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Recovery from traumatic brain injury a long, uncertain road

Doctors have called Rep. Gabrielle Giffords' recovery so far nothing short of spectacular. But as she begins rehabilitation at a facility in Houston, many Maryland experts on traumatic brain injury caution that what awaits her is a long, arduous road full of uncertainties.

The work of retraining the brain after a severe gunshot wound like the one Giffords sustained two weeks ago can take years, beginning with months of intensive speech, occupational and physical therapy to teach the Arizona congresswoman to master basic functions many of us take for granted: dressing herself, eating and, perhaps, uttering a few words.

"I tell many of the families of patients I deal with, you can't be in a hurry," said Dr. Robert Stevens, an associate professor of neurology at the Johns Hopkins University School of Medicine. "This is a long, drawn-out process, and it can be extremely frustrating. There can be days where things are so much better, and some days where nothing is changing."

Nevertheless, the brain has a tremendous ability to repair itself, even after a traumatic injury like a gunshot wound, a fall or motor vehicle accident that damages cells in the brain and results in significant impairment. Evidence from animal studies shows the brain's capability of reorganizing and regenerating, producing new synapses, neurons and blood vessels, said Stevens, who called this one of the most exciting elements of neuroscience in the last 15 years.

While the most dramatic changes occur six months to a year after injury — and doctors often use that period to predict the extent of recovery a patient can make — many patients can continue to show improvements three to five years out, said Stevens.

The first step in the rehabilitation process is typically a full neurological evaluation, said Dr. Michael Makley, medical director of the brain injury unit at Baltimore's Kernan Hospital, a 33-bed unit that sees about 300 patients a year. During the evaluation, doctors observe a patient's strength and motor skills, test cognition and test the ability to speak and remember.

Giffords, who arrived Friday at the Texas Medical Center, has a drain in her brain because of a fluid buildup, doctors said. Because of the risk of infection, she will remain in the intensive-care unit for at least a week before she is moved to the center's TIRR Memorial Hermann rehabilitation hospital.
Whether Giffords will be able to speak is one of the larger question marks, since her wound was to the left side of her brain, the area that controls language, Makley said. And there's a wide range of potential impairment of her speech.

Right now, Giffords moves her lips, her doctors said, but it's not clear whether she is mouthing words.

"There is no medicine to fix this, and there's really no timetable to say when she'll get better," Makley said of regaining speech. "Some people have trouble getting words out, while others are uncoordinated in making the sounds and the words. Their mouth, their larynx and tongue aren't working in coordination with each other."

Therapy often starts small with relearning basic tasks, gaining strength and following simple commands. More complex problem-solving and reasoning skills follow. Beyond, patients may also need help for behavioral changes caused by the injury.

Because such injuries can damage the part of the brain that controls cognition and impulse, some patients get depressed, angry and aggressive during rehabilitation, said Amy Liu, manager for rehabilitation at the specialty hospital at Levindale in Baltimore, a 120-bed hospital that focuses on chronic conditions.

People are often disoriented, she said. Uncertain what happened to them, unable to communicate effectively, they grow frustrated and sometimes lash out.

For some, that can be the toughest part of all — coming to terms with the limitations the injury has caused.

"You have lost who you really are for a while," Liu said. "It's just like going through a grieving process. They are grieving for losing who they were and coming to terms with who they are now."

Such patients may receive medication to treat depression and therapy to hone coping skills, said Liu.

Of course, not every patient struggles with the same problems. And that is one of the aspects of treating traumatic brain injury that is so frustrating to doctors. There is a huge range of recovery, even among patients with seemingly identical injuries and results on neurological tests, said Stevens. Doctors believe that genetics might be at play for the differences, but they aren't certain.

Neurologists have been awed by the amazing strides Giffords has made and say her case offers a chance to study ways to help others, Stevens said.

"Based on what we know about the type of injury she sustained, she is doing extremely well and has surpassed the expectations of those taking care of her," he said. "This is something that should encourage us all. We should be compelled to try to understand what allowed this person to recover so quickly and so well. What we can learn about her we can use to treat the others that don't do so well."

The Associated Press contributed to this article.

Traumatic brain injury

•1.7 million people sustain traumatic brain injuries annually

•About 275,000 people are hospitalized annually. The majority are treated and released from an emergency room.

•About 52,000 a year die of traumatic brain injury.

Source: Centers for Disease Control and Prevention

Source: By Kelly Brewington, The Baltimore Sun

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