If one defines recovery as complete restoration of the person to who he was before the TBI with all the same abilities and the same level of performance of daily activities, the likelihood of recovery decreases as the severity of the TBI increases. For very severe TBI (e.g. patients with post-traumatic amnesia of one month or more) there is no chance of recovery in that sense of the word. For patients with very mild TBI, the odds of recovery in that sense of the word are fairly good, but without any guarantee. Physiatrists and other “rehabilitationists” who care for TBI patients in the post-acute setting, tend to use the terms “recovery” in a different sense.
For them, recovery stands for the process by which the patient gains awareness of his deficits, works to improve them, accepts the permanence of the ones which fail to improve beyond a certain point, practices and masters new strategies of thinking and behaving to compensate for those deficits, readjusts personal goals to conform in a realistic manner to objective limitations of function, and learns to find pride and pleasure in achieving the new goals rather than making oneself sulky or angry at persistent failure to achieve pre-injury goals which are now out of reach. With all that said, rehabilitationists strive always to keep hope alive while offering a realistic perspective.
To deprive a TBI person of hope is to doom him to non-recovery. No one can know or predict in advance exactly how far a given patient will move beyond her early deficits. Clinicians have published accounts of near miracles. Robust health, solid education and good attitude before the TBI certainly help as do the presence of loving, supportive and encouraging family or friends.
With regard to the rehabilitation process, for severe, and some cases of moderate brain injury, recovery will begin in the hospital, continue in a post-acute rehabilitation facility and then proceed on an out-patient basis with varying degrees of in-home assistance or follow-up home assessments. Cognitive therapy, occupational therapy, behavioral therapy and vocational rehabilitation with job coaching may be used. Persons with mild brain injury will have an assisted recovery only if a diagnosis is made.
When the diagnosis is made the “assistance” may involve outpatient neuropsychological evaluation and counseling, anti-depressant medication, individual psychotherapy and sometimes family as well, support group meetings and medical care for problems like migraine, double vision, falling, insomnia, etc. Recovery tends to progress most quickly for the physical symptoms, more slowly for the deficits in thinking and slowest for behavioral problems like depression, irritability, lost impulse control, etc.
Rules of thumb on recovery for mild brain injury indicate that many persons recover substantially within the first 3-6 months and most by 12 months. It is often stated little or no recovery can be expected beyond 18-24 months post-injury, and that approximately 10-15% of persons diagnosed with mild brain injury will have permanent problems (the “miserable minority”).
These rules of thumb are statistical generalizations covering a highly diverse population and do not always predict what will happen to any one person. They are also more accurate for the obvious physical and cognitive impairments not the more subtle behavioral ones like changed personality. It has also been proven that some persons with brain injury do benefit positively from various forms of rehabilitation even 7-10 years after their injury.
The duration and completeness of recovery will be affected by many variables including severity of initial injury, age, previous education, previous employment situation, existing psychological strengths or weaknesses, personality type and coping style, alcohol or drug abuse triggered by or exacerbated by the injuries, existence or non-existence of supportive family and friends, denial of deficits caused by organic damage to the brain or due unconscious refusal to acknowledge them, depression, and stress from job loss, debt, marital conflict, disputes over insurance benefits, tort litigation and other difficulties associated with the injuries.
One tragic statistic is that only 1 out of every 20 persons with a TBI receives truly comprehensive and adequate rehabilitation services. This can change only with increased education of the public, and advocacy by TBI organizations directed at government officials, HMO executives and other “gatekeepers” to medical services. One exception is the American Academy of Neurology, which fully grasps the tragedy of insufficient rehab services to persons with a TBI and other persons with chronic neurologic conditions. The AAN is spending its own money to promote patient advocacy efforts.
