Frequently Asked Questions About Brain Injury

The Northern Brain Injury Association encourages survivors, their families and friends to learn as much as they can about brain injuries. To help, we have prepared the following list of frequently asked questions and answers.

1. What is a severe brain injury?

The brain is a complex part of our neuroanatomy. A severe brain injury occurs when the brain receives a neurological injury which results in physiologic changes to a person’s brain. The four main types of injury may cause trauma to the brain are:
Closed: Closed head injuries occur when the brain tissue strikes the inside of the skull. This impact can cause bleeding, resulting in increased intra-cranial pressure, bruising, tissue damage, neurochemical changes and/or fluid buildup.
Penetrating: Penetrating injuries are the entry of any foreign object into the brain, such as blows that cause open fractures of the skull, gunshot wounds, etc., that result in damage to the neurological structure of the brain.
Anoxic: Anoxic brain damage occurs when there is a lack, or reduction of oxygen to the brain, to the point it causes brain cells to die. Injuries from anoxia can produce widespread effects throughout the brain.
Toxic: Toxic brain injury is caused by the ingestion or exposure to toxic chemical agents, which cross the blood-brain barrier to damage or kill brain cells.

2. How is brain injury severity determined?

The Glasgow Coma Scale is used to rate brain injury severity, and determines how responsive the person is to behavioral measures. The Glasgow Outcome Scale is used at various points after the injury to determine the prognosis, or likelihood, of the person regaining independence.

Brain injury is commonly rated as mild, moderate and severe. Other measures, like the Rancho Los Amigos Scale, are used to assess consciousness, responsiveness and receptive skills. Often, the full effects effects of the brain injury are not fully understood until after the survivor completes emergency medical treatment and has entered into the recovery phase.

3. What are the clinical features of severe brain injury?

A low Glasgow Coma Scale grade at the time of the initial medical intervention indicates severe brain injury. The survivor is often in a coma, or state of diminished consciousness, which may last for hours, or days, and may extend for weeks. Usually there is also a second assessment 24 hours after the injury.
Symptoms often include:
• No response, or reduced ability to respond to stimuli
• Changes to rigidity and tone of muscle
• Difficulties with autonomic functions like respiration and other vital functions
• Intra-cranial pressure or fluid buildup, requiring close monitoring and possibly neurosurgery

4. What is the rate of severe brain injury?

In Canada, each year there are on average 50,000 brain injuries at all levels of severity, and of those, 11,000 Canadians die. While most injuries are in the mild to medium categories, brain injury at all levels can produce negative effects that may last a lifetime.

5. How does the person feel about their ‘new self’ after injury?

It is common to hear survivors talk about how the think they are “going crazy”, and to feel totally confused and/or depressed. It is very difficult for them to understand the changes they are going through, and to cope with their suddenly altered abilities.

6. Does the site of an injury effect how severe it will be?

Yes. The control of physical, cognitive, emotional and behavioral functions are all brain-based, so the location of the injury can, and will, affect the severity of problems. In reality, there are few “simple” brain injuries, and the effects may be experienced by survivors throughout the course of their lifetime. Certain specific, or “focal” injuries, often produce similar and predictable challenges.

7. How is the survivor affected by severe brain injury?

A severe injury produces a variety of physiologic, cognitive, emotional, psychological and behavioral changes, such as; medical problems like incapacitating headaches and pain, physical functions like standing, walking and eye-hand coordination and fatigue, and cognitive changes to thinking, memory and language. The survivor’s personality may also be affected. Survivors may become very introverted, or lose natural inhibition and behavior control, leading to unacceptable behaviors. The bottom line is that the effects of a severe brain injury are varied, extremely widespread and will impact all areas of a survivor’s life.

8. Is there a difference between adult and childhood severe brain injury?

Yes, but the jury is still out on this one. It is thought that children with severe brain injury have the advantage, and disadvantage, of youth on their side. The disadvantage is that children are more susceptible to injury due to how thin their developing skull is, and many effects will not be seen until they mature. When an adult acquires a brain injury, it may result in the ‘loss’ of a function. But children may not have acquired certain skills and functions yet, so instead of experiencing loss, they may never acquire the skill of function to begin with. Additionally, psychological and behavioral problems may affect school entry/re-entry, and a return to family and peers.

The advantage of their youth is that it is believed children can train their brains to replace lost functions more easily than adults with similar injuries. However, it is important to note that childhood brain injury may present many cognitive or learning problems quite different from those experienced by adults, and some of their challenges may not show up for years. In some cases, the initial injury may be forgotten or ignored, which can lead to inappropriate diagnosis and treatment. Many child survivors will require recovery efforts that extend into the school environment to achieve success.

9. What are the physical symptoms associated with brain injury?

Some of the most common physical complaints are:
• Dizziness
• Nausea and motion sickness
• Fatigue
• Ringing in the ears
• Recurrent headaches
• Hypersensitivity to light, noise, touch, smell or taste
• Sensitivity to crowds and busy environments

10. What are the potential psychological or emotional problems?

Brain injury often causes a “personality change” in the individual, such as increased shyness, or they may become very out-going.
Other common symptoms are:
• Depression and anxiety
• Changes in sleeping habits
• Increased or decreased sex drive
• Heightened fears
• Changes in temperament
• Increased levels of fatigue
Individuals may experience problems in judgment, or do things that were unlikely to do prior to their injury. This may include use of drugs or alcohol in a pattern very different from pre-injury use.

11. Will a person with brain injury recover?

Yes. However the degree of recovery will depend on several factors, such as help to develop strategies to manage their cognitive difficulties, cope with the psychological and emotional changes, and the reduction of conditions and barriers caused by physical problems. The injury will be very stressful to the family, and counseling may be required. The participation of family and friends helps the survivor to adjust to the changes created by the injury. Community-based rehabilitation and recovery programs, focused on peer support and providing functional solutions offer the best opportunities for optimum recovery.

12. What is the typical process of recovery?

Immediately following the accident or incident that caused the injury, the survivor will require medical intervention and stabilization to monitor and manage basic life systems. As the survivor stabilizes, and the life threatening issues subside, hospital-based medical rehabilitation usually begins. There is a window of time following injury commonly called the ‘spontaneous recovery period’ when the brain begins to recover and repair damaged neurons, and may take weeks or months. Often during this period a person must re-learn both physical and functional skills. Medical recovery programs usually provide restorative therapies, such as physiotherapy, occupational therapy and speech therapy, along with medical and nursing supervision.

13. What happens once the survivor is released from hospital?

Once the survivor’s primary medical care is completed and they return home, there are many steps that families and friends can take to assist recovery. The survivor may require community-based recovery programs, and/or ongoing outpatient services, but, in cases where the injury has caused severe persisting deficits requiring extensive care and assistance, they may be best cared for in an extended or long-term care environment. In this is the case, transitional and supported living programs may be appropriate.

14. How much will a survivor recover from a severe brain injury?

No one knows the answer to this question. No two brains or injuries are alike, therefore recovery outcomes are very different for each survivor. The degree of recovery depends on multiple factors, such as which areas of the brain were injured, the severity of the injury and the quality of assistive programs. Therapeutic intervention should begin as soon as the survivor is medically stable. Recovery can only be measured individually, and the return of functional skills may continue for years following the injury. There is currently no accurate way to know how long recovery will take, or to what degree it will happen.

15. How does rehabilitation (recovery) influence outcome?

First, it must be noted that rehabilitation infers a return to ‘normalcy’, which may, or may not happen. According to survivors, recovery, remodelling, renovation or restoration are more appropriate terms, so for the purposes of the information provided herein, rehabilitation means recovery. We have learned that the human brain is capable of overcoming significant problems created by injury. Recovery using coping strategies helps stimulate the brain to heal damaged neurons, and retrain other neurons to take the place of those that died, to redesign the network controlling communication between neurons. In the early phases, the focus is on maximizing the natural recovery process by identifying specific deficits or problem areas, and then developing treatment directed at improving function within those areas.

16. What does rehabilitation involve?

It involves professionals developing individualized strategies and interventions in response to each person’s unique challenges. As the survivor moves past the acute phase of recovery, the focus shifts to replacing and retraining lost skills and functions. Teaching the survivor to remain flexible and adapt while re-learning is heavily reinforced through the strategies and skills taught to solve problems. Strategies must be done at the survivor’s pace, with an emphasis placed on enhancing natural recovery and independence. The goal is always helping survivors to return to lives of independence, self-worth and dignity.

17. What happens after rehabilitation ends?

For some people, recovery may extend for years beyond a person’s initial injury. And, changes will continue to occur throughout a survivor’s entire lifetime, so there is benefit from peer support groups, various rehabilitation therapies to maintain and learn new skills. By increasing independence and community mobility, many individuals will return to pre-injury roles at home, at work and in the community, but many others may not. There are also people who will recover in most ways, yet may require continued support and assistance with certain aspects of their lives. And, as survivors of brain injury age, specialized support services may be needed to assist them in maintaining their independence. This support and assistance may come from family members, trained professionals, and/or paraprofessionals.

18. What is a coma, and do some people remain in a coma forever?

The term “coma” is generally used to describe a prolonged state of diminished consciousness where a person’s ability to respond to stimuli is significantly reduced. It can be for a short period, or last for many years. The term “persistent vegetative state” is used to describe individuals who do not recover from coma following their injuries. Little is known about what people hear or see while in a state of coma, however, it is widely believed that they are aware of their environments, and of people and events. This understanding has dramatically changed how individuals in comas are treated.

19. What is a “Locked-in Syndrome”?

For a long time we thought that individuals who were in a coma were unable to respond, or were ‘locked in’. However, through years of working with people with severe brain injuries and diminished responding capacities, we have learned that the person may be receiving information, but is unable to produce an effective response. Some people may communicate with an eye blink, a facial gesture, or even by moving a toe. The term “Locked-in Syndrome” has been used to describe the state in which the person has become unable to effectively respond to stimulation. Rehabilitation services for these individuals may focus on developing a communication system, in addition to maintaining physical conditioning and health.
Effective coma recovery programs:
• Provide gentle, but consistent stimulation
• Involve all of a survivor’s senses
• Enable them to interact with his or her environment
• Do not assume the survivor is unaware of his or her environment

20. What is the role of a neuropsychologist?

Neuropsychologists are very important members of the recovery team. They may perform a neuropsychological assesment to evaluate the problems the person is experiencing, the extent of their problems, and then determine the optimum approach for recovery. In some cases, counseling is offered. In subsequent neuropsychological evaluations, the neuropsychologist will determine the recovery course and rate.

21. What are cognitive problems?

Cognitive problems are specific skill deficits that may occur following a brain injury.
Some of the most common cognitive problems are:
• Arousal or over-stimulation
• Attention and information filtering issues
• Information processing and retrieval (memory) issues
• Learning, both using old information, and acquiring new information
• Problem solving
• Higher-level thinking skills also known as “executive skills”.
Some cognitive problems resolve themselves over time, while others may persist and require specific recovery interventions. And, there is a relationship between cognitive problems and neurobehavioral problems.

22. What are neurobehavioral problems?

Neurobehavioral problems are behavior problems attributed to specific aspects of a brain injury. Sometimes normal inhibitions and judgment are reduced due to the injury, and survivors may develop difficulty with self-regulation or self-control, impulse control, over-arousal, frustration tolerance, and problems in perception. They may overreact to situations, get angry without provocation, and/or behave in socially unacceptable manners.
A neuropsychologist may assess the person for the presence of a seizure disorder to see if it is what may be causing irritability and loss-of-control issues, such as anger, disinhibition and aggression, and then will design an appropriate behavior learning strategy. Again, in some cases medications are effective in helping to control behavior.

23. What causes the inability to control anger and aggression after injury?

There is a correlation between the location of a brain injury and the appearance of anger and aggression. Anger and aggression are frequently present when the injury affects the frontal lobe, and seems to be caused by a reduction of impulse control due to damage to the brain’s ‘filters’.

24. What causes difficulty controlling emotions and inappropriate sexual behavior?

The answer is similar to the question about anger and aggression. Following a brain injury, some people struggle with appropriate boundaries when experiencing sadness, happiness and sexual feelings. This loss of inhibition and impulse control can result from the location of their brain injury, or the loss of communication between areas of the brain, as seen see in individuals with Diffuse Axonal injuries. Often a neurologist, psychiatrist or psychologist who specializes in neurological cases is needed to help the person deal with the injury in a healthy way.

25. What is a frontal lobe injury?

The frontal lobes of our brain controls many of our cognitive and behavioral functions through complex processes of integration and mediation responses. Neuropsychologists relate executive deficits (problems in higher-level thinking) to frontal lobe injuries. Many aspects of frontal lobe function are important for the control of our thinking and behavior. Frontal lobe injuries are common due to the structure of the brain, and direction of trauma. Most severe brain injuries involve the effects of one or both of the following:
Coup and Contra coup injuries: These are injuries where the brain moves in a back and forth motion, striking the skull.
Rotational or shearing injuries: These are injuries caused by the sideways movement, or twisting of the brain inside the skull, stretching and tearing neurons. There may be multiple areas of involvement, and the loss of connectivity between areas of the brain, resulting in Diffuse Axonal Injury.

26. What is a brain stem injury?

The brain stem is a critical junction between brain and body, and controls many of the body’s physiologic systems. Injuries to the brain stem are likely to create problems in mobility, motor control and central functions. This could result in difficulty standing, walking, getting in and out of a bed or chair, lifting, throwing, catching, feeding oneself, writing, and performing other normal daily activities. People with brain stem injuries tend to require a prolonged period of medical supervision, and may have long-term physical deficits related to their injuries. Because much of our ability to live with independence relates to our capacity to perform motor tasks, there are specific therapies developed that can help a person to regain motor control, and maximize motor skills.

27. What are neuromotor problems?

The circuitry of the brain is extremely complex, and neuromotor problems are physical movement and body control difficulties that result from injury to the motor control areas of the brain.
People may experience difficulty:
• Initiating or starting a movement
• Maintaining muscle control
• Sustaining a movement
• Executing a complex movement, such as walking

28. What is the likelihood of a person returning to a life of independence after brain injury?

There is no answer for this question. Independence will depend on the location and severity of injury. Although there are no guarantees, many people make dramatic strides toward recovery. We often see continued survivor improvement sometimes years after the injury, and in many cases, people are able to return to the ones they love, and lives filled with purpose and meaning.

29. What is mild brain injury?

Mild traumatic brain injury is also called “subtle acquired brain injury”, or ‘concussion’. People with mild or subtle brain injuries may or may not have cognitive, psychological and physical symptoms that occur after the injury. They usually do not experience a prolonged period of unconsciousness or coma. In fact, some individuals report no loss of consciousness. The effects of a mild brain injury can range from psychological problems such as depression and anxiety, to substance abuse and/or addiction. Through recent research we have learned that even mild brain injury can produce problems that occur long after the initial injury, and can affect many aspects of a person’s life.

30. Can a mild brain injury create psychiatric problems?

Many individuals with a mild brain injury do end up under psychiatric care. For some people, the injury causes severe psychological reactions, or triggers symptoms of an underlying psychiatric disease. There is a high likelihood of biochemical disruption related to brain injury. The psychiatrist, or other mental health professionals, need to be made aware of the person’s brain injury prior to the start of treatment. If individuals are experiencing symptoms of Post Traumatic Stress Disorder (PTSD) in addition to their mild brain injury, their psychological abilities to respond to the issues created by their brain injury may be further impacted.

31. When do the symptoms of mild brain injury emerge?

There are actually two sets of symptoms: one that is observed right after the injury, and a second set that occurs some time after the initial phase.
The first set of symptoms includes:
• Uneven pupil dialation (one pupil lager than the other)
• Headaches (can be dull continous, sharp stabbing, or migraine like)
• Nausea (from loss of appetite to vomiting)
• Dizziness
• Confusion (may not recognise people or places)
• Agitation (may have a short temper, no patience)
• Disorientation (unsure of where they are at, what it is going on, etc.)
• Amnesia (loss of memory, usually short term, may not recall the injury)
• Fatigue (mental and physical exhaustion, they feel ‘done’)
Some of these symptoms, such as headache and fatigue, may continue for months after the injury.
The second set occurs when the person attempts to return to his or her pre-injury life activities at home, work or school. The interplay between the persistent cognitive, emotional and physical symptoms can affect the functional capacities of the individual, and they are often difficult to manage.

32. Is a concussion considered a mild brain injury?

Yes. In some cases a concussive action can produce a mild brain injury, but it is usually temporary. However, a concussive injury can lead to stretching and tearing of nerve fibers in the brain, resulting in longer-term effects. The cognitive, emotional and physical results of a concussive injury are called ‘Post Concussion Syndrome’ (PCS). Concussion injuries usually don’t show up in CAT scans and neurological examinations, as they occur at the cellular level. In some cases, since the person never “lost consciousness”, a full neurological exam never takes place.

33. What happens when a person experiences multiple concussions, such as sports-related injuries?

Each time the brain receives a concussive injury, more stretching and tearing of nerve fibers occurs. The effects of multiple concussive injuries are cumulative. Eventually, a person’s ability to “return to normal” is diminished, causing both the initial and secondary symptoms to persist for longer periods. Multiple concussive injuries are particularly dangerous due to the absence of a loss of consciousness, or other physical symptoms that would create the need for medical attention. The likelihood of the injury increases with each injury.
Sports coaches and players need to be aware that a blow to the head, or even an abrupt, sudden stopping movement of the head, such as a rough tackle in football, can cause a concussive injury. Current research into repetitive concussive injuries indicates that the effects may lead to the development of protein tangles known as TAU, which are associated with conditions such as Chronic Traumatic Encephalopathy and Alzheimer’s Disease.
Concussion survivors frequently experience:
• Mood changes
• Temper control difficulties
• Problems with attention and concentration
• Sleep problems
• Loss of appetite
• Change in sex drive
The symptoms of post concussion syndrome are often not understood, or are misdiagnosed by professionals treating the person, especially if they are not aware of the existence of a brain injury.

34. Can someone “fake” mild brain injury symptoms?

Possibly for the short term, but it is very hard for a person to consistently fake neurological symptoms, or to maintain a consistent pattern of cognitive deficits. There are tests to determine “malingering”, and neuropsychological and psychiatric assessments that will identify other personality or psychiatric problems that may also be present.

35. When can the survivor return to work?

As with any brain injury, the return to work is an important part of the recovery process. Individuals who return to work without coping strategies and work supports, report that they experience great difficulty with the cognitive aspects of their work tasks. In some cases, they are overwhelmed by the work’s psychological demands. Co-workers may not understand the cognitive and personality changes they see in the injured individual, and may incorrectly attribute the problems to the wrong cause. To be effective, the recovery program needs to extend into the work setting, and needs to include vocational assessments, work re-entry, job coaching and job re-engineering. In some cases, the person may need to return to a modified job, and some find that they are simply incapable of working anymore.

36. Can the survivor drive after a brain injury?

Again, the outcome of a brain injury is largely dependent on the part of the brain affected, and how badly it is injured. It is the law that doctors are required to inform the Superintendent of Motor Vehicles that a person has a health condition which impairs their ability to drive if the injury is serious enough. However, this does not mean a person will never drive again. Nonetheless, individuals that have sustained a brain injury should not drive unless their doctor says it is safe to do so. In British Columbia, once the survivor, their doctor, and/or healthcare team are confident in their ability to drive safely again, the Office of the Superintendent of Motor Vehicles (OSMV) will determine the legality of driving – usually evaluated through authorized testing. The OSMV will then restrict or prohibit driving privileges as they see fit in order to best protect the public.