June 14, 2011 -- 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.
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"No two brain injuries are alike," said Dr. Steve Flanagan, chair of the Rusk Institute for Rehabilitation at NYU Langone Medical Center. "She has received some of the best rehab anyone can conceive -- a lot longer than a lot of folks because of her status.
"A brain injury that's as severe as hers is not measured in days or weeks or sometimes even months, but many years," Flanagan said. "It could well be very hard for her and would not be unusual for severe disability that will require some rehab for years."
Typically, injuries such as Giffords' create a host of cognitive and behavioral problems, from impairing walking, to washing and dressing, language, attention span and memory.
"Sometimes there is a change in behavior or mood and there is a worsening of irritability and they are anxious or agitated," he said.
Brain injuries can also add stress to the family.
"Oftentimes roles change and the impact isn't just on the patient," Flanagan said. "It changes the family dynamics."
Doctors also report marital break-ups, depression and even suicide among those with brain injuries.
Patients often tell their doctors, "I am completely different," according to Dr. Brian Greenwald, medical director of brain injury rehabilitation at Mt. Sinai Medical Center.
"Although we think of ourselves as our car or our house or what dress we like, what we are is our brain -- the mush in the head that is the same consistency as Jell-o," he said. "It's our thoughts and our emotions and our moods."
The challenges are enormous, say doctors, who point to the 30-year struggle of Jim Brady, the former press secretary to President Ronald Reagan, who was shot in the head during the 1981 assassination attempt outside the Washington Hilton.
His injuries were more serious than Giffords because he had been shot in both hemispheres of the brain.
In a March editorial in the Washington Post on the anniversary of his shooting, Brady's wife Sarah lamented how the "vivacious life" she and husband shared before his life was shattered in a "few seconds" by a bullet to the head.
Today, at 70, Brady is partially paralyzed, confined to a wheelchair, and undergoes physical therapy several times a week. Though his speech is sometimes slurred, he has full cognitive function.
His neurosurgeon, Arthur Kobrine, said in a January article in the journal Nature right after Gifford's shooting, Brady would "kind of cry-talk for a while," and had difficulty controlling his emotion and didn't recognize loved ones.
"It's a constant battle," said Paul Helmke, president of the Brady Center to Prevent Gun Violence, who worked with the Bradys to pass the 1993 Brady bill. "You want to encourage the patient and hold out and be positive with great progress, and the family and friends want them to be up. But it's a real challenge to the body.
"He tires quickly and has trouble with his eyesight as a result of his brain injury," he said. "There are so many things. Traveling is tough for him. The pain comes and goes."
Helmke said the Bradys were rooting for Giffords, knowing she will be an advocate for their cause, strengthening gun control laws.
"Our dream is that she recovers quickly, gets back to Congress and asks why no one has done anything about this issue," he said.
But medical experts like Greenwald say this is an unrealistic scenario.
"It's still early on and I think there is still reason to be optimistic overall," Greenwald said. "But being able to speak again and rejoining Congress are two different issues."