Our Medical Advisors
||Bill Levinger, MD
and, head injury survivor
||Hugh R. MacMahon, MD
Neurology, Sea, WA
impairments caused by brain injury may be characterized in terms of three
damage rarely affects just one of these systems. Rather, the disruptive
effects of most brain injuries, regardless of their size or location, usually
involve all three systems." --
Source Neuropsychological Assessment, 3nd Ed., 1995, by Muriel
intellect which is the information-handling aspect of behavior;
emotionality, which concerns feelings and motivations; and
control, which has to do with how behavior is expressed ."
"A number of years ago, while engaged in a head trauma research program
at New York University Medical Center, we became concerned with
the other, ignored end of the head trauma spectrum: minor head
a number of professionals have written consistently and eloquently in this
area (notably Thomas Boll, Jeffrey Barth, and Dorothy Gronwall),
we found gross ignorance and neglect of the long term problems associated
with "minor" head trauma: those injuries where patients spent a brief time
(if any) in the hospital, make quick medical recoveries, and were discharged
directly home without any perceived need for formal rehabilitation.
We discovered, as others had reported, that these patients appeared fine
until they attempted to resume their responsibilities at home, work, or
school, When they did so, a significant number experienced
They complained of inability to remember, concentrate, organize, handle
a number of tasks at once, and get as much work done efficiently as they
Their relationships with family, peers and bosses often suffered, and they
developed psychological problems.
Their doctors were unable to find anything wrong with them, and they were
thought to be having psychiatric problems - or worse yet, to be malingering.
They became the bane of neurologist, psychologists, psychiatrists, and
vocational counselors, all of whose usual techniques did not produce positive
"Minor Head Injury: An Introduction for Professionals" December
Thomas Kay, Ph.D.,
Coordinator, Head Trauma Research Project
|for a short period of time, or permanently.
In many cases recovery becomes a lifelong process of adjustments and accommodations
for the individual and the family.
Depending on the extent and location of the
injury, impairments caused by a brain injury can vary widely. Among the
most common impairments are difficulties with memory, mood, and concentration.
Others include significant deficits in organizational and reasoning skills,
learning, cognitive, and executive functions.
Recovery from a brain injury can be inconsistent.
In many cases gains may be closely followed by setbacks and plateaus. A
"plateau" is not evidence that improvement have ended. Typically, plateaus
are followed by gains. This pattern of gains and setbacks can continue
in memory and organizational skills after a brain injury makes it difficult
to function in complex environments. The tutorials and quizzes in this
section are designed to help you understand how daily routines and life
in general may be affected by brain injury.
Links on this page help you create a compensatory
system, teach you how to use it, and monitor how well it is working. A
number of those pages provide practical suggestions for gathering
information and developing effective action plans for coping with brain
injury in daily living.
the brain. The brain has been described as a three pound
universe. It has come to be thought of in those terms because quite
literally; we live in our brains. The brain is our personal, private universe.
It is through our brains that we experience ourselves and the environment.
It is though our brains that we understand our relationship to others.
Scientists think of the brain as the organ of reason, language, complex
social relations, and morality. It is, after all, what makes us distinctly
The brain can be thought of as a sensory processor.
Our experience of ourselves, and our environment is dependent on the brain's
ability to receive, process, store, retrieve and transmit sensory information.
The ability to think, see, smell, feel, remember, and behave appropriately
is dependent on an intact brain. Even minor brain damage can result in
permanent impairments in these functions. Such impairments can interfere
with normal everyday activities.
Brain damage, whether from surgery, strokes, tumors, disease, toxins,
near drowning, electric shock, lightning strike, or head injuries can
rob a person of a sense of self. It can turn a person into a
mere shadow of his or her former self At the very least brain
damage can seriously compromise quality of life. While brain damage may
strike a single individual, in reality it is the family that bears the
brunt of its destructive impact.
Injury (TBI), results from damage to brain tissue caused
by an external force. Leading causes of TBI are motor vehicle accidents,
acts of violence, falls, sports and recreational injuries, lightening strikes,
electric shocks, and blows to the head. TBI can occur
without any outward physical evidence of injury or trauma. Examples include,
and shaken babies. Also see Brain
Injury Support Groups for links to information and resources.
mood and fatigue are common complaints of brain injury patients. Intellectual
dullness and mental rigidity are obvious signs of brain injury. Personality
changes are common, and rapid mood swings alternate with waxing and waning
energy levels. Taken individually, such impairments might not amount to
much. However, such impairments usually appear in groups or clusters.
In many cases the impairments are widespread and disrupt many brain systems.
The overall effect can be profoundly disabling.
Acquired Brain Injury, (ABI), results from damage to
the brain caused by strokes, tumors, anoxia, hypoxia, toxins, degenerative
diseases, near drowning and/or other conditions not necessarily caused
by an external force. Go to Brain
Injury Links for more information on acquired brain injury and
Head Injury. The
terms head injury, traumatic brain injury and acquired brain injury are
often used interchangeably. However, most people associate the term "head
injury" with some type of external physical damage to the head. Many
such head injuries are superficial, and amount to nothing more than a temporary,
although bothersome, injury and associated discomfort.
The most severe types of head injury can cause extensive functional
limitations such a paralysis, and severely limited mental functioning.
A little further down the continuum of head injuries you will find moderate
head injuries. Moderate head injuries are characterized by
corresponding degrees of functional limitations mostly in the form of diminished
mental skills. Then on the other end of the continuum you'll find what's
called concussion, mild or minor head injuries. Like the moderate head
injuries, mild head injury can cause impairments in mental functioning.
The irony of mild head injuries is that often times, such injuries do not
even require a hospital stay, yet they result in changes so profound that
lives are forever changed. The term mild head injury belies
the true nature of the resultant impairments.
Concussion. A concussion results from the brain being
battered or violently shaken. Typically, it is followed by a alteration
in consciousness. That is, the person is knocked out, loses consciousness,
or remains conscious, but appears dazed, witless, disoriented. The
term concussion is often used interchangeably with the terms: head
injury, mild brain injury, head dinged, or bell rung. It is important to
note that a blow to the head is not required for brain damage to occur.
Also see Concussion FAQ
Symptoms. Early symptoms of concussion include headache;
dizziness or vertigo; lack of awareness of surroundings; and nausea and
vomiting. Late symptoms of concussion include: persistent low-grade
headache, lightheadedness, poor attention and concentration, memory dysfunction,
difficulty doing simple math, difficulty finding words, slowed reaction
time, fatiguability, irritability and low frustration threshold, intolerance
of bright lights, difficulty focusing vision, intolerance of
loud noises, occasional ringing in the ears, anxiety, depression, mood
swings, and sleep disturbances. Also see Concussion
The Dangers of Concussion
" ...during the minutes to few days after concussion
injury, brain cells that are not irreversibly destroyed remain alive but
exist in a vulnerable state. This concept of injury-induced vulnerability
has been put forth to describe the fact that patients suffering from head
injury are extremely vulnerable to the consequences of even minor changes
in cerebral blood flow and/or increases in intracranial pressure and apnea....
"Experimental studies have identified metabolic
dysfunction as the key postconcussion physiologic event that produces
and maintains this state of vulnerability. This period of enhanced vulnerability
is characterized by both an increase in the demand for glucose (fuel) and
an inexplicable reduction in cerebral blood flow (fuel delivery).58 The
result is an inability of the neurovascular system to respond to increasing
demands for energy to reestablish its normal chemical and ionic environments.
This is dangerous because these altered environments can kill brain cells."
The American Orthopaedic
Society for Sports Medicine - url: http://www.intelli.com/vhosts/aossm-isite/html/main.cgi?sub=151
Severe Head Injury. Severe head injuries usually
result from crushing blows or penetrating wounds to the head. Such injuries
crush, rip and shear delicate brain tissue. This is the most life threatening,
and the most intractable type of brain injury. Also see our
Typically, heroic measures are required in treatment of
such injuries. Frequently, severe head trauma results in an open head injury,
one in which the skull has been crushed or seriously fractured. Treatment
of open head injuries usually require prolonged hospitalization and extensive
rehabilitation. Typically, rehabilitation is incomplete and for most part
there is no return to pre-injury status. Closed head injuries can
also result in severe brain injury.
Moderate and Minor Head Injuries. Most brain injuries result
from moderate and minor head injuries. Such injuries usually result from
a non-penetrating blow to the head, and/or a violent shaking of the head.
As luck would have it many individuals sustain such head injuries without
any apparent consequences. However, for many others, such injuries result
in lifelong disabling impairments.
of Injury. The brain is somewhat mobile within the spiny
interior of the skull. Under normal circumstances the delicate brain is
protected from contact with the spiny contours of the skull. This protective
barrier is known as cerebrospinal fluid. It surrounds the brain, and under
normal circumstances, cushions the brain from contact with its hard, spiny
However, when the head is subjected to violent forces,
such as those exerted in: automobile accidents; violent shaking or
whiplash; forceful falls and blows; the brain may sustain permanent
damage. Such damage results from the delicate brain being forcibly rotated
and battered within the spiny skull, also known as, the brain vault. During
such episodes brain tissue is ripped, torn, stretched, battered and bruised.
Such battering is followed by bleeding, swelling and bruising of brain
tissue. Sometimes the brain can recover from such insults without
any apparent consequences. In other cases the resultant difficulties
can last a lifetime. (Also see 2nd
Brain Damage. Such damage, which results in functional impairments,
can substantially interfere with the ability to return to a normal lifestyle.
They are known as functional impairments because they interfere with the
ability to perform basic functions such as walking and talking, thinking
and knowing remembering and understanding. For example, memory, mood and
fatigue top the list of the many on-going impairments that are caused by
brain damage. Even a minor brain injury can have substantial, lifelong
consequences. See TBI
Lifelong Consequences. After brain injury, things that once
were easy and familiar become strange and difficult. Intensive mental effort
is usually required to do things that required little or no effort before
brain injury. Work and school, personal and family life often suffer too.
Typically, children become unmanageable, grades drop, personalities change
and they regress to a earlier developmental stage.
In adults, deadlines are missed, jobs
are lost, savings dwindle and nerves fray. Behavior regresses and becomes
upredictable, unreliable, frequently inappropriate, and sometimes violent,
role reversals are common. While only one family member may have
sustained a brain injury the entire family suffers from its massive intrusion.
Scope of the Problem. Each year an estimated 5 million persons
in the United States sustain head injuries. Of that number, 2 million Americans
sustain head injuries that result in permanent impairments. Many such injuries
do not even require a stay in the hospital, yet they result in impairments
so profound that lives are forever changed.
Recognizing the Problem. Often, the effects of minor to moderate
brain injuries are not immediately apparent. Many months may go by before
brain injury changes become apparent. Even then, special training and expertise
are required to properly diagnose such impairments. Such fields of specialization
are known as Neuropsychology and Neuropsychiatry.
Recognizing such problems is made even more difficult by
perceptual and expressive impairments caused by brain injury. Brain injury
causes diminished self-awareness that interferes with the ability to recognize
changes in the self. It also causes mental confusion and a sense of uncertainty
about experiences. Difficulties finding familiar words to communicate thoughts
and desires hinders communication and fuels frustration. Many individuals
do not report such symptoms out of fear of being thought of as mentally
unsound. Others are shamed by such symptoms in themselves.
Additionally, the very nature of brain injury
interferes with the ability to recognize the problem. Frequently, brain
injury causes memory impairments and expressive disorders. In real terms,
this means that even when the memory survives the words might become elusive.
Such impairments can hamper the ability to provide the doctor an accurate
Even minor head injury,
known as concussion, can cause substantial difficulties or impairments
that can last a lifetime. Whiplash too, can result in the same difficulties
as head injury. Such impairments can be helped by rehabilitation, however
many individuals are released from treatment without referrals to brain
injury rehabilitation, or guidance of any sort.
HELP IS AVAILABLE. For many who sustain head injuries, the effects
last for a few days or weeks. When the effects last longer than a few months
medical, legal or rehabilitation services might be advisable. Whether the
need is for expert professional help or knowledgeable self-help headinjury.com
can empower you navigate the mysterious landscape of brain injury.
Go to the menu
above for additional resources, or call for your personalized consultation,
Adapted with permission from: "Don't Get Mad Get
Powerful, A Manual for building Advocacy Skills," MI P&A
|Rimel, R.W., RN, NP, Giordani, Bruno, M.A., Barth, J.T., Boll, Thomas,
PhD, & Jane, J., MD, PhD, Disability Caused By Minor Head Injury,
Neurosurgery, 1981; Vol. 9, Number 3:221-227
|Lezak, Muriel, Ph.D., Neuropsychological
Assessment, Oxford University Press, 1983.
|Fisher, Jerid, Ph.D., Cognitive and Behavioral
Consequences of Closed Head Injury. Seminars in Neurology, Vol. 5, Number
3, September 1985.
|Hooper, Judith & Teresi, Dick, The
3-pound Universe. Dell Publishing Co., NY 1986.
|Kay, Thomas, Ph.D., "Minor Head Injury:
An Introduction for Professionals." U.S. Dept. of Education,
|Packard, Russell C., M.D., "WS6: Mild
Head Injury." Association for Applied Psychophysiology and Biofeedback,
|Galski, Thomas, Ph.D., and Carnevale, George,
P.D., "Proving Cognitive and Behavioral Brain Injuries." Trial Magazine,
|Kelly, P. James, M.D., and Rosenberg, Jay
H., M.D., Diagnosis and Management of Concussion in Sports, Neurology
|Wrightson and Gronwall, Mild Head Injury, Oxford University
|Also see our Noteworthy
Seattle, WA 98124-5451