Here I have tried to provide a consistent approach to brain injury rehab.This approach will guide the survivor and professionals from the coma to early stages of having no real thoughts, to having some thoughts about activities of daily living and then to having some thoughts about what life will look like now. At the risk of being presumptuous I would like to call it the string theory of brain injury rehabilitation. This string theory consists of, the first stage where there is only an automatic response from the body, (this includes tests such as the Glasgow Coma Scale and the Ranchos Los Amigos Scale). The second stage where there is limited ability to consider surroundings, and the third is when the survivor can do an analysis of their surroundings with a mechanical mind due to cognitive rigidity. The final stage of this process is when the mind has regained the majority of its smoothness and abstract reasoning is now a part of the mind of the survivor once again. This while the goal for so much of rehabilitation, is not even considered realistic by most professionals.This string theory of brain injury rehabilitation focusses on the survivor more than other rehabilitation models. It is all about the survivor after all. The system has been set up by the insurance companies who want to minimize their exposure, and the professionals who want to maximize their gain. More than this though these parties have a self-preservation mindset coupled with keeping the status quo on the current method of operation of these brain injury claims. As with any autocratic system without checks and balances it will eventually go awry. The professionals have become, in my experience, untouchable in their assertions of who will be able to be restored to what level of functioning.

An open mind should be given to the assessment of all individuals.At first things will be very murky and avoidance at all costs for a premature judgement of abilities should be undertaken.As things progress a concerted effort should be made to perform an asset based evaluation of skills.What their pre-morbid activities were like and what they want to do now that they have done an asset based analysis of their characteristics will dictate how they spend the rest of their lives on earth.During rehabilitation an inquisitive self-stimulating mind should be sought. This is also something that has its roots in the pre-accident mind. This though can be encouraged in anyone with an open mind who seeks what is best for themselves. A combination of these factors make for a successful rehabilitation.

Using what executive function you are entrusted with at the earliest stages of rehab is important. Doing laundry is something everyone requires. Using your executive function to sort your socks is a basic building block of your new brain. Checking your toilet paper before you go shopping and making a list each time you go are also important steps in re-organizing your brain. There are numerous other examples of using your executive function in your activities of daily living so as to make their repetition here unnecessary. Other more  sophisticated examples include when you note that the air is cooler and look at the chair you are going to sit in and see that there is not a sweater nearby you go to the room where you know there is a sweater and put it on before going to sit in the chair. These tasks may be done after more simple tasks such as remembering your keys when you leave the house or remembering your hat when you go out. Both of these sorts of tasks should be seen as the initial building blocks for more complex decisions.  Where you are going to live for the rest of your life or how you will address your deficit coping strategies. These are the more challenging life issues that need to be addressed after all the back to work rhetoric is over. There should be some back to life rhetoric going along with all the back to work talk. Your executive function should be made to work for you. To assist you in your activities of daily living,  These seemingly facile things are the beginning points of having a good working executive function again.

To go from no thoughts to mechanical thoughts you need people helping you.  Progress can be quite surprising yet slow here. A simple “Hello” here is sufficient at these first stage. The survivor has so many things going   on around and in them.  An animated one-sided discussion on the hospitals staff side would be sufficient for this stage of rehab. Here all that is required of someone is a brief sentence.  Though this in itself is progress, a mere grunt or other reaction are other alternatives.  Then progressing to a couple of sentences, starting from a word expressing an entire thought can even be and should be encouraged at this stage.  If they are badly aphasic then some other way needs to be thought of to get a response from the survivor, all things and situations should be considered here. This option should always be open though. In this is where some perceived attitudes need to change. The survivor did not   ask to be in this   position, however, it is the professionals’ job to help them out of it. I had some very good people at this stage. One guy when he would come into the room would always give me a big hello … eventually a modest return was made – this is progress at this stage – I was being challenged to make a response and I succeeded. It was a good practise I believe to engage with the survivor on a level that challenges them.

This is where the initial thinking takes place. Thoughts may not occur all that frequently at first. However, in order to facilitate this process I propose using a method of thought.  This method would take an isolated thought and make a complete process out of it. For example recently I was wondering how to do the second load of laundry. In the end I decided to wait   till the current load was finished the wash cycle before going and getting the other load from the bedroom and bring it to the laundry nook. Then I would remove the finished load from the washer and put it in the dryer- debating whether I needed to clean the lint trap I decided not to, and turned the dryer on and then put the soap in the washing machine. Upon adding the clothes I turned the dial to the standard setting and started the machine.  This sort of repeated thinking and reflection are what drive the neurons to get connected again. Taking the time to recollect, reflect, re-examine and plan.Then moving along, this goes from isolated thoughts to a more mechanical sort of mind. Do this and this happens. This is where some experience with mechanical things comes in handy as things at least on a large picture scale are always predictable.  Start by planning your week. I was required to do this as part of my therapy at first, then it became a habit as it remains now. Write this down. Then go over the events in your mind. Reflecting on all the individual steps that need to be taken in the larger picture of things. The things on my list include things like going to the store to buy food, going to the gym, as well as what exercises I will do that day.  Other activities could include banking, a visit to the local coffee shop when the owner is not busy.  Going through the activities of daily living ahead of time, thereby encouraging memory, planning and the executive functions in general is a good thing.Sorting your laundry is a good example of this sort of thing. If you are like me then you will take your already dried clothes in a hamper to your room to be sorted. As you pluck the dried clothes out of the hamper make some of the standard decisions that you will always make. Hold the single socks in your one hand, then as you pluck the next piece of clothing from the hamper decide what to do with it. If it is a sock then try and match it with the other one of the pair in your other hand. If there is no match simply add it to your collection in your other hand. Then take the next item from the hamper, if it is underwear add it to the pile on your top of your set of drawers before proceeding to take the next piece from the hamper. If this next piece is a t-shirt then simply throw it on the bed for folding after the hamper is empty. Hopefully when the hamper is empty all the socks will be matched. If not perhaps you will find the other odd ones as you fold the shirts. Having finished emptying the hamper move all the socks and underwear to the drawer that you have set aside for this. I personally do not arrange the socks and underwear in this drawer although if this is something that you like, continue to do it.  Then I proceed to fold the shirts and trousers. Set them aside for now. When all your shirts are folded then stack them if you haven’t already. Then proceed to put these in a drawer, while doing so you may need to alternate the already clean shirts with the new laundry somehow.   Be methodical in the way this is done each week as well as being meticulous and thorough. This act of consistency will produce self-confidence again – this is sorely needed after the browbeating you receive typically day to day in the rehabilitation world. As this becomes a little repetitious and boring add some things to keep it interesting.   Bake a banana bread and do the dishes, meantime the laundry is going through its cycle.If this becomes too easy then try cooking an omelette at the same time. Make a phone call, answer an email, and find something in your own life that gives you something to occupy yourself.  This is how a person should be busy, this is multi-tasking. Because they are driven to be busy. Not because they are told to be busy by someone else – but by your own drive to accomplish something. Find other tasks from your own personal space that need to be performed and integrate them into your life this way.

Be ready to do this all your spare time. No not the laundry, I mean activities of daily living. Practise on these, life skills and the self awareness that lets you re  examine an already solved problem ….by you  and put it into a slot  where it can be used for further problem solving. To store this already solved  problem with all the variables in order to regain the  problem solving ability for other problems. This is the activity that is most missing in ABI rehab… The ability to solve small problems leads to the ability to solve larger problems.   After all none of us started by solving theoretical physics problems, we started by figuring out how to  put cheerios in our mouths because we were hungry.  Do this and other brain functions will follow.Grow the Neurons.There needs to be imbedded in the rehab process some aspect of continuous learning. Rehabilitation does not end if you go back to work.  Even then there are whole aspects to your functioning that are not developed by the work mindset. Some areas of rehabilitation are all about going back to work as this is what minimizes the losses to the insurance companies.

Community is important in rehabilitation. This fact has been widely recognized. The sheer number of stimuli that occur within any given time frame is so much greater in community than isolation should leave little doubt to this fact.  There was a presumption in rehabilitation that busyness was always better.  The basic premise here is that the mind needs to be occupied with activities and with being challenged and thereby healed. This has been the basic premise of brain injury rehabilitation for some time now. I do concur only with the addition that being busy of the body does not necessarily challenge the mind in the ways it needs to be stimulated. Being in community with others who are doing the same thing is helpful. Being in community period is beneficial.  Whether it is a spiritual community, a sports community or a household community, all these forms of community are helpful.A topic concerning the outcome of survivors is resilience. This comes, in part, from having dealt with some adversity in their lives prior to the brain injury. Dealing successfully with these circumstances in the   past will likely yield better results after the occurrence of a brain injury. This means your ability to have unforeseen circumstances imposed on you and reacting with a sense of adventure will be heightened.The physical stimulation does for sure help, however if these methods are not open to you then one must resort to having an active mind alone.    This can be produced with lots of repetition.  Whatever your occupation was before the accident then this has all changed now. Now your job is to regain as much cognitive functioning as you can.   There are many, many factors involved in this mystery.  The main one being that time is on your side. There is only that, time and reviewed expectations of life now. This is in spite and as a consequence of the challenges that life with a brain injury has now brought you.While there are tasks which must be learned and improved on in private, the majority of the rehabilitation process should be done in conjunction with others. This will improve on the isolation, and increase the value of the therapy. You will always have those that lag the group and those that lead it, and perhaps these special cases should be provided with special care.Slowly, with patience and practice these mechanical thought processes will shift to being smoother. The once mechanical decisions you had to make about baking your weekly banana bread start to smooth out. This, I believe is also true of larger issues in life. But the base of life is built with the small decisions. Practise, practise, practise. New neurons are not initiated by a one off circumstance.It does help to have a degree of resilience. The more the better, as there are many hurdles and temporary setbacks during any rehabilitation process. Unfortunately you have to experience some adversity before the accident in order to build this sort of thing up. This is the best kind to have. Perhaps, memory is foundational to these processes. This is also a presenting fundamental problem with life after a brain injury.

How does one restore the memory function? While this topic alone is worthy of additional emphasis, here, this is not the primary focus.Memory are a function of ones abilities prior before. This provides a bleak prospect for most survivors. As with thinking memory is started slowly. Perhaps, the best use of this is with the activities of daily living. Where do I keep my toothbrush? Where do I keep my aforementioned socks? You need some memory to begin to do the multitasking mentioned earlier.They do play off each other.  A person skilled in this area will have numerous advantages over one who simply lets rehabilitation run their course.Try to remember only important things. What is important for you is nowhere more evident than in brain injury rehabilitation. Endeavour to get your activities of daily living back as quickly as possible. Then seek to optimize them as this sort of challenge does not require any one else to be around.  Try to maintain the big picture of life.  Engage in activities which aid in this pursuit.

There are more ideas and suggestions for brain injury rehabilitation practices in my book . There is also some additional information on my website .You are on a new adventure.
You did not ask to be where you are but nevertheless the show must go on.
How you will make the best of a bad situation is up to you.
One thing is for sure you need to do an asset based evaluation of your skills and keep your head up.Stand tall.