E. What Is the Long-Term Impact of a Moderate of Severe TBI in the Person's Functioning?

Overview
In considering the long-term impact of TBI on the individual, it is most important to emphasize that there is no "typical" person with TBI. People who have experienced a TBI vary on many dimensions:
1. severity of initial injury
2. rate of physiological recovery
3. completeness of physiological recovery
4. types of functions affected and mix of functions
5. meaning of these dysfunctions in the individual's life
6. dynamics of recovery affecting long-term impairments
7. resources available to aid recovery of function
8. areas of function not affected by TBI, and so forth
Thus, the most important point to emphasize is that the consequences will be different for each individual injured.

In reviewing the effects of TBI, we have already discussed immediate physiological recovery (which may continue over months and years). When the moderately or severely injured person has completed this initial recovery, the long-term functional deficits associated with TBI come to the fore. What areas of functioning can be affected by injury to the brain? Any or all of the functions the brain controls can be impacted.

a. Cognitive effects

The person with a brain injury may experience problems in basic cognitive skills: sustaining attention, concentrating on tasks at hand and remembering newly learned material. Their cognitive functions may slow down post-injury: They may think slowly, speak

They may become confused easily when normal routines are changed or when the stimulation level from the environment exceeds their threshold. They may perseverate at tasks, being unable to switch to a different tactic or a new task when encountering difficulties. Or, on the other hand, they may jump at the first 'solution' they see, substituting

They may be unable to go beyond a concrete appreciation of situations, to find abstract principles that are necessary to carry learning into new situations. Their language processing may be impaired: word-finding

A major class of cognitive abilities that may be affected by TBI are referred to as "executive functions" -- the complex skills and processing of large amounts of intricate information we need to function creatively,

Thus, after injury the person with TBI may be unable to function well in his/her social roles because of difficulty in planning ahead, in keeping track of time, in coordinating complex events, in making decisions based on broad input, in adapting to changes in life and in otherwise 'being the executive' in ones own life. However, after a period of time, with appropriate training and other supports, the person may be able to learn to compensate for some of these difficulties.

b. Sensory/perceptual effects

Any of the ways we have of sensing/perceiving may be affected by TBI. Vision may be affected in many ways: loss of vision, blurred visual images, inability to track visual material, loss of parts of the field of vision, reduced depth perception and sometimes disconnection between visual perception and visual comprehension,

Changes also may occur in the senses of hearing, smell, taste and touch; the individual may become overly sensitive or insensitive. Further, the person may have difficulty sensing the location of his/her own body in space. Other individuals with TBI may have recurring problems with balance, vertigo and ringing in the ears.

c. Seizures

Two types of seizures may occur. Major motor seizures refer to what were once called grand mal seizures and involve loss of consciousness and vigorous, uncontrolled movement of the major muscle systems. Local motor seizures do not lead to loss of

Some individuals with TBI use anticonvulsive drugs to prevent seizures or stop them during the course of a seizure. A relatively small percent of individuals with TBI experience seizures. For most of these, the initial onset of seizures occurs soon after injury. For others, the onset may take place up to several years post injury.

d. Other Physical Changes

If motor areas of the brain are damaged, the person with TBI may experience varying degrees of physical paralysis or spasticity, affecting a wide variety of behavior -- from speech production to walking. Damage to brain tissue can also evidence itself in chronic pain, including chronic headaches. Also, evidence is growing that hormonal, endocrine and other body systems are affected by the brain

Consequently, the individual may lose control of bowel and bladder functions, may sleep poorly, may tire easily, may lose appetite for food or be unable to control eating and/or may be unable to regulate body temperature within normal boundaries. Women with TBI often experience menstrual difficulties.

e. Social-Emotional Changes

When our brain is injured, the systems that control our social-emotional lives typically are damaged at the same time. The consequences for the individual and for his or her significant others may be hard to face, as these changes may imply to them that "the person who once was" is no longer "there". Thus, personality

The person who was once an optimist may now be very depressed. The previously tactful and socially skilled "negotiator" may now be blurting comments that embarrass those around him. The person may also be characterized by dependent behaviors, emotional lability, lack of motivation, irritability, aggression, lethargy, disinhibition and/or an inability to modify

A very important change that affects many people with TBI is referred to as denial (or, lack of awareness): the person becomes unable to compare post-injury behavior and abilities with pre-injury behavior and abilities. For these individuals, the effects of TBI are, for whatever reason, simply not perceived -- whether for emotional reasons, as a means of avoiding the pain of fully facing the consequences of injury, on the one hand, or, on the other, for neurological reasons, in which brain damage itself limits the individual's ability to step back, compare, evaluate differences and reach a conclusion based on that process.
The unique mix and meaning of changes
With this 'catalog' as context, it should be reiterated that the direct effects of TBI are complex and will vary greatly from one injured person to the next. Thus, any injured individual may experience only one, a few or most of these symptoms. Further, a change in any of these functions, if it occurs at all, will vary in intensity across individuals -- from very subtle to moderate to life threatening.

Also, the severity of the injury and the resulting direct effects on the individual's body systems may not predict the amount of impact in a person's life. This follows, first and foremost, because each of us draws differentially on differing parts of our brains. A severe frontal injury may have less impact on an agricultural worker's job performance than a relatively 'mild' frontal injury would have on a physicist's work.

In sum, the meaning of the various changes in any person's life will vary as a function of pre-injury life style, personality, goals, values, resources, as well as the individual's ability to adapt to changes and to learn techniques for minimizing their effects.

We know in general that the variability of patterns of change associated with brain injury are shaped by many factors: the severity of injury, time in coma, time since injury, length of PTA, the resources and services available to the injured person, the barriers met or advantages offered within different social contexts, the social and role demands that exist within the individual's life and so on.

How these factors work, in what ways and how often is not clear. We know that TBI 'hits' people differently, but have less knowledge of the number of people that experience various types of consequences and the specific factors affecting this.
Dynamics of recovery of function and permanence of impact
The effects of TBI focused on immediately after injury are those that center on physical-structural issues. Once issues of life-and-death have been addressed and the individual's 'structure' has been tended to, the person's functioning as a cognitive-emotional-social entity comes to the fore. The individual is faced with many or a few of the possible changes described above. Are the impairments lasting or will they disappear? Does the person ever recover his or her old self?

It has been suggested that "recovery" is a misnomer and that "improvement" better describes what happens in the long run after TBI (Kay & Lezak, 1990). The word "recovery" may, indeed, suggest that the effects of TBI will disappear, similar to symptoms vanishing when we recover from a cold.

With TBI, some of the effects may truly dissipate -- after one year, two years or more; but more frequently these long-term changes linger on -- subtly or not so subtly -- changing only slowly if at all over the life course. Thus, the changes associated with TBI vary greatly across individuals and vary within each person over time.

The other factor that affects the permanence of impact is that impairments that are due to injury of brain tissue can be ameliorated through reeducation of the individual and through modification of the environment.

Thus, for example, although the brain circuits involved in memory may never function in the ways and at the levels found before injury, remembering -- a necessary skill in day-to-day life -- may be improved by the individual's learning compensatory skills, such as using a daily diary to remember appointments, and by adjusting environmental elements, such as alarm clocks, computer reminder programs and family members, to jog memory.

The boundary of improvement is set by the individual's ability to learn new ways of doing things or relearn formerly familiar skills. Since the brain mediates all learning and the brain is damaged, learning is often slow and/or incomplete.

Finally, some individuals with TBI largely move away from the notion of "recovering" the pre-injury self. They, instead, reach a point when the losses/changes/deficits come to be viewed as "simple facts" or even "opportunities".

For these people, terms such as "devastation" and "loss" get redefined and no longer are seen as applying to them. Their injury has let them see other possibilities for their lives than what they saw before injury. These possibilities may be just as or more satisfying to the person with TBI than what was "in store" for them prior to injury.
That which remains unchanged
It is important to be aware also that not all functions of the individual are impacted by TBI. For example, feelings toward family, long-term memories, the ability to ski or cook, ones knowledge of the world, and so forth -- all may be intact, along with numerous other characteristics of an individual, even one who has experienced a moderate to severe injury.

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