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Brain injury

The North Wales Brain Injury Service (NWBIS) is based at Colwyn Bay Community Hospital. It has a North Wales remit. The NWBIS has input from Neuropsychology, Neurology, Physiotherapy, Occupational Therapy, Social Work, Speech and Language Therapy and others.

During 1995 a clear need to develop services for individuals with brain injuries was identified by the Welsh Affairs Committee. The voluntary organisation ‘Headway´ played an important role in the process of lobbying for a service for North Wales.

During 1998 the North Wales Health Authority released Welsh Office funding for the first appointments of staff for a brain injury service in North Wales to be made. The service was initially based in the main building of the Colwyn Bay Community Hospital. As the service expanded, the old outpatients Department was extensively redeveloped by the Conwy & Denbighshire NHS Trust to serve as an outpatients unit for the NWBIS.

The NWBIS aims to provide an assessment and consultation service in the management of acquired brain injury to practitioners throughout the region. Close working links with other agencies in the community is viewed as a very important aspect of service delivery. In addition, some direct rehabilitation interventions are offered, which include group work.

Most referrals to the NWBIS are received from General Practitioners and Consultants. The service mainly works with people who have had a traumatic brain injury but the patient group also includes some people who have sustained brain injuries as a result of a stroke or infection.

The service also offers training opportunities in assessment and treatment of acquired brain injury and research in collaboration with the University of Wales, Bangor. It is therefore common for students or trainees to work for the NWBIS as part of their training. This ensures that local expertise is developed for North Wales. From time to time training events are offered. The NWBIS aims to maintain close working relationships with the voluntary sector.

Introduction

Most people do not pay much deliberate attention to what the brain does. It is involved in everything we do including all forms of movement, communication, planning, problem solving and self-awareness, to name just a few. An injury to the brain can result in various physical and mental changes that can be long-term or even permanent. The brain is a complicated organ that is not fully understood.

Because of it´s complicated nature and other factors the effects of a brain injury vary greatly from one person to another. For people living with brain injury understanding what has happened can be a long and slow process.

Approximately one million people in the United Kingdom present to hospital with a head injury each year. The experience of brain injury, either first-hand, or to a partner, relative or friend can be very confusing and difficult. It can happen very suddenly and unexpectedly. Often individuals and their families are caught off-guard and are left without clear information about the nature of brain injuries.

This information sheet intends to go some of the way towards providing information in terms of what to expect when someone has had a brain injury, ways to cope and where to go for further support and information. If you are unsure of anything in this resource, ask a professional person to provide more information.

HOW DOES THE BRAIN GET INJURED?

Head Injury

A head injury does not always result in an injury to the brain. A head injury refers to the mechanical effects of a blow to a person´s head. Depending on the severity of the injury to the head the brain can become damaged.

The brain can be damaged in different ways. The initial injury to the brain can set off a series of events that can cause further injury to the brain. To help explain how the brain can become injured the processes are categorised into primary, secondary and tertiary injuries.

Primary Brain Injury

A Primary brain injury refers to the tissue damage caused by the blow received to the head. Penetrating or open head injuries, in which an object passes through the skull into the brain, fall into this group. The brain can also become injured in other ways, which are not accompanied by visible wounds to the head. These are called closed head injuries, which are caused by sudden and severe movement. Examples of these would be when the head is caused to move forward at great speed (acceleration) or when it comes to a sudden severe standstill (deceleration). Imagine a person driving a car at speed and suddenly colliding into a wall. The brain would be thrown forward and would come to a sudden stop. The brain is cushioned by fluid in the skull and in this situation it would follow the movement but hit against the hard surface of the skull. Such severe changes in motion can result in damage to the brain tissue.

Secondary Brain Injury

Immediately after the initial injury an interruption in oxygen supply to the brain (Hypoxia or Anoxia) can cause secondary damage. Blood cells carry oxygen to the brain and when blood pressure drops (Hypotension), which can happen when a lot of blood is lost, the brain cells can be starved of oxygen and will die.

Common types of secondary brain injury

  • Diffuse Brain Injury - widespread and extensive injury to brain tissue caused by the brain swelling and pressing against the skull
  • Contrecoup Brain Injury - a severe blow to the head can cause damage at the site of impact and can knock the brain against the opposite side of the skull causing further damage

Tertiary Brain Injury

Third injuries can develop hours, days, or even months after the initial injuries. Different processes can cause these additional injuries. When the brain gets injured it can bruise and swell (contusions) just like any other part of the body. Bruising and swelling can be caused by earlier injuries. However, because the distance between the brain and the skull is short and the skull cannot move to accommodate a lot of swelling, the build-up of pressure can result in brain matter becoming torn and damaged. Pressure caused from collected blood (clot or hematoma) can also cause brain tissue damage in the same way. Pressure build-up can also interrupt oxygen supply making the injury worse.

A major blow to the head can lead to more than one injury to the brain. The effect the injury has on a person varies greatly from one individual to another.

There are other ways in which the brain can become injured that do not involve external forces. Stroke is a common term that describes various conditions that are called Cerebrovascular Disorders. They all involve a disturbance in the blood supply to the brain and can result in a loss of brain function. Most common causes of stroke are blood clots and cholesterol in the blood - arteriosclerosis.

This narrows the arteries in which blood travels to the brain. Blood carries oxygen to the brain and if the supply is limited the brain becomes starved of oxygen. Brain cells rapidly die without oxygen. As in other types of brain injury, secondary swelling can cause further damage, and severity and loss of function can vary widely. The loss of function will depend on the area of oxygen loss in the brain. Strokes are often associated with old age but they do occur in younger adults and children.

Encephalitis is usually caused by a viral infection. The specific viruses involved may vary. Brain damage can result from the viral infection and the pressure that results from the inflammation.

WHAT CAN HAPPEN IN THE EARLY STAGES?

In the early stages after a brain injury a person can be confused, unresponsive, agitated or in an altered state of consciousness (coma). The length of time someone is in a coma and the degree to which they are conscious depends on the type and severity of the injury. Coma is a prolonged state of altered consciousness in which the person is less responsive to things going on around them.

Various tests are conducted at the hospital to assess the extent and severity of the brain injury. These can include scans (see for example MRI & CT scans below) and also specialised tests for evaluating the degree of consciousness (Glasgow Coma Scale). In the early stages it is difficult to predict the implications of the injury. The long-term effects depend on a number of things (e.g. the severity of the injury and where it occurred, age of the person, to name only a few) many of which are not well understood. This can be very frustrating for loved ones, who wish to know what to expect.

Types of Brain Scans

  • Computer Axial Tomography (CAT or CT) - An x-ray procedure used to examine soft brain tissue.
  • Magnetic Resonance Imaging (MRI) Provides more detailed images of the brain using magnetic fields instead of x-rays.

Following a period of coma the person may appear to ‘come round´. Although they behave in a relatively normal way, talking and moving about, they can seem confused, disorientated and behave out of character. This is called post-traumatic amnesia (PTA). A person´s memory of things that happened during PTA can be poor. PTA can also occur when there is no coma. The Glasgow Coma Scale is a specially designed assessment for evaluating the severity of a brain injury. It rates patients´ responses in 3 categories - eye opening, best verbal response, and best motor response.

WHAT CAN HAPPEN AFTER A BRAIN INJURY?

The kind of problems a person can develop after a brain injury and the severity of these can vary widely. The effects of brain injury are often grouped into the following categories: Physical, Cognitive, and Emotional & Behavioural.

PHYSICAL EFFECTS range from quite noticeable difficulties with movement and balance to more subtle problems with headaches and tiredness. Recovery from the more marked physical problems can be good in the first year or so.

EPILEPSY - an injury to the brain tissue increases the likelihood of epileptic seizures. Scarred brain tissue effects electrical activity in the brain, which can cause involuntary changes in behaviour. There are different types of seizures, some are very subtle and involve a lapse in concentration or slight physical twitching, whilst others can involve very noticeable physical changes in behaviour and attention.

HEADACHES - are a common complaint even after a mild brain injury. They can vary in intensity, frequency and duration. Some people experience headaches up to two years or more after a brain injury. It is best to seek medical advice for persisting headaches. In some cases, headaches may be a sign of ‘overdoing´ things. If they stop when a person has finished doing something, they may be caused by over-activity. For headaches that are brought on by stress, relaxation practices can help.

TIREDNESS - can dramatically effect the person´s ability to do things. It can come on suddenly and intensely. It can be difficult to accept such a change in one´s capacity to do things. Activities that appeared effortless before the injury can be exhausting. Tiredness can also have a negative impact on a range of abilities e.g. attention, memory and managing emotions. Watch out for warning signs of fatigue and learn what a person´s limits are. Allow time for rest.

COGNITIVE EFFECTS - are those that draw on mental abilities, which include thinking and remembering. Compared to physical problems, the cognitive effects are often less obvious but can create considerable difficulties.

ATTENTION and CONCENTRATION - require the ability to focus on information and to stay focused whilst ignoring background events, and the ability to shift attention when appropriate. With problems in this area a person can become easily distracted or can find it difficult to do more than one thing at a time. Minimise distraction e.g. limit conversation and other noise. Keep information short and simple.

COMMUNICATION - in this information sheet refers to reading and writing, as well as expressing and understanding language. There are a variety of changes in communication that can result from a brain injury. Problems with language expression range from specific problems with naming objects to more noticeable problems with moving vocal muscles to produce the sounds for talking. Writing by hand can take longer and can be unsteady. Difficulty with reading, and expressing and understanding body language can also occur.

MEMORY - refers to the ability to remember information about events, places and people etc. For some people, the injuries they have sustained can result in permanent memory difficulties. They can find it difficult to form new memories or to recall things that happened before the injury. A specialised assessment can help to understand the kind of memory problems and what compensatory strategies would be suitable. Being organised, writing things down, and using a diary can help. Ask someone to accompany you to appointments, they can help to remember information.

SLOWNESS - can effect behaviour in various ways. As well as taking more time to do physical things, e.g. brush teeth, it can take longer to think things through and make decisions. It will help if people are patient and allow more time. Avoid over-stimulation in the very early stages after injury. Later, avoid only over-demanding activities; a person needs some stimulation.

PLANNING GOAL-DIRECTED ACTIVITIES - the ability to plan the necessary steps required to carry out an act or achieve a goal requires a variety of skills. Problems with concentration and memory, for example, can make it difficult for a person to plan effectively. For a person living at home, planning problems may show in a difficulty with organising shopping and preparing meals. Verbal and written prompts can help when carrying out such activities.

Many people experience EMOTIONAL and BEHAVIOURAL changes after a brain injury. Like the cognitive effects, emotional and behavioural problems are not as easy to understand but can cause a great deal of difficulty.

ANGER - is common following a brain injury. Anger can be due to the emotional impact of the trauma or to changes in the brain´s functioning. A person´s tolerance of potentially frustrating events is often reduced so that seemingly minor irritations can result in intense anger. Although the physical mechanisms of anger are similar from person to person, the kind of things that make someone angry and the way the anger is expressed can vary considerably.

ANXIETY - is associated with feeling nervous, tense or panicky and fear of not being able to cope and losing control. It is normal for a person to experience some anxiety as a result of experiencing trauma. However, if the symptoms are severe and do not diminish over time medication and training in self-help strategies may be beneficial.

DEPRESSION - is an emotional reaction that is commonly experienced later on in recovery. Depression can be described as feeling ‘blue´ or ‘low in spirits´. It is a natural response to developing an awareness of the impact of the brain injury. Although a person may be distressed to learn of their losses, having insight into what has happened is a positive development in terms of recovery. Until a person has realised the extent of their injuries they may not move on to adjusting to the changes.

EMOTIONAL REACTIONS - Some anger, anxiety and depression are to be expected given what has happened. However, it can become problematic when emotional reactions are too prolonged, frequent, and intense and have a negative effect on the person and others. Treatment (psychological or medical) can help. Learning about the physical effects of emotions and situations that trigger emotions hand in hand with strategies for relaxing mental and physical activity can help. Remember tiredness can make a person more emotional.

MOTIVATION - can be a problem for some people. Lack of drive, enthusiasm and ‘get-up and go´ are commonly reported. This can be challenging to the individual and others when things need to be done. Having a program of activities for the day may help.

PERSONAL CHARACTERISTICS or BEHAVIOUR - can seem mildly or dramatically different following a brain injury. Family and carers often say, ‘they´re not the person I used to know’. A person who was once quiet and reserved can seem outgoing, provocative or inappropriately jocular. For those who know the person well these changes can be difficult to come to terms with.

UNDERSTANDING and AWARENESS - draw on various skills. As part of development we learn what our strengths and weaknesses are and develop an awareness of our social and physical environment. With that knowledge we are able to judge what behaviour would be suited in a given situation. Following a brain injury this ability can be compromised. The person may say or do things that seem unsuited to the situation, which can be a worry to family and carers.

COPING WITH THE EFFECTS OF A BRAIN INJURY

What follows below is some general advice, which may be of value to follow in addition to, or to complement any treatment you may receive:

  • A DIFFERENT PERSON - After a brain injury a person can appear very unlike their "old self". In some cases the physical changes can be quite dramatic and it can be hard to recognise the person. You might find that characteristic mannerisms and gesticulations do not appear to exist anymore. Such changes can be subtle or very obvious depending on the nature of the injury. You should be able to identify something of the person you remember which can be reassuring.
  • ADVOCACY - An advocate is someone, sometimes a volunteer, who can act on a person´s behalf in various situations. For someone with a brain injury this could be help with filling in forms or being accompanied to meetings for practical support. Your local Headway service may advocate for some issues or may recommend others who can help with specific problems.
  • ANGER - If someone experiences problems with anger, those close to them often do not know what to do and this can add to the distress. It can help to learn what is causing the anger, so that you are able to avoid it in future. Learn to identify when the person is angry and encourage him or her to talk about it. Being able to listen in a non-judgmental way can be helpful. Carers should realise that sometimes it is best for the person to leave the situation until he or she has completely calmed down before discussing the cause of the upset.
  • DRIVING - Being able to drive is vital for many people. It has special importance in a rural area like North Wales in terms of the person´s independence. You are advised to contact the Driver and Vehicle Licensing Agency (DVLA) regarding driving after a brain injury. They may contact your GP in order to assess your case.
  • EDUCATION & EMPLOYMENT - After a brain injury there can often be difficulties with returning to education/work. Important developments in recovery need to be made before the person attempts to go back to work. It can be devastating to fail and therefore it may be better to change the kind of education/work sought and to access individualised support. Education/employment can be very important for developing skills, confidence and self-worth.
  • FAMILY AND LOVED ONES - The effects of a brain injury can take its toll on those who are close to the injured person. When faced with the trauma feelings of devastation, disbelief, guilt, and stress are common. It can help to learn about what has happened and obtain practical and emotional support. Your local brain injury services should be able to help with this.
  • UNDERSTANDING THE CHANGES - A brain injury can result in the loss of various skills. People worry about leaving someone alone in case they come to harm from doing things that they can no longer manage. Because the injured person may not fully understand their deficits they may think it is okay to do things that could be dangerous. People have dealt with these concerns by asking someone else to stay when they need to go out. It can also help to gently draw the injured person´s attention to potentially dangerous situations.

WHAT IS REHABILITATION?

Rehabilitation is a service that is provided to enable people who have sustained a brain injury to achieve their best possible level of functioning. The aim is to help a person achieve as much independence as possible and enhance their quality of life.

Early rehabilitation often aims to complement and enhance natural recovery. Recovery can be dramatic in the first 6 to 12 months. Recovery over the next year may be slower after which the process may level out. However, further gains are often made over the long term. Rehabilitation can often help achieve this.

Because of the complex difficulties following brain injury many different people can be involved in rehabilitation. The injured person and their loved ones are the most important; they play a vital role in recovery and rehabilitation. The areas of focus in rehabilitation are cognitive, emotional, behavioural, educational, occupational, physical and social. This focus can vary over time to meet the changes in the individual's needs.

The long-term outcome following brain injury can vary enormously. It is often very difficult to predict what the outcome will be for a specific individual.

WHO CAN HELP?

During rehabilitation, people who specialise in different areas may contribute at different times to a person´s care. Who becomes involved is dependent on the individual´s needs, which can change over time. Below is a list of some of the professionals who may become involved.

  • GENERAL PRACTITIONER - GP - The general practitioner treats physical problems following traumatic brain injury, provides follow-up and is generally seen as the ‘hub of the wheel´ of a person´s health care.
  • NEUROLOGIST - The neurologist focuses on specific physical problems after traumatic brain injury of which post traumatic epilepsy is the most common. They may also provide follow-up regarding other neurological problems.
  • NEUROPSYCHOLOGIST - A neuropsychologist is a psychologist specialising in the assessment and rehabilitation of individuals with a brain injury. They may assess thinking, memory, judgement, emotions, behaviour and personality using specially designed tests. This information can be used to help guide treatment. They can identify a person´s abilities and develop compensatory strategies for weaknesses. Help is sometimes provided regarding coming to terms with the injury and understanding it´s effects.
  • OCCUPATIONAL THERAPIST - Occupational therapists evaluate a person´s ability to perform everyday activities. For example, dressing, bathing and domestic tasks. These activities require memory and organisation. They may be involved in accessing treatment or equipment needed for safe independent living. They may also assist with the person´s educational and employment needs. In some situations Occupational Therapists have the role of case manager.
  • PHYSIOTHERAPIST - Physiotherapists can have a lot of involvement in the early and post-acute period. They use techniques to minimise risk of chest infection and movement procedures to avoid the muscles stiffening (contracting) and in extreme cases becoming spastic. Evaluating and treating weaknesses in a person´s strength and balance are important, and sitting, standing and walking are areas of focus. Treatment can include physical exercises and instructions for using equipment like canes, or wheelchairs.
  • PSYCHIATRIST - A psychiatrist primarily deals with medical treatment for psychiatric problems that are the result of the brain trauma e.g. depression and anxiety. Neuropsychiatrists have specialist knowledge regarding the assessment and treatment with medication of psychiatric, behavioural and emotional problems following brain injury.
  • SOCIAL WORKER - A social worker can provide emotional and practical support. They can help the individual and their family adjust to being in the hospital. Practical help may include assistance with discharge planning, referral to community resources and dealing with questions related to finance or disability. Social Workers sometimes function as case managers.
  • SPEECH AND LANGUAGE THERAPIST - The speech and language therapist tests and treats speech, language, thinking and swallowing problems. They can offer alternative methods of communication if suitable.

INFORMATION AND SUPPORT FOR BRAIN INJURY

There are many organisations that can offer information and support. You can find a selection in the printable version of this information sheet. Your local brain injury service can help with meeting your information needs.

BIBLIOGRAPHY

Head Injury: A Practical Guide. Written by Trevor Powell. Published in 1994.

Head Injury the Facts: A Guide for Families and Caregivers. Written by Dorothy Gronwall, Philip Wrightson & Peter Waddell. Published in 1990.

Living with Brain Injury: A Guide for Families and Caregivers. Edited by Sonia Acorn & Penny Offer. Published in 1998.

Neuropsychological Assessment (3rd ed.). Written by Muriel Lezak. Published in 1995.

Patients perspectives of cognitive deficits after head injury. Written by Jane Brewin & Penny Lewis. In The British Journal of Therapy and Rehabilitation, June 2001, Volume 8, No 6.

Report of the working party on the management of patients with head injuries, 1999, The Royal College of Surgeons of England.

Stroke at your Fingertips. Written by Anthony Rudd, Bridget Penhale & Penny Irwin. ISBN: 1872362982. Publisher: Class Publishing.


Written by Nicola Hayes and Rudi Coetzer
North Wales Brain Injury Service
Colwyn Bay Community Hospital, Hesketh Road
Colwyn Bay, LL29 8AY
Telephone 01492 807521 or 01492 807770
Fax: 01492 807777
Flesch-Kincaid level: 10.5
Date written: August 2007
Date for review: November 2015
Page last updated: 03.06.2015