Stephane is a 45-year-old man who suffered a severe TBI on January 11 in a bicycle-car collision. His initial Glasgow Scale score was 8. He remained in a coma for 5 days. The duration of post-traumatic amnesia (PTA) is estimated to be 10 days. He suffered multiple bilateral cerebral hemorrhagic contusions, mainly in the frontal region, as well as multiple fractures: C2-C3 cervical (Miami 24/24 collar), facial mass (orbit, skull base), right clavicle, right humerus. Stéphane had a convulsive episode 48 hours after coming out of the coma. On February 9, his medical condition was stabilized and he was admitted to the ICU. 

He had no previous health problems other than chronic low back pain and was not taking any medication. 

Stéphane is married and has two children. He has worked as an engineer in a consulting engineering firm for several years. His work weeks vary between 40 and 50 hours. He uses his car to get to work. He is an avid cyclist and trains on a regular basis and occasionally participates in competitions. In his spare time, he is busy renovating the family home. 

Those close to him describe him as hyperactive, organized, a perfectionist, hard-working and concerned about the well-being of others. He is described as action-oriented, rather reserved, but enjoys humor and the company of others. He is generally calm and good-humoured, but can become angry, especially at himself, when he makes a mistake. Stephen is very demanding of himself, feels responsible for others and is not in the habit of asking for help. 

His wife has a full-time job. She was able to take a sick day to support her husband, but will have to return to work gradually in mid-March. The children attend elementary school. The family has a good social network. 

The couple owns a duplex. The second floor is occupied by tenants. Before the accident, the couple shared all the tasks. The wife did the shopping and meal planning. Stephen was involved in preparing dinner on a daily basis. The wife was responsible for other household tasks. Stephen was responsible for the exterior maintenance of the house and the renovations. He also managed the maintenance and repairs of the car. Finances were managed jointly on a monthly basis.  

At the first interdisciplinary team meeting on February 24 (6 weeks post-TBI), rapid and encouraging progress was noted. A first weekend outing was made at home, but without sleeping. A second outing (with sleeping) is planned in a week. Stéphane’s clinical picture is as follows. 

Opioid withdrawal is ongoing. Headache intensity has decreased. The pain is constant, but tolerable, and Tylenol is effective in controlling it. Stephen rarely misses treatment because of the headache.  

The weight-bearing ban on the right arm is still in effect until the orthopedist reassesses the healing of the scapula fracture. The arm is supported by a sling during the day because Stephen forgets not to use it.  

Stephen can move around without technical aids, but his walking is slow and hesitant due to diplopia, cervical condition (cervical collar in place all the time) and dizziness. He tends to walk along the walls for safety and occasionally takes breaks by closing his eyes to rest. Stephen holds onto the handrail when using the stairs because he does not feel strong enough on his legs. A slight general muscle weakness is indeed noted (deconditioning).  

Fatigue is still important. Stéphane takes 2 naps of about 1.5 hours per day. At night, his sleep is light and he is frequently awake. Fatigue increases during the day with exacerbation of symptoms in the evening. Despite his fatigue, Stéphane manages to participate in rehabilitation activities.  

Stephen is well oriented in time and in his immediate space. He generally goes to his treatments alone, thanks to the schedule prepared by his caregivers, but he needs supervision to avoid inattention errors when he records information. Also, they may show up at the wrong time at the wrong place. It is now rare to have to go to his room to get him. Stephen is generally aware that his cognitive functioning is affected, but he does not seem to worry about it and does not necessarily recognize forgetfulness or inattention when it occurs. The team observes that the pace of learning is slowed by the attention and memory problem and that resistance to cognitive effort is diminished.  

The people close to Stéphane notice changes in him. They consider him rather apathetic, less interested, distracted, easily in the moon. They notice that he is less engaged in the conversation and that his words are not always easy to follow (insufficient context, inappropriate change of subject, imprecise vocabulary). It is sometimes necessary to question him in order to understand his thoughts. Also, Stephen’s wife notices that he doesn’t always tell things as they happened.  

In groups, he tends to “unplug” and go off into the moonlight. He prefers to stay in his room to eat, because the bustle of the cafeteria makes him irritable.   

Stephen realizes that he is searching for his words and that his pronunciation is more relaxed than before, without being made to repeat himself.  

Stephen is used to reading the newspaper in the evening, but he usually gets bored before he reaches the end of the articles. He gets distracted, has to reread passages and loses interest. The diplopia forces him to adjust his head position, which creates additional discomfort and fatigue. Shortly after reading, he already needs clues to bring back bits and pieces of the information he has read.  

Stephen’s behavior is generally adequate, but those close to him notice that he smiles less and is less interested in others. They find him “neutral”. Stephen tends to lie down if he has nothing to do.  

Those close to him note that he constantly comes back to two favourite subjects: his leave from the RFI (réadaptation fonctionnelle intensive) and his return to work. He gets angry when it is pointed out to him.  

Certain situations and contexts are conducive to the expression of irritability: noise, fatigue, confrontation with his difficulties, forgetfulness, unexpected changes. Stephen expresses his irritation by raising his voice and formulating his ideas in a categorical manner. He reproaches more often than before and has no regrets afterwards.  

In the last few days, he has begun to talk down to himself and has become more withdrawn. He suggests to his wife that she might be better off without him. Despite this mood dip, he is cooperating well with treatments, but he needs to be genuinely interested and stimulated by the activities to remain attentive.  

Stephen needs stimulation and assistance with his personal hygiene, but he does most of the steps on his own. In general, the supervision helps him to keep his focus on the activity in progress. He is slowed down in his movements by the problem of arm mobility and diplopia. When dressing, he is also limited and slowed down by the immobilization of the arm and by the cervical collar. He sometimes tries to use his right arm despite frequent reminders.  

As far as meals are concerned, Stéphane is able to heat up a meal and prepare a (simple) lunch for himself. He currently eats with his left hand and needs help cutting food. Supervision is still needed to prevent him from forgetting the stove is on.  

Stephen recently spent a day at home with his family. He complained of discomfort during the car ride. He had to close his eyes to avoid being disturbed by visual stimulation and had a headache when he arrived home. During the day, his wife had questions to ask him about their tax return, but Stephen couldn’t think straight and quickly became irritable. He settled down in front of the television and fell asleep. Stephen is contributing less than before to the running of the home and his wife has to take over. She also had to remind or encourage him to take his medication.  

A week later, a second home visit was made and confirmed that Stephen was able to stay home alone during the day without risk to his safety. However, he is not strong enough to go out on his own and walk in his neighbourhood. Moreover, he does not ask for help when he gets lost. Generally speaking, when faced with a dead end, he has difficulty evaluating more than one possible solution and does not realize his mistakes.  

Stéphane was discharged from the RFI (réadaptation fonctionnelle intensive) on March 8 and was referred to the Réadaptation Axée sur l’Intégration Sociale (RAIS) to continue his rehabilitation.

Case #2 is a 25-year-old woman named Jane who was injured in a motor vehicle accident. In addition to lower extremity fractures, she sustained a relatively severe traumatic brain injury with an initial Glasgow Coma Scale of 8, a coma lasting about 1 week, and an initial head CT scan showing multiple cerebral contusions and small hemorrhages.

She was seen for an initial rehabilitation evaluation about 9 months after her injury by an outpatient team that included a rehabilitation physician, a neuropsychologist, a PT, and an OT. Completing the MPAI-4 48 by consensus, this team rated her in the mild-moderate range on the Ability Index (raw score = 12; National T-score = 42; Mayo T-score = 46) noting mild problems with hands, nonverbal communication, and novel problem-solving, and more significant problems with attention and memory. Social and emotional adjustment, self-awareness, and family support were judged to be relatively good, resulting in a low score on the Adjustment Index (raw score = 7; National T-score = 35; Mayo T-score = 30). Restrictions were noted on the Participation Index, however, in social and recreational involvement, independent living, transportation, and money management. Jane was also unemployed. Her score on the Participation Index was also in the mild to moderate range (raw score = 17; National T-score = 46; Mayo T-score = 51). Outpatient rehabilitation and community-based services were organized that focused on developing methods to compensate for cognitive problems, primarily through the use of a “memory notebook,” as well as in a number of functional areas that included increasing social and leisure activities, independent living, and money management skills, and vocational rehabilitation. Re-evaluation with the MPAI-4 was done periodically throughout this process to assess progress. After 6 months of outpatient rehabilitation and community services, Jane greatly increased her social activities and was living and working in the community. Scores on the MPAI-4 documented a little improvement on the Ability Index (raw score = 8; National T-score = 37; Mayo T-score = 39) but more dramatic improvement on the Participation Index (raw score = 2; National T-score = 25; Mayo T-score = 29). Jane had re-engaged with her community despite her remaining cognitive and physical impairments.

Case #3 is a 46-year-old man named Ralph who sustained a mild TBI. He collided with another player in a softball game and was briefly unconscious (a few minutes) and experienced a period of post-traumatic amnesia lasting about a half hour. He was taken to a hospital Emergency Room where a head CT scan was normal and he was dismissed home without hospitalization.

Ralph worked as a software developer in a relatively intense environment with high demands for productivity and meeting deadlines. He attempted to return to work after his injury but was unable because of problems with memory and frequent severe headaches. He was evaluated by a rehabilitation physician and a neuropsychologist who also conducted neuropsychometric testing. The physician and neuropsychologist coalesced their assessments of his case by completing the MPAI-4 together. They found little impairment on the Ability Index (raw score = 3; National T-score = 25; Mayo T-score = 27), noting mild problems with the attention that probably accounted for Ralph’s experienced “memory” problems. Neuropsychometric test results were generally within normal limits except for mild variability indicating difficulty sustaining attention and mild impairment on the more demanding attentional tasks. A number of indicators on the Adjustment Index were elevated (raw score = 24; National T-score = 54; Mayo T-score = 55). Ralph appeared depressed, anxious, and irritable. He experienced frequent headaches and fatigue. The doctors debated to what degree difficulties with attention represented the residuals of mild TBI vs. the effects of depression, headache pain, and associated sleep disturbance and fatigue. Although his symptoms appeared genuine, he was very focused on them and this increased his distress. All these factors interfered with his family and social life and with his participation in leisure activities. However, with the exception of mild limitations in social and recreational activities and being currently unemployed, Ralph was generally participating fully in areas measured by the Participation Index (raw score = 8; National T-score = 40; Mayo T-score = 41). 49 Planned intervention focused on medical treatment of depression and headache, and psychological treatment to address adjustment issues, including vocational reassessment, and coping with stress. Ralph’s family was involved in a number of these psychotherapy sessions. After several months of treatment, emotional and social adjustment problems had resolved. Headache and intermittent attentional problems remained but not at a level that interfered with everyday functioning. Ralph started his own software company in which he was able to work from home at his own pace. His old employer was one of his primary customers, contracting with Ralph for the development of software components that were a specialty for him. Re-evaluation with the MPAI-4 at dismissal from outpatient services revealed all Tscores below 30.

Case #4 is a 31-year-old man, John, who sustained a severe traumatic brain injury (initial Glasgow Coma Scale = 8; coma X 2 weeks; multiple areas of hemorrhagic contusion on head CT) in the context of multitrauma. He had a history of alcohol dependency prior to his injury and his wife, Mary, is concerned about his current use of alcohol.

John was evaluated about three years after his injury by a multidisciplinary rehabilitation team who completed the MPAI-4 by consensus. Staff noted relatively severe problems in most areas reviewed by the MPAI-4 resulting in T-scores above 60 on all three Indices using Mayo norms. As part of this evaluation, John independently completed the MPAI-4 as did his wife. One of the issues raised by staff in rating the MPAI-4 was impaired self-awareness. Consistent with this observation, John rated himself much lower in most areas. T-scores for Mayo norms for John’s completion of the MPAI-4 were all below 40. His wife’s ratings on the MPAI-4 resulted in scores between John’s and the staff’s ratings, that is, T-scores in the 50s on the Ability and Adjustment Indices and 48 on the Participation Index. Mayo norms were used in computing these T-scores because norms are available for this sample for the MPAI-4 completed by people with ABI and SO as well as by Staff. The higher scores on the Participation Index by staff compared to scores from John and his wife suggest that staff may have overestimated the degree to which John’s community participation was limited. Nonetheless, there was little question that John was struggling with a complex array of physical and cognitive impairments, emotional, social, and other adjustment issues, and had not been successful to date in returning to many usual social, leisure, and vocational activities in the community. The rehabilitation team recommended that John enroll in an intensive day treatment program. Participation in this rehabilitation program was coordinated with intervention and recommendations from substance abuse specialists. Despite his initial objections, John agreed to this type of treatment with pressure from his wife. After about a month in the program, his awareness of how some of the impairments that had resulted from his injuries interfered with social and vocational adjustment appeared to be improving. He resisted participating in formal substance abuse treatment. However, with support from the rehab team, his wife became more assertively insistent about and supportive of John’s not drinking. With only a few short relapses in the course of the program, John appeared to maintain sobriety. Following about 6 months of day treatment, John started a job in the community with ongoing support. He was compensating for his cognitive problems and his wife felt that his communication and behavior in social settings and with her were much improved. John, his wife, and the rehabilitation staff independently completed the MPAI-4 again at the end of the program. All T-scores from all raters were between 40 and 50. John’s status had improved significantly from the perspectives of his wife and the rehabilitation staff, and all parties appeared more “on the same wavelength” than before the program.