Thanks to Alice Bellavance, Teresa Chiu, Angela Colantonio, and Laura Moll for providing this information. This is Section A of Traumatic Brain Injury Resources. A new page will be posted weekly. Check back for more information every week. Future pages are: B – Health Care Team and Treatment, C – Recovery, D – Daily Caregiving, E – Caregiver challenges, F – Caregiving Concerns Section, G – Caregiving Coping, H – Legal and Financial Support

About Brain injury

Acquired brain injury
• An acquired brain injury is an injury to the brain that occurs after birth.
• It causes problems with how a person thinks, talks, moves, and interacts with others.
• There are two types of acquired brain injury:
• Traumatic brain injury
• Non-traumatic brain injury
• A non-traumatic brain injury may result from a stroke, tumor, anoxia, aneurysm, encephalitis, Fetal Alcohol Spectrum Disorder and hydrocephalus.

Traumatic Brain Injury
• Traumatic brain injury (TBI) means damages to the brain caused by an outside force.
• It happens when the head hits an object, or when an object gets into the skull and enters the brain tissue.
• A person may have a TBI after a fall or from a car collision.
• It may result from a sports injury, such as concussion during a football/hockey game.

Causes of Traumatic Brain Injury
From 2003 to 2004, 16,811 were admitted to hospitals compared to 25,665 in 1994–1995.
• The majority of people who had a brain injury were male.
• Children and youth, as well as adults over 60 years old were most likely to be hospitalized after having a brain injury.
• Older adults who have brain injury tend to stay in the hospital longer.
• Older adults tend to be more likely to die in hospital.

From 2003 to 2004, statistics still suggest:
• Cycling is one of the leading causes of brain injury among children and youth
• Falls was the leading cause of brain injury among seniors
• Motor vehicle incidences were the leading cause of brain injury for adults.

Concussion
• Any blow to the head can cause a concussion.
• Concussions range in severity from mild to severe, but they all share one common factor — they temporarily affect the way your brain works.
• They can affect memory, judgment, reflexes, speech, balance and coordination.
• Concussions do not always involve a loss of consciousness. In fact, most people who have concussions never black out. Many people have had concussions and not realized it.

Signs and symptoms
• The signs and symptoms of a concussion can be subtle and may not appear immediately.
• Symptoms can last for days, weeks or longer.
• The two most common concussion symptoms are confusion and loss of memory (doctors may call memory loss as amnesia).
• A concussion may not be present with a loss of consciousness.
• However, most of the times, the loss of memory is linked with a concussion.

Other immediate signs and symptoms of a concussion may include:
• Headache
• Dizziness
• Ringing in the ears
• Nausea or vomiting
• Slurred speech

Some symptoms of concussions do not appear until hours or days later. They include:
• Mood and cognitive disturbances
• Sensitivity to light and noise
• Sleep disturbances

Brain Injury is very common in young children. However, concussions can be difficult to recognize in infants and toddlers because they cannot readily communicate how they feel. Behaviours that may suggest concussion are:
• Listlessness, tiring easily
• Irritability, crankiness
• Change in eating or sleeping patterns
• Lack of interest in favorite toys
• Loss of balance, unsteady walking

In general, there are three levels of brain injury
Mild traumatic brain injury:
• Period of confusion, a person might not lose consciousness
• A loss of consciousness is very brief.
• Person with traumatic brain injury experiences fatigue, sleep disturbances, headaches, confusion, blurred vision, unable to concentrate and memory.
Moderate traumatic brain injury:
• Loss of consciousness is longer.
• Recovery is longer.
• Longer change in behavior, memory, thinking, movement, and emotion.
Severe Traumatic brain injury:
• Person is in severe coma, and could die.

Risk of Having Another Brain Injury
Having a brain injury may increase the chance of having another brain injury in the future. Perhaps the person’s balance has gotten worse, the person may be more likely to fall and have another brain injury. On other cases, the person may not have a good judgment of safety and they may risk having another brain injury when playing contact sports.

Some of the reasons may increase the risk of another brain injury:
• problems with balance,
• impulsivity,
• poor decision-making,
• poor safety judgment
• slowed reaction time
• slower information processing speed

It is important to be careful not to get another brain injury because the conditions may get complicated with multiple injuries. The following provides you some tips to prevent another brain injury from happening.

For more strategies to minimize the risk of having another brain injury , you may go to the following section:
• Prevent a Brain injury
• Prevention Strategies for children

Preventing Another Brain Injury
You can prevent another traumatic brain injury. There are many ways to prevent it. Here is a list of what to do to prevent an injury.

Driving
• Wear a seat belt every time you drive or ride in a motor vehicle.
• Do not drive after drinking or using drugs.
• Use a suitable child safety seat (e.g., booster seat) for your children according to their age, height and weight.
• Tighten the seat belt of your children.
• Put on the child-proof lock of your car if your car has this feature.

Playing Sports
You should wear a helmet when you are engaged in the following:
• Ride a bike, motorcycle, snowmobile, or all-terrain vehicle.
• Play a sport game which has personal contact, such as football, ice hockey, or boxing
• Use in-line skates, roller blades, riding a skateboard
• Ski or snowboard.
• Bat and running bases in baseball or softball.
• Riding a horse.

Falls Prevention at Home
• Using a step stool with a grab bar to reach objects on high shelves.
• Installing handrails on stairways.
• Removing tripping hazards such as small area rugs and loose electrical cords.
• Using non-slip mats in the bathtub and on shower floors.
• Putting grab bars next to the toilet and in the tub or shower.
• Seeing an eye doctor regularly for a vision check to lower the risk of falling.

Children’s Safety at Home
• Installing window guards to keep young children from falling out of open windows.
• Using safety gates at the top and bottom of stairs when young children are around.
• Make sure the surface on your child’s playground is made of shock-absorbing material, such as hardwood, mulch, and sand.
• Keep firearms stored unloaded in a locked cabinet or safe. Store bullets in a separate secured location.

Non-Traumatic Brain Injury
Stroke
• Having a stroke means having some brain damage caused by poor blood supply to a part of the brain.
• The blood supply problems happen when the blood vessels are broken and/or blocked.
• Risk factors of stroke are:
• smoking
• overweight
• high blood pressure
• heart disease
• diabetes

Brain Tumor
• A brain tumor means there are new, uncontrolled growth of cells in the brain.
• There are many different kinds of brain tumors because of the abnormal growth of different cells in the brain.
• When there is abnormal growth of some brain cells, the functioning of the normal brain cells would be affected.

Anoxia
• Anoxia means the brain ihas a lack of oxygen for a period of time
• This could happen when the oxygen supply to the brain is affected when the heart or the lungs are not working properly

Aneurysm
• Aneurysm means there is widening of the blood arteries in the brain
• This abnormal change could be like swelling along the wall of a blood vessel
• This abnormal change could also be like a balloon on the wall of the blood vessel
• It means the walls of the blood arteries are weakened
• The blood vessels become swollen and could burst in the brain

Encephalitis
• Encephalitis means inflammation to the brain
• The inflammation causes swelling in the brain
• Encephalitis is usually caused by viruses

Brain Injury in Children
Fetal Alcohol Spectrum Disorder
Alcohol can hurt the brain and body of an unborn baby. People born with brain damage may have FASD. FASD stands for Fetal Alcohol Spectrum Disorder.

Other names for FASD
The following names refer to specific problems that are included in FASD.
FAS is often used to describe the full range of problems a baby can have when the mother drank during pregnancy. These include brain damage, low birth weight and growth, and facial feature unique to Fetal Alchohol Syndrome (FAS).
Partial FAS is used when some, but not all of these problems are present.
You may also see the term ARND. It stands for Alcohol Related Neurodevelopmental Disorder. ARND refers to any developmental problems a person has due to alcohol-related brain damage. Typically individuals with ARND do not have poor growth or facial features as described above.

Cure of FASD
There is no cure for FASD. The brain damage to an unborn baby when a mother drinks is permanent. They do not grow out of it. There is no way to fix it.
FASD is 100% preventable. Drinking alcohol is the only cause.

Problems with FASD
There are many different problems caused by FASD. Some people may have 1 or 2 problems. Other people may have many of the problems listed below. Sometimes, the types of problems a person with FASD have change as they get older.

Babies and Children with FASD:
- may be born very tiny and stay quite small
- may not develop as quickly as children who do not have FASD
- trouble sleeping
- trouble paying attention
- trouble speaking well and learning to read
- trouble learning at school
- a lot of trouble when things in their lives change (i.e. need routine)
- impulsive – this means they act without thinking
Kids in Elementary School with FASD
- trouble learning in school
- trouble learning from their mistakes – they may repeat the same mistake over and over
- they may not understand the relationship of “cause and effect”
- they may not fit well into groups and may have trouble making friends
Teenagers and Adults with FASD
- problems completing school
- problems finding or keeping a job
- some teenagers and adults break the law because they have problems learning from their mistakes
- problems with being addicted to alcohol or other drugs
- problems with emotions, e.g., depression, anxiety

Other health problems with FASD
Some people with FASD also have other health problems that are linked with their FASD. Mental health problems can be a problem for some people with FASD. Some people born with FASD have heart, bone, kidney, eye or hearing problems. People with FASD are at risk for a traumatic brain injury due to impulsivity (i.e. acting without thinking).

Things to do if I think my child has FASD
Talk to your family doctor or someone who knows about the resources in your community. They may be able to refer you to a doctor who is specially trained to diagnose FASD. Many people will help the specially trained doctor find out if your child has FASD. Some of these people include:
- neuropsychologists
- nurses
- teachers
- mental health professionals
- physical therapists
- occupational therapists
- speech therapists
These people look for many different things. If you are the birth mother of your child, they will also ask if you drank when you were pregnant. The most important thing to do is to find out what type of help your child needs to be successful and happy.

I think I have FASD. What do I do?
Talk to your family doctor or medical person in your community. They can send you for testing for FASD.

More information about FASD
You can visit the following websites:
http://www.come-over.to/FASCRC/
http://www.faslink.org/toc2.htm
http://www.acbr.com/fas/

Concussion in Children
Any blow to the head, face or neck, or a blow to the body which causes a sudden jarring of the head may cause a concussion (e.g., a ball to the head, being checked into the boards in hockey, or bouncing a soccer ball of the head).

Symptoms and Signs of Concussion
It is important to know that your child may not be knocked out or lose consciousness if the person has a concussion. You may observe a variety of problems which may happen after a concussion, including:

Child’s Complaints:
• Headache
• Dizziness
• Feels dazed
• Feels “dinged” or “stunned”, or “having my bell rung”
• Sees stars, flashing lights
• Ringing in the ears
• Sleepiness
• Loss of vision
• See double or blurry image
• Stomach pain or nausea

Thinking Problems
• Does not know time, date, place, period of game, opposing team, score of game
• General confusion
• Cannot remember things that happened before and after the injury
• Knocked out

Other Problems
• Poor coordination or balance
• Blank stare/glassy eyed
• Vomiting
• Slurred speech
• Slow to answer questions or follow directions
• Easily distracted
• Poor concentration
• Strange or inappropriate emotions (i.e., laughing, crying, getting mad/angry easily)
• Not playing

Seeking help
Every child who gets a head injury should be seen by a doctor as soon as possible. You should take him/her back to the doctor IMMEDIATELY if, after being told your child has a concussion, he/she has worsening of symptoms such as:
1. being more confused
2. has a headache that is getting worse
3. vomits more than once
4. doesn’t wake up
5. has any trouble walking
6. has a seizure
7. has strange behaviour

The length of time taken for recovery
The signs and symptoms of concussion (see above) often last for 7-10 days but may last much longer. In some cases, children may take many weeks or months to heal. Having had previous concussions may increase the chance that a child may take longer to heal.

Treatment to a concussion treated
• The most important treatment for a concussion is rest.
• The child should not exercise, go to school or do any activities that may make him/her worse, like riding a bike, play wrestling with brothers/sisters/friends, video games, or working on the computer.
• If your child goes back to activities before he/she is completely better, he/she is more likely to get worse, and to have symptoms longer.
• Even though it is very hard for an active child to rest, this is the most important step. Once your child is completely better at rest, he/she can start a step-wise increase in activities (see “Return to Sport” in the Recovery section). It is important that your child is seen by a doctor before he/she begins the steps needed to return to activity, to make sure he/she is completely better.
• If possible, your child should be seen by a doctor with experience in treating concussions.

Prevention Strategies for Children
Preventing Vehicle and Pedestrian Injuries
• Kids under 12 should sit in the back seat of a car
• Enter and exit a vehicle on the curb side
• Talk and play quietly so you don’t disturb the driver
• Sit still and keep head, arms and legs inside the vehicle
• There’s a “danger zone” of three meters around the front and the back of the bus. The driver can not see a person in that area. Pedestrians should stay clear of this area.
• Pedestrians should always walk on sidewalks or on the side of the road facing the traffic
• When crossing a street always stop and look left, right and left again before crossing
• Don’t play in a street or driveway
• Do not move a victim trapped in car – leave them there unless there is danger of a fire
Preventing Cycling Injuries
• Always use a bicycle that is the right size (rider should touch both feet on the ground while sitting on the seat)
• Always keep bicycle in good repair
• Equip bicycles with reflectors, headlights and bell or horn
• Always wear a CSA approved, properly fitting bicycle helmet
• Always ride single file on the right side of the road with traffic
• Never carry a passenger on a bicycle built for one
• Allow pedestrians to go first at street crossings and on sidewalks
• Always watch for cars coming out of driveways, other streets and pulling away from curbs
• Always obey traffic rules such as signs and signals
• Walk bicycles across intersections and railroad crossings
• Wear bright clothing and reflective stickers
Preventing Injuries Involving Sports and Recreation Activities
• Always wear the proper protective equipment that has been designed for each particular sport/activity
• Only play on properly installed and maintained playground equipment
• When playing on playground equipment, take off your helmet, necklaces and any loose clothing
• Use skipping ropes only for skipping
• Wait for your path to be clear before sledding down a hill
• Always sled away from the road and railway tracks
• When skating – check for debris and wet spots on the ice; never trip others
• Never swim or play in water without adult supervision
• Wear a life jacket (PFD) during water activities
• Always make sure that water is deep enough to dive
• Always swim with a buddy
Preventing Weapon Related Injury
• Children should be taught to use non-violent conflict resolution skills
• Prevent access to firearms by storing all guns and ammunition separately in locked areas that children cannot reach
• Learn what to do when children find a weapon- STOP, DON’T TOUCH, LEAVE THE AREA, CALL AN ADULT
• Children that have been taught to hunt must understand the rules involved in gun safety by taking hunter safety course
Preventing Strangulation, Suffocation and Choking
• Adults should always supervise children who are playing with balloons
• Always use aluminum helium-filled balloons instead of latex ones
• Make sure carbon monoxide detectors are installed near your furnace
• Always keep plastic bags away from young children
• Learn the appropriate techniques involved in clearing a child’s blocked airways
• Always remove the doors from discarded refrigerators and freezers
• Always take small bites of food and chew well (e.g., cut wieners in half or suitable size for easy chewing)
• Always tuck in loose clothing and remove hood draw strings from children’s clothing
• Always supervise children in playgrounds
• Make sure that playground equipment meets the Canadian Standards Association’s guidelines
• All window blind cords should be tied up and out of reach

Brain Injury before Birth
• Brain Injury could happen to a child before birth or when the mother is giving birth to her child
• Lack of oxygen or nutrient supply to the brain often cause brain injury before the baby is born
• Injury could also happen when excessive physical force during the delivery of the baby
• Cerebral Palsy is a term used to describe the brain injury that happen before birth, during the delivery of the baby, or soon after the baby is born
• Hydrocephalus is another common cause of brain injury when the baby has fluid trapped in its brain before birth

Hydrocephalus
• Hydrocephalus is a condition when the fluid from the spinal cord is not moving well within the brain
• When this fluid is not moving well in the brain, it causes swelling and expands the space in the brain
• Usually, children have this condition. But it could also happen to adults and elderly
• A shunt can be surgically put in place to drain the spinal fluid

The Brain
• There are many parts of the brain important for many functions.
• Any part of the brain can be damaged by a brain injury.
• Different parts of the brain have their own names. Some areas we know about their functions, you may have heard about their names.
-The Skull (also called the cranium) is made up of many different bones that are joined together. The skull protects the brain inside.
-The Brain is a very complex control centre for the body. Once it receives signals from different organs, the brain tells the body what to do.
-The Brainstem passes messages between the body and the brain. It controls breathing, blood pressure, body temperature, heart rate and sleep patterns. It also detects hunger and thirst.
-The Cerebellum controls our posture, balance, coordination and movement. It controls actions such as walking.
-The Cerebrum helps us understand our environment and tells our body how to respond. It also controls our emotions, as well as our ability to talk, think, read and learn. -The Cerebrum has four lobes.
-The Frontal Lobes are responsible for movement. They help us to control behaviours and thinking, such as planning and organization, sense of orientation, judgement, appreciation.
-The Occipital Lobes are located at the back of the brain. They are responsible for what we see.
-The Parietal Lobes are also responsible for hearing and movement. They help us to feel pain, temperature, sizes, shapes, and other sensations.
-The Temporal Lobes are responsible for hearing, memory and emotions. They help us to understand words and sound.

Refer to figure below from family handbook from Hamilton Health Sciences of how the brain works.

Functional Difficulties
A person with brain injury can have different functional difficulties. Below are common functional problems. Some people may have some or all of these problems.

Physical Changes after injury
Normal motor movements such as walking, making coffee or shooting a basketball may seem easy but may be difficult for a person with brain injury.
Examples of physical limitations may be:
• Physical weakness (also called paralysis)
• Muscle tightness (also called spasticity)
• Sleep disorders
• Loss of stamina
• Appetite changes
• Regulation of body temperature
• Menstrual difficulties

In this part, you will learn about some of the physical changes that could happen after a brain injury:
• movement
• joints
• pain
• senses
• speech and language
• seizures
• arousal
• weight
• swallowing
• bladder control
• bowel control
• skin
• fatigue
• drugs and alcohol

After the injury, your family member may have a number of problems.
Common problems are described below.
Movement
A change in the ability to move is one of the most common problems after a brain injury. A person may have one or more of the following:
• loss of movement or weakness of one side of the body
• loss of movement involving one or both legs, and one or both arms
• poor balance
• low endurance
• difficulty planning movements
• poor coordination
• muscle stiffness, tension or trembling
• inability to control the trunk of the body
• damage to muscle and bone tissue

Joints
As a result of chemical changes in the brain and reduced activity,
• extra bone may form around some joints. This is called heterotopic ossification.
• It may be very painful and restrict movement.
• People with this problem need to exercise. Medications may also be helpful.

Due to changes in brain activity,
• contractures could also occur. A contracture is when muscles or tendons become shortened.
• Once the muscles/tendons are shortened, it cannot be changed. This causes a limb to become deformed.
• Surgery and splints may help.

Pain
• Pain and headaches can result after a brain injury.
• This can make it hard for the person to concentrate or remember.
• Pain can also affect sleep and mood.
• The person may resist doing things to avoid feeling pain.

Different Types of Pain
Acute pain is the pain you feel when you bend too far, or twist the wrong way. Your body lets you know whaten you are in danger of injury.
You may also feel acute pain if you injure yourself or if a part of your body needs attention.

Chronic pain is painful feeling that stays for a long time or keeps coming back.

Things to remember:
-No matter where your pain is felt, pain is processed in the brain. That means, if you stub your toe, you feel it there because your brain creates the painful feeling.
-People can feel pain for no obvious reason. An unexplained pain can go away quickly or last a long time.
-Some people have a condition called “congenital insensitivity to pain”, which means they cannot feel pain.
-Due to changes in thinking, they may not know what pain is, how to interpret it or explain what they are feeling – may be expressed in behaviours (e.g., anger)

Pain Medications
Your doctor may give you pain medications. Pain medications may come in different forms. Sometimes only one type of medication is used and other times, different kinds of medicine may be given at the same time

Other Suggestions:
-Using a heating pad ,or warm cloth, or an ice pack on the painful area can often help you feel less pain.
-Generally, cold is used to relieve pain from bruising, muscle strains, spasm, sprains and insect stings.
-Heat is used for aches and stiffness in muscles and joints.
-By concentrating on something else, such as imagining a favourite place or activity, you can keep you brain busy and you may not feel as much pain.
-Sometimes, doctors suggest exercise (or physiotherapy or water therapy) to help your body heal after an injury. It includes doing exercises and stretches to help your body to return to good working order.

Sensation
Sometimes a person with TBI cannot see well, smell or taste his/her favorite food.
Examples of sensation problems may be:
• Loss of sense of smell or taste
• Blurred vision
• Ringing in ears
• Distorted hearing or inability to interpret sounds (e.g., cannot understand the meaning of the fire alarm by hearing the sound)

Any of the senses such as, hearing, vision, taste, smell and touch, may change following an injury. This may be the result of damage to:
• the area of the brain that controls that sense
• the sensory organ itself, such as damage to the ear
• the nerve carrying the messages from the sensory organ to the brain

The person could have any of the following sensory problems:
• over-sensitivity to touch — this may result in withdrawing, crying, yelling or striking out when touched
• inability to feel pain, touch, hot or cold
• inability to see certain objects in view loss of vision, double or blurry vision, sensitivity to light lack of attention to one side of the body or room — this is called neglect
• changes in sense of smell or taste ringing in the ears,
• intolerance to noise
• sensitivity to movement or lack of awareness of movement
• inability to understand where limbs are located in relation to the body and surrounding space

Speech and Language
A person may have problems with communication.
Some speech problems involve:
• making sounds
• pronouncing words
Some language problems involve:
• expressing thoughts
• finding the right words
• understanding what people say

Seizures
Seizures can occur after a brain injury. They can cause a part of the body or the whole body to shake. Most often, seizures cause loss in attention.
Signs to tell you someone may have had a seizure include changes in:
• the way a person thinks
• a person’s sensations
• the way a person behaves
• a person’s moods
• a person’s level of alertness

These signs are important, especially if the person appears very tired after showing one or more of these signs.
• Seizures may occur early after the injury, or not until months or years later.
• They can be triggered by drinking alcohol, illicit drugs or using over-the-counter medications.
• If a person has had seizures, driving a car is unsafe.
• The person may lose his or her driver’s license for the time being or forever.
• Most seizures can be prevented or controlled by medication.

Arousal
• Arousal is a person’s ability to be alert.
• During the first stages of recovery, the level of arousal can vary from hour to hour or day-to-day.
• To make the most of rehabilitation efforts, the team will schedule activities during periods of alertness.
• Medication may increase arousal. Arousal can improve with recovery.

Weight
People who have had a brain injury have the same need for nutrition as everyone else. This means eating a healthy diet based on Canada’s Food Guide to Healthy Eating. Canada’s Food Guide to Healthy Eating includes a balance of fruits, vegetables, meats, dairy and grains.

Weight loss right after a brain injury is common because:
• there is a high level of physical stress on the body
• the person may not even feel hunger

Suggestions:
• Remind the person to eat
• provide the person with frequent small snacks and meals.

Later on, weight gain might become a problem because:
• the person can’t tell when the stomach is full
• the person forgets that he or she already ate
• changes in activity level and the way the body burns calories.
• appetite control mechanism in the brain may have been damaged

Suggestions:
• Take a lower calorie diet
• Have fewer snacks

Swallowing
A person may not be able to chew and swallow regular foods or drink liquids. A special diet may be recommended, including:
• pureed foods, such as mashed potatoes
• thickened fluids.

Thin liquids are harder to swallow than solids because the muscles in the throat need to contract more. Thin liquids such as water, are often not recommended.

Some people cannot eat at all. Some people cannot eat enough to meet their dietary needs.
• They will have a tube put into their nose or stomach.
• Liquid food is then fed through this tube.

Bladder Control
A brain injury can affect the bladder in these ways:
• the bladder may be overactive or underactive
• the person may not feel the urge to urinate or know what to do if they do feel the urge

• These changes can allow bacteria to grow in the bladder. The bacteria can lead to infections.
• To prevent bladder infections, go to the toilet often.

Some ways to deal with bladder problems include:
• going to the bathroom often
• wearing diapers if there is no bladder control.
• Using diapers when going out if you do not have enough time to go to the washroom
• using a condom drainage system for males — a condom drainage system is a condom with a tube leading to a urine bag
• using intermittent catheterization. This means a catheter is put into the bladder through the urethra. Then, the bladder is drained and the catheter is removed.
• using an indwelling catheter. This means the catheter is left in the bladder.

Bowel Control
A brain injury can affect the bowels in these ways:
• the bowels may become overactive or underactive, causing either many loose bowel movements or constipation
• the bowels may not empty completely
• the person may not be able to communicate the need to move his/her bowels.

Bowel problems often improve as the brain heals. To have regular bowel movements, the person should:
• eat a healthy diet — this includes foods high in fibre, such as whole wheat products, fresh vegetables and fruits
• drink lots of fluids — hot drinks may also help
• use a stool softener, laxative or suppository as needed
• maintain a regular routine
• keep proper positioning in a bed or chair
• maintain overall muscle fitness
• sit on a commode in an upright position

Skin
Changes to the skin are common after a brain injury. The person’s skin should be checked routinely for any sores, abrasions or changes in colour.
Special attention should be paid to the feet, back and buttocks. The following are common changes that can occur in the skin:
• skin sores – may be caused by rubbing the skin on sheets or clothing too often or by not moving enough. When a person does not move enough, the weight of the body restricts blood flow which causes tissue to die. This can result in a decubitus ulcer. This happens most often on a bony area such as the skin over the tailbone, ankles, hips, knees, heels, elbows or ears.
• rash – may be caused by contact with urine or bowel movements, or by sensitivity to diapers.
• bruises or cuts – may be caused by improper transfers from bed to chair or neglect of a paralyzed limb.
• acne – changes to the brain may signal the oil glands in the skin to work very hard. This can cause acne on the face, back or chest.
Acne may also be caused by some medications.
The person’s skin needs to be cleaned regularly with a shower or sponge bath. Special cushions or mattresses may be of benefit.
Eating healthy foods and getting enough fluids can promote healthy skin.

Fatigue
Fatigue is common for many reasons. The body needs extra rest for injuries to heal. When the person begins rehabilitation, there is even more demand on the body’s energy.
• The injury to the brain can also cause mental fatigue. It can affect the person’s sleep and make it harder to think and learn. A person with a brain injury can be easily overstimulated by noise and activity. An injured brain will tend to shut down when overloaded.
• Some people have both physical and mental fatigue.
• To improve learning, the person should rest in a quiet room when tired.
• The person may not know that he or she is tired and may need to be reminded to rest.
• If fatigue is a problem, it may be best to schedule activities for shorter periods of time, followed by a rest period. As the person recovers, he or she may be able to do longer activities with shorter rests.
• Pain, infection and other health issues can also cause fatigue as the body uses extra resources to cope

Drugs and Alcohol
A person who has had a brain injury should not take illicit/street drugs or drink alcohol. The brain injury can affect balance, coordination and decrease control over emotions.

Drinking alcohol or taking drugs:
• makes balance and coordination worse, which increases the risk of falling
• further reduces self-control
• affects recovery of brain cells

The combination of alcohol and some drugs can cause:
• seizures
• visual problems
• additional loss of brain cells
• unpredictable reactions to medications

Please see Caregiving Challenge for more information about Alcohol and Drugs Misuse.

Cognitive Changes after injury
People with TBI often have difficulty on concentrating in on tasks or making decisions such as planning daily activities. Often they forget.
Examples of thinking difficulties may be:
• Lack of concentration
• Difficulty remembering
• Difficulty in decision-making
• Slowness in thinking

Language and Speech
It is sometimes hard to understand what someone with brain injury is saying.
Examples of communication difficulties may be:
• not understanding the spoken word (receptive aphasia)
• difficulty speaking and being understood (expressive aphasia)
• slurred speech
• speaking very fast or very slow
• problems reading
• problems writing
• problems with spelling
• problems with word or number recognition

Emotional Changes after injury
It is normal to feel angry at some one for doing something or to impulsively disrupt a conversation. But, people with TBI are often angry at trivial things and impulsive all the time. They may curse often or blurt out thoughts that are rude.
Examples of dependent behaviors may be:
• Emotional ability
• Lack of motivation
• Irritability
• Aggression
• Depression
• Disinhibition
• Denial/lack of awareness

Healing and Recovery
Recovery
• Rate of recovery is different to fordifferent every peoplerson, because of factors such as age, gender and types of brain injury.
• There are people who can recover well despite he/shebeing maybe very sick.
• During the first few months, recovery from brain injury is the fastest.
• Recovery is slower the longer the time an injury has happened.
• A person tends to be able to lead a healthy life after the injury although there may be some symptoms that last s longer.
• There is more information in the Recovery Section.

Healing of the Brain
• The nerve cells send messages to other parts of the brain and body.
• For the brain to work, its nerve cells must be functioning.
• If a certain part of the brain is injured, the cells in that brain area might be damaged.
• If the damaged cells die, it will lead to the loss of certain abilities.
• If the brain cells are damaged, they may recover on their own.
• The other brain cells may make new connections and take over the job of damaged brain cells.
• The brain begins to heal after the swelling goes down.
• In the beginning, certain abilities such as motor movement may be lost.
• He or she will need to practice them through rehabilitation in order to regain them.
• Some abilities such as decision making and planning may be different.