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The brain is a universe unto itself.
That's why people are infinitely complex, wonderful, unpredictable and weird.
To maintain an upright posture and move legs and arms
in a variety of activities without pain or difficulty
To relearn tasks such as bathing, eating and dressing,
and regain independence in daily life
To relearn swallowing and speaking, guide memory
exercises and help rebuild conversational skills
When a bullet pierces the protective skull or a powerful blow jars the head, the gelatinlike brain becomes terribly vulnerable. The intricate wiring goes askew, never to be the same again.
But the brain also is resilient, putting other areas to work to compensate for injury.
It is this process of healing and rewiring that U.S. Rep. Gabrielle Giffords and thousands of other patients with traumatic brain injuries are going through.
They include people like Ashlee Johnston, a Kansas teen who suffered a brain injury in a wreck last year and has made great progress. And Omahan Ken Hupka, who experienced considerable brain damage when he touched a power line on the job. Hupka's recovery has been far less dramatic.
How much of a patient's intellect, communication and mobility return hinges on where in the brain the injury occurred, how bad it was, how quickly treatment was given, the quality of support and rehab, and perhaps other factors that remain unclear.
“The primary issue is that we don't really understand how the brain functions in a deep way,” said Dr. Bill Thorell, an assistant professor of neurosurgery at the University of Nebraska Medical Center.
Giffords will rebound from her brain injury only with time and effort, and even then a return to her former lifestyle is doubtful.
“There's not going to be any reliable way of predicting what her recovery rate is going to be like and what her deficits are going to be,” said Dr. Amanda Mohler, a rehab physician at Immanuel Rehabilitation Center in Omaha.
Bullets tear through brains. Falls and auto wrecks, which cause the majority of the 1.7 million traumatic brain injuries a year in this country, jolt the brain and damage the soft matter.
Johnston has worked for more than five months to recover.
She was riding in the backseat of a car last Sept. 3 near Manhattan, Kan., when the car was smashed in the side by another vehicle. Johnston, now 16, was ejected.
A doctor in Topeka, Kan., compared Johnston's brain injury to the damage done to Jell-O in a shoebox that has been kicked.
Physicians thought she might die the first night, and, after she survived, wondered if she would be in a vegetative state. Besides her brain injury, her pelvis and jaw were broken, and one eye stopped functioning correctly.
They eventually transferred Johnston from the University of Kansas Medical Center to Madonna Rehabilitation Hospital in Lincoln in late September.
She arrived at Madonna on a stretcher and with a blank expression on her face. She had minimal awareness of what was going on and couldn't speak.
Her therapists initially helped her just to sit up in her inpatient bed at Madonna. They eventually had her pick up a light beanbag and hand it to her mother, Angela Tierney. They did this repeatedly. Take the beanbag. Hand it to your mom.
Johnston would grow so weary from that exercise and others that she would lie back, curl up and try to sleep. She had a tracheotomy in her throat for breathing and a feeding tube in her stomach.
Tierney was just so thankful her girl was alive that she vowed to accept whatever progress Johnston made.
A brain contains 100 billion nerves — as many nerves as there are stars in the universe, said Dr. Charles Murrin, a UNMC pharmacologist who has studied the brain for 40 years. Those nerves interact through electrical and chemical processes.
Over the past 10 or 15 years, scientists have discovered that while certain portions of the brain typically handle certain functions, other portions will step in if an area is damaged.
Areas that don't typically handle certain functions might not do them as well, but they can be trained to perform them to a certain level of functionality. It's almost as though the brain has a hunger to serve and work.
In one kind of dementia, while one part of the brain loses its power, some patients begin to develop artistic skills they never had before, said Dr. Sanjay Singh, chairman of the neurology department at the Creighton University School of Medicine.
Singh said scientists believe that the dementia may damage a region of the brain, removing inhibitions and allowing artistic abilities to emerge.
This means “the brain has many mechanisms that we were not aware of,” Singh said. “It's a very complicated system.”
Understanding that the brain can compensate for damage done to it has been a game-changer for brain rehab experts, said Dr. Roger Riss, a Madonna neuropsychologist and researcher.
Patients with injured brains don't have to just make do with what they have left, Riss said. And rehab therapists now know to drive a patient intensely to work the brain.
They pushed Johnston at Madonna, although she recalls nothing of her first month there. Besides beanbag therapy those first few weeks of October, she practiced many exercises throughout the day.
She tried repeatedly to write her name. She put large plastic rings over a cone. She poured Froot Loops into a bowl. She worked at feeding herself. She folded clothes and hung shirts on hangers. She played cards and worked with a light board, pressing lights as they came on and trying to recall the patterns as they came on and turned off.
Her mother believed Johnston would speak again, but also already had found acceptance. Whatever version of Johnston emerged, she would be grateful.
Johnston faced the physical challenges of a surgically repaired pelvis and jaw, and an eye that was first shut, then wasn't coordinating with the other eye.
Her therapists put her through at least three hours of therapy daily and more as she became stronger.
Johnston broke through one morning in late October. In a whisper, she spoke her first words in weeks: “Hi, Mom. I love you.”
Tierney wept. Johnston hugged her mother and wiped her tears. Johnston said it's the first moment of her rehab that she can recall. It's like a light turned on.
Every brain injury is different, just as every brain is different.
Anne Hupka, case manager for the brain injury team at Immanuel Rehabilitation Center, is just grateful her son is alive.
Ken Hupka suffered considerable brain damage in 2004 when he touched a power line as an Omaha Public Power District technician. His brain was starved of oxygen for many minutes, and physicians warned his mother that he might be in a vegetative state the rest of his life.
Less rewiring could occur because the absence of oxygen killed or severely damaged portions of Hupka's brain. Further, the damage from oxygen deprivation generally is more widespread than that caused by trauma.
Today the 33-year-old man can talk a bit, put a fork to his mouth, walk a little. He needs to be told where to go and what to do because he can't initiate action. He knows his family and old high school buddies. He has childhood memories but no short-term memory. He lives at Quality Living, a post-hospital rehab center in Omaha.
Anne Hupka said sometimes if she is in a hurry and encourages him to hustle along, he screams in frustration. She knows then she's put too much pressure on him.
“We're just very fortunate to have him alive and have the function that he does have,” she said.
Anne Hupka, a registered nurse, became involved in brain-injury conferences and education and support groups after her son's brain injury. Immanuel hired her six months ago to work with families, teach them about brain injuries, help form discharge plans and communicate between families and staffers.
Agitation is common in rehab. Immanuel's Mohler said it's frustrating to patients when they don't understand why they're in the hospital, can't identify people and feel they should be heading back to work or school.
Some feel they're much further along in their progress than they truly are. At Madonna, patients use an auto simulation machine not only to work on skills, but also to see that they would most likely cause accidents if they tried to drive.
Some people make steady advances. Some plateau, then take off again. Others have an up and down rehabilitation.
Mohler said rehab progresses most rapidly in the first three months, but strides continue to be made for a year or two. Even after that, baby steps can occur.
Anne Hupka said she sees her son take small steps. There are days when he puts the fork directly and smoothly to his mouth, she said, but not every day is like that.
Once discharged from a rehab hospital, some rely on sticky notes all over their homes. Turn off the coffee pot, get your keys, get your purse, turn the lights off, lock the doors.
Some keep memory books, daily planners or tape recorders with meticulous reminders of what must be done that day and who their family members and doctors are. One woman Hupka knew kept a memory book that read: “If you have found this book, I am lost.”
Some lose their inhibitions and comment to strangers that their clothing is ugly or that they shouldn't eat so much because they're already fat.
Some lose their friends. They look the same but their personalities have changed.
The brain regulates a personality. In fact, it is the personality.
“That's where people are at,” said UNMC's Thorell. “You can change out their heart. You can change out their liver. But you can't change out your brain.”
Look at British genius Stephen Hawking, Thorell said. Lou Gehrig's disease ruined Hawking's body but his brain just keeps firing.
“That guy is still in there,” Thorell said.
Johnston and her mother say progress came swiftly after that morning in late October when the teen whispered loving words to her mom.
Her handwriting and reading improved. She was able to walk some. They took occasional shopping trips in Lincoln. She began to see out of her right eye, although she frequently saw double.
Johnston's parents say that before the wreck occurred, their girl had been rebellious and difficult. Johnston drank booze and lied to her parents about where she was going. Her parents prayed hard that their girl would have an epiphany and see she was headed in the wrong direction.
A different girl has emerged from the rehab. In early January, Johnston spoke at the Mormon church she attends in Manhattan with her mom. She kept it short, saying her parents had been trying to put her on the right path for years. Now, she told the congregation, she knows the gospel of Jesus is true.
Asked two weeks ago if she had willed herself to change or if her brain had simply been altered by the wreck, Johnston said it might be both.
“Even before the accident, I'd started to change,” Johnston said. “And the accident kind of just woke me up.”
The tracheotomy is long gone, leaving a red scar on her throat. The feeding tube was removed in November.
She still walks slowly and with a limp, at least in part because of her pelvis injury. Therapists have her wear glasses that block the vision in one eye, then the other. They hope to strengthen her right eye and compel it to coordinate with the left.
She has a long way to go physically and mentally. She returned home two days ago and will continue rehab from there.
Nova Adams, director of the Therapeutic Learning Center at Madonna, said Johnston will resume her sophomore year at Manhattan High School this month.
Adams has coordinated with Johnston's high school and has assigned her to work on algebra and write a narrative about the accident. Adams said Johnston's school knows she will need extra help early on.
Adams said Johnston certainly will graduate from high school and probably will attend college. She should be able to live independently and enjoy a career.
Two-and-a-half weeks ago, Johnston prepared chocolate chip cookies under the supervision of Madonna occupational therapist Sarah Hamilton.
Johnston loves chocolate. “I think that it makes you better,” she joked.
She poured flour into the cookie mix and stirred. “Keep going,” Hamilton told her. “Great.”
Hamilton then asked what Johnston had to do next.
“I have to stir the chocolate chips in.”
Johnston tried hard to tear open the plastic bag of chocolate chips.
“If you can't get it open by hand, what do you need?” Hamilton asked.
Johnston still struggled to get the bag open with the scissors. Hamilton held the bag and Johnston cut it.
Johnston stirred the chocolate chips into the mix. Then she began to scoop the cookie batter onto a cookie sheet.
“Do you remember how many people will be eating today?” Hamilton asked.
Hamilton asked her to find on the bag how many cookies could be made with this recipe. Johnston couldn't find it and Hamilton pointed to “two dozen” written on the bag.
“And how many is two dozen?” Hamilton asked.
“Twenty-four.” Johnston made about two dozen cookies and a giant one with leftover dough.
Johnston sat down with about 10 other patients in a dining room. They ate.
Her short-term memory continues to give her trouble. She loses her train of thought, her mother said, and doesn't remember certain events before the accident.
“I don't think anybody can tell me exactly what the prognosis is,” Johnston's mother said. “What is she going to be like a year from now? I don't know.”
Johnston left the dining table and came to her mother.
Hamilton, the therapist, walked up. “Here's your giant cookie,” Hamilton said.
Johnston smiled broadly and turned to her mother. “I made a giant cookie,” she said.
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