Setting Goals, Rehabilitating After Brain Injury
NEAL CONAN, host:
This is TALK OF THE NATION. Im Neal Conan in Washington. At Cape Canaveral this morning, Americas best-known brain injury patient watched her husband blast off aboard the space shuttle Endeavor. Gabrielle Giffords trip from a Houston rehabilitation hospital just four months after the Arizona Congresswoman was shot marked an important milestone in a remarkable recovery.
Its important for patients with traumatic brain injuries to set and work towards goals, a process that can be filled with surgeries, therapies and experiences that no one can truly predict. If you or a family member went through rehab for a brain injury, what surprised you about the process? Our phone number is 800-989-8255, email us email@example.com. You can also join the conversation on our website, thats at npr.org. Click on Talk Of The Nation.
Later in the program, well talk with Graham Motion whos getting Animal Kingdom ready for the second leg of horse racings Triple Crown. But first, traumatic brain injury, we being with John Keller whose motorcycle got hit by a car three years ago. He flew across five lanes of traffic before he hit the pavement. He arrived at the TIRR Memorial Hermann Hospital in Houston in a vegetative state and doctors there thought that his was among the worst cases theyd ever seen.
After aggressive therapy and family support, that prognosis changed drastically for the better. And John Keller joins us now on the phone from his office in McClellan, Texas. Nice to have you on the program today.
Mr. JOHN KELLER (McClellan, Texas): Hey, Neal. Nice to hear your voice.
CONAN: Thanks very much. Nice to hear yours. I'm that when you first got to the hospital there in Houston, you couldnt move your eyes.
Mr. KELLER: No, sir. Didnt do anything.
CONAN: When did you first become conscious?
Mr. KELLER: Three-hundred-and-forty-four days after my wreck, February 17, 2008.
CONAN: After all that time, you finally became conscious.
Mr. KELLER: Yes, sir. 344 days without walking, talking, eating or anything.
CONAN: And what did you think?
Mr. KELLER: I woke up and I was like, what happened? And whats going on? I had to ask. It was really confusing. I dont remember much of the wreck, actually.
CONAN: I cant understand that. At that point, what did you have to relearn?
Mr. KELLER: Basically, everything. My vision was really messed up. It was like looking through a magnifying glass. So my memory was basically next to nothing because I didnt really see it happen clearly, you know? So its come around now, and the vision has way cleared up, thank God.
CONAN: I bet. That must have been difficult.
Mr. KELLER: That was really challenging, yes.
CONAN: And a surprise. I would have thought, yes, memory lapses, I would have expected. The vision thing, thats
Mr. KELLER: Well, yeah, on top of that, I have no well, I do now, its really close. I had no sense of smell at all. And I was really freaked out and going, wow, if my vision was like that, I would have been blind. How scary would that have been, huh?
CONAN: And it started to come back there, too.
Mr. KELLER: Oh, yes, sir.
CONAN: And as I understand it, to relearn a lot of those things after an injury on the scale that you had, is teaching your neural pathways to rebuild in new ways.
Mr. KELLER: Yes, definitely.
CONAN: And a lot of its just well, describe some of the therapy you went through.
Mr. KELLER: LearningRX, amazing. I got a (unintelligible) and Brain Fitness Program on the computer and I had done that for, what, three to six months after I got back. And I was really getting frustrated, going, uh-oh, Im hitting a glass ceiling. Anyway, my sister lives in San Antonio. She found this LearningRX that has gotten kids off of ADD and autism, stuff like that.
Anyway, she got me into the program and oh, my gosh, what a lifesaver. I thank God for that. I was stuck like Chuck.
CONAN: I have heard your doctors describe you, now, as pretty much normal.
Mr. KELLER: Pretty much, yeah.
CONAN: Whats left between pretty much and normal?
Mr. KELLER: Well, Im still waiting on some vision, just a little afraid of the blind sides Ive got on the right and left side. And its pretty cool, walking and I will tell you that what has done amazing for me, too, is all the walking. I was walking two hours a day to burn some fat, too. But the gym, as in weights and the therapy, which I did to my I was pretty built before the wreck so I did it all again and its been wonderful.
CONAN: I bet. After 344 days, there wasnt much left.
Mr. KELLER: Not much after the atrophy. My arms got down to 11 inches. Theyre 17 right now. Thats cool, huh?
CONAN: Thats a lot of work.
Mr. KELLER: Theyre actually two inches bigger than before the wreck. Can you believe it? All my traits came back, but they just came back a little extreme.
CONAN: Given what you went through, does it come as a surprise to you when you read about Congresswoman Giffords?
Mr. KELLER: Yeah, thats really cool. What now? Im sorry.
CONAN: Does it come as a surprise to you that shes done so well.
Mr. KELLER: Oh, yeah. No, not at all. And I wanted to tell you this. God created such a resilient body and brain that its just going to heal over time. Once she passes the threshold, you see her start making leeway, man. Shes on the road, it just takes time.
CONAN: And do you have any doubt that your life, from now on - yes, there are going to be challenges, but pretty much normal.
Mr. KELLER: Its pretty much normal and Im this is really cool. I go in public now. And as long as Im dropped off in a location, like a restaurant or something, I can walk around. I had a hard time walking. I was so weak for a while. And anyway, Im really smooth. You cant tell whats going on behind the eyes. Everybody loves my personality now, and basically, nobody can tell anythings happened to me. Thats really cool.
CONAN: Are you the same person you used to be?
Mr. KELLER: I think Im the person I used to be in high school. I really do. Definitely. My mother ministered to me a lot and I am a lot like her now in the hospital. But it was kinda
CONAN: An accident like that cant help but change you, though.
Mr. KELLER: It can actually help bring out the real person somewhere in there. I love people now. I love relationships now. I really do. Like, I really love talking to you. Before, I was so tight, I would be like, no, Im too busy, cant talk, you know? That guy. Im glad hes dead. Whatever.
CONAN: Hes changed anyway.
Mr. KELLER: Yeah, definitely. Oh, most definitely.
CONAN: What do you look forward to next, in terms of setting yourself a goal?
Mr. KELLER: Well, Im really happy about getting my body back in shape and whatever God wants me to do. And whatever - talk show - whatever. Whatever comes my way and get back to work, I guess. So much for my vacation, right?
CONAN: So much for your vacation.
Mr. KELLER: Yeah, its fixin to be over.
CONAN: John Keller, good luck to you. Thanks very much for taking the time to speak with us today.
MR. KELLER: Thank you.
CONAN: John Keller joined us from his office in McAllen, Texas. He wrote a book about his experience. Its called A Miracle: On The Road To Recovery. Joining us now, from TIRR Memorial Hermann hospital in Houston is Dr. Gerard Francisco. And that hospital treats nearly 50,000 patients every year, including this year, Congresswoman Gabrielle Giffords, whos going through the rehab process.
Dr. Francisco oversees her care. Hes the chief medical officer at the hospital, chair of the Department of Physical Medicine and Rehabilitation at the University of Texas. And with us in the studio at our member station KUHF in Houston, and nice of you to be with us today.
Dr. GERARD FRANCISCO (TIRR Memorial Hermann Hospital): Thank you for having me here.
CONAN: And I know that John Keller is just as important to you as Gabrielle Giffords, but it mustve been a special moment to see her today at Cape Canaveral when her husband took off in the space shuttle.
Dr. FRANCISCO: Oh, it was a great moment. The team thats treating her is so proud of the accomplishments that shes achieved in the last several weeks.
CONAN: And is the kind of recovery that we were hearing about from John Keller we know the terrible extent of her injuries, but is that kind of recovery unusual once you get over what he called that threshold?
Dr. FRANCISCO: Not really. Each person's recovery from a brain injury is different, and in John's case or another patient's case, it's something that we monitor closely, knowing that the rate of recovery varies from person to person.
So the challenge for us is to try to push that recovery further and identify any potential obstacle so that our patients can recover to their maximum capabilities.
CONAN: So to a civilian like myself, first of all the idea of someone who had been shot in the head, well, the first thing you think of is they're not likely to survive, or if they do survive, they are not likely to recover.
Well, if they do survive the trauma, whether it's a car accident or a gunshot, what you're telling me is it's not that unusual for them to recover.
Dr. FRANCISCO: Not unusual at all. There are some people who do very well following a brain injury from different causes - from a car crash, from a gunshot wound. And unfortunately, there are others who don't recover as well.
CONAN: What is the major difference between those two?
Dr. FRANCISCO: A lot of factors. One is the injured brain itself. In general, the younger you are when you have the brain injury, your chances for recovering will be better, as well, as compared to someone who's much older. The type of the injury, the severity of the injury or if there were any complications that occurred after the brain injury.
That is why the first several days following a brain injury is critical, because there are complications that are quite difficult to prevent. No matter what we do, they occur. And many times those complications, when they set in, even with the best therapies given may hinder a person's recovery in the long term.
CONAN: Swelling of the brain.
Dr. FRANCISCO: Swelling of the brain. There are complications such as hydrocephalus, which is an abnormal collection of fluid in the brain. Someone may have an infection. Someone may have lost blood, or the blood pressure is not maintained well. And those factors can contribute to a poor recovery.
CONAN: We also hear that - we've learned that various parts of the brain regulate certain parts of human activity. And when someone like John Keller says I lost my sense of smell for two years, how does - if that section of the brain has been lost due to the injury, if that's the part of the brain that's been taken out for one reason or another, how does the brain re-teach itself to smell?
Dr. FRANCISCO: Oh, there are different ways. Loss of smell is one of the more common problems that we encounter with people, especially those who have a fracture in the front part of their skull because the nerve that controls smell is located in that area.
It's a very fragile nerve. So it's easily injured. And fortunately, that test -smell is not tested all the time in many people with brain injuries, either because our patients are not able to respond accurately, or sometimes the clinicians just forget to test that.
But an injury to the nerve that causes a loss of smell is not rare at all. And there are different ways to treat this. Sometimes in spite of all efforts, that ability cannot be recovered. But we try to incorporate that in therapies by presenting different stimuli, different smells.
And, you know, that's quite important for us to assess because if we're going to send someone home from the hospital, and this person is going to live by himself or herself, and if unfortunately there is a gas leak, how will this person know? So it's something that we will look at. So if we are not successful in rehabilitating this sense of smell, then we have to find ways how we can get around that.
CONAN: Dr. Francisco, stay with us if you will. We're talking about recovery from traumatic brain injury. Stay with us. I'm Neal Conan, TALK OF THE NATION, NPR News.
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CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan in Washington. We're discussing recovery after traumatic brain injury. Half of those injuries are caused by traffic accidents: cars, motorcycles, bicycles, pedestrians.
Falls are the most common cause after the age of 75. Some 20 percent of all brain injuries are due to violence. Half of all injuries are alcohol-related, and men are more likely to suffer TBI than women.
Traumatic brain injury has also become the signature wound of the war in Iraq, largely because of roadside bombs, and improvements in battlefield medicine allow more wounded troops to survive those attacks.
We've talked several times in recent years about those kinds of wartime injuries and the medical advances now helping many civilians recovery from their injuries, too. You can find a link to those stories at npr.org.
If you or a family member went through rehab for a brain injury, what surprised you about the process? 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Our guest is Dr. Gerard Francisco, chief medical officer at TIRR Memorial Hermann Hospital in Houston, Texas, chair of the Department of Physical Medicine and Rehabilitation at the University of Texas.
And this is an email: Thank you for discussion of this trauma topic. One comment, we hear so much about recent and progressive recovery but so little about the immediate attention provided by the male nurse that happened to be at the scene of the shooting tragedy. Can you discuss the impact of immediate attention to a brain injury, what that has on the prognosis. Dr. Francisco?
Dr. FRANCISCO: Sure, I think that relates to what I mentioned earlier. The earlier we can prevent complications from happening, we're giving our patients a better chance for recovery.
So I should have added that care starts at the EMT level, when they respond to an accident or a certain incident. What they're going to do may have a profound impact on the eventual outcome of our patients.
CONAN: Let's get a caller in. This is Mike(ph), and Mike's on the line from San Antonio.
MIKE (Caller): Hi there, interesting comment he just made, too. The person I was going to talk about, I'm just going to call her Maggie(ph), a friend of mine.
MIKE: Was driving home from work one day, and a truck - a concrete loader in front of her with an uncovered load bounced a piece of concrete loose, went through the windshield and shaved off her skull right above her ear.
And when that happened, of course she had an accident. Well, luckily, the first person onsite was an RN and kept her stabilized until the AirLIFE showed up.
But the thing that she told me - was the oddest thing about her recovery was the fact that, for a while, she lost the association between an item and its name.
She'd be able to point at a refrigerator - the most common example she gave me - she pointed at a refrigerator, tell you how it works, tell you different things in it, but she could not say the word refrigerator while actually looking at the fridge.
The same thing, she could open up milk. She could tell you about the milk and the cow and such but not be able to tell you that that is called milk. It took her months and months to start rebuilding the associations.
CONAN: Dr. Francisco, is that unusual?
Dr. FRANCISCO: That's not unusual at all. What you've described seems to be a type of aphasia we call anomia, or the inability to name objects. That is something that we see after a stroke or after a traumatic brain injury if the region of the brain that governs that part of language is affected.
MIKE: Well, thank you very much. I thought I may have heard the name before, but thanks for reminding me. And great article, by the way. Thank you all very much.
CONAN: And Mike, how's Maggie doing, by the way?
MIKE: Oh, this was 15 years ago. Within a year and a half, the only way you could tell that anything had happened to her is one side of skull was slightly shallower than the other.
She's now, you know, back at work. It was a military hospital. We happened to be here in San Antonio, one of the medical facilities of the military, and she went back to work. She's been representing the Air Force. Right now, she's retired. But she went on to become, you know, just a really great speaker.
So even though she may have lost that association for a while, and several others, of course, but that was the most uncommon one I'd ever heard. But she is still doing - she's well. You would not be able to tell the difference just by looking at her except for a slight shallow spot on one side.
CONAN: All right, Mike, it's good news to hear. Thanks very much.
MIKE: Thank you all very much. Take care.
CONAN: Let's go next to - this is Trisha(ph), Trisha with us from Ouray in Colorado.
TRISHA (Caller): Yeah, Ouray.
CONAN: Ouray, okay, go ahead.
TRISHA: My son, July 26th of last year, fell asleep at the wheel and hit a tree at 60 miles an hour coming home from the drive-in. He sustained - his whole, entire face was crushed, basal skull fractures and plus all numerous traumas to his body.
If it wasn't for the first responders, the accident happened at 12:08, they were there at 12:13. Thank God we live in a small area. He was Flight For Lifed to Grand Junction, and he stayed a month in the hospital with coma and brain swelling, and he was leaking (unintelligible) spinal fluid out his ears and nose, suffered a small stroke.
My biggest shock with this whole process, when he was discharged from the hospital, the number of doctors and therapies, plus he had tremendous headaches. On a scale from one to 10, they always were like at a 10, constantly.
CONAN: Does he still have them?
TRISHA: They're down to about a three to a four now. He's 18. He's only in school two days a week for three hours a day. He's a junior in high school. He'll be repeating his junior year, next year again.
He's doing a lot better, tremendously better. Probably his recall is a little off. He - and these are subtle differences that you see, a teacher would see, or a parent would see.
CONAN: But the big surprise to you was the headaches?
TRISHA: The headaches and the therapies that needed to be - that he needed to go to.
CONAN: Well, we'll get more on those in just a second. Dr. Francisco, what about those headaches?
Dr. FRANCISCO: Post-traumatic headaches are quite common, and there are different reasons why the headache develops. It's tempting to say that it's the brain itself. Sometimes we call it the pain in the brain. But we think that there are other mechanisms, aside from the brain injury itself.
For instance, with what you described, his accident involved hitting a tree while driving at 60 miles per hour. There's a very big chance that he may have strained his neck muscles, as well. And that, along with the brain injuries and the fracture that he had, may all contribute to the headache.
CONAN: She talked about the therapists, as well. That's part of the team that is working on rehabilitation. Occupational therapists help tasks - help patients with tasks most of us take for granted: brushing their teeth, combing their hair, dressing themselves.
Sarina Piergrossi is a occupational therapist and clinical manager for the Brain Injury Program at the Kessler Institute for Rehabilitation in West Orange, New Jersey, and joins us now from member station WBGO in Newark. And nice to have you with us today.
Ms. SARINA PIERGROSSI (Occupational Therapist, Clinical Manager, Brain Injury Program, Kessler Institute for Rehabilitation): Hi, thank you.
CONAN: And at the beginning of the program, we spoke with John Keller, who made a remarkable recovery after a motorcycle accident. Three years later, he could walk and talk and even work again. That comes after a lot of hard work. And, of course, not everybody who has a traumatic brain injury is so lucky. I wonder: You work with these people every day.
Ms. PIERGROSSI: Yes.
CONAN: And what - is it that simple that repetition of something like brushing your teeth can really teach you something like that?
Ms. PIERGROSSI: It's possible. You know, there's a variety of approaches that we typically use. And repetition of a task, performing it over and over again, can certainly cause patients to show improvement.
Another thing, though, is that you can just adapt the task. So if someone - if you think of the example of brushing one's teeth, if someone was unable to grasp the toothbrush or sequence the task appropriately, then you could certainly target interventions towards those parts of the task.
The other thing that you can do is just try to adapt the task to that patient's skill level. So, you know, using an enlarged grip on the toothbrush can help assist with that lack of grip strength. So you can really go about it in a lot of different ways.
CONAN: These are things - are these things that we usually associate with what we call muscle memory, like tying a tie?
Ms. PIERGROSSI: That is part of it, yeah. That is part of it, and certainly the more repetition of the task, the more someone practices the task, the more fluid the motion can be, the more coordinated it can be.
But then certainly as you're repeating it, you're strengthening the muscles that are involved in performing that task.
CONAN: What's the most challenging part of your - I know when I perform those tasks, if I have to think about it, I'm doomed. You know, I can't tie my shoes if I have to think about it. That must be difficult to work with people like that.
Ms. PIERGROSSI: It is. I mean, and we see both sides of that coin. So sometimes if you do something within the appropriate context, so if go down to the patient's room, and I have them actually attempt to brush their teeth as part of their typical morning routine, and sometimes you'll see the skill level almost start to kick in, in a way.
And then there are other times where you really do have to draw the patient's attention to each part of the task, and it's certainly effortful, but you're hoping to see that pay off in the end.
CONAN: Is that the most challenging part of your job?
Ms. PIERGROSSI: There are many challenges. I would say that for - you know, we're talking today about some really dramatic improvements. And sometimes when the progress is much slower, that can really be a challenge.
You know, some of our patients are discharged at a severely disabled level. And so trying to encourage the patient and the family not to give up, to keep at the therapies, to keep working on all of those skills can sometimes be a challenge.
CONAN: So frustration, effectively.
Ms. PIERGROSSI: Yeah.
CONAN: Dr. Francisco, I wonder: I know you have experience with that, as well. Is frustration a significant problem?
Dr. FRANCISCO: It is. And unfortunately, a lot of people tend to give up because they do not see the changes that they want to see in a quick - in a short time. So we have to act as advocates to our patients and their families, as well, and remind that sometimes it takes a very long time before recovery can take place. You heard this from John Keller earlier.
Dr. FRANCISCO: The caller from San Antonio, for instance, mentioned that it took about a year and a half before they saw any significant improvement with -in his friend. So while it really is - it would have been great if we can see all the changes within a week or two. That is not the reality.
Our - many of our patients take very small steps. We do not expect big changes in a week or two, even after their discharge from rehabilitation, which may last as long as three to four weeks. Once they're discharged, we tell them that this is not the end of the recovery. Recovery will take place over a long period of time.
CONAN: Sarina Piergrossi, I wonder, sometimes do people understand that they still need therapy, they still need help?
Ms. PIERGROSSI: Not always. That can be the tricky part, especially with brain injury, although we see it sometimes with stroke patients. But that lack of insight or awareness into one's deficit - so, you know, the rehabilitation process is definitely hard. And if you have a patient that doesn't necessarily buy into the need for using a piece of equipment or using some sort of strategy to complete a task, then that certainly make it much more difficult.
And so sometimes, the therapy then is directed at getting them to see those deficit areas, to understand how they impact their function or their performance, their ability to return to work or to return a social life, and trying to kind of expose them to that over time so that they start to buy into the need for more therapy or their need for some sort of alternate approach to a task.
CONAN: Let's see if we get - oh, I'm sorry. Dr. Francisco...
Dr. FRANCISCO: I just said, I couldn't agree more with Sarina. Many times, we find ourselves negotiating with our patients and their caregivers, their family members. We have to explain to them exactly why a particular device is needed, or why therapy for a long period of time will be needed. And many times, they burn out, so sometimes we give them a break. And then after that, we reengage them into rehabilitation process.
CONAN: We're talking with Doctor Gerard Francisco, chief medical officer at TIRR Memorial Hermann Hospital, an institute for rehabilitation and research in Houston, and chair of the Department of Physical Medicine and Rehabilitation at the University of Texas. He's with us from KUHF, our member station in Houston. With us from WBGO in Newark is Sarina Piergrossi, occupational therapist and clinical manager for the Brain Injury Program at the Kessler Institute for Rehabilitation in West Orange, New Jersey. You're listening to TALK OF THE NATION, from NPR News.
And Sarah's on the line, calling from San Mateo.
SARAH (Caller): Hi. I'm also an occupational therapist, and I've worked in brain injury for many years. And I was agreeing with Sarina saying the - sort of buying into the deficit or being able to see the deficit, the lack of insight is often an issue. And you were speaking of, doctor, earlier, the lack of smell, and a lot of times that's not assessed. And I try often, in an occupational therapy evaluation, to definitely assess the sense of smell and whether it's functional or not.
And I had a patient who really didn't believe he had a lack of smell or a problem with smelling, and I had to convince him, build that insight, build that awareness. So I turned him around in the clinic, and behind his back, across the clinic, use a wood-burning kit and actually burnt wood to the point of smoke, and had him turn around to prove to him that he couldn't smell the smoke prior to turning around, to show him that he needed to have the smoking -smoke alarms, have, you know, batteries working and to inspect his food visually, you know, defend on or compensate with another sense, like vision, because of lack of smell, to read expiration dates on foods, to have, you know, ventilation and open windows when using cleaning products. I was trying to build compensations for the sensory deficit. So...
CONAN: That's interesting. He didn't realize the range of things he'd need the sense of smell for. Of course, you'd probably need a smoke detector, anyway, even if you do have a sense of smell.
SARAH: Right. Right.
CONAN: But, Sarah...
SARAH: To be on it, that the batteries are current.
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CONAN: Every time you - every time we spring forward or fall back. Anyway...
SARAH: That's right.
CONAN: ...thanks very much, Sarah.
SARAH: Thank you.
CONAN: Bye-bye. Let's go next to Sandra, Sandra with us from Sheridan in Oregon.
SANDRA (Caller): Hi. It's Sandra, but...
CONAN: Oh, I'm sorry. Go ahead, please.
SANDRA: Well, my husband had a terrible accident. He was riding a bicycle, and he was going down the road, and a dog ran out in front of him. And he flipped over the handlebars and landed on his head and was unconscious. And luckily, he was with a partner. And he had to be airlifted to Portland.
And he was unconscious for a few days, had no memory. When I finally got to him, he did recognize me, said, oh, that's Sandra. That's Sandra. It's been a long, hard process. He had to relearn to walk and talk. His body was injured, as well as his brain. And he's also a diabetic, so...
CONAN: Is he the same person that he used to be?
CONAN: Is the same person...
SANDRA: No. No, he's not. And that's good and bad.
CONAN: It's different.
SANDRA: And there's a - he's not the same person he used to be. And I miss the old Jim. He certainly can't function on the same level that he used to. He's a very intelligent man and was a constant reader and a trainer and...
CONAN: I just wanted to get a quick comment from Dr. Francisco. Is that something you have to prepare families for, that people will have changed?
Dr. FRANCISCO: We do. And sometimes it's the most challenging thing that we have to discuss with them, because in many of our patients with severe traumatic brain injuries, personalities change, as well. I think our caller hit the nail on the head when she said that this is not the same person. I miss the old person. This is something that we really have to confront from the very start.
We should not be shy in discussing this with our patients and their families. They have to be aware of this, the likelihood that this person is not going to be 100 percent the same person that they knew before the traumatic brain injury will most likely happen. They have to be prepared for it, because relationships may erode when personalities change. Someone can say, this is not the same person that I married 20 years ago. This is not the same mother that I've known all my life. They have to be prepared for that.
We always say that the brain injury does not affect only the person who had the brain injury. It also affects the families and the caregivers who are around them.
CONAN: Sandra, thanks very much for the call. We wish you and your husband the best of luck. Our thanks also to Dr. Gerard Francisco and Sandra Piergrossi.
This is NPR News.
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