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Mapping Rep. Giffords' Long Road to Recovery

Despite early progress, Rep. Gabrielle Giffords faces a long road to recovery from the bullet wound in her brain. If all goes as planned, she will be transferred as early as today to TIRR Memorial Hermann Rehabilitation Hospital in Houston, where intensive rehabilitation will begin. Here are some answers to basic questions about her recovery:

USA TODAY's Steve Sternberg asked Mark Ashley, chairman emeritus of the Brain Injury Association and CEO of Neuro Skills rehabilitation centers, based in Bakersfield, Calif., to answer some basic questions about her recovery:

Q: How will Rep. Giffords' treatment in the rehab center differ from the treatment at the University Medical Center in Tucson?
A: Doctors will obtain higher resolution images of her brain to map the damage. They'll use an MRI scanner, which produces clearer pictures and much more information about which tissues have survived the injury than the CT scans typically used for medical and surgical treatment. They'll provide any needed medical care and take steps to prevent blood clots and pneumonia.

They may also perform follow-up procedures to resolve problems that might slow healing, such as the eye socket surgery carried out in Tucson Saturday to remove bone fragments. Sometime in the next year, surgeons will also cap the hole in her skull with the flap removed to allow for swelling or with a prosthesis made to fit the wound.

Q: Can doctors do anything to help her brain to heal?
A: The whole purpose of rehabilitation is to help the brain to heal. It's a complicated process. "You have a hundred billion brain cells, each functioning as a micro-computer that has a specialized function to perform," Ashley said. And each cell is wired to all of the other brain cells, or neurons, so they can act in concert. An injury like this damages not only the cells, but the wiring that connects them.

One step her doctors may take is to treat her with drugs that ramp up or adjust the chemical signals that transmit nerve impulses.

That can help the brain develop new nerve circuits to replace those damaged or destroyed by the bullet. Therapists will also push her to use her brain. This forces the brain to create new nerve centers to handle tasks once done by damaged tissue — or to move tasks to uninjured regions of the brain.

Q: What sort of therapy will she undergo?
A: Among many other things, therapists will focus on her physical abilities, her speech, her ability to carry out what we call "the activities of daily living," her vision, her cognitive skills and her behavior.

Q: What does physical therapy involve?
A: The wound on the left side of Rep. Giffords' brain may weaken her right arm and leg. Physical therapists will work with her to make sure that she uses her legs so that they remain limber and the joints don't begin to lose their range of motion.

They'll help her to sit for longer and longer periods without fatigue. As she gains strength and endurance, they'll help her stand and work to improve her balance. Once she's standing, they will help her walk.

Because a fall could be devastating, she may have to redevelop the reflexes she'll need to catch herself if she stumbles.

Q: What other skills will she have to relearn?
A: Occupational therapists will focus on helping Giffords learn to take care of her personal hygiene, dress herself and, eventually, master more complicated activities of daily living, including cleaning and cooking.

Q: What about her speech?
A: It depends on the course of the bullet. Speech therapists will focus on a range of things, including her ability to swallow food without choking, her ability to understand what's said to her and her ability to use speech. She may not be able to speak at all, or she may be able to use words, but not completely.

"She may not be able to speak at all, she may make nonsensical works or she may be able to use words, but not fully or completely," Ashley said. "Patients may also have very thick or slurred speech, very imprecise sound production."

Q: How do you put your finger on the different impairments in Rep. Giffords' thinking?
A: Neuropsychologists can determine what parts of the brain are functioning, and which are not, using paper and pencil testing and other methods. "Physical skills recover pretty quickly; cognitive skills take the longest time to recover," Ashley said.

Q: How long will this phase of her rehabilitation last?
A: Four to eight weeks. After that, she'll be moved to a residential rehabilitation facility, where the work will become more intensive, 17 hours a day, seven days a week. That phase of rehab will last four to six months.

Q: Is it possible to predict how well she'll do?
A: No. One study showed a clinical evaluation is no more accurate than a doctor's best guess. "The closer we are to the date of the injury, the less reliable our predictions will be," Ashley said.

Sources: USA TODAY research; Mark Ashley, chairman emeritus of the Brain Injury Association and CEO of Neuro Skills