The Fighting Spirit Who Refused to Give Up

Breaking difficult horses was C.A.'s passion. She seemed to speak the same language as the horses with which she worked. C.A. had a "tough", often stubborn personality which made this a perfect job for her. These same personality traits would be assets in her recovery from a serious brain injury.

It was a beautiful spring day in California when C.A. went out to work with her horses. While trying to ride one of the horses, C.A. was suddenly thrown off. She landed on her head and was knocked unconscious. By the time emergency personnel arrived at the scene, C.A. had regained consciousness and was combative. Her confusion and disorientation were evident and she was unable to follow simple commands.

Upon arriving at the emergency room, a CT scan was performed on C.A.'s brain to identify the areas that had been damaged in her fall from the horse. Unfortunately, the CT scan revealed many areas of blood in the brain. C.A. had an intracerebral hemmorhage, blood in the fourth ventricle and areas of subarchnoid blood. In addition, C.A. suffered a skull fracture near the back of her head and a contusion on the frontal areas of her brain.

Once C.A. was medically stabilized she was transferred to an acute medical center to address conditions related to her traumatic brain injury. One major area of concern was C.A.'s behavior. Trying to escape from the medical center, extreme agitation, emotional lability, being loud and difficult to redirect were some of the behaviors that C.A. manifested following her brain injury. She was even verbally abusive to the sitter that was assigned to keep her from leaving the medical facility. Due to the severity of these behaviors, several combinations of pharmacological drugs were used in an attempt to control C.A.'s behavior. These drugs included a combination of Haldol, Benadryl, and Ativan, as well as, Lithium, Zyprexa, and Trazodone. However, C.A.'s hitting, biting, kicking, screaming, and exiting behaviors persisted. Progress in the areas of balance, coordination, visual-perception, speed of processing, memory, orientation, and adjustment to disability were slow due to the severe behavior. It became obvious that C.A.'s behavior was out of control and that she needed a rehabilitation program that specialized in, and effectively treated, behavioral challenges.

Approximately, one month after falling from her horse, C.A. was admitted to Centre for Neuro Skills® (CNS) in Bakersfield, California. CNS is a post-acute, brain injury program that has been rehabilitating individuals with traumatic brain injury for 26 years. It is a comprehensive, intensive and structured rehabilitation program that has considerable experience with treating severe behaviors such as C.A.'s.

Upon admission to CNS, C.A. required 24-hour supervision due to her attempts to leave the residential setting, as well as, disorientation and confusion. C.A. required two staff members in addition to her treating therapist to control her physical aggression. At the time of admission, C.A. was not able to express goals for rehabilitation. Her family wanted her to be able to return home to live with her husband, train horses, drive and independently manage her daily routine. Given these goals, C.A.'s therapeutic program focused on the balance and coordination needed for working with horses; the visual-perceptual skills, processing speed, and problem solving skills needed for driving; and memory, orientation and attentional abilities that are needed for independent and safe living. Adjustment to disability and appropriate social skills were addressed so that C.A. could re-integrate into the community. The maladaptive behaviors that C.A. demonstrated such as kicking, biting, exiting, hitting and yelling were addressed in each therapeutic discipline and at the residential setting, guided by a structured behavioral program. The frequency of these target behaviors were recorded at both the clinic and residential setting to allow for decisions regarding specific medication changes. Frequent data was also collected regarding her skill development and deficit resolution.

Ironically, C.A. was like the difficult horses that she trained prior to her injury. Horses kick and bite because they are doing what they think they need to do in their environment. It is very possible that C.A.'s survival instinct was activated shortly after her injury. Giving C.A. drugs to sedate her and mask her behaviors only made them worse because C.A., like a difficult horse, was only doing what she thought was necessary to survive. C.A.'s stubborn personality and "fighting spirit" were what she was relying on to get her through the difficult process of rehabilitation following a traumatic brain injury.

CNS treated C.A.'s aggressive behaviors with firm structure, a rigorous routine and plenty of feedback. In addition, she was taken off of the "behavioral cocktail''of medications that she was taking prior to admission to CNS. Often, individuals who have suffered a traumatic brain injury such as C.A.'s are given these medications to help control their behavior. Certain medications have a sedating effect and make the individual easier to deal with in the short-term. However, this strategy does not identify or treat the underlying causes of behavior, which is needed for the individual to truly recover from the consequences of their injury.

C.A. made remarkable progress after being at CNS for approximately three months. Physical aggression, yelling, trying to escape and her level of confusion all decreased dramatically. Once C.A.'s behaviors decreased, she was able to fully participate in the rehabilitation process and make progress towards returning home and to her horses. Community outings, which had been avoided due to her behavioral outbursts, became a regular part of C.A.'s routine. She no longer needed two extra staff to supervise her every move. C.A. was reaching her goal of independence.

Although C.A. did not remember much about those first couple of months following her brain injury, she realized that she was difficult and upon discharge from CNS to her home, she was able to express her gratitude to the CNS staff for "not giving up" on her. C.A.'s "fighting spirit" and personality enabled her to not give up on herself. Guidance, structure and a rehabilitation program that is experienced in dealing with behaviors following brain injury, enabled this "fighting spirit" to return home and continue her work taming "fighting spirits" of another kind.

For more than 26 years, CNS has been committed to helping those who have sustained a brain injury achieve the highest possible level of functioning and quality of life.