By DeAnna Frye, Ph.D. and JoAnn M. Ovnic, M.A.,CCC/SLP

What are common memory problems following TBI?

Short term memory loss is a common impairment following TBI.  Generally long term memory, such as recall of historical information, childhood and other events prior to injury are preserved.  The degree and location of injury affects the severity of memory problems.  Some examples of short term memory loss include:

• forgetting what happened during the day
• forgetting placement of items
• forgetting tasks completed throughout the day
• losing train of thought during a conversation
• having trouble with note taking
• difficulty retaining information in class
• difficulty recalling the main details of a recently read article or book chapter

What is the difference between short term memory, long term memory and post traumatic amnesia?

In general, most neuropsychologists define short term memory as an individual’s ability to remember information over the course of a few hours or across a day or week after a TBI.  For example, the ability to recall what you did this morning is an example of short term memory.

Long term memory is generally reserved for recall of events that occurred prior to the injury.  Remembering an incident from childhood is an example of a long term memory for an individual injured in their 30s.

Post traumatic amnesia is the period of time that the individual is unable to recall events following the injury.  For example, some individuals may not recall the events of the day their injury occurred or being in the hospital for the next month after the injury.  Post traumatic amnesia is then estimated to be about 30 days long.

Please tell me about post traumatic amnesia – how long does PTA last?

Post traumatic amnesia refers to a disruption in the memory system of the brain as a result of an injury.  PTA begins at the time of the injury and includes the coma period.  It does not end until the individual is able to continuously report events that have occurred. In other words, a person may be out of coma and talking with their family members but has no recall of the conversations.  This individual is still experiencing PTA.  As a general rule of thumb, PTA usually lasts 4 times the length of coma.  So an individual who is in a coma for two weeks typically experiences PTA of eight weeks.

As an individual recovers from the injury, he/she will begin to remember events of the day and days before.  However, the person will have no memory of the events immediately following the injury.  This is not due to psychological trauma, but the neurological injury itself.

The inability to remember hours, days or weeks of your life can be stressful and uncomfortable.  Reassuring the individual repeating what happened during this period may be helpful.  Most important, however, is acknowledging that their PTA has resolved and that they can remember events now.

My CT scan of the brain was normal, yet I am still having problems with my memory.  How is this possible?

CT scans are helpful diagnostic tests used by physicians to identify physical changes to the brain.  CT scans can identify tumors, bleeding, swelling or bruises involving the brain.  They are not sensitive enough to identify the microscopic tearing and shearing that commonly occurs after a traumatic brain injury.  Therefore it is not unusual for a CT scan to be normal following a brain injury.  This simply reflects the CT scan’s limitations with regard to identification of the physical changes in the brain. 

A survivor of TBI may initially demonstrate abnormalities on CT scan, such as swelling or bleeding.  A repeat CT scan several months later, however, may be considered normal. However, the survivor may still be experiencing functional changes such as memory problems

My doctor has recommended a functional MRI. How is this different from a CT scan or MRI?

A functional MRI or fMRI is an image of brain activation as a function of change in cerebral blood flow or blood oxygenation. Usually the analysis is based on blood oxygenation changes.  When a part of the brain is activated there is an increase in oxygen rich blood.  Changes in neural activity are evaluated by measuring changes in local blood oxygen levels in the brain during performance of a specific task.

During the completion of an MRI, the individual is required to complete some cognitive activities, such as memory tasks.  The scan then reveals the changes in blood oxygen levels in the brain during the completion of the task.  This allows your doctors to determine how your brain is processing specific types of information.  Individuals who have had normal CT or MRI scans have shown abnormalities on fMRI.

I have been discharged from therapies but want to continue to work on improving my memory and other cognitive skills.  What are some things I can do to continue to work on my cognitive abilities?

Just as physical exercise is good for the body, mental activity is good for the mind.  Continuing with any strategies or home exercise activities that your therapists have recommended is important.  In addition, continuing to challenge yourself with mental activities every day will help you maintain the abilities you gained in therapy and help you continue to improve.  Reading the newspaper, magazine or a book can help with concentration, reading and memory.  Watching the news keeps you up to date on what is happening in the world.  There are many games that you can purchase that are not only good family entertainment but also require reasoning skills.  Doing crossword puzzles or word searches can help if you have difficulty with language skills.  The most important thing is that you find activities that you enjoy doing, as you will be more likely to continue them.  Consistently applying the strategies you learned in therapy to your daily life will allow you to adapt more quickly and accomplish your goals. 

How can I help my family member remember appointments and day-to-day events?

Daily routines are helpful.  Encourage your family member to keep a calendar and write down appointments.  If he can not do this himself, set aside a time during the day to review and write down information.  Keep a notepad and pen near the phone to write any phone messages.  Create a “To Do” list for the day.  Have your family member check off each task or activity as it is completed.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

After Brain Injury: Telling Your Story, A Journaling Workbook

By Barbara Stahura and Susan B. Schuster, M.A., CCC-SLP

This workbook guides survivors of brain injury and blast injury through the powerful healing experience of telling their own stories with simple journaling techniques. By writing short journal entries, survivors explore the challenges, losses, changes, emotions, adjustments, stresses, and milestones as they rebuild their lives.

The Memory Workbook

By Douglas Mason, Psy.D. and Michael Kohn, Psy.D.

Workbook for families and adults explains types of memory and effects of aging, brain injury, and brain damage on memory.  Includes practical exercises and tips for adults, family members and caregivers for brain injury rehabilitation. Recommended for persons with mild brain injury or mild cognitive impairments due to trauma, aging, or disease.

By DeAnna Frye, Ph.D.

What is the relationship between brain injury and depression?

Depression is the most common psychiatric diagnosis after brain injury.  Individuals may experience symptoms immediately after their injury or not until several years post injury.  Individuals with depression after brain injury have poorer rehabilitation outcomes, poorer quality of life, less social and recreational activity, greater caregiver burden and poorer subjective well-being.  As a result, it is important that individuals receive treatment for their depression.

The preferred form of treatment for individuals with depression following brain injury is psychotherapy.  Medications can also be beneficial but caution should be taken as individuals with brain injury are more likely to experience side effects from these medications.

Since her discharge home from the hospital my daughter has been telling us that she wished she hadn’t survived the accident.  This really upsets us, as it is a miracle that she is alive today.  How should we respond when she says this to us?

Your daughter may be expressing feelings of grief over the significant changes in her life as a result of her injury.  This is a normal part of the grief process and you should encourage your daughter to talk with you and a counselor about her feelings of loss.  While most individuals who recover from a brain injury experience similar feelings, it is also important to make sure that your daughter is not clinically depressed and suicidal.  While it is common for individuals to express feelings that they wished that they had not survived their injury, this does not mean that they currently wish to die. An individual who is expressing a desire to end their life needs immediate medical attention to ensure their safety.  If your daughter is expressing suicidal thoughts, you should call her psychologist or doctor immediately and alert them to the situation.

The holidays are approaching.  How much alcohol is a safe amount to drink after a brain injury?

Research has shown that there is no “safe” amount of alcohol after a brain injury.  Important factors to consider include interactions with any medications the individual is taking as well as history of alcohol abuse or dependence. Individuals also may react differently to alcohol after a brain injury, which may place them at greater risk for additional injury.

Why does my treatment team tell me not to drink alcohol now that I have had a brain injury?

It is important to realize that alcohol is a neurotoxin – in other words, it kills brain cells. After a brain injury, alcohol can interfere with the healing process.  Alcohol can also cause seizures.  While this is pretty rare for healthy individuals, your risk for seizures is higher after a traumatic brain injury.  Drinking alcohol increases that risk even further. Individuals who drink to the point of intoxication also demonstrate changes in their cognitive skills, with judgment being one of the first skills affected.  As a result, intoxicated individuals may do things that put them in situations where they may be harmed and perhaps sustain another brain injury.

Some individuals turn to alcohol as a means of coping with their loneliness, depression or anger.  Research that has been conducted to look at safe alcohol consumption for individuals with traumatic brain injury has concluded that there is no safe amount.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.
Many individuals struggle with depression after brain injury. This Tool Kit helps individuals, families and clinicians recognize symptoms and triggers ranging from mild depression to effects of PTSD.

For more information, see:

The Depression Tool Kit after TBI

Many individuals struggle with depression after brain injury. This Tool Kit helps individuals, families and clinicians recognize symptoms and triggers ranging from mild depression to effects of PTSD.

By Dr. DeAnna Frye and JoAnn M. Ovnic, M.A.,CCC/SLP

My speech is fine, but after my brain injury my doctor referred me to a speech-language pathologist. Why?

The term speech-language pathologist is deceiving.  Speech-language pathologists (SLP) are skilled in assessment of speech, language, and cognitive functioning.  Following a head injury or other trauma to the brain there are cognitive (thinking skills) problems.  Sometimes these problems will be quite obvious, whereas other times they may be quite subtle.  In addition to speech and language, an SLP will observe and assess swallowing, memory, orientation, problem solving reasoning and attention.  Mathematical skills, planning and organizational skills are also areas in which speech-language pathologists evaluate and treat.  The speech-language pathologist is part of the rehabilitation treatment team.  Once the evaluation period is completed, results of testing and recommendations for treatment are shared with the client, family members, and the clinical treatment team.

What is aphasia?

Aphasia is a language disorder that results from damage to the language centers of the brain.  It can affect a person’s ability to understand language as well as the ability to express thoughts.  Aphasia commonly occurs following a stroke but can occur following traumatic brain injury, brain tumors or an anoxic episode (lack of oxygen to the brain).

Depending on the area of the brain affected, people may experience expressive or receptive aphasia, or a combination of both.  Expressive aphasia is commonly characterized by difficulty with coming up with the right word (”it’s on the tip of my tongue”) writing, and using gestures to communicate thoughts.  Receptive aphasia, on the other hand affects one’s ability to understand what is being said or read.  Even though a person may be able to hear or read words, they may sound or look jumbled.

Several factors may contribute to the severity of difficulties with language.  They include severity of damage to the brain, age, educational level and health prior to injury.  One person might only be able to speak in single words, whereas another may have occasionally have trouble finding the right word in a conversation.  Another person may be able answer simple questions and directions (i.e. “Did you like the movie?” or “Point to the comb.”) while another may have trouble following multiple directions or have difficulty reading more than a simple one or two paragraph article.

A speech-language pathologist assesses and treats people with aphasia with drills and strategies to improve communication.  Exercises vary based on the severity of the problem and take into account a person’s language needs.

My daughter is not able to communicate with us since she had a severe brain injury. Her doctor told us she has receptive and expressive aphasia.  Her arms and hands seem to work fine.  Why doesn’t someone recommend that she learn sign language?

Aphasia occurs as a result of an injury to the language center of the brain.  The degree and type of impairment varies based on the injury.  For example, some individuals may be able to understand what others are saying, but are not able to verbally respond.

When an individual is diagnosed with a language disorder, treatment from a speech therapist is indicated with a focus on regaining speech functions and developing compensatory strategies to help the person develop communication skills, such as through use of gestures or pointing out pictures on a daily communicator.  Learning sign language is a complex task.  While the hands are used as the primary means of communicating, the individual still needs to be able to access language functions in the brain.  Due to injury in the language center, this may not be possible.

What is dysarthria? 

Dysarthria is a speech disorder that results from involvement of the nervous system.  These conditions include stroke, progressive diseases such as Parkinson’s, and less frequently following traumatic head injury.  It affects the quality of speech production and is often characterized by slurred speech and facial weakness.  Symptoms include limited tongue, lip and jaw movements, breathy voice quality, drooling of saliva, chewing and swallowing difficulty, change in voice quality, slow or rapid rate of speech and abnormal intonation (rhythm).

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

After a Stroke

By Cleo Hutton

Book on stroke and brain damage for adults and families with practical suggestions and tips for coping with the physical, communicative, cognitive and emotional changes.

By DeAnna Frye, Ph.D. and JoAnn M. Ovnic, M.A.,CCC/SLP 

When I wake up in the morning I feel good and am usually able to get a lot of things done.  By afternoon, however, I’m pretty tired.  I’ve been told this may be due to cognitive fatigue.  What is cognitive fatigue and what can I do about it?

Everyone has a limited amount of energy available each day to accomplish our goals.  The amount of energy we have varies due to a variety of factors, including how well we sleep at night.  How quickly we “spend” our energy during the course of the day has an effect on our level of fatigue.

After a brain injury, individuals typically find that certain activities require more energy than they did before the injury.  For example, eating at a busy restaurant can use up more energy for an individual who has difficulty with attention and is easily distracted. Cognitive fatigue occurs when you are reaching your limit with regard to the amount of energy you have left to spend.

One strategy to combat cognitive fatigue is pacing.  Pacing involves first identifying how long an individual can work at various tasks before becoming fatigued.  For example, you may find that you can work for an hour on a task, such as paying bills, in a quiet environment but can handle attending to conversations  in a crowd for only thirty minutes.

Identifying your limits and then scheduling breaks throughout the course of the day can help you combat cognitive fatigue.  Planning your day in advance when possible can also help.  For example, if you know you have a family reunion to attend on Saturday afternoon at the park, you may want to plan quiet activities at home in the morning, instead of going to the grocery store.

I have difficulty focusing on what I’m doing. How come?

Attention is a vital part of our everyday functioning.  All of us from time to time become distracted, whether it is a phone call in the middle of cooking dinner, or being interrupted to attend a meeting while in the middle of writing a report.  When a person sustains a brain injury, attention is an area of cognition that impacts the ability to concentrate and focus for various amounts of time and in various conditions.  The following types of attention may be affected:

• Focused: the ability to attend to an activity or task with no other distractions. For example a person might do a crossword puzzle in quiet.
• Selective: being able to attend to a task and block out unimportant information. For example reading a book while playing background music.
• Alternating: the ability to switch between tasks. This is especially noted in real-life situations. For example: working in an office and being interrupted by phone calls, filing and greeting clients.
• Divided: The ability to do two or more tasks at the same time. One of the most common examples is driving a car while changing radio stations and looking for an unfamiliar exit.

Why would my doctor prescribe a medication that is used for people with attention deficit disorder when I have had a brain injury?

While Attention Deficit Disorder  is not the same as a traumatic brain injury, research has shown that individuals who have experienced a change in their attention abilities after a brain injury benefit from the same medications that are used for Attention Deficit Disorder.  Quite simply, attention is a function of our brains.  When attention abilities are impaired, certain medications may help to correct the problem, regardless of the underlying cause.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

Hero’s Journey

By Kit Malia, B.Ed., and Anne Brannagan, M.Sc.

Educational group curriculum on brain injury for adults and survivors to increase understanding and adjustment. For use by clinicians, caregivers and families in rehabilitation, community and home settings.

Survival Kit, A Planner and Organizer for Survivors of Brain Injury

By Debbie Leonhardt, M.A., N.C.C., L.P.C.

TBI workbook and organizer for persons with brain injuries and cognitive disorders affecting memory, planning and organization. For use in rehabilitation, community programs or home.

By DeAnna Frye, Ph.D. and Denise Bailey, P.T.

Can physical therapy help with balance problems after a brain injury or should you just “learn to live with it”?

Although balance disorders are challenging, there are exercise protocols specifically designed to address our balance/vestibular systems.  This system integrates information from different parts of the body to give us good balance and tolerance to motion.  The programs are highly effective, but good outcomes are strongly correlated with thorough evaluation and a multidisciplinary approach.  Contact your physician to see if physical therapy may be appropriate to treat your balance dysfunction.

Chronic low back pain following an injury can limit one’s participation in exercise as part of a healthy lifestyle.   Is it okay to forget exercise because it can hurt and become a “couch potato”?

Unfortunately, chronic pain (low back or elsewhere), can induce a cycle of pain, decreased activity, increased dysfunction and heightened pain.  This pain disuse-dysfunction cycle must be broken.  By selecting an appropriate exercise modality, you can build a strong, healthy musculoskeletal system to manage pain and reduce the associated dysfunction, without provoking the pre-existing low back pain.  A physical therapist can help identify appropriate ways to accomplish this, along with cardiovascular conditioning to optimize function and reduce the debilitating effects associated with this cycle.

My brother had a brain injury and was in the hospital for three months.  He is home now and going to outpatient therapy.  It still takes him a long time to get dressed in the morning so I help him instead of letting him do it himself.  I figure that he is practicing how to dress himself in therapy, so it is not important that he dress himself at home.  My sister disagrees.  Who is right?

While it is important that your brother participate in outpatient therapy, it is also important that he practice these skills as often as possible.  The purpose of practice is to help the brain re-establish the connections that are needed to complete tasks such as dressing.  The more opportunity your brother has to practice, the more progress he will make in his recovery.  It can be frustrating to watch a loved one struggle to do tasks that used to be so simple.  Sometimes it’s hard for family members to allow the person to do things, as the family member feels it is their responsibility to do it for them.  Try to allow extra time for your brother to complete tasks so that you don’t feel rushed and frustrated.  Remember, encouraging your brother to do things for himself now whenever possible will help him be more independent in the future.

I often feel very tired and dragging, like I’m “out of gas”. It makes it hard for me to start a project or accomplish anything. What’s my problem?

After brain injury, physical deconditioning is prevalent. Your lifestyle may have become more sedentary, medications may cause lethargy, and recovery from injuries may have delayed your return to your daily routine.  All of these factors may contribute to reduced physical stamina/endurance.  In addition, changes in internal drive and motivation, plus initiation of activity, can be problematic following brain trauma due to cognitive impairments. 

Good, old fashioned physical activity is the best way for improving our physical endurance to combat the feelings of lethargy and deconditioning . A prescribed conditioning program can improve our energy levels and our energy reserves to support a more active and productive lifestyle. Cognitive aspects can be addressed by appropriate team members to support success in your program. A physical therapist can help identify conditioning activates that suit your interests and goals.

After my injury, it was recommended I use a cane for walking. I’d rather not use an “assistive device” to get around. Should I get rid of it?

Without question, we are driven by an inherent desire to be physically independent.  None of us want to feel we need a device to walk or may be uncomfortable with the attention it may create.  However, walking safety is the primary issue. If a device allows you to be independently safe and mobile, then it is well worth it.  We must minimize our risk of a potential fall and the injuries that may be associated.

Walking quality is another consideration; is your walking more energy efficient and even/symmetric using a cane?  Striving for the most normal quality gait is important for good biomechanical joint and muscle function, keeping additional stresses off our body to avoid pain and dysfunction.  Carefully consider these areas and discuss your feelings with your physician to determine if gait training/gait analysis may be of benefit before your decide to leave the cane behind. [Denise Bailey, PT Remed].

Why do doctors and therapists ask me if I lost my sense of smell when they are evaluating me?

Our sense of smell is also one of the functions controlled by the brain.  An individual who has sustained a brain injury can lose the sense of smell due to damage to the part of the brain that controls this ability.  You do not have to have an injury to your nose to lose your sense of smell.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

For more information, see:

Daily Living Functional Rehabilitation Activity Manual

By Barbara Messenger, MEd, ABDA and Niki Ziarnek, MS, CCC- SLP/L

Brain injury rehabilitation manual with functional activities on daily living for brain injury programs and adults with disabilities.

Cognition Functional Rehabilitation Activity Manual

By Barbara Messenger, MEd, ABDA and Niki Ziarnek, MS, CCC-SLP/L

Brain injury rehabilitation manual with functional activities on cognition for brain injury programs and persons with disabilities.

By DeAnna Frye, Ph.D.

What is the difference between a physiatrist, a psychiatrist, a psychologist and a counselor?

Physiatrists and psychiatrists are professionals who have graduated from medical school and earned either an M.D. or D.O. degree. Physiatrists complete special training in rehabilitation medicine and typically provide services to individuals with brain injuries, spinal cord injuries and chronic pain. A psychiatrist completes additional training in mental health treatment. Physiatrists and psychiatrists can prescribe medication.

A psychologist is an individual who has graduated from a doctoral program and earned a Ph.D. or Psy.D. Psychologists receive training in the diagnosis and treatment of mental health issues. Psychologists administer psychological tests and provide therapy services to address mental health concerns.

Counselors are individuals who typically have earned a Master’s Degree in counseling or a related field. Counselors may or may not have a license and may work under the supervision of other health care professionals. Counselors provide therapy services for mental health issues.

What is the difference between a psychological evaluation and a neuropsychological evaluation?

A psychological evaluation is used to evaluate personality characteristics and on occasion will also include some tests of cognitive abilities, such as intelligence or academic abilities.  Psychological evaluations are typically completed when an individual is concerned about emotional abilities, such as depression or anxiety.

Neuropsychological evaluation is a more extensive evaluation of how an individual is functioning with regard to cognitive and behavioral abilities.  A neuropsychological evaluation typically includes evaluation of attention, memory, intelligence, visual-spatial skills, executive functions, language abilities and personality/behavior.  A complete neuropsychological evaluation typically takes at least 4 hours to complete, depending on the specific tests administered and the abilities of the individual completing the testing.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

Recommendations for more information:

The Get Well Soon…Balloon!

By Vicki Sue Parker and Susan Beebe

Story book helps children understand their emotions and reactions when a parent has a brain injury. Describes coma, rehabilitation, coming home, and therapy from a child’s perspective. Recommended for families of injured veterans and service members.

By DeAnna Frye, Ph.D.

What does diagnosis of traumatic brain injury mean?

Traumatic brain injury (TBI) occurs when a sudden physical assault on the head causes damage to the brain.  The head does not have to be struck directly for the brain to be injured.  The damage can be focal which means it is confined to one area of the brain, or it can be diffuse and involve more than one area of the brain.  TBI can result from a closed head injury or a penetrating head injury.

Symptoms indicating a TBI diagnosis may include headache, nausea, confusion or other cognitive problems, a change in personality, depression, irritability, and other emotional and behavioral problems.  Some people may have seizures as a result of a TBI.

What are the types of head injury?

A closed head injury occurs when the head suddenly and violently hits an object, but the object does not break through the skull. 

A penetrating head injury occurs when an object pierces the skull and enters the brain tissue.

A concussion is a jarring injury to the brain.  A person who has a concussion may not pass out or may lose consciousness only very briefly. The person may feel dazed and may lose vision or balance for a while after the injury.

A skull fracture is when the skull cracks.  Sometimes the edges of broken skull bones cut into the brain and cause bleeding or other injury.  A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain. 

Shaken baby syndrome is a severe form of head injury that occurs when a baby is shaken
forcibly.

Can blood collect in the brain?

A brain contusion is a bruise of the brain.  This means there is some bleeding in the brain, that may cause the brain to swell.  A contusion can also occur in response to shaking the brain within the confines of the skull, an injury called “countrecoup.”

A hematoma is bleeding in the brain that collects and clots.  A hematoma may not be apparent for a day or even as long as several weeks.  So it’s important to tell your doctor if someone with a head injury feels or acts oddly.

Damage to a major blood vessel within the head can cause a hematoma, or heavy bleeding into or around the brain.  The severity of a TBI can range from a mild concussion to the extremes of coma or even death.  A coma  is a profound or deep state of unconsciousness.

What is the difference between a traumatic brain injury (TBI) and an acquired brain injury (ABI)?

A traumatic brain injury is the result of an injury to the brain by an external physical force that may produce a change in consciousness and results in impairment of cognitive abilities, physical functioning or changes in personality/behavior.  Types of TBI include diffuse axonal injury, concussion, contusion and coup-contrecoup injury.  This kind of injury can occur from car crashes, falls, sports injuries, or physical violence.

An acquired brain injury is an injury to the brain that occurs after birth and is due to a change in neuronal activity, usually as the result of another medical condition.  Examples of ABI include anoxia, which is an injury that occurs when the brain does not receive any oxygen, or hypoxia, when the brain receives some, but not enough oxygen.  Causes of ABI can include heart attacks, aneurysms, near drowning, choking, electrical shock or airway obstruction.

What is “Second Impact Syndrome?”

Second impact syndrome is also known as recurrent traumatic brain injury and can occur when an individual has a second brain injury before the first injury has healed.  The second injury can occur days or weeks after the first one and is more likely to cause swelling of the brain and widespread damage.  Individuals experiencing second impact syndrome need to seek emergency medical treatment immediately as death can occur rapidly following the second injury.  This is why it is important that anyone recovering from a brain injury take all possible precautions to avoid further injuries until all of their symptoms from the first injury have resolved.  This includes all types of brain injuries, even concussions.

Dr DeAnna Frye has a B.S. in Psychology, M.S. in Counseling Psychology, Ph.D. in Counseling Psychology. She is currently employed by Neurology Neuroscience Associates of Akron. Her special interests are psychotherapy and counseling to patients with neurological disorders with special expertise in brain injury. She is a founding member and the current co-chair of the Summit County Traumatic Brain Injury Collaborative located in Akron, Ohio.

Recommendations for more information:

Brain Injury: It is a Journey

By Flora Hammond, M.D. and Tami Guerrier, B.S.

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions.

Understanding the Effects of Concussion, Blast and Brain Injuries

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals and Army Medical Facilities.

By John W. Richards, M.S.W., MBA, Survivor and

Marjorie Crigler, Family Member

Brain injury recovery.

The days, weeks or months after a brain injury that a loved one is in a coma, in the intensive care unit (ICU), in the hospital or a rehabilitation program are difficult and stressful times for families. There are so many questions and uncertainties about the future. From our perspectives as a survivor of a brain injury and as a family member, this information may help family members and friends address those difficult questions of…

• what’s needed
• what’s best
• what to try
• what to work on.

How can I help as my loved one recovers from a brain injury?

We are not doctors, but we are going to share with you some of the things that, in our experience, have made a difference.  We call them the intangible ingredients to brain injury recovery.

The doctors and staff cannot make precise predictions about the long term outcome or prognosis of your loved one. They probably have a good idea of the general issues and challenges, as they have seen other people in similar situations. However, they can not know how some of the intangible factors will impact your loved one’s recovery. These intangibles are described next.

Does it make a difference if our family is involved during the hospital stay?

Yes, absolutely and completely! It helps when families are consistent, persistent, positive, hopeful, and determined to be involved. Ideally, your hospital or rehabilitation program welcomes and supports your family’s frequent and ongoing presence. The staff may be highly capable and very motivated, but they do not and can not know your loved one as you do.

Tips on what you can do…

• Be with your loved one as much as you can.
• Try to think of the medical and rehabilitation staff as a team which also includes family members, friends and anyone else who is contributing to your loved one’s recovery and well-being.
• Share information with them, such as nicknames and favorite music.
• Remember to thank them for their hard work!
• Keep the lines of communication open so that everyone knows the progress your loved one is making.
• Be positive and hopeful without misrepresenting or skewing reality.

Tips for when you are with your loved one…

• A warm, caring touch is wonderful.
• “I love you” really helps.
• Any kind of cognitive stimulation is a good thing.
• Listen to music, read books aloud, sing, read the newspaper, watch sports.
• Bring the outside world inside.
• Include your loved one in the conversation, even if there is not much response right now.
• Talk to him/her, not about him/her.
• Play games, ask questions, bring in puzzles.
• Review things that you did twenty years ago.
• Ask and discuss trivia questions about a vacation you have taken.
• Talk about Cousin Harry and Auntie Em.
• Dream up anything you can to get your loved one’s mind working on anything.

How can I help motivate my loved one?

Recovery from a brain injury is a loooooong, difficult process. It takes tremendous work. Rehabilitation is a marathon, not a sprint! Therapy exercises are an important part of recovery as the survivor’s brain learns and builds new neural pathways to get the body moving again.

Does faith make a difference?

Faith and hope go a long way for families and survivors. Having and holding onto a positive faith that your loved one will get better goes a lot further than a negative outlook of being doomed to a life of disability. A spiritual faith helps answer the difficult questions of:

• “What was I saved for?”
• “What is the greater purpose for which I lived through this injury?”

These are far more useful and productive questions than, “Why did this happen to me?”

How will people react once my family member comes home?

Connections to the community are tremendously important. Get your loved one back out there to anything your family member can get to. Survivors need to relearn a whole lot of things about the world and how it operates. It is very likely that your loved one will lose friends and relationships over time. In general, people don’t know much and feel uncertain about how to relate to survivors. Unfortunately, survivors are collectively a pretty stigmatized group. Many survivors who can pass without being noticed generally do. Most people, when thinking about survivors of brain injury, generally just know that they don’t want to be one. The Brain Injury Association in most states offers support groups for survivors and some have them for families as well. They can be found on the Internet or through the Brain Injury Association of America. You will meet a number of people there who very much understand what you and your loved one are going through. If there isn’t a support group in your area, start one. There are 3.17 million other people living with brain injuries out there in the US who understand very well what you are going through.

What kind of support does a survivor need?

It will be different for everyone because each brain injury is different but all survivors can use consistent and ongoing support. Recovery from brain injury takes much longer than anyone would like or than you think it should or will. You are in this for the long haul.

Make sure you take care of yourself. You won’t be any help to a brain injury survivor if you yourself are unhealthy in mind or body.

How can I deal with all that has to be done and find what is needed?

Be a firm and persistent advocate for your family member. There will be a tremendous amount of paperwork to and from the insurance companies, agencies, the state, etc.

Part of your role is to…

• deal with it
• do it, and
• follow it.

Setting up and carrying a notebook or folder to meetings helps keep everything organized as you advocate for the best treatments and services. Another part of your role is to understand, as best you can, what the medical folks are doing and recommending. Bear in mind that they are human, too. They are doing the best that they can, but current medical science does not include a cure for brain injury.

How can I deal with the tough stuff?

There are a few things that have the potential to slow and substantially detract from your loved one’s recovery. Many survivors feel depressed as they recover, particularly as they are coming to some awareness of the time, abilities, jobs, friends, and relationships that have changed or ended. The losses after a brain injury can be tremendous.

Brain injury and alcohol do not mix well at all. Sadly, one of the strategies that many survivors use to cope with depression involves drugs and alcohol, which only makes things worse. Don’t go there! This applies to family members as well.

Summary

As we say in the brain injury community, a brain injury is a family injury. Yes, only one person actually got hit in the head, but the entire family is hurt in countless ways. They are called upon to do many things that are unfamiliar and unknown to get their loved one, and the entire family, back to functioning as best they can.

Finally, outcomes to brain injury are largely unknown. You can try all you can, do all you want, and there is no guarantee of what the end result will be. Following some of these thoughts has helped others who have walked “the path of recovery.” Best wishes to you on your journey.

References

Dr. Thomas Frye, Specialty Hospital, Crotched Mountain, Greenfield, NH

Centers for Disease Control, www.cdc.gov

Recommendations for more information:

Survivor Kit 

By Debbie Leonhardt, M.A., N.C.C., L.P.C.

Brain injury workbook and organizer for persons with brain injuries and cognitive disorders affecting memory, planning and organization. For use in rehabilitation, community programs or home.

For more articles by John Richards, see:

Coping with Survival 

Tip card by John Richards on negative and positive approaches to life after acquiring a traumatic brain injury.

Communication in Children after Brain Injury

 By Roberta DePompei, Ph.D.

Lash & Associates Publishing/Training, Inc

I often hear the term cognitive communication. What does that really mean?

Communication is much more than words. It involves listening, speaking, and reading, writing and gesturing. Cognitive communication is the combination of thinking skills and language. It is the ability to use language and all the underlying skills for communication.  This includes attention, memory, self-awareness, organization, problem solving and reasoning. When these thinking skills are combined with language, the result is communication.

Our son was doing pretty well in school until he went to junior high school. Now he has a lot more reading assignments and homework. Even though he spends much more time on his homework, he can’t seem to keep up and is falling behind.

As students enter middle, junior high and high school, school work becomes more complex. The student with a brain injury may face new difficulties with reading, writing and thinking. Much of school work now requires abstract reasoning and problem solving. This places new demands on different parts of the brain than were used in earlier grades. Multiple classes and teachers mean different teaching styles and homework assignments.

Any difficulty with these changes is an indication that a student’s cognitive communication abilities need to be reevaluated.

Our son’s speech was really slow and difficult to understand for several months after his brain injury. As he made physical progress, his speech also improved. Is there any reason to have him followed by a speech pathologist now he is back in school?

The ability to speak and hold conversations can be misleading. Language skills often return after a brain injury, but communication can still be affected. While conversation may seem normal in non-stressful situations, this can change when the child or adolescent is tired or under stress.

Changes in communication in youths are mostly likely to show up in school under the pressures of time, being graded, completing assignments and keeping up with classmates. A speech and language pathologist can evaluate ongoing progress, identify problems and help the student develop compensatory strategies. As part of the educational team, the speech pathologist can help others recognize and respond to changes in cognitive communication.

What are some of the changes or warning signs that parents and educators can watch for?

Too often, parents and teachers aren’t concerned until the student is failing or has lowered grades. It is important not to wait until the student is in trouble to get help. Early warning signs that an evaluation by a speech and language pathologist is needed are:

• speaking or writing that is disorganized
• difficulty concentrating and paying attentionconfusion when new ideas are introduced
• confusion when new ideas are introduced
• slower rate of handling information, and
• difficulty learning new vocabulary or grasping ideas.

By evaluating these areas every three months during the two years following a brain injury, difficulties can be spotted early and help provided before the student fails.

How do we find a speech and language pathologist who has experience with students with brain injury?

Speech and language pathologists may be licensed in their state and may also be certified by the American Speech-Language-Hearing Association. When choosing any professional, it is important to ask questions to make the right fit between a specialist, your child and your family. Look for a speech and language pathologist who has experience with brain injury and who has worked with children of similar age. If your child is in school, look for a speech and language pathologist who regularly works with schools and is familiar with special education.

For more information by Dr. DePompei, see:

Communication: How communication changes over time 

By Roberta DePompei Ph.D. and Jean Blosser Ed.D.

Brain injury can affect a child’s speech, language and communication. Tip card gives information for parents, educators and therapists to identify changes in language development and learning in school.

All About Me!

By Roberta DePompei Ph.D. and Bob Cluett

Interactive booklet helps elementary school age children identify the physical, cognitive, and behavioral effects of traumatic brain injury and describes help needed in school.

Learning and Cognitive Communication Challenges

By Roberta DePompei Ph.D. and Janet Tyler

Manual with teaching strategies for students with acquired brain injury and challenges with behavior, attention, cognition and language.

Athletes with Concussion or Mild Brain Injuries

By Phil Hossler

ATC Certified Athletic Trainer ATSNJ & NATA Halls of Fame

How common is concussion?

A mild brain injury, often called a concussion, is the most common brain injury in sports. Parents, teachers, school nurses and coaches see children and youth with concussions every day.  The Centers for Disease Control and Prevention estimate that there are over 300,000 concussions in the United States each year.

Is a concussion anything to worry about?

Although the majority of concussions have no lingering effects, some concussions result in persistent long-term and even devastating disabilities. Every concussion is a brain injury and injuries need evaluation, adaptations in routine and time to heal. This is especially true in adolescents whose brain tissue has increased vulnerability when compared to that of an adult (1). Phil Hossler and Ron Savage take a unique approach to concussion in schools by addressing everyone in the athlete’s “neighborhood” including teachers, the athlete, parents, friends, the school nurse, coach, physician, and certified athletic trainer.

What should teachers do when a student has a concussion?

Teachers are often the first to notice subtle changes in the student’s ability to concentrate, remember new information and interact with classmates after a concussion. Teachers can help by being aware of the student’s need for mental rest and by making accommodations in the classroom and for homework while the athlete is still feeling the effects of a concussion. Example: Tests taken while the student still has symptoms of a concussion may affect academic achievement levels.

What can the athlete do after a concussion?

The athlete usually is disappointed when faced with sitting out practice or games. The athlete may be incapable of thinking clearly after a concussion. It is important that the athlete not dismiss any changes and report any headaches, worsening vision or ringing in the ears. Example: Be honest with yourself. Your brain is too important to gamble with; when in doubt, sit out.

How can parents help their child recover from a concussion?

Parents know their child better than any other person in the neighborhood. They are best suited to pick up subtle changes in a child’s behavior, problem solving and organizational skills after a concussion. Example: Parents need to know and watch for the danger signs of a blood clot forming on the brain after a concussion.

How can friends help?

The athlete’s friends are a vital source of information. They are often there when the athlete’s guard is lowered and true feelings are expressed. A friend to an athlete with an undiagnosed concussion might be the first to suspect that “something just isn’t right.” Example: Peers may be annoyed by their friend’s behavior if they aren’t aware of the signs of a concussion.

How can the school nurse help the student and teachers understand the effects of a concussion?

School nurses play a very important role in monitoring the concussed athlete during recovery. They can notify teachers so that accommodations are made in the classroom. They can be the communication link between parents and school staff. Example: A student may report to the nurse’s office complaining of a headache.

What do coaches need to know about concussion?

 Every coach should know how to recognize the signs and symptoms of a concussion and be prepared to help the athlete deal with its effects. Coaches must not ignore signs and symptoms on the field. They must help the athlete still feel “part of the team” while recovering. Example: When I asked Tim why he missed those last two passes, he didn’t remember the plays.

Should the child’s physician be involved?

Doctors are the legal/medical guardians of the athlete’s health. They should be included in the athlete’s evaluation at an early stage of care and communicate with all parties involved to ensure the athlete’s safe return to activity. Example: Doctors should know the clinical guidelines for return-to-play decisions and use them.

What about the certified athletic trainer?

Athletic trainers who are certified by the National Athletic Trainers’ Association are gatekeepers of the athlete’s health during sports. They are first on the scene and make key decisions related to injury severity and referral. Seeing the athlete daily, speaking with parents, coaches, teachers and the school nurse ensure comprehensive care of the athlete with a concussion. Example: Always insist on safety first, participation second.

Conclusion

Health care professionals are learning more about the recognition and management of the physical demands and restrictions associated with concussions. However, close scrutiny, care and management do not always accompany athletes when they return to school. Academic accommodations may be needed as part of the overall management plan for student-athletes to ensure their health and to promote educational growth. Thus, an entire “neighborhood” program needs to be put into action so that all members are aware of their roles when a student athlete has a concussion. These roles are explained in the manual Getting A-Head of Concussion - Educating the student-athlete’s neighborhood by Phil Hossler and Ron Savage.

References:

(1) Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Journal of Sport Medicine 2003:13:222-229

For more information, see:

Getting A-Head of Concussion

By Phil Hossler, ATC and Ron Savage, Ed.D.

Concussion is the most common type of brain injury among children and adolescents in school.  By describing the student-athlete’s neighborhood, this manual takes an innovative and comprehensive approach to educating parents, teachers, physicians, coaches, athletic trainers, school nurses, and peers about how the effects of mild brain injury.