At NRI, we encourage patients and families to learn as much as they can about brain injuries. Please read through the questions below to learn more about brain injuries. We also invite you to visit our Ask the Doctor section to receive a personalized response to your inquiry from NRI’s CEO, Dr. Rolf Gainer.

What is a severe brain injury?

A severe brain injury occurs when trauma to the brain produces a significant neurological injury resulting in physiologic changes to a person’s brain. Four types of injury may cause trauma to the brain:

  • Closed Head Injuries: This type of injury occurs when brain tissue impacts the inside of the skull. This can cause bleeding, bruising, tissue damage, specific neurochemical changes and increased intra-cranial pressure or fluid buildup.
  • Penetrating injuries: These include open fractures of the skull, gunshot wounds or the entry of any foreign object into the brain, resulting in damage to the brain structure neurons.
  • Anoxic injuries: These occur when the lack or reduction of oxygen causes brain cells to die. Anoxic injuries can produce widespread effects throughout the brain.
  • Toxic injuries:  This form of brain injury is caused by exposure to certain toxic chemical agents, which can cross the blood-brain barrier and damage or kill brain cells.

How is brain injury severity determined?

Brain injury is commonly rated at three levels—mild, moderate and severe. The severity of an injury indicates the extent of damage to the brain and the effects of the neurological injury on other body systems. The Glasgow Coma Scale rates injury severity following an injury and determines how responsive the person is to behavioral measures. There is also a Glasgow Outcome Scale, which is used at various points following an injury to determine the prognosis or likelihood of the person regaining his or her independence. Other measures, like the Rancho Los Amigos Scale, are used to assess consciousness, responsiveness and receptive skills. Often, the devastating effects of a brain injury are not fully understood until after the patient has completed medical treatment in an ICU and has entered into rehabilitation.


What are the clinical features of severe brain injury?

Severe brain injury is indicated by a low Glasgow Coma Scale grade at the time of the initial medical intervention. Usually there is also a second assessment 24 hours after the injury. The individual is often in a coma or a state of diminished consciousness, which lasts for hours—and may extend to days or weeks. Symptoms often include:

  • Reduced ability to respond to stimuli
  • Changes in muscle tone
  • Difficulties in respiration and other vital functions
  • Increased intra-cranial pressure or fluid buildup, requiring monitoring and in some cases, neurosurgery

In the case of a brain injury we often see other severe physical injuries, such as fractures of the skull and internal injuries. Overall, the key medical goal is to maintain vital functions while assessments and interventions are carried out to address the multiple physical injuries and the effects of the brain injury.

What is the frequency of severe brain injury?

In North America, each year there are 200 brain injuries at all levels of severity in every 100,000 people. Severe brain trauma occurs in approximately 15% of brain injuries and mortality from brain injury occurs in approximately 11% of injuries. There are over 1.7 million new cases of brain injury each year, with motor vehicle accidents accounting for 60% of the injuries. Work-related accidents account for 15%, sport-related accidents account for 15% and assault-related injuries, including gunshots, account for 10% of the injuries. While most injuries are in the mild category, brain injury at all levels can have negative effects that last a lifetime. Severe injuries have a greater likelihood of producing lifelong disabilities.


Do seat belts and airbags prevent brain injury?

Yes! Seat belts and airbags save lives by reducing injury severity. All safety devices (i.e. helmets, seat belts, airbags, etc.) are critical to increasing safety and preventing injury in motor vehicle, bicycle and sporting accidents. Due to the use of safety devices, more people survive accidents that would otherwise be fatal. This increased survivorship has resulted in an increase of people with severe brain injuries. In addition to advanced safety systems, the tremendous increase in technology available to emergency and neurosurgical medicine has also reduced the number of fatalities from brain injury. Med flight services extend lives by getting injured people to hospital care within minutes of the accident.

Increasing safety awareness and exercising good judgment are also important. Driving while under the influence of drugs or alcohol–or even some prescription medication–increases the likelihood of accidents. We must work to prevent brain injuries through safety-awareness programs.

How does a severe brain injury affect the individual? 

A severe brain injury produces physiologic, cognitive, emotional, psychological and behavioral changes. Some individuals develop medical problems related to specific deficits caused by the brain injury. The part of the brain that is injured determines the long-term effects. Often a severe brain injury involves multiple areas of the brain, resulting in multiple disabilities. Physical functions can be affected, such as standing, walking and eye-hand coordination. Cognitive changes can include issues with memory and language. Personality traits can be affected. People may lose their natural inhibitions and behavior control, leading to inappropriate behavior. The effects of a brain injury can be extremely widespread, impacting all areas of a person’s life and requiring extensive medical and rehabilitative treatment.


What is the typical process of recovery?

Following the accident, a person with a severe brain injury requires medical stabilization to monitor and manage basic life systems such as respiration. Many individuals need neurosurgery to control bleeding inside the brain or between the brain and the skull, repair damaged tissue, or control fluid pressure within the brain. These procedures are invasive and generally require a highly specialized medical treatment team. There may be a phase of intense medical supervision in an Intensive Care Unit (ICU) or in a Neurological Intensive Care Unit (NICU).
As the patient stabilizes and the life threatening aspects of the injury subside, a hospital-based medical rehabilitation program should be considered. Medical rehabilitation programs provide restorative therapies such as physiotherapy, occupational therapy and speech therapy, while continuing to provide medical and nursing supervision. Once hospital-based rehabilitation has been completed the person may require a community-based program or ongoing outpatient rehabilitation services. In cases where the injury has caused severe and persisting deficits and high care needs, the patient may require ongoing rehabilitation in extended or long-term care environments. In these cases, transitional and supported living programs may be appropriate.


How much can a person expect to recover from a severe brain injury?

This depends on the areas of the brain that were injured and the extent of the injury. There is a window of time after the injury that is called the spontaneous recovery period. This is when the brain attempts to recover and repair the bruised neurons. The process takes weeks and may extend for months beyond the date of the injury. Rehabilitation helps stimulate the brain to retrain other neurons to take the place of those that have died, and to redesign the network controlling communication between neurons. Often, a person must relearn physical skills as well as functional skills. Through rehabilitation, the person also learns to use adaptive strategies and apply skills to solve the problems they are experiencing in their recovery. Therapeutic intervention should begin as soon as the person is medically stable. The recovery process can only be measured individually due to the complexity of the brain and its ability to continue recovery over time. The return of functional skills continues for years following the injury.


How does rehabilitation influence recovery?

In the early phases of rehabilitation, the focus is on maximizing the natural recovery process. Specific deficits or problem areas are identified, and treatment is directed at improving function within these areas. As the person progresses through rehabilitation, the focus shifts towards replacing skills and functions that have been lost. In the post-acute phase of rehabilitation, the emphasis is on functional skills retraining. Relearning and adaptation are heavily emphasized in brain injury rehabilitation. We have learned that the human brain is capable of overcoming significant problems created by injury. Effective rehabilitation takes people from a medical environment into the community and even into their homes, schools or workplaces. With that approach, the rehabilitation professionals can develop strategies and interventions with the individuals, which are customized for their unique problems.


What are the phases or steps involved in rehabilitation?

No two brain injuries are alike and the course of rehabilitation is different for each participant. Individuals progress through rehabilitation at their own pace and require unique rehabilitation programs. In the acute or medical phase, the emphasis is on enhancing natural recovery and establishing strategies that promote independence. In the post-acute phase, the emphasis is on teaching functional skills and bringing rehabilitation into the individual’s home, work, community and school. Rehabilitation may extend for years beyond a person’s initial injury and changes may occur throughout a person’s lifetime.


What happens after rehabilitation ends?

For some people rehabilitation is a lifelong process. They may continue to benefit from various rehabilitation therapies to maintain skills and to learn new skills required by their increased independence and community mobility. Many individuals return to their pre-injury roles at home, at work and in the community.

There are also people who require continued support and assistance in certain aspects of their lives. This support and assistance may come from family members, trained rehabilitation professionals and paraprofessionals. The goal of rehabilitation is to assist each person in returning to a life of independence, self-worth and dignity. As people with brain injury go through the aging process, specialized support services are needed to assist them in maintaining their independence.

What happens to children with severe brain injuries?

Children with severe brain injury have the advantage of youth on their side. Children can train their brains to replace lost functions more easily than adults can with similar injuries. Yet, brain injury for children can create many cognitive or learning problems. Additionally, psychological and behavioral problems may affect school re-entry and a return to family and peers. Many children require rehabilitation that extends into the school environment to achieve success. Children may experience problems stemming from their brain injury years after the injury has occurred. In some cases, the initial injury has been forgotten or ignored, which can be the cause of inappropriate diagnosis and treatment unless consideration is given to the long-term effects of the initial injury.


Do some people remain in a coma forever?

The term “coma” is generally used to describe a person whose ability to respond to stimuli is significantly reduced. However, the term can be misleading. In some cases, the significant alterations of consciousness that we see in severe brain injury persist. 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 coma. We believe that people in a state of coma are aware of their environments, of people and of events. This understanding has dramatically changed how individuals in comas are treated.

A prolonged state of diminished consciousness is called a minimally conscious state and requires an effective program that:

  • Provides gentle, but consistent stimulation
  • Involves all of a person’s senses
  • Enables an individual to interact with his or her environment
  • Does not assume the person is unaware of his or her environment

What is a “Locked-in Syndrome”?

For a long time we thought that individuals who were in a state of diminished consciousness were unable to respond. 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.


What is the role of a neuropsychologist?

Neuropsychologists are very important members of the rehabilitation team. They perform an assessment to evaluate the problems the person is experiencing and determine the optimum approach for rehabilitation. Definitive aspects of the cognitive and psychological deficits are identified and a course for rehabilitation is planned. In some cases, counseling is offered. In subsequent evaluations, the neuropsychologist determines the recovery course and rate.


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 filtering issues
  • Information coding 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 and through rehabilitation, while others may persist and require specific rehabilitation interventions. There is a relationship between cognitive problems and neurobehavioral problems.

What are neurobehavioral problems?

Neurobehavioral problems are behavior problems that are attributed to specific aspects of a brain injury. Sometimes normal inhibitions and judgment are reduced due to the injury. Individuals 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 or behave in socially inappropriate ways. In some cases, medications are effective in assisting them with behavior control. A neuropsychologist may help design an appropriate behavior learning strategy. A neurologist may assess the person for the presence of a seizure disorder that may be causing irritability and loss-of-control issues, which are seen as problems with anger, disinhibition and aggression.


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

There is a correlation between the location of a brain lesion and the appearance of anger and aggression. This trait is frequently present when the lesions affect the frontal lobe. Anger and aggression seem to be caused by a reduction of impulse control as the result of the brain lesions.


What causes difficulty controlling emotions and inappropriate sexual behavior?

This is similar to the question about anger and aggression. Following a brain injury, some people lose appropriate boundaries when they experience sadness, happiness, and sexual feelings. This loss of inhibition and impulse control can result from the location of their brain lesions, or the loss of communication between areas of the brain, like we 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.


What is a brain stem injury?

The brain stem controls many physiologic systems. An injury to the brain stem is 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.


What is a frontal lobe injury?

The frontal lobes control many cognitive and behavioral functions through complex processes of integrating and mediating 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 adjacent skull areas. Most severe brain injuries involve the effects of one or both of the following:

  • 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 that form essential connections. These injuries may result in multiple areas of involvement and the loss of connectivity between areas of the brain, resulting in Diffuse Axonal Injury.

Does the location of an injury effect severity?

The location of the injury can affect the severity of the problems experienced by individuals throughout the course of their recovery, rehabilitation, and lifetime. The brain is a complex part of our neuroanatomy. Controls for physical, cognitive, emotional and behavioral functions are all brain-based.

In reality, there are few “simple” brain injuries. Most are complex and affect more than one aspect of brain-based functions. Certainly specific or “focal” injuries produce specific deficits and problems. The circuitry of the brain is extremely complex.

What are neuromotor problems?

Neuromotor problems are physical movement and body control difficulties resulting 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

Specific therapies can help a person regain motor control and maximize motor skills. Much of our ability to live with independence relates to our capacity to perform motor tasks.

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

Although there are no guarantees, many people are able to make dramatic strides toward recovery.  We often see continued improvement in our patients, sometimes years after the injury.  In many cases people are able to return to lives filled with purpose and meaning with the ones they love.


What is mild brain injury?

Mild traumatic brain Injury is also called “subtle acquired brain injury.” People with mild or subtle brain injuries 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 mild brain injury can produce problems that occur long after the initial injury and can affect many aspects of a person’s life.

What sort of cognitive problems are seen in mild brain injury?

Some of the most common cognitive problems associated with mild brain injury include:

  • Attention and filtering issues
  • Short-term memory loss
  • Information processing issues
  • Difficulty with problem solving
  • Problems with organization
  • Difficulty with judgment and decision-making
  • Problems with higher-level thinking skills known as executive skills

What are the physical symptoms associated with mild 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

What are the potential psychological or emotional problems?

People who interact with victims of a mild brain injury often see a “personality change” in the individual. 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 that is very different from their pre-injury use.

Can a mild brain injury create psychiatric problems? 

Many individuals with a mild brain injury 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 that is related to the 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.


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:

  • Headaches
  • Nausea
  • Dizziness
  • Confusion
  • Agitation
  • Disorientation
  • Amnesia
  • Fatigue

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. They are often difficult to manage.

Is a concussion considered a mild brain injury?

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


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. 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 of concussive injuries 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.


How does the person respond after the initial injury?

We often hear the person talk about “going crazy” or feeling depressed. They have great difficulty understanding the changes they are experiencing and their altered functional abilities. Many individuals report incapacitating headaches, pain and fatigue. They also frequently experience:

  • Mood changes
  • Temper control difficulties
  • Problems with attention and concentration
  • Sleep problems
  • Loss of appetite
  • Change in sex drive

The symptoms of mild brain injury or post concussion syndrome are often not understood by professionals who are treating the person, especially if they are not aware of the existence of a brain injury.

Can someone “fake” mild brain injury symptoms?

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 a sound neuropsychological and psychiatric assessment will identify other personality or psychiatric problems that may be present.


Can rehabilitation help the person with mild brain injury?

Yes. A program of functional neurological rehabilitation will help the person develop strategies to manage their cognitive difficulties, cope with psychological and emotional changes and reduce the disabling conditions caused by physical problems. Counseling may be required and family participation can help the adjustment to the changes created by brain injury. Community-based programs that focus on functional solutions may offer the best opportunities for rehabilitation.


When can the person return to work?

As with any brain injury, the return to work is an important part of the rehabilitation process. Individuals who return to work without rehabilitation 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 that they see in the injured individual and attribute the problems to the wrong cause. To be effective, the rehabilitation program needs to extend into the work setting to include vocational assessments, work reentry, job coaching and job reengineering. In some cases, the person may need to return to a modified job.  (Note: Reference podcasts here)

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