EFFECTS OF TBI (TRAUMATIC BRAIN INJURY)
TBIs are associated with a vast number of neurologic, psychological, and physical consequences that drastically impact an individual’s behavior, physical abilities, and quality of life. There are three general types of problems that can happen after TBI which are physical, cognitive and emotional/ behavioral problems.
Cognition is the act of knowing or thinking. Cognitive abilities include the ability to choose, understand, remember and use information. Cognition also includes attention and concentration; the ability to process and understand information; memory; communication; planning, organizing, and assembling; the ability to utilize reasoning, problem-solving, decision-making, and judgment; and the ability to controlling impulses and desires and being patient.
Cognitive consequences of TBI depend greatly on what regions of the brain the injury affects. The severity of the injury also significantly affects what cognitive difficulties patient experiences and the extent of those cognitive difficulties. In general, cognitive deficits are greatest in the weeks and months following the brain injury, with improvements generally noted over time. Neuropsychological testing can be helpful in identifying cognitive strengths and weaknesses and clarifying how cognitive difficulties may impact work/school functioning, and/or monitoring changes over time.
Specific cognitive deficits that are often associated with TBIs include:
Trouble paying attention and concentrating
An individual with TBI may have difficulty focusing, paying attention, or attending to more than one thing at a time. Difficulty concentrating may lead to restlessness and being easily distracted or they may have difficulty finishing a project or working on more than one task at a time. Problems carrying on long conversations or sitting still for long periods of time may be noticed.
Attention and concentration may be improved over time with techniques such as decreasing distractions and focusing on one task at a time; practicing attention skills on simple, yet practical activities (such as reading a paragraph or adding numbers) in a quiet room and gradually attempting harder tasks (such as read a short story or balance a checkbook) or by working in a more noisy environment. Often taking breaks when the individual becomes tired is noticed.
Feeling confused or mentally “foggy”; Slowed thinking speed; Problems understanding others
After a brain injury, a person’s ability to process and understand information often slows down. These complications may result in an individual requiring more time to grasp what others are saying or requiring more time to understand and follow directions. They may have trouble following television shows, movies, etc. or require more time to read and understand written information including books, newspapers or magazines
There may be delays in reaction time, and being slower to carry out physical tasks including routine daily living activities such as getting dressed or cooking. An individual’s delayed reaction time is especially important for driving, which may become unsafe if the person cannot react fast enough to stop signs, traffic lights or other warning signs. Individuals with TBI should not drive until their visual skills and reaction time have been tested by a specialist.
Problems remembering and/or selecting the proper words and speech
Communication problems may cause individuals with TBI to have difficulty understanding and expressing information. Individuals may have problems thinking of the right word; trouble starting or following conversations or understanding what others say; rambling or getting off topic easily; difficulty with more complex language skills, such as expressing thoughts in an organized manner.
You may notice trouble communicating thoughts and feelings using facial expressions, the tone of voice and body language (non-verbal communication). They may have problems reading others’ emotions and not responding appropriately to another person’s feelings or to the social situation and may misunderstand jokes or sarcasm.
Learning and memory difficulties
Individuals with TBI may have trouble learning and remembering new information and events. Individuals may have problems remembering events that happened several weeks or months before the injury (although this often comes back over time). Individuals with TBI are usually able to remember events that happened long ago but may have problems remembering entire events or conversations. In these instances, the mind tries to “fill in the gaps” of missing information and recalls things that did not actually happen. Sometimes bits and pieces from several situations are remembered as one event. These false memories are not lies.
Techniques for improving memory problems include:
- Organizing a structured routine of daily tasks and activities
- Using memory aids such as memory notebooks, calendars, daily schedules, daily task lists, computer reminder programs and cue cards
- Devoting time and attention to review and practice new information often
- Being well rested and trying to reduce anxiety as much as possible
- And speaking with your doctor about how medications may affect your memory.
Difficulty completing complex tasks
Persons with TBI may have difficulty planning their day and scheduling appointments. They may have trouble with tasks that require multiple steps done in a particular order, such as laundry, managing a checkbook, driving or cooking.
Individuals with TBI may have difficulty recognizing when there is a problem, which is the first step in problem-solving. They may have trouble analyzing information or changing the way they are thinking (being flexible). When solving problems, individuals may have difficulty deciding the best solution or focusing on one solution and not considering other, better options. Individuals may also make quick decisions without thinking about the consequences, or not use the best judgment.
Inability to understand one’s own impairments
Individuals with TBI may lack self-control and self-awareness, and as a result may behave inappropriately or impulsively in social situations. Individuals may deny they have cognitive problems, even if these are obvious to others. Individuals may say hurtful or insensitive things, act out of place, or behave in inconsiderate ways. Individuals may lack awareness of social boundaries and others’ feelings, such as being too personal with people they don’t know well or not realizing when they have made someone uncomfortable.
Other cognitive difficulties
Individuals with TBI may experience include problems judging distances and getting lost in familiar places.
Emotional and behavioral difficulties following TBI can be a direct consequence of injury to the brain if regions involved in emotional processing are affected. They can also result from difficulties coping with problems experienced following the brain injury, and/or can be associated with pre-existing emotional difficulties (e.g., problems with depression/anxiety prior to the TBI).
Research suggests that more than 50% of individuals who have sustained a brain injury may experience depression or other emotional difficulties (e.g., anxiety). Treatment for these emotional and behavioral difficulties typically includes medications and psychotherapy.
Specific psychological consequences that are often associated with TBIs include:
Depression is a feeling of sadness, loss, despair or hopelessness that does not improve over time and is so overwhelming to the individual that the condition interferes with the individual’s daily life. When an individual feels depressed or is losing interest in usual activities at least several days per week and the symptoms last for more than two weeks, depression may be the root of the problem.
Symptoms of depression include:
- Feeling down, sad, blue or hopeless
- Loss of interest or pleasure in usual activities
- Feeling worthless, guilty, or that you are a failure
- Changes in sleep or appetite
- Difficulty concentrating
- Withdrawing from others
- Tiredness or lack of energy
- Moving or speaking more slowly, or feeling restless or fidgety
- Thoughts of death or suicide.
Sadness is a normal response to the losses and changes a person faces after TBI and will be experienced by the majority of individuals who suffer a TBI. However, prolonged feelings of sadness or not enjoying the things that one used to enjoy are often key signs of depression, especially if an individual is also suffering from some of the other symptoms listed above. Depression is a common problem after TBI, and roughly half of all individuals with TBI are affected by depression within the first year after injury. Even more (nearly two-thirds) are affected within seven years after injury. In the general population, depression affects fewer than one person in 10 over a one-year period. Over half of the individuals with TBI who experience depression also deal with significant anxiety.
Depression may occur while the individual struggles to adapt to temporary or lasting disability and loss, or to changes in the individual’s roles in the family and society caused by the brain injury. Depression may also arise if the injury has affected areas of the brain that control emotions. Both biochemical and physical changes in the brain can lead to depression.
Treatment of Depression
A vast number of treatment options and techniques are available to help individuals experiencing depression after suffering a TBI. If you have symptoms of depression, it is important to seek professional help as soon as possible with a health care provider who is familiar with TBI. Depression can be a medical problem, just like high blood pressure or diabetes.
An individual cannot overcome depression by wishing it away or using more willpower. Anti-depressant medications and counseling from a mental health professional who is familiar with TBI, or a combination of the two, can help most people who have depression. Aerobic exercise and structured activities during each day can sometimes help reduce depression. Seeking treatment early is the best course of action to prevent needless suffering and worsening symptoms.
Anxiety is a feeling of fear or nervousness that is out of proportion to a given situation. Individuals with TBI may feel anxious and not know the reason why or may worry and become anxious about making mistakes, failing at a given task, or about whether or not they will be subjected to criticism.
Situations that once presented no difficulty to an individual can be more difficult to handle after brain injury and cause anxiety, such as being in crowds, being rushed, or adjusting to sudden changes in plan. Some individuals may experience a sudden onset of anxiety that can be overwhelming which is commonly referred to as panic attacks. Since each form of anxiety calls for a different treatment, anxiety should always be diagnosed by a mental health professional or physician.
The onset of anxiety after suffering a TBI is often caused by a number of different factors. Difficulty reasoning and concentrating can make it hard for the person with TBI to solve problems. These situations can lead to an individual feeling overwhelmed, especially if he or she is being asked to make decisions. Anxiety often happens when there are too many demands on the injured person, such as returning to employment too soon after injury. Time pressure can also heighten anxiety. Situations that require a lot of attention and information-processing can make people with TBI anxious. Examples of such situations might be crowded environments, heavy traffic or noisy children.
Personality changes; anger; irritability or agitation; difficulty controlling emotions; emotional lability; and mood swings
A brain injury can change the way an individual feels or expresses emotions. An individual with TBI can have several types of emotional problems. Some individuals may experience emotions very quickly and intensely but with very little lasting effect. For example, individuals with TBI may anger easily but get over it quickly or they may seem to be on an emotional roller coaster in which the individual is happy one moment, sad the next and then angry. This cycle is referred to as emotional liability.Mood swings and emotional liability are often attributable to damage to the part of the brain that controls emotions and behavior. Often times there is no specific event that triggers an individual’s emotional response which can be confusing for family members who may think they accidentally did something that upset the injured person.
In some cases, the brain injury can cause sudden episodes of crying or laughing. These emotional expressions or outbursts may not have any relationship to the way the individual feels. In some instances, the emotional expression may not match the situation (such as laughing at a sad story). Usually, the individual is unable to control their expressions of emotion. Fortunately, this situation often improves in the first few months after injury, and individuals commonly return to a more normal emotional balance and expression. If an individual with TBI is having problems controlling emotions, it is important to talk to a physician or psychologist to find out the cause and get help with treatment.
Family members of individuals with TBI often describe the injured person as being irritable or having a quick temper. Temper outbursts after TBI are likely caused by several factors such as Injury to the parts of the brain that control emotional expression; Frustration and dissatisfaction with the changes in life brought on by the injury, such as loss of one’s job and independence; Feeling isolated, depressed or misunderstood; Difficulty concentrating, remembering, expressing oneself or following conversations, all of which can lead to frustration; experiencing fatigue or tiredness more frequently and easily; and the pain associated with TBI.
Apathy or fatigue
Fatigue is a feeling of exhaustion, tiredness, weariness or lack of energy. After TBI, an individual may experience physical fatigue, mental fatigue, or psychological fatigue. When experiencing fatigue, individuals are less equipped to think and express themselves clearly or to do physical activities. If overwhelmed by fatigue, individuals have less energy to care for themselves or do things they enjoy. Fatigue can negatively affect an individual’s mood, physical functioning, attention, concentration, memory, and communication skills. Fatigue can also interfere with the ability to work or enjoy leisure activities and can make activities such as driving dangerous.
Fatigue is one of the most common problems people have after a TBI. As many as 70% of survivors of TBI complain of mental fatigue. In individuals with TBI, fatigue routinely occurs more quickly and frequently than it does in the general population. The cause of fatigue after TBI is not clear but may be due to the extra effort and attention required of the individual to do simple daily living activities such as walking or talking clearly. Brain function may be less “efficient” than before the injury.
Other psychological consequences often associated with TBI include:
- Difficulty understanding social norms
- Behavioral disinhibition (i.e., saying the first thing that comes to mind or something inappropriate)
- Mania (mental illness marked by periods of great excitement, euphoria, delusions, and overactivity)
- Rigidity, inflexibility, preservation (getting stuck on a topic)
- Psychosis, hallucinations, delusions
Physical consequences of TBI depend greatly on what regions of the brain were affected by the injury. Many individuals will experience injury to other body regions (e.g., limbs, spine) in the traumatic event that caused their TBI, which may also result in physical limitations. Individuals may participate in rehabilitation therapies to directly improve their physical functioning and/or identify adaptive technologies to decrease functional limitations. Individuals with TBI may experience a vast majority of physical consequences including weakness on one or both sides of the body and increased clumsiness or decreased coordination.
Specific physical consequences/effects that are often associated with TBIs include:
Headaches are one of the most commonly experienced symptoms after traumatic brain injury (often called “post-traumatic headache”). Over 30% of individuals report having headaches which continue long after injury. Headaches after TBI can be long-lasting and may continue even beyond one year. Headaches can make it difficult for individuals to carry out daily activities or affect an individual’s ability to think and remember things. Individuals with TBI may experience headaches because of the surgery on their skulls or because they have small collections of blood or fluid inside the skull. Headaches can also occur after mild to moderate injury or, in the case of severe TBI, after the initial healing has taken place. These headaches can be caused by a variety of conditions, including a change in the brain caused by the injury, neck and skull injuries that have not yet fully healed, tension and stress, or side effects from medication.
Some of the typical headaches experienced after a TBI are:
Migraine headaches occur when an area of the brain becomes hypersensitive and triggers a pain signal that spreads to other parts of the brain. Migraine headaches are typically associated with certain symptoms including: Dull, throbbing sensation, usually on one side of the head; Nausea or vomiting; Light and sound sensitivity; Pain level rated as moderate to severe; and warning signals that a migraine is coming on such as seeing bright lights or spots.
Tension-type headaches are associated with muscle tension or muscle spasms and stress. Tension-type headaches often occur later in the day and include symptoms such as a tight, squeezing sensation around the entire head or on both sides of the head and a pain level rated as mild to moderate.
Cerviogenic headaches are caused when there is injury to the back of the muscles and soft tissue in the neck and the back of the head. Cerviogenic headaches often arise in the neck, shoulders and back of the head, and sometimes travel over the top of the head. Neck movement or positioning can exacerbate the pain of cerviogenic headaches. These headaches are typically not accompanied by nausea and can range from mild to severe pain.
Medicines used to treat headaches can actually cause headaches, known as rebound headaches. When pain medicines are taken daily on a regular schedule, missing one or two doses can result in a headache. Most headaches are not dangerous. However, in the first few days after a concussion or head injury, an individual should see a health care professional with experience in treating TBIs if the individual headaches worsen or nausea or vomiting accompanies the headache. Medical treatment should also be sought if the individual experiences arm or leg weakness, problems speaking during the headache, or increased sleepiness during the headache.
DIZZINESS AND/OR BALANCE PROBLEMS
People with traumatic brain injury (TBI) commonly report problems with balance. Between 30% and 65% of people with TBI suffer from dizziness and disequilibrium (lack of balance while sitting or standing) at some point in their recovery. Dizziness includes symptoms such as lightheadedness, vertigo (the sensation that you or your surroundings are moving), and imbalance. How bad your balance problem is depends on many factors including: How serious your brain injury is; Where in your brain you were injured; Other injuries you had along with your brain injury such as cervical spine injuries, rib injuries, and or leg injuries; and the medications used to manage the medical issues connected with the traumatic event or accident.
Common Causes of Balance Problems after suffering a TBI
Medications: A number of commonly used medications can lead to dizziness, lightheadedness and decreased balance. Some blood pressure medications, antibiotics, tranquilizers, heart medications, and anti-seizure medications may lead to these complications. An individual should consult with his/her doctor in the event that any of the medications he/she is taking may be causing dizziness or balance problems. A change in medications or dosages may improve the problem.
Drops in blood pressure: A drop in blood pressure when standing or sitting up suddenly, known as postural hypotension, can make individuals feel lightheaded and dizzy. Drops in blood pressure may occur when an individual gets up quickly from sitting on the toilet or a chair, or getting out of bed. Measuring blood pressure while in a lying, sitting, and standing position may help diagnose blood pressure-related balance problems.
Vision impairments: Eyesight is one of the key senses for assisting in an individual keeping his/her balance. Eyesight problems such as double vision, visual instability, partial loss of vision, and problems with depth perception often lead to balance problems.
Inner ear problems (vestibular impairments): The inner ear contains many tiny organs called the vestibular system/labyrinth that help individuals keep their balance. The inner ear has three loop-shaped structures (semicircular canals) that contain fluid and have fine, hair-like sensors that monitor the rotation of your head. It also has other structures (otolith organs) that monitor linear movements of your head. These otolith organs contain crystals that make individuals sensitive to movement and gravity. If the vestibular system is damaged from a head injury, an individual may experience balance problems, dizziness, or a sudden sensation of spinning.
The three types of vestibular impairments are Benign paroxysmal positional vertigo; Labyrinthine concussion or injury; and Traumatic endolymphatic hydrops. Benign paroxysmal positional vertigo is one of the most common causes of vertigo. With trauma, the crystals in the inner ear can be moved out of place, increasing sensitivity to changes in gravity. Benign paroxysmal positional vertigo is associated with brief episodes of vertigo, and symptoms may be triggered by specific changes in head position, such as tipping your head up or down, and by lying down, turning over or sitting up in bed. Symptoms may also be experienced while standing or walking. Labyrinthine concussion, or injury to the nerve to the vestibular system, are also causes of vertigo and imbalance commonly observed after brain injury. Traumatic endolymphatic hydrops occurs when there is a disruption of the fluid balance in the inner ear. When this happens, individuals may have periods of vertigo, imbalance and ringing in the ears that last for hours to days.
Brainstem injury: A traumatic injury to the brainstem and cerebellum (parts of the brain that control movement) can make it hard for an individual to walk and maintain balance.
Leakage of inner ear fluid into the middle ear (called perilymph fistula): This condition sometimes occurs after head injury. The condition can cause dizziness, nausea, and unsteadiness when walking or standing and can worsen when an individual is more active. This condition may get better with rest.
FATIGUE, LACK OF ENERGY, DROWSINESS, SLEEP DISTURBANCES SUCH AS TROUBLE FALLING ASLEEP OR SLEEPING MORE OR LESS THAN USUAL.
Many individuals with TBI suffer from sleep disturbances. The brain directs sleep by putting the body to rest. Injury to the brain often leads to changes in sleep. Lack of sleep can increase or worsen depression, anxiety, fatigue, irritability, and an individual’s sense of well-being. Lack of sleep may also result in poor work performance and traffic or workplace accidents. Sleep disorders are three times more likely to be seen in TBI patients than in the general population and nearly 60% of people with TBI experience long-term difficulties with sleep. Women are more likely to be affected than men, and sleep problems become more likely to develop as the person ages.
Insomnia is one sleep disorder commonly associated with TBI. Individuals with insomnia experience difficulty falling asleep or staying asleep and often times their sleep does not leave them feeling rested. Insomnia can worsen other problems resulting from brain injury, including behavioral and cognitive (thinking) difficulties. Insomnia makes it more difficult to learn new things. Insomnia is typically worse directly after injury and often improves as time passes. Other sleep disorders commonly associated with TBI include Excessive Daytime Sleepiness (Extreme drowsiness); Delayed Sleep Phase Syndrome (Mixed-up sleep patterns); and Narcolepsy which is a condition that causes individuals to fall asleep suddenly and uncontrollably during the day.
Injuries to the base of the skull can damage nerves that emerge directly from the brain (cranial nerves). Cranial nerve damage may result in difficulties with sensory perception such as loss of smell or taste and numbness and/or tingling. Nerve damage to the brain may also cause paralysis of facial muscles; damage to the nerves responsible for eye movements, which can cause double vision; Loss of vision; Loss of facial sensation; and swallowing problems.
An individual with a traumatic brain injury (TBI) may experience seizures during recovery. Although most people who have a brain injury will never have a seizure, it is good to understand what a seizure is and how to address a seizure should one arise. Most seizures happen in the first several days or weeks after a brain injury. Some seizures may occur months or years after the injury. About 70-80% of people who have seizures are able to treat their condition with medications and can return to most activities. Seizures can make an individual’s condition much worse or even result in death. Generally speaking, the risk of post traumatic seizures is related to the severity of the injury- the greater the injury, the higher the risk of developing seizures. Even mild to moderate injuries can result in seizures.
Seizures happen in 1 of every 10 people who have a TBI that required hospitalization. Seizures usually occur when there is a scar in the brain as a result of the injury. Seizures cause sudden abnormal electrical disturbances in the brain which lead to multiple symptoms such as:
- Strange movements of your head, body, arms, legs, or eyes
- Stiffening or shaking
- Unresponsiveness and staring
- Chewing, lip smacking, or fumbling movements
- Strange smell, sound, feeling, taste, or visual images
- Sudden tiredness or dizziness
- Not being able to speak or understand others.
Symptoms of a seizure happen suddenly and cannot be controlled by the individual. Seizures usually last only a few seconds or minutes, but sometimes continue for 5 to 10 minutes. Bladder or bowel accident or biting down on the tongue or the inside of the mouth may occur during a seizure. After the seizure, individuals may be drowsy, weak, confused. After a severe seizure that lasts longer than 2 minutes, it may be harder for an individual to stand, walk or accomplish basic daily living activities for a few days or longer.
A seizure in the first week after a TBI is called an early post-traumatic seizure. About 25% of individuals who have an early post-traumatic seizure will experience another seizure months or years later. A seizure more than seven days after a brain injury is called a late post-traumatic seizure. About 80% of people who have a late post-traumatic seizure will have another seizure (epilepsy). Having more than one seizure is called epilepsy. More than half of individuals with epilepsy will be forced to deal with this condition for the remainder of their lives.
Medications that are used to control seizures are called antiepileptic drugs (AEDs). Commonly prescribed AEDs include Carbamazepine (also known as Tegretol); Lamotrigine (also known as Lamictal); Levitiracetam (also known as Keppra); Gabapentin (also known as Neurontin); Oxcarbazepine (also known as Trileptal); Phenobarbital; Phenytoin/ fosphenytoin (also known as Dilantin); Pregabalain (also known as Lyrica); Topiramate (also known as Topamax); Valproic acid or valproate (also known as Depakene or Depakote); and Zonisamide (also known as Zonegran). Upon having a seizure it is important to seek care from a health care professional to determine the best course of treatment for the individual with the TBI and whether any of these medications
Sustaining an injury to the head or neck increases ischemic stroke risk three-fold among trauma patients younger than 50, according to research presented at the American Stroke Association’s International Stroke Conference 2014.
Researchers studied the health records of 1.3 million patients younger than 50 years who had been treated in emergency trauma rooms. About 11 of every 100,000 patients (145) suffered a stroke within four weeks. Since 2 million patients are seen in U.S. trauma rooms each month, this suggests 214 young people a month have an ischemic stroke after a trauma.
Stroke after trauma may be caused by a tear in the head or neck blood vessels that lead to the brain, which can be a source of blood clots that cause a stroke. Diagnosing these types of tears from the outset of the injury is very important for treatment purposes. If doctors are able to diagnose a tear in these arteries at the time of the trauma, an individual can be prescribed an anti-clotting medicine to help prevent stroke. In the study, 10 percent of the people who had a stroke were diagnosed with this kind of tear, but not all the patients were diagnosed with it prior to stroke.
- For more information on this study and the statistical trends regarding stroke in individuals with TBI click here: http://www.beltlawfirm.com/2014/02/head-injury-triples-stroke-risk-in-youth/
- For more information on the risk of stroke associated with TBI click here: http://www.beltlawfirm.com/2013/09/traumatic-brain-injury-increases-risk-of-strokes/
Other complications that commonly arise after suffering a TBI include sensitivity to noise and/or light; difficulties managing bodily functions such as regulation of blood pressure or body temperature; and chronic pain.
BEHAVIORAL/EMOTIONAL CONSEQUENCES OF A TBI
Individuals who suffer a TBI often undergo changes in behavior as well as emotional difficulties. Common behavior changes associated with TBIs include:
- Less effective social skills
- Impaired self-awareness.
Emotional difficulties associated with TBIs include:
- Mood swings.
Behavioral/Emotional issues can be due to the injury to the brain itself, and/or they may reflect the person’s distress in adjusting to changes since the TBI.
Patients suffering from a TBI often encounter bouts of depression during their recovery in the year following the TBI. Risk factors for depression following TBI include prior history of depression, younger age at time of injury (18-29 years vs. >60 years), and lifetime alcohol dependence.
Emotional and behavioral changes experienced by persons with TBI are often one of the more significant sources of difficulties and stress for the individual and his/her family and may have a substantial impact on performance in work and school settings.
- Personality changes are often associated with TBIs. Examples of personality changes include but are not limited to the individual becoming more or less outgoing, irritable, active, etc. or experiencing changes in interests (e.g., loss of interest in previously enjoyed activities).
- Anger/frustration: After experiencing a TBI, the individual may become “short tempered” and quick to get angry/frustrated. Individuals may also seem less patient and become less tolerant of changes (i.e., daily routine, etc.). Problems with frustration tolerance may be noticeable in new situations and/or when the individual is tired or stressed. An individual who suffered from a TBI may become more likely to have anger outbursts, and may become verbally or physically aggressive.
- Emotional distress: TBIs are commonly associated with symptoms of emotional distress such as anxiety and/or depression. Individuals may experience anxiety in the form of panic attacks or general nervousness or restlessness. Individuals may also experience fear/anxiety in situations that are similar to that which led to the TBI such as riding in a car after sustaining a TBI during a car wreck.
- Difficulties in social situations or in relationships: TBIs are often associated with deficits in communications skills such as taking turns in conversations and listening to other participants; Using appropriate eye contact; Awareness of and respect for other’s personal space; and awareness and appropriate use of non-verbal communication skills (e.g., gestures, facial expressions, body language). Individuals with TBI may also become less sensitive to social norms and have less sensitivity to the feelings of others. Such difficulties may be evidenced by the individual’s use of inappropriate language or socially unaccepted behavior at home and in public.
- Executive function difficulties: TBIs often impair an individual’s ability to regulate their behavior or to use logic to respond to given situations. Reduced self-control and increased impulsivity are common consequences. Problems with judgment and reasoning may also arise which can lead to increased suggestibility (ability to be led or influenced by others) and poor decision-making (e.g., related to managing finances) may occur. Individuals often experience decreased motivation and/or interest (apathy) to engage in activities after suffering a TBI. The individual with TBI may becomes more likely to fail to follow through with plans; be less likely to speak unless spoken to; and may spend most of their time not engaged in activities (e.g., staying in bed late).
TREATMENT FOR TBI AND ASSOCIATED COMPLICATIONS
Professional Treatment for Behavioral/Emotional Issues
Behavioral/emotional difficulties following a TBI may be best addressed by combining interventions by healthcare professionals with strategies used by the person with TBI and their family, friends, and coworkers. Physicians and Rehabilitation Psychologists/Neuropsychologists are two types of healthcare professionalS who can offer valuable interventions.
Physicians Significant behavioral/emotional difficulties may respond to medications in combination with behavior-based interventions and strategies. Medications may be prescribed by physiatrists and/or psychiatrists to reduce agitation/anger, depression, emotional lability.
Rehabilitation Psychologists/Neuropsychologists These providers are able to assess cognitive and behavioral functioning and offer therapy services to persons with TBI and other affected individuals such as family members. Goals of therapy can include:
- Identification of specific strategies to manage behavioral changes from TBI
- Anger management
- Impulse control strategies
- Emotional liability
- Reduced motivation/apathy
- Help with psychological adjustment to changes in functioning caused by the TBI
- Address lowered self-esteem secondary to TBI-related difficulties
- Provide specific strategies for managing depressed mood, anxiety
- Assistance with adjustment to changes in family roles that can occur after a TBI (e.g., if parent with TBI now requires help from the child in doing daily activities).
Management Strategies for Behavioral/Emotional Issues
Treatment from healthcare professionals plays an vital role in helping address behavioral/emotional issues in persons with TBI, whether they are having minor or substantial effects on the individual’s functioning. In situations where the affected person’s emotional distress is high (e.g., there are concerns about potential for self-harm), professional help should be sought immediately.
Many treatment strategies can be used by the person with TBI and those interacting with him/her which have positive effects on behavioral/emotional functioning. Below are some specific strategies that can be used to address common behavioral/emotional difficulties following TBI. As with all strategies for changing human behavior, patience, consistency, and repetition in the use of these strategies are needed to obtain the best results.
- Strategies for Others
- When the individual is angry, talk in a soothing manner.
- Acknowledge the individual’s frustrations and help with problem-solving if possible.
- Try to distract the individual and help divert his/her attention to something else if he/she is too upset to problem-solve effectively.
- Serve as a role model for the individual by using effective anger management strategies.
- Be patient in the moment and persistent over time in helping the individual manage his/her anger.
- Avoid trying to reason with the individual when he/she is at peak anger levels.
- Avoid criticizing the individual if his/her strategies for managing anger don’t work at first.
- Strategies for the Person with TBI
- Practice anger-management strategies before anger occurs.
- Learn to identify early signs of anger.
- Learn to identify situations (“triggers”) that can lead to anger.
- Avoid triggers if possible, or learn and use anger-management strategies in those situations.
- Get help from family, friends, and others in efforts to learn and use anger-management strategies.
- Seek to include regular activity, hobbies, and other sources of enjoyment in one’s life.
- Strategies for Others
- If the individual appears down, ask about his/her mood in an accepting, non-judgmental manner (acknowledging that it is OK to feel distressed).
- Try to help the individual identify source of distress (e.g., is it related to transient issue, or does it reflect ongoing distress about situation, etc.).
- If the distress is related to specific issue, encourage and help the individual to problem-solve regarding how to address the issue.
- Alternatively, try to distract the individual if the issue is not one that can be readily addressed.
- If distress is related to general sense of loss since the TBI, consider the following strategies:
- Acknowledge the individual’s sense of loss as a result of changes following the TBI.
- Provide honest but supportive feedback regarding changes observed (e.g., don’t deny difficulties, but also be sure to highlight ongoing strengths).
- Support the individual’s efforts to develop new ideas about him/herself and what he/she may be able to do.
- Help to identify new goals (both short-term and long-term) and think of ways to achieve these goals.
- Ensure that the individual has opportunities for positive experiences. This may include:
- Spending time in settings the individual enjoys (e.g., outside, in nature).
- Gathering with supportive friends/family.
- Engaging in activities the individual enjoys (e.g., movies, etc.).
- Avoid criticizing the individual with statements about differences in his/her behaviors/skills/etc. prior to the TBI.
- Avoid attempts to minimize or make light of the individual’s distress about perceived changes in self since the TBI.
- Avoid assuming that the individual is not aware of, and possibly distressed by, changes that others observe.
- Strategies for the Person with TBI
- Acknowledge and allow self to grieve changes/losses that occurred since the TBI.
- Accept support/encouragement offered by others.
- Work to move from focusing on TBI-related difficulties to instead recognizing current strengths and abilities.
- Enlist the help of trusted family and friends in identifying strengths.
- Identify new, reasonable goals given strengths and weaknesses.
- Work with family members, friends, and healthcare providers (rehabilitation psychologist/neuropsychologist ) to develop strategies to achieve these goals.
- In addition to striving for accomplishment, pursue hobbies and/or other sources of enjoyment.
- Strategies for Others
- Work with the individual with TBI to identify situations that are associated with emotional liability (e.g., frustration, fatigue).
- Use some basic strategies to de-escalate potentially problematic situations:
- Recognize early signs of increased emotionality.
- Use distraction to decrease focus on cause of emotional reaction.
- Encourage/help the individual take a break from the situation associated with the emotional reaction (e.g., leaving the room and going to a safe, quiet place).
- When the individual is emotionally liable, maintain an interactional style that is non-confrontational and soothing (e.g., speaking in a calm voice, with non-threatening body language).
- Acknowledge the individual’s distress and help with problem-solving if possible.
- During non-emotional times, help the individual identify words that can be used to communicate with others about his/her emotions.
- Avoid engaging in discussions/arguments with the individual when he/she is experiencing high levels of emotionality.
- Avoid escalating the individual’s emotions by responding with intense emotions.
- Avoid attempting to reason with the individual during periods of high emotionality.
- Strategies for the Person with TBI
- Attend to early signs of emotionality.
- Be aware of factors that contribute to increased emotionality (e.g., fatigue, pain).
- Try to minimize exposure to situations that are associated with increased emotionality, particularly when at risk for increased emotionality (e.g., due to fatigue, pain, etc.).
- Use strategies to cope with high emotionality, including:
- Using words to express emotions.
- Removing self from the stress-inducing situation.
- Using relaxation techniques (can be developed with the aid of psychologist).
- Enlist the help of trusted family member, friends, healthcare providers in developing strategies to manage emotional responses.
- Strategies for Others
- Be aware of the relationship between TBI-related changes in brain functioning and increased impulsivity.
- Work with the individual to identify triggers to impulsive behaviors (e.g., increased emotionality, influence of peers).
- Try to identify environmental changes that may help avoid triggers (e.g., minimize contact with peers having a negative influence).
- Develop a subtle signal (e.g., a hand gesture) to help the individual remember to stop and think before acting when questionable behaviors are occurring in social contexts and use redirection as needed.
- When not in social situations, provide the individual with non-judgmental feedback regarding the appropriateness of his/her behaviors/decisions.
- This may initially be tried while the behaviors are occurring. If the individual responds negatively at that time, follow-up at a later time after his/her behaviors and emotions have stabilized.
- Balance encouraging independence with helping the individual with TBI recognize his/her limits in decision-making.
- Talk with the person about “pros” and “cons” for decisions/behaviors. Help him/her to weigh the positive and negative aspects.
- Serve as a model by making important decisions in a thoughtful manner and including the individual with TBI in the reasoning process.
- Avoid criticizing the individual for impulsive behaviors without providing constructive ideas about other ways to behave.
- Avoid comparing the individual’s past and current abilities.
- Avoid trying to convince the individual to change behaviors when his/her level of emotionality is high (use distraction and wait until the individual is calm before addressing the issue).
- Strategies for the Person with TBI
- Identify triggers to impulsive behaviors with help of trusted others (e.g., family, friends, healthcare providers).
- Develop strategies to reduce the likelihood of acting before considering consequences.
- Have family members/friends give a signal to help with stopping and considering behaviors before acting further.
- Accept feedback from trusted others (e.g., family, good friends) regarding when it is important to stop and consider behaviors even if it is difficult to recognize the need for this.
- Strategies for Others
- Recognize that apathy may result from changes to the brain associated with TBI.
- Recognize that apathy can also be a sign of depression.
- Look for other symptoms of depression (e.g., sadness, appetite/sleep difficulties, feelings of worthlessness).
- If other signs of depression are present, consider using strategies for coping with Depression (see above) in addition to seeking help from healthcare providers .
- Use techniques to enhance initiation, including:
- Work with the individual to develop a set of agreed-upon goals.
- Develop a schedule of daily activities and check off each activity as it has been completed.
- Develop a schedule that involves slowly increasing activities and responsibilities over time.
- Add 1-2 new responsibilities each week, and reward the individual for successfully adding new tasks.
- Choose activities or other rewards that the individual will receive after completing less interesting tasks.
- Strategies for the Person with TBI
- Accept help from trusted others (e.g., family, friends) in identifying plans/schedules for activities.
- Use a timer to provide prompts when a task needs to be done (e.g., a watch alarm can sound when medications need to be taken).
- Set appropriate goals for activities each day, with the help of trusted others.
ACUTE INPATIENT REHABILITATION
Inpatient rehabilitation is designed to help improve function after a moderate to severe traumatic brain injury (TBI) and is typically provided by a team of people including physicians, nurses and other specialized therapists and medical professionals. Inpatient rehabilitation can be utilized to treat a number of the problems associated with TBIs such as:
- Thinking problems – difficulty with memory, language, concentration, judgment and problem solving.
- Physical problems – loss of coordination, strength, movement, and swallowing.
- Sensory problems – changes in sense of smell, vision, hearing, and tactile touch.
- Emotional problems – mood changes, impulsiveness, irritability.
Eligibility for inpatient rehabilitation
- Individuals will be eligible to receive inpatient rehabilitation if:
- They have a new TBI that prevents them from returning home to family care;
- Their medical condition is stable enough to allow participation in therapies (For people relying on Medicare for funding, this means being able to participate in at least 3 hours of therapy per day. Specialized rehabilitation in a nursing facility is an option for those who cannot participate in 3 hours of rehabilitation per day.).
- They are able to make progress in therapies.
- They have a social support system that will allow them to return home or to another community care setting after reasonable improvement of function.
- They have insurance or other ways to cover the cost of treatment.
How inpatient rehabilitation works
- Therapies will be designed to address the individual’s special needs. An individual will receive at least 3 hours of different types of therapy throughout the day, with breaks in between, 5-7 days a week.
- The program will be developed and implemented under the care of a physician who will see the individual at least 3 times a week.
- Most TBI rehabilitation inpatients participate in physical therapy, occupational therapy, and speech therapy. Each of these therapies may be provided in an individual or group format.
- Rehabilitation team
- Rehabilitation care usually involves a team of highly trained practitioners, often referred to as the “multidisciplinary team.” This team works together every day and shares information about your treatment and recovery. Members of the multidisciplinary team are:
- Physician: This may be a physiatrist (physician whose specialty is rehabilitation medicine), neurologist or other specialist familiar with TBI rehabilitation. He/she is in charge of the individual’s overall treatment and directs your rehabilitation program. Specifically, he/she will evaluate the individual’s physical abilities, along with their thinking and behavior; prescribe medication as necessary to manage mood, sleep, pain and nutrition; and prescribe tailored therapy orders for physical therapy, occupational therapy, and speech therapy.
- Rehabilitation Nurse: The rehabilitation nurse works alongside the physician in managing medical problems and preventing complications. The nurse’s duties include assessing a variety of issues, including self-care, bowel and bladder function, sexuality, nutrition and mobility. The nurse will also help to reinforce the treatments of the other team members and provide education about the brain injury and medications.
- Psychologist/Neuropsychologist: He/she will assess and treat problems the individual may be experiencing with thinking, memory, mood and behavior. The psychologist/neuropsychologist may also provide counseling and education to the individual’s family members, thus ensuring that they have an understanding of the treatment plan and possible outcomes.
- Physical therapist: The physical therapist (PT) will develop a program to help improve the individual’s physical function and mobility. The PT’s role is to teach the individual how to be as physically independent, active and as safe as possible within their environment. The PT will seek to accomplish their role through therapeutic exercises and re-education of your muscles and nerves, with the goal of restoring normal function. Specific goals to be accomplished through physical therapy include strengthening the individual’s muscles and improving endurance, walking, and balance.
- Occupational therapist: Occupational therapists (OT) provide training in activities of daily living to help you become more independent. These activities typically include eating, bathing, grooming, dressing, and transferring to and from your bed, wheelchair, toilet, tub and shower. Depending upon where the individual receives treatment, occupational therapists may also assess thinking skills, such as orientation, memory, attention, concentration, calculation, problem-solving, reasoning and judgment; assess visual problems; help manage more complex activities such as meal preparation/cooking, money management, and getting involved in community activities; and recommend and order appropriate equipment the individual may require before returning home.
- Speech-language pathology therapist: The speech-language pathology therapist is responsible for the treatment of speech, swallow and communication problems. He/she will help an individual with communication problems such as difficulty understanding what others say or expressing oneself clearly; teach exercises and techniques to improve the ability to speak and express oneself, including exercises designed to strengthen the muscles used in speech/swallowing, and speech drills to improve clarity; assess the individual’s language skills, such as orientation, memory, attention, concentration, calculation, problem-solving, reasoning and judgment; Provide a communication device if the individual requires a breathing tube (tracheotomy); Evaluate swallowing abilities if the individual experiences difficulty swallowing (dysphasia); and if necessary, recommend the types and consistencies of foods and drinks that an individual may safely consume.
- Recreation therapist: The recreation therapist’s role is to provide the individual with recreational resources and opportunities to improve health and well-being to enable the individual to become reconnected to his or her community. Returning to recreation and/or finding new recreational activities is an important part of recovery.
- Social worker: The social worker will provide the individual and his/her family with information about community resources and help plan for the individual’s discharge from the hospital. The social worker can assist in helping to determine eligibility for benefits, such as Medicaid and Social Security; make referrals to community resources; and provide ongoing supportive counseling to help the individual adjust to his/her new situation.
- Nutritionist/Dietitian: The dietitian evaluates the individual’s nutritional status and makes recommendations about proper nutrition and diet. Individuals are often malnourished and underweight after staying in the hospital for an extended period, and thus individualized attention to diet and caloric intake assists in recovery. The dietitian will also educate the individual regarding menu selection, proper food consistencies, diet changes, etc., as it fits the individual’s needs.
- Rehabilitation care usually involves a team of highly trained practitioners, often referred to as the “multidisciplinary team.” This team works together every day and shares information about your treatment and recovery. Members of the multidisciplinary team are:
DISCHARGE FROM THE HOSPITAL AFTER SUFFERING A TBI
Every discharge plan is different and reflects a patient’s unique personal and social situation. Recovery from a brain injury takes months and even years, so after discharge most people will require ongoing therapy. Discharge plans fall roughly into one of four categories:
- Discharge Home, with Referral for Home-Based Rehabilitation Services: This discharge plan is appropriate for individuals who are well enough to be at home, but who are not well enough to travel for therapy. The individual’s social worker will typically make a referral to a nursing agency that will visit the individual at home to assess their needs. The nursing agency will also provide needed services which may include physical and occupational therapy and a home health attendant. It is important to note that family is almost always needed to provide some of the help that the individual will require at home.
- Discharge Home, with Referral for Outpatient Services: This discharge plan is appropriate for individuals who are well enough to be at home and able to travel to an outpatient clinic for therapy. Family members will provide the individual with all needed help and supervision at home, and the individual’s rehabilitation therapies will be provided through the most convenient outpatient clinic.
- Discharge to a Residential Brain Injury Rehabilitation Program: This discharge plan is appropriate for individuals who are well enough to live in the community but require a supervised and structured environment. This option is generally best for individuals who do not need inpatient supervision by a nurse or physician but may benefit from continued therapy to help the transition back into the community. The availability of these programs varies based on insurance type and where you live.
- Discharge to a Nursing facility: This discharge plan is appropriate for individuals who are not yet ready to return home and who would benefit from continuing their rehabilitation therapies in a structured environment with nursing care. The nursing facility can provide nursing care and ongoing rehabilitation therapy in specialized rehabilitation wings (subacute rehabilitation), usually for up to three months. Length of stay varies based on medical need, degree of progress in that setting, and availability of rehabilitation benefit. If an individual’s team recommends a nursing facility that provides subacute rehabilitation, the social worker will help the individual find one that meets the individual’s needs.
RECOVERY FROM A TBI
The fastest improvements after suffering a TBI typically occur during the first six months after the injury. Most individuals continue to improve between six months and two years after injury, but this varies for different people and continuing improvements may not happen as fast as the first six months.
Improvements typically slow down substantially after two years but may still occur many years after injury. Most individuals continue to have some problems, although they may not be as bad as they were early after injury. Rate of improvement varies depending upon the individual and severity of the TBI.
Family members of individuals with TBI commonly have questions about the long-term effects that the injury will have upon their loved one and their ability to function in the future. Unfortunately, the long-term effects of a TBI are difficult to estimate for several reasons.
First, brain injury is a relatively new area of treatment and research, and thus health care professionals have only begun to understand the long-term effects on individuals with TBI for one, five, and ten years after the injury. Brain scans and other medical testing is not always able to reveal the extent of the injury which presents difficulty in understanding the severity of the injury at the beginning of the individual’s treatment.
Furthermore, the type of injury and extent of secondary problems drastically varies from individual to individual. An individual’s age, pre-existing conditions, and pre-injury abilities also greatly impact how well the individual is able to recover. However, research indicates that the more severe the injury the less likely the individual will fully recover. The length of time an individual remains in a coma and duration of loss of memory (amnesia) following the coma are useful in predicting how well a person will recover.
The most common form of TBI is concussion. A concussion may result when the head or body is moved back and forth quickly, such as during a motor vehicle accident or sports injury. Concussions are often called “mild TBI” because they are typically not considered life-threatening. Most concussions occur without a loss of consciousness. However, concussions still can cause serious problems, and modern studies suggest that repeated concussions can be particularly dangerous. Recognition and proper response to concussions when they first occur can help prevent further injury or even death
Recovering from concussions
Although most individuals recover fully after a concussion, how quickly improvement occurs depends on many factors. These factors include the severity of the concussion, age, the individual’s state of health before the concussion, and how the individual’s take care of himself/herself after the injury.
Rest is a very important part of treating a concussion because it helps the brain to heal. Ignoring symptoms and trying to “tough it out” often makes symptoms worse. Only when concussion symptoms have reduced substantially, in consultation with the health care professional, should an individual attempt to slowly and gradually return to daily activities, such as work or school. If symptoms return or new symptoms arise upon becoming more active, this indicates that the individual is pushing himself/herself too hard, too early. In these circumstances, individuals should stop the activities and take more time to rest and recover. As the days go by, most individuals will gradually feel better.
GETTING BETTER: TIPS FOR ADULTS
- Get plenty of sleep at night, and rest during the day.
- Avoid activities that are physically demanding (e.g., heavy housecleaning, weightlifting/working out) or require a lot of concentration (e.g., balancing your checkbook). They can make your symptoms worse and slow your recovery.
- Avoid activities such as contact or recreational sports, that could lead to another concussion. (It is best to avoid roller coasters or other high speed rides that can make your symptoms worse or even cause a concussion.)
- When your health care professional says you are well enough, return to your normal activities gradually, not all at once.
- Because your ability to react may be slower after a concussion, ask your health care professional when you can safely drive a car, ride a bike, or operate heavy equipment.
- Talk with your health care professional about when you can return to work. Ask about how you can help your employer understand what has happened to you.
- Consider talking with your employer about returning to work gradually and about changing your work activities or schedule until you recover (e.g., work half-days).
- Take only those drugs that your health care professional has approved.
- Do not drink alcoholic beverages until your health care professional says you are well enough. Alcohol and other drugs may slow your recovery and put you at risk of further injury.
- Write down the things that may be harder than usual for you to remember.
- If you’re easily distracted, try to do one thing at a time. For example, don’t try to watch TV while fixing dinner.
- Consult with family members or close friends when making important decisions.
- Do not neglect your basic needs, such as eating well and getting enough rest.
- Avoid sustained computer use, including computer/video games early in the recovery process.
- Avoid travel as some people report that flying in airplanes makes their symptoms worse shortly after a concussion.
GETTING BETTER: TIPS FOR CHILDREN
Parents and caregivers of children who have had a concussion can help them recover by taking an active role in their recovery:
- Having the child get plenty of rest. Keep a regular sleep schedule, including no late nights and no sleepovers.
- Making sure the child avoids high-risk/ high-speed activities such as riding a bicycle, playing sports, or climbing playground equipment, roller coasters or rides that could result in another bump, blow, or jolt to the head or body. Children should not return to these types of activities until their health care professional says they are well enough.
- Giving the child only those drugs that are approved by the pediatrician or family physician.
- Talking with their health care professional about when the child should return to school and other activities and how the parent or caregiver can help the child deal with the challenges that the child may face. For example, your child may need to spend fewer hours at school, rest often, or require more time to take tests.
- Sharing information about concussion with parents, siblings, teachers, counselors, babysitters, coaches, and others who interact with the child helps them understand what has happened and how to meet the child’s needs.
CONCUSSIONS IN SPORTS
An unfortunate consequence of participating in sporting activities includes the danger of sustaining a concussion. In order to recognize and treat concussions, athletes should be carefully observed for any changes in the athlete’s behavior, thinking, or physical functioning after sustaining a blow or jolt to the body or head that results in rapid movement of the head.
When assessing a possible concussion, coaches should observe athletes for the following signs:
- Appears dazed or stunned
- Is confused about assignment or position
- Forgets an instruction
- Is unsure of game, score, or opponent
- Moves clumsily
- Answers questions slowly
- Loses consciousness (even briefly)
- Shows mood, behavior, or personality changes
- Can’t recall events prior to hit or fall
- Can’t recall events after hit or fall
When assessing a possible concussion, it is important to be mindful of the following symptoms that may be reported by the athlete:
- Headache or “pressure” in head
- Nausea or vomiting
- Balance problems or dizziness
- Double or blurry vision
- Sensitivity to light
- Sensitivity to noise
- Feeling sluggish, hazy, foggy, or groggy
- Concentration or memory problems