. Ask a friend to go with you to stores or holiday parties. They can help you navigate crowds and anxiety-producing situations.
  7. Plan in advance as much as possible. Ask your hosts what their plans are so you aren’t surprised by anything.
  8. Volunteer to help with the holiday activities that you enjoy the most and are the least stressful for you.
  9. Remember to ask for help and accept help if it is offered to you.
  10. Ask someone you trust to help you with a budget to avoid overspending on gifts.
  11. Take a nap if you need a break.
  12. Remember that it’s okay to skip the big parties and plan to celebrate in a way that makes you comfortable and happy.
  13. Check in advance to see if fireworks are part of outdoor celebrations - and skip them if they make you uncomfortable.
  14. If flashing lights bother you, ask your friends and family to turn off the flashing feature on Christmas tree lights or other decorations when you visit their homes.
  15. You can let your host know in advance that you may need to leave early. It will help you feel comfortable if you need to get home or to a quiet place, and it can also help avoid any hurt feelings.
The more support that family and friends can offer to a loved one when they are struggling or identifying what they may need for relief, the more successful they will be with effective implementation of these strategies. Here are a few tips:
  1. Have this list handy to help remind your loved ones of skills they can engage in, while also increasing your own awareness of what can be done to help.
  2. Keep an eye on them. If you notice they are disengaging, demonstrating signs of pain (i.e., holding their head, closing their eyes, tensing their muscles) or struggling with keeping up in conversation, gently suggest utilizing some strategies for relief.
  3. Be flexible. Often times your loved one may not know exactly how an environment will trigger them until they are there, even if they plan for it. Be open to plans changing a bit.
  4. Be available. As amazing as the holiday season can be, it will most likely pose some of the greatest challenges for your survivor. They may rely on your support to make it through.
  5. Ask for help yourself. You do not have to be the only one providing support. Let others know when you need a break.
Hopefully these tips will promote a safe and happy holiday season! If you need more support, consider reaching out to one of these local resources: https://www.biami.org/ https://www.apa.org/helpcenter/index.aspx https://www.brainline.org/ https://www.origamirehab.org/

Reference:

  • 15 Tips for Surviving - and Enjoying - the Holidays with Brain Injuries. (2013, November 21). Retrieved from https://www.brainline.org/article/15-tips-surviving-and-enjoying-holidays-brain-injury
Dr.Jayde Kennedy, PhD, LP, CBIS
Clinical Psychologist, Origami Brain Injury Rehabilitation Center

Dr. Kennedy graduated from The Chicago School of Professional Psychology in Los Angeles with a PsyD in Clinical Psychology in 2014. Her academic focus was primarily on treatment for children and adolescents. Her practicum, internship, and fellowship experiences allowed her the opportunity to work with a variety of populations including children, adolescents, teens, adults, and geriatrics. Dr. Kennedy has practiced in several settings including, outpatient, inpatient, community mental health, and residential treatment utilizing individual and family therapy modalities. She has been a member of the Origami Brain Injury Rehabilitation team since 2015.

Dignitas
Eisenhower Center
Special Tree
Community Connections
rainbow_logo
Lightouse Neurological Rehabilitation Center