I’ve been doing some research on this. So there's just a lot we don't know about neuroplasticity, but there's a lot of things that we do know. So the brain is really fascinating where it can regenerate and reorganize itself to make new connections in order to compensate for the injury and kind of adapt. It can make new nerves and can change structure and reorganize what we call cortical maps. That's been really studied with stroke patients, but not so much with tbi patients. I think it really depends, plasticity can really vary depending on where the traumatic brain injury happened and the severity of it. I think with that being said it's just so important for people to participate in rehab and do your therapy, especially in the first three to six months. So really focusing on therapy, and then also because even if you're in therapy that's only three hours a day for the most part, so making sure that you're following up and doing therapy outside of the sessions. I think that patients that do that are you know the most successful in recovery.

Occupational Therapist

Our brain is compensating after a brain injury, so when we have damage, unfortunately we do not regenerate cells once there's damage.&nbsp; If there is a bleed in a certain area of the brain, that area does not regenerate like everything else in our body.&nbsp; So what we need to do is establish neural pathways and rewire and compensate for what's not there anymore.&nbsp; That's why we train a different hemisphere that can potentially take over what the damaged area did before, but that requires a lot more effort.

speech language pathologist

Are there parts of the brain where neuroplasticity does not work well?

I think you need to follow up with your team, so talk to your occupational therapist, talk with the team to see if it's appropriate because sometimes, especially in the beginning of rehab and especially after having a brain injury, you kind of want to limit distractions as it can be over stimulating to the person. Also, having a visitor there all day can be really fatiguing so I think just talking to the therapist and seeing if it's appropriate for you to come in. I think it's a good idea to have you there if they think that's fine. We want you to be involved as possible and sometimes therapists want you to be involved early on so you can have an idea of what to expect when you go home. We want to do a lot of family training so you know what to expect when you go home and how much assistance your son needs for activities with cognition, if they need cues, or with their self-care. Do they need assistance with pants management, mobility, a device to walk? I think it's just really important just to talk to the team, talk with case management, talk to the therapist, and kind of see if it's appropriate for you to be there.&nbsp;

When restrictions lift, is it a good idea to do some occupational therapy with him when visiting or is it best to leave it to the professionals? And if it's a good idea, can you tell me what would help?&nbsp;

My son has a hypoxic injury and is currently in rehab and i'm allowed only 30 minutes of visiting time at the moment. 

After brain injury, your somatic sensory system can be affected and that's really a brain signal to the rest of your body, your joints, and your muscles to integrate tactile information, you know hot and cold,sensation, pressure, pain, proprioception. A lot of times people might have difficulty with knowing where their arm is in space or knowing where their leg is in space when they're walking and then they can't even put their foot placement or are dropping things all the time on the floor. So, I think a really important thing is that when you have sensory deficits especially with proprioception is really using your vision to compensate for your arm movements or leg movements, so using your eyes to compensate and making sure you're looking at what you're doing to compensate for that. There's also repetition of trying to do those movements and whatever movements you're trying to do like open a container, try doing that over and over again, kind of reintegrate your brain. Also, if you're super sensitive to touch, that could happen too, so you can work on touching various textures. Start with like a cotton ball and rub it against your skin and then go rougher. You know textures and whatever you can tolerate. That's a way to kind of help with that. Also, with people who have difficulty with hot and cold, use another part of the body such as elbow or arm to kind of detect those things. Another thing that can happen is people not being able to identify objects. If you go and l take something out of your pocket, you might not be able to know what that is with your eyes closed. You can you can feel it, you know you can detect what that is, so you can practice working on that by just trying to you know feel around the coins and try to identify what it is and practicing doing those activities will be helpful.

Can you talk a little bit about sensory integration issues and some things that may help?

I’m not sure, I think you could. I don't think there's any drawback, but let me just say this. I think with botox, your movement or your spasticity might be immediately gone so you actually wouldn't want to cast at that point because they will now be able to move their arm a little bit more. You might not need a cast because now you want to try to see if you can get more movement and more strength in the arm. The botox only lasts for a little while, a few months. You have to keep getting injections, which kind of stinks.&nbsp;

Would ever use casting alongside botox or baclofen? or are those never used together?

Exactly. A lot of times at my facility we use focus agility rigidity cast, so depending on what range of motion that they're at, you would put them a little bit less than that and then you would cast them at that level and then kind of just have them get used to wearing itfor a week a couple weeks and then see if you get more range of motion. Then, you might do another cast for them. It depends on what you want to do. Focus rigidity casting is beneficial. It's nice to have it at night time- it helps with giving a stretch and in positioning of the arm, but you'd have to make more frequent cast which is kind of annoying whereas serial casting you would leave it on for one week and then take it off and then you make another one and sometimes that results are a little bit better because you're in it for a longer time period. However, it's kind of hard sometimes since you have to bag it up when you have to walk, shower, and everything else. So there's some pros and cons for both.&nbsp;

It sounds pretty interesting, is that something that basically just holds your arm kind of in place at night so that it's not tensing up and continuing to to reduce that range of motion?&nbsp;

Can you talk about serial casting and just casting in general?

I’m happy to hear that he’s in some therapy. That's good, it might be beneficial to maybe see if you can get an OT consult, but I would also just make sure outside of his therapy sessions that you're doing passive range of motion of the hand. It's going to be really important to make sure that the joints are loose and there's no limitation in range of motion. I think what’s really important is repetition of movement. I know that he's able to grasp a cup, so you know repetition of doing that activity and doing other activities. It sounds like he might be able to do a little bit more, so it might be beneficial to get an OT consult too just to think about feeding and being able to hold a spoon. Maybe using built up utensils to help with grasping. We also have things like a universal cuff- if you can't grasp you can just put a cuff on the hand and put the spoon in and kind of bring up to the mouth. If the grasping doesn't help, there's other options. Just using a loofah or wash mitt to wash the face might be good to kind of see if he can start incorporating those things into more functional activities since he's getting some movement. Just doing a lot of practice, like mass practice, is really really good and shown some good for recovery. Also thinking about electrical stimulation, but you have to talk to your doctor first because if he has seizures, a pacemaker, or cancer, it shouldn't be done. So talk to the doctor first, but with electrical stimulation, electrodes are placed on the weak muscles and help re-educate those muscles to build strength. Just kind of working on that motor learning and increasing the circulation, decreasing swelling if there's any swelling, and increasing range of motion. I think that would be beneficial for him.&nbsp;

His physical therapists are working on loosening up his right arm, leg, and his core. His right side, his predominant side, was affected. He uses his right hand to pick up and drink from his cup and his index finger to spell on his alphabet board. Are there any exercises you can recommend to help bring back and finesse the use of his right hand, especially since that's how he communicates?&nbsp;

 My brother-in-law has a tbi and suffers from brain abscesses. 

Unfortunately, I cannot tell you whether your son's hand or function will come back. I think that's really something that you need to talk to your neurologist about. I cannot be the one to tell you whether or not that's gonna happen. I don't know, but what's concerning is that he can't open his hand so I think really the important thing is skin integrity in the palm and the hand. Make sure his nails are cut- a lot of times when people can't open their hand, their nails are cutting in and they have redness and skin breakdown. They can start to smell so really thinking about reducing skin breakdown in the hand and working on some passive range of motion of the fingers. It will be resistive and you can't move the hand, but passively arrange the fingers in the hand and the wrist. Also, doing the arm too, but making sure just to limit to like 90 degrees just in case there's any kind of weakness in the shoulder. You don't want to impinge your shoulder doing overhead so you might want to also talk to your therapist. If you don't have therapy involved actually, maybe get an occupational therapist evaluation as it might be beneficial depending if you can actually passively move his hand. Maybe getting a splint at night time to actively passively move it by putting in a position where it could be protected and positioned so the fingers are extended. That could be made by occupational therapists. Also it's important to just try to incorporate movement of the arm as much as possible. Think about if I know the hand is closed but maybe if you can open it passively like if you need to open containers or anything. Actually put a container in the arm or the hand and then try to open it actively, try to move and incorporate it in dressing to try to engage the arm and not use it all if possible. I think something else that might be beneficial is mental practice, which is rehearsing an activity in your head before trying it or before doing an action. Research has shown that it's beneficial for motor recovery. Just kind of thinking about an action and kind of thinking about your arm moving and trying to think about maybe brushing hair before actually trying to incorporate the arm and movement.&nbsp;

He cannot open his right hand and has very limited use of his arm. What would help and will it ever come back?

My son has a traumatic brain injury on his left side.  

This is hard- so you just have to really wait it out. So take like making a sandwich or something. You might have to have hand over hand assistance, verbal cues, repetition, practice, and then decrease the cues. You can also work on seeing what they know first. If you're making a sandwich, have the person work on verbalizing the steps of making a sandwich and see what they know and then kind of take it from there if that doesn't work. Give them the cues for that and if that doesn't work, write out the steps of the activity and then have them tell you what to do first so they can work on sequencing. Also, if you have a patient or someone that's lower level, you can have them work on pictures of making a sandwich by having a picture board or pictures. Having them actually put the pictures in order and then complete the activity makes them go through various steps to see if they can be able to figure it out. I think you just have to kind of see where the person's at initially and let that guide the way that you're going to implement, whether you're going to do cues or whether you're going to do pictures or whether you're going to ask them a question and kind of work your way around that.

Once someone can perform a task when asked, how do you enable them to figure out and plan when to do the task? 

I should start with making sure that you use the device that your physical therapist prescribed for you so don't just try to throw it out and willy-nilly and try to do some of these activities. Make sure that you use the device you're exposed to and then if you or your loved one has significant balance deficits, don't try these activities without advice and without having someone nearby. You want to make sure that you stand by assistance just to be on the safe side.&nbsp;So some things that I was thinking you could do at home or around your house that are really good are just putting things in cabinets, taking dishes out of the dishwasher, reorganizing shelves, folding laundry standing level. Doing that standing is always really good since it takes a lot of balance cooking and meal prepping. Not only will it help with balance, but also it helps with anything that requires standing for a longer duration such as doing a ball toss with kids, washing windows, putting things in drawers, or hanging up clothes in the closet.&nbsp;

What are some of the best balancing exercises? 

Specificity is very interesting and a little complicated, so try to make it a little simpler. So, spasticity is involuntary movement of a muscle and it's in response of a stretch which causes tightness. So, the muscle remains contracted and it doesn't shut off. It is resistive to being stretched so when you try to stretch someone out it locks up. That pretty much happens when the signals in the brain are just not communicating to the muscle to turn it off. The movements are just not fluid, there's a lot of stiffness, and it can cause pain and discomfort. Spasms are a component of spasticity so spasms are involuntary tightness or a quick or prolonged contraction in one or more muscle group. They range from small muscles or larger muscles- you can get them in their hand or even in your leg for some other disorders like MS. You might have involuntary moves and spasms in your upper body, your lower body, or your legs, but really spasticity is based on damage in the brain and how severe it is. It can be worse sometimes and sometimes it just really depends on movement. If you're moving the limb quickly, then the spasm or the spasticity will be stronger. A lot of times when I see patients I’ll see how people have more of that spasticity in their hand or their arm when they start to walk. When they're doing an activity, it starts to get really strong and they go into this flexure like a flexion pattern. Hopefully, it will get better once the brain is healing and over time, but there are some ways to decrease spasticity. We like to try to reiterate relaxing the arm as much as possible, trying to train the brain to try to relax your muscle group that is contracted or not contracted but stiff in that particular position. Also, talk to your doctors. There's also medications that can help with spasticity. There's one that's popular called baclofen that people get to help with specificity and spasms. They also have things like muscle relaxers that can help with that but it really depends on the diagnosis and depends on if you have any core mobilities. If you're able to take those medications,&nbsp; follow up with your doctor.&nbsp; Another thing that is important is just range passive range of motion of wherever that extremity is, just to prevent it from getting super tight and you losing range of motion as we don't want that. Another thing that you can also do is some splinting if you have an OT working with you. There's also things called focused rigidity casting which is a cast that you can put on and take off that can be made for you. Say you want to put it on the elbow. You can use that and you can measure it and have the person in that cast for night time. Usually, they'll just have it at night time or you can do in the daytime. It gives them a stretch so their arm can relax for a little bit and then you can make another one as needed to increase range of motion in the arm or leg. There's also cereal casting which is a cast that actually stays on for like a week and then they saw it off. That is useful too and has good benefits to increase range of motion. Additionally, if it is severe enough and it's really bad, you can also do botox injections which can help. Then if it's really really severe, which I don't want to get too much into, you can also get a baclofen pump inserted where you get the medication all the time to help with spasticity.&nbsp;

What makes them flare at times worse than others? Does it get worse before it gets better? Or does worsening spasticity just mean you're going downhill?&nbsp;

BosCelt8393's Answers