Speech Therapists Are Experts

Nearly half the individuals with severe traumatic brain injuries who receive inpatient rehabilitation were initially comatose, and 1 in 10 had some reduction in consciousness when admitted to the nearby hospital. In fact, that decision may play an even bigger role than a patient’s clinical status in determining whether the patient recovers. The main message here, however, is that improvement is possible in a person who has awakened from a coma and has a disturbance of consciousness, roughly defined as not following instructions and dozing off when not stimulated. Whether improved consciousness predicts functional recovery is unclear. And many studies suggest it doesn’t. Of patients who are comatose and receive critical care, 40% achieve partial or complete functional independence during rehabilitation. Patients who become comatose while hospitalized and are discharged with low functional status experience greater absolute improvement during rehabilitation. How long an individual has been comatose is an unreliable predictor of awakening because the person may have been sedated to control agitation or to facilitate mechanical ventilation. Using brain scans to predict prognosis also isn’t reliable. Some patients with negative findings on imaging do better than others. Individuals who are severely disabled after a head injury may be able to return to work in sheltered workplaces, usually with reduced duties. The ability to rejoin the workforce and hold a job also may be limited by visual difficulties, nonspecific sensations of vertigo, and panic and fear attacks that resemble stress reactions.

As Right As Rain

The result may be less functional independence. Approximately 3 out of every 4 patients admitted to rehabilitation centers for traumatic brain injuries also have episodes of violent agitation. Depression and apathy can occur together and may respond to medications that simulate brain function. A comprehensive program is required to treat these issues. A stroke may be caused by a clot inside a brain artery or vein that interrupts blood flow to and away from certain areas of the brain. In either case, brain areas deprived of blood quickly die. A stroke also may result from a clot inside the brain that directly damages brain tissue and places surrounding tissue under increased pressure. I’ve also seen patients with a previous large stroke in one brain hemisphere who’ve then become comatose after having another stroke in the opposite hemisphere. Coma results when both hemispheres of the brain are involved. If function in one hemisphere is restored, the individual awakens, but neurologic problems are present. Other parts of the brain may be able to take over the functions of damaged parts, or at least mitigate some of the injury. We see this in patients with weakness and speech problems.

When The Lights Go Out

In contrast, some problems, such as double vision, may last for a while or never fully resolve. A clot in a main brain artery, such as the middle cerebral artery, can lead to a large stroke, with a higher likelihood of swelling. Not surprisingly, evidence suggests that decompressive surgery done before the patient develops major signs of deterioration is more beneficial than if performed afterward. Outcomes for patients with smaller hemispheric strokes also depend on the level of neurointensive care that they receive. Weeks later, additional reconstruction is done. As a patient regains mobility, a helmet is worn to protect the head during healing. When they do, an individual can look quite bad on admission. Because strokes in the brainstem are often small, the functional outcome for patients who have them is good. A stroke in the cerebellum or thalamus or in the occipital lobe can be quite disabling initially because it impairs stance, motility, vision and speech, but the outlook for functional recovery is quite good. That’s why we try to remove such clots surgically when possible. Strokes in the occipital lobes also can be quite disabling, causing blindness. In many cases of stroke, a patient’s outcome is determined both by the brain’s recovery potential and the results of rigorous neurorehabilitation.

Trapped Again

Neurorehabilitation doesn’t necessarily increase the chances of improvement, but it can help an individual learn to adapt to the new handicap. How well comatose patients recover from major disabling symptoms varies, and it happens in very small steps. Some neurologic impairments, such as difficulty speaking, may completely define an individual’s disability, and resolving it improves daily functioning. Fortunately, we usually see substantial improvement in speech within the first two weeks after a stroke. The progress may continue for up to six months, after which it may reach a plateau. To a certain degree, speech therapy may help. Speech therapists are experts at finding new ways of communicating, and practicing their techniques can help promote recovery from a stroke. Cognitive function is unaffected, and the individual is conscious and awake, but can’t move or speak. Communication can only occur by way of eye movements and blinking, and with the help of sophisticated computers. Hope for further recovery was their major motivation. Many patients do improve to some degree, which may make communication easier. Better results are to be expected with the legs than the arms. For example, an individual who’s had a stroke may not be able to see or feel one side of his or her body, making the world seem strange and unnatural. It’s a major impediment to recovery. Initially, the situation may look dire, but it may improve in a day or two after efforts to restore brain function. Approximately 1 in 5 individuals with a ruptured brain aneurysm who arrives at the hospital in a poor state may still have a good outcome without major disabling cognitive defects. About the same number will remain markedly impaired. Although expected, this major setback is hard on family members. The patient may be drowsy, sleepy, and very hard to awaken for days, but most get through it. To raise blood pressure, more fluids and additional treatments are given, including medications to widen the blood vessels in the brain. In most individuals, a change in brain function may first become apparent with a gradually decreased level of consciousness. When patients improve, they typically do so rather quickly, as expected.