There have been major medical advances in the area of traumatic brain injury treatment and rehabilitation in the last 10 - 15 years (not to mention major advances in fashion since 1972). If you are interested in current rehabilitation trends, peruse the literature (i.e., medical journals) at your nearest medical or university library. This Internet site, as well as others, contains a good list of references to start with. For treatment options, you may want to consult your state Brain Injury Association for information on programs specializing in brain injury. The national Brain Injury Association in Washington, D.C. can refer you 202-296-6443  to your state affiliate. And if you're one of those misguided individuals who is swept up in the 70's "retro" thing, stop it.

There is no typical course of recovery from traumatic brain injury since TBI affects each person in a unique way. After all, we start out as individuals, and even after the injury, we still are individuals. In general, a person achieves the most dramatic recovery during the first year after the brain injury. Intensive rehabilitation services can greatly enhance one's improvement. However, improvement can continue to occur over the next several years. The physical healing of brain tissue eventually will taper off, but the door remains wide open for personal growth. The key is for the individual with brain injury to STRIVE for continuous improvement. Participation in appropriate therapeutic activities and embracing a healthy, active lifestyle are good for your brain, body, and soul. So, see good therapists, participate in a dance class, take a course in Chinese cooking, and meditate, instead of, say, munching Cheeto's in front of "McHale's Navy."

A periodic consultation with a professional, such as a physical therapist, might be a good idea. . A physical therapist willing to come to your friend's home would be best. Check with rehabilitation clinics versus major hospitals for therapists that do some private work. You could attend the consultation with your friend and his family and learn some techniques to help him at home. The therapist could be hired to come once a week, once every two weeks, or even once a month to assess your friend and give you guidance on helping him with exercises. Of course regular, frequent physical therapy that tapers off as the person makes progress is best; however, you can be creative and at least get some guidance from a professional who can help you keep your friend active. Some help is better than none, in Pat's opinion. Also, think of ways to help your friend fund more therapy. He should apply to social services for help, at least. Maybe you and his other friends could get together and hold a small fund-raiser. If nothing else, your being there and helping him use his body and mind (instead of lying on the couch all day) will be extremely beneficial.

You are on the right track in considering Occupational Therapy, which focuses on helping people perform activities of daily living, such as self-care. In addition, you may wish to consider referring your brother to a neuropsychologist for evaluation and treatment recommendations. Neuropsychologists specialize in addressing how a brain injury affects/impairs behavior. The neuropsychologist, working with the Occupational Therapist and possibly others, can help your brother and your family understand the problems and formulate potential solutions. If your brother has not been in a formal brain injury rehabilitation program, consider this option -- it is the best way for your brother to receive comprehensive services. The state Department of Vocational Rehabilitation can help by paying for services, like those mentioned, IF they are necessary to help the person become employable. Basically any person who has a disability and the potential to work can receive services from the Department. Fees are based on individual income. Definitely contact your state Department of Vocational Rehabilitation to find out about eligibility and available services.

CT scans are good at showing many types of physical damage to the brain. However, they aren’t perfect and there can be damage that the CT scan doesn’t pick up. I would suggest that you consider a neuropsychological assessment. This evaluation won’t tell you what your brain looks like. Instead, you will be given a number of tasks related to attention, memory, auditory and visual processing and visual-motor skills to assess how your brain is working. In many cases, it may be helpful to also have a follow-up evaluation in about 6 months to determine if things are getting better or worse or staying the same.

Pat can’t figure out from your question why your neuropsychologist has suggested you go back into therapy, or what kind of therapy is being suggested. It sounds like you’re getting a lot of advice. Remember that these are choices about your life and you get to make them. Brain injury or not, you’re an adult and you’re entitled to make choices about your own life. Consider what the neuropsychologist suggests. Be sure you understand what his or her concerns are and why therapy is being recommended. Sometimes people try to get their "old life" back too soon. Maybe that’s the concern. However, discuss this with your fiancée, family, friends and other people you trust. You can always try therapy for a while and change your mind if things are going well. Or if you and your loved ones think you are doing well now, you could try life without therapy and try it later if you need help. It’s really up to you.

As for your mother, this is not at all uncommon. Your mother is likely very concerned that you can’t handle things or will get hurt again. She may be afraid that you’re trying to do too much, too fast. Maybe she’s concerned your fiancée doesn’t understand everything about your injury. She could be right. Talk with your mother, fiancée and others about those concerns. Find out if the medical professionals that work with you share her concerns. Then make an informed decision. Remember that it’s your life. As an adult, it perfectly appropriate for you to start your own household and, at some point, your mother is going to need to let you and your fiancée live your own lives and make your own decisions – whether you’ve had a brain injury or not.

One of the things family members want the most is for their loved one to be back "they way they were." I would love to tell you that with enough therapy, love, and prayer that is what will happen. Unfortunately, total recovery rarely happens after a serious brain injury. Persons with brain injury followed for 10, 15 or more years often continue to report problems associated with their brain injury. Many are unable to return to work. The other thing to keep in mind is that the fastest recovery takes place in the first 6 months. Further recovery often occurs, but it can be a slower process. Recovery occurs at its own pace. It is important to view recovery on a day-to-day basis rather than to compare things to way they were before the injury. Goals should be set based on your brother’s current status. I’ll bet that if you look at where he was back in December, you can see some progress from where he was. Some families like to videotape things so they can look back two or three months to see if progress has been made. Many families are amazed at how much progress they didn’t see – because they kept thinking back to "the way the person was" instead of appreciating how far the person had come already.

The best thing you can do for your brother is to continue to spend time with him, talk with him, and encourage him. Even though he may have trouble talking, it sounds like he can hear you and I’ll bet he appreciates the time you spend with him. Talk with the hospital staff to see what you can do to help. If your brother can communicate through gestures or writing, use those and don’t get frustrated by his not talking. It sounds like the doctors are saying that your brother had a very serious injury = a kind that often occurs when the brain is jostled around during a motor vehicle accident. (Try shaking an egg really hard and then cracking it. The yolk and whites are all mixed up. It’s a similar thing when the human brain gets shaken really hard during a car accident). Given the injury you describe, the length of time since the injury, and the symptoms you describe, I expect the doctors are correct in saying that he won’t ever get back to the "way he was." But that doesn’t mean he won’t improve. It doesn’t mean his life doesn’t have meaning or value. It certainly doesn’t mean you should give up hope. Just be realistic about what you hope for.

Certainly it will help to keep your brother busy and playing games that involve memory or problem solving may be very helpful. If you brother is working with rehabilitation professionals, be sure to talk to them and get advice. They will know the details of your brother’s condition and have a sense for his strengths and weaknesses. Most importantly, talk to your brother. He is the only one who can tell you what does or does not frustrate him. Remember to be patient and don’t expect him to get his memory back right away. Depending on his injury, it’s also possible that he won’t ever remember those past events like your sister’s wedding. Keep spending time with him, and encourage him to follow-up regularly with his doctors and to stick to his rehabilitation plan.

Pat recommends having your daughter evaluated by a neuropsychologist before the school year begins. This will serve as a baseline so you can measure her recovery over time. A neuropsychological evaluation can also help you to evaluate her current strengths and weaknesses and identify any areas that might lead to academic problems. If necessary, the neuropsychologist can help you to work with the school to develop an individual educational plan for your daughter.

With only one month post-injury, probably the best thing you can do for your daughter is to give her a lot of love and reassurance. Most recovery takes place in the first six months post-injury. Don’t expect a 100% recovery by next week or even next month. Keep her involved with rehabilitation and make sure all of the doctors’ recommendations are followed. In terms of specific strategies, I can’t really give any more advice without knowing what areas you are concerned about (attention, memory, behavior, etc.). Good luck. I’ll be hoping your daughter makes a good recovery.

You may be put in the unfortunate position of making a very difficult decision. Most people want to return home immediately after a brain injury. However, agitation, mental confusion, aggression, and diminished impulse and emotional control are frequent consequences of brain injury. These behaviors are not easy for family members to deal with. Unfortunately, survivors often cannot control their behaviors. Also, remember that inpatient rehabilitation units provide intensive services that are often not available in the home (such as physical, speech, occupational, or psychological therapies). In the long run, it may be better to wait until your son is in better control of his behavior and you have a better sense of his long-term needs. If you do decide to take him home, please be sure to educate yourself as fully as possible about what to expect. Arrange for home health care if needed. If agitation is a problem, he will probably need someone monitoring him at all times. No matter how much your son wants to come home, it’s important that you realistically understand everything that will entail.

Boating accidents are an increasingly common problem and I'm sorry to hear about your son's tragedy. I doubt the doctors were intentionally providing the "worst scenario." However, they do want to provide a realistic picture of a person's risks. Sometimes people beat the odds, but the doctors need to be honest and tell patients and family members when the odds aren't good. In your case, it sounds like your son is doing better than expected.

I'm not sure which "stages" you are referring to. People have come up with several ways to rate recovery from coma or traumatic brain injury. One of the most commonly used scales is the Rancho scale which includes eight stages.

Understanding the eight Rancho Levels can be helpful to track patients following traumatic brain injury. The levels and descriptions are listed below. Keep in mind that some people may plateau at a certain level and there is no way to accurately predict how fast someone will progress or where they may plateau.

The Rancho levels:

I. No Response

Patient appears to be in a deep sleep and is unresponsive to stimuli.

II. Generalized Response

Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. Reflexes are limited and often the same, regardless of stimuli presented.

III. Localized Response

Patient responses are specific but inconsistent, and are directly related to the type of stimulus presented, such as turning head toward a sound or focusing on a presented object. He or she may follow Simple commands in an inconsistent and delayed manner.

IV. Confused-Agitated

The patient is in a heightened state of activity and severely confused, disoriented, and unaware of present events. Behavior is frequently bizarre and inappropriate to his immediate environment. Patients are unable to perform self-care. If not physically disabled, they may perform automatic motor activities such as sitting, reaching and walking as part of the agitated state, but not necessarily as a purposeful act.

V. Confused-Inappropriate, Non-Agitated

Patient appears alert and responds to simple commands. More complex commands, however, produce responses that are non-purposeful and random. The patient may show some agitated behavior, but it is in response to external stimuli rather than confusion or distress. The patient is highly distractible and generally has difficulty in learning new information. He or she can manage self-care activities with assistance. Memory is impaired and verbalization is often inappropriate.

VI. Confused-Appropriate

Patients show goal-directed behavior, but rely on cues for direction. They can relearn old skills such as activities of daily living, but memory problems interfere with new learning. Awareness of self or others begins to re-emerge.

VII. Automatic Appropriate

The patient goes through a daily routine automatically, but this is robot-like with appropriate behavior. He or she will have some recall of activities and superficial awareness of his or her condition. The patient requires at least minimal supervision because judgment, problem solving, and planning skills are impaired.

VIII. Purposeful - Appropriate

Patient is alert and oriented, and is able to recall and integrate past and recent events. He or she can learn new activities and continue in home and living skills, though deficits in stress tolerance, judgment, abstract reasoning, social, emotional, and intellectual capacities may persist.

I'm glad to hear your friend has so many people that care and show her love and support. Probably one of the best things you can do is to continue to be such a great friend - social support and companionship are very helpful. As for continued rehabilitation, it may be helpful, but based on the length of time post-injury, improvements will likely be slow and gradual. Some people find that persons with balance or motor problems can build strength by exercising in a swimming pool (although consult with her physician first!). Playing video or board games that emphasize memory and/or motor skills can be helpful and fun. Talk with her physician and/or a physical therapist about activities that will help to build strength and maintain good health.

The best thing to do now is to focus on your friend's strengths. From what you wrote, she has made tremendous progress over the past 2-1/2 years! Encourage her to set goals and to develop her interests and hobbies. Work with her to identify things she can do and enjoys doing. What can she do to help her feel more involved and productive? Since you say she communicates well, talk with her about what she would like to do. What future goals does she have? How can those goals be achieved? Let your friend guide you into what activities she would like. With friends like you, I know she's in good hands.

It's very unusual for a person to be admitted to an inpatient facility several years after discharge without some type of deterioration. Certainly if you can afford the costs, you can probably find a facility willing to admit your brother and provide intensive services. However, keep in mind that 4 years post-injury, further improvement is likely to be gradual. In addition, it is unclear whether a person will actually benefit from intensive therapies that many years post-injury. In some cases, too much therapy can leave patients stressed and fatigued, possibly even slowing further recovery. My advice is to talk these issues over with your brother and other family members. If your brother agrees that he would like more intensive therapy on an inpatient basis, you may want to investigate full-day treatment programs or having in-home therapies before you consider the very expensive option of an inpatient placement.

As for locating rehabilitation facilities, the following links may be helpful -

A checklist of questions to ask when looking for a Rehabilitation Center

http://www.headinjury.com/rehabfind2.htm#questions

A listing of some rehabilitation sites in the United States (This is far from exhaustive, but might be a good starting point).

http://www.headinjury.com/rehabfacility.htm#topofpage

Rehabilitation facilities should be accredited by either CARF or JCAHO (but not necessarily both).

To check on a facility's accreditation with JCAHO, visit their website at:

http://www.jcaho.org

For a list of CARF accredited rehabilitation facilities, contact CARF at:

CARF
4891 E. Grant Road
Tucson, AZ 85712
Voice/TDD (520) 325-1044
Fax (520) 318-1129

You sound like a really good person who is trying to give to others. And you work for free? Can we clone you?

One thing you could look into is whether you could locate a church or civic group to organize volunteers to spend extra time with the people at this home. You may even be able to organize an outing if you can get the permission of the facility. Try to find an ally among the case managers or staff. If you can find someone with some authority that also would like to increase the opportunities for community involvement, you will probably make some progress.

Although you have good intentions, also keep in mind that you do not have access to medical/psychiatric records. Many patients in nursing homes may have significant cognitive deficits that are not evident to a lay person. Seizures, high risk for stroke, or other health complications may require intensive observation and low stress levels. Some patients may have periods where they are alert and aware, but may also have episodes of confusion or delirium. Some may even be prone to aggressive or violent outbursts if frustrated, frightened, or overwhelmed. Remember that nursing homes are very controlled environments with regular routines. Pat has seen patients that look "OK" in nursing homes, but were completely unable to function outside of a very controlled environment. Without access to medical records, it's impossible to know the medical or psychiatric issues involved.

Nursing homes are usually overseen by state agencies and/or accredited by outside agencies. You might want to research your nursing home's affiliation. If you believe that patients' rights are being violated, you could contact one of these agencies and make a formal complaint.