Rep Gabriele Giffords , bright eyes peering out from behind blue wire-framed glasses, looks radiant in a recently released Facebook photo. But experts say her half-tilt smile suggests her recovery from a gunshot wound to the head will be complex.
The Arizona congresswoman has astounded all her doctors, climbing stairs recently to board a plane for Florida to watch her husband, astronaut Mark E. Kelly, at the launch of the shuttle Endeavour and responding to her family and caregivers.
Now, as Giffords prepares to leave TIRR Memorial Hermann Hospital in Houston, Texas, to begin her long-term rehabilitation, brain injury experts say public hopes for a return to the House may be unrealistic.
"If I had to guess, I would expect her to have some deficiencies for the rest of her life," said Dr. Anand Germanwala, chief of cerebral vascular and skull-based neurosurgery at the University of North Carolina Medical School. "The brain is a very unforgiving organ.
"I certainly wish her all the best and hope she has complete recovery -- it is possible," he said. "But realistically thinking, this is a young lady in a high profile job, well-educated and eloquent. That requires a lot of brain tasks to successfully execute the job. To expect that now, it's not fair."
Her husband, who has been the most consistent optimist, admits the road back is "months not weeks away."
Rosy rhetoric and hope are critical for healing, say doctors, but brain injuries like the one Giffords sustained five months ago can change a person's abilities and behavior unalterably.
Giffords was shot at point-blank range at a community event outside a Tucson grocery store on Jan. 8. The bullet tore through the left side of her brain, the heart of cognition, speech and movement.
The photos, taken in May by P.K. Weiss, a professional photographer and longtime friend of Giffords, show an upbeat woman, but even her chief of staff Pia Carusone warns about being overly optimistic, saying Giffords speaks in only one- or two-word sentences and uses her hands and facial expression to be understood.
"Add it all together and she's able to express the basics of what she wants or needs," she told The Arizona Republic last week. "But when it comes to a bigger and more complex thought that requires words, that's where she's had the trouble."
Speech is very complicated, according to experts. It requires not only the ability to communicate verbally, but to comprehend and to know when to move the lips.
"The whole process takes a million connections in the brain," said Germanwala.
Giffords is experiencing aphasia, a disorder associated with brain injury that impairs her ability to process language, although those close to her say she does understand her surroundings.
Centers of speech and movement are only "a few centimeters apart," and so Giffords could have just an isolated speech injury and be spared disabilities in movement, said Germanwala. But looking at the photos, he said he "suspects" some weakness in the right arm and leg.
"We are human beings and we hope for the best," he said. "But the honest answer is no one really knows the extent of her recovery. ... In my own experiences, the maximum amount of recovery is at one year after the event."
Giffords could also suffer from a range of other long-term complications from Parkinson's disease to dementia, say doctors. About half of all those who have a traumatic brain injury go on to develop epilepsy.