The Relationship Between the Severity of the Injury and the Functional Ability of a Person with a Brain Injury

Although each brain injury is unique, some generalizations may be made regarding individual characteristics. The medical definitions define the severity of the injury but are not wholly prescriptive of the recovery potential. In other words, it is generally true that the more severe the injury, the more impairment the individual will suffer, however, it is not always true. Sometimes, people with “mild” brain injuries (by the medical definition) suffer severe consequences in their daily lives; more rarely, some people with severe injuries are able to have a relatively “mild” impairments.

Either way, a brain injury is forever.

This discrepancy between the medical definition of the level of injury and the outcome is why the Brain Injury Association of Kentucky developed a second paradigm for evaluating outcomes. This has not been formalized but we hope to encourage discussion about “functional outcomes” which means “what a person is able to do” in the long run. This helps provide a picture of the impact of their injury on their life. We believe this can become a quantifiable description which will ultimately improve cognitive return and at a minimum, help people more fully define the nature of their injury.

A functional outcome focuses on the specific traits that a person has at a given time. For example, an adult with a brain injury either has a driver’s license or doesn’t; either lives independently, or doesn’t. This makes it possible to describe one’s injury not only in relation to the actual injury (severe, moderate, mild) but in relation to the outcomes (profound, severe, moderate impairments).

The Alabama Head Injury Foundation has provided a list of seven areas which are evaluated for functional abilities from their work on a Developmental Disabilities task force. These include:

Self-care: The day-to-day activities which enable a person to meet his or her needs for food, drink, cleanliness, favorable appearance, and personal safety.
Receptive and expressive language: The verbal and nonverbal communication that enables the individual to understand others, to be understood, and to exchange information.
Learning: The general cognitive ability to acquire knowledge, insight, new behaviors, and to transfer these experiences to new situations.
Mobility: The ability to employ fine and gross motor skills for movement, to move from one place to another with or without mechanical aids, and to employ public or private conveyance with assistance if necessary.
Self-directors: The management and control over one’s personal, social, financial, and spiritual life. The ability to make decisions favorably affecting self-interest.
Capacity for independent living: The ability to live without special assistance from others, especially with regard to shelter and normal housekeeping, and related activities.
Gainful employment: The ability to earn funds for the maintenance of a full, independent life in society.

A person in a nursing home with little or no interaction with his or her environment has a profound impairment. A person who cannot live independently, return to work, or maintain relationships may be described as having a severe impairment. A person who can live independently, but is unable to return to work or most of the previous relationships, has a moderate impairment. A person who is basically able to return to life as it was before the injury, but with some new deficits could be described as someone with mild impairments. From a medical perspective, any one of these people may have initially suffered a severe, moderate, or mild brain injury. One has to do with the injury; the other has to do with the result of that injury.

Functional Abilities

Characteristics of the Profound Impairment Profile:

* Virtually no physical capabilities
* Cognitive abilities at Rancho 1-3
* Medically complex ranging from high to low intensity, from stable to unstable
* Totally dependent in all needs
* No interaction with environment

General Needs of People with this level of Severity:

* 24-hours per day, physical maintenance
* Long-term medical care
* Intense physical therapy
* A reduction in frequency of intermittent hospitalizations
* Cost-effective treatments for life
* Protection of the financial resources of the family
* Treatment and financial resources for individuals cared for in the home
* Respite care for family members and other care givers

Characteristics of the Severe Impairment Profile:

* Physically diverse with significant to insignificant physical involvement and impairment
* Cognitive abilities or lack of abilities at Rancho 5 and 6
* Behavioral issues which triage under physically diverse
* Not living independently - requiring 24-hour supervision
* Interacting with environment
* Educational and vocational re-entry into productive activity at the sheltered workshop setting with need for great deal of structure
* Incapable of maintaining stable relationships
* Struggles with relational issues regarding self, family, and community

General Needs of People with this level of Severity:

* Initially intense physical, occupational, speech, and other therapies in the acute setting followed by sub-acute therapies
* Medical monitoring following release
* Transportation for sub-acute treatment, vocational programs, and general mobility
* Equipment such as wheelchairs and augmentative communication devices
* Possible 24-hour supervision for own protection and safety
* Possible medical supervision involving feeding, swallowing, blood level checks, etc.
* Respite for family members and care givers to allow for long-term care
* Case management to encourage effective use of available resources and programs
* Possible behavioral programs to manage inappropriate behaviors, to regain as much independence as possible, and to avoid institutionalization

Characteristics of the Moderate Impairment Profile:

* Good physical capabilities
* Cognitive abilities at Rancho 7 and 8
* Independence divided into subcategories ranging from “capable of living in community independently” to “needing supervised living arrangements”
* Possible behavioral issues
* Vocational and educational re-entry
* Possible relational issues with self, family, and community

General Needs of People with this level of Severity:

* Increased public awareness of problems related to brain injury
* Increased access and funding for rehabilitative services
* Access to appropriate mental health services and counseling
* Decreased social isolation and improved socialization
* Independent living options
* Community-based services and living resources
* Long-term case management
* Long-term social service support systems
* Possible need for behavior programs
* Increased access to vocational rehabilitation and supported employment
* Increased awareness of rights and responsibilities

Characteristics of the Mild Impairment Profile:

This is not to be mistaken for a “mild” injury; some people with “mild” injuries have severe or moderate impairments. A person with a mild impairment is able to function in the work (or volunteer) force, maintain significant relationships, live independently, and communicate effectively. However, virtually every aspect of one’s life is affected, even slightly, by the injury. If there is no awareness or recognition of this impact, it can become increasingly difficult to maintain these qualities and relationships, and life can worsen. There is also some evidence that the natural aging process and impact on mental abilities made become more pronounced in a person with mild impairments. In other words, given a long period of time, a mild impairment may become a moderate impairment.

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