Physical Effects of Brain Injury

After a TBI, the nerve cells in the brain may no longer send information to each other the way they normally do. This is why people with a TBI may have changes in their physical abilities.

A brain injury can affect physical abilities, such as:

• balance
• mobility
• coordination
• muscle strength, tone, and control.

It may also affect the body’s senses, including:

• hearing
• vision
• smell
• touch
• taste.

A TBI can cause fatigue and conditions such as seizures, spasticity, and bladder, bowel, and swallowing difficulties.

Some of these effects will get better quickly, others will take time, and still others may become a lasting problem.

Every person with TBI has a unique set of physical effects. Each person has a unique pace of recovery.

This chapter describes many physical effects that people with a TBI may experience. Some information in this chapter may apply to your service member/veteran, but other information may not. Some information may apply now, but not in the future.

With the help of the health care team, many physical effects can be treated or managed with positive results.

You can help your service member/veteran with TBI by following through on treatment plans from the health care team. You can also use the suggestions in this chapter. But first, check these ideas out with the health care team.

The health care team will have many more suggestions and treatments than are listed here. Talk to the team members about “what to do” if your service member/veteran begins to have new symptoms or problems, or reacts differently to treatments than he or she has been.

What are Common Physical Effects of TBI?

Headaches

Headaches are common following TBI. Some people have a headache all the time, and some people’s headaches come and go. Fatigue, stress, and a history of migraines make these headaches worse.

Fortunately, post-TBI headaches usually improve over time.

Treatment Options

Medication: It can take some trial and error to find the right medicine to treat post-TBI headaches. Your family member should take all medications exactly as the doctor directs. He or she should talk with the doctor before changing how much medicine he or she takes, or how often.

Other options: Stretching and strengthening exercises may help. Follow the directions of the health care team on these. Exercise, such as swimming in warm water, can help loosen the muscles that cause headaches. Acupuncture, occipital nerve blocks, biofeedback, Botox®, and physical therapy are possible treatments.

How you can help:

• Ask your service member/veteran to lie down in a dark and quiet place; sleep can relieve a headache.
• Use heat or ice as directed by the doctor.
• Encourage your family member to:
  • Avoid bright sunlight, especially going from a dark building into bright sunlight (may need to wear very dark sunglasses).
  • Avoid alcohol.
  • Avoid foods that trigger headaches. These include cold foods, aged hard cheeses, or chocolate.
  • Manage stress. Take breaks during activities, practice deep breathing exercises, exercise, and have some fun.
  • Keep track of headaches in a journal. Note the time of day, the activity, and intensity of the pain. Share this information with the doctor.
  • Take medications at the same time every day.

If headaches do not improve or worsen, call the doctor. Your service member/veteran does not need to suffer. New treatment options can be tried. Your family member may be referred to a headache specialist (such as a neurologist) if headaches do not improve with standard treatment.

Sleep Changes

Altered sleep patterns are very common after TBI. This problem is usually worst in the first several weeks to months after injury.

Many people with TBI sleep during the day and are awake at night. They may nap now, when before they did not.

Stay hopeful. Most people with TBI do usually resume a more normal sleep routine similar to the one they had before the injury.

Time, patience, and some creative problem-solving help. Developing a consistent routine, using medications on a temporary basis, and changing the bedroom can improve sleep.

What you might see:

• Difficulty falling or staying asleep (insomnia)
• Awake at night, sleeping during the day
• Frequent naps
• Sleeping too much or too little.

How you can help:

• Work with the health care team to establish healthy sleeping patterns.
• Encourage your service member/veteran to:
  • Limit daytime naps (talk to the health care team first).
  • Avoid caffeine (coffee, tea, energy drinks, dark soda) after the morning.
  • Exercise during the day; avoid exercise too close to bed time.
  • Avoid fluids two hours prior to bedtime.
  • Try to eat the last meal of the day four hours before bedtime.
  • Go to bed at the same time every night and get up at the same time every morning.
  • Avoid use of bed for activities other than sleep and sex (e.g., watching TV).

• If worrying or nightmares are contributing to poor sleep, consult a doctor or nurse.
• Monitor the bedroom: turn the clock away from the bed, use room darkening shades. Most people sleep better in a cooler environment.
• If your service member/veteran simply cannot fall or stay asleep, have him or her get out of bed and watch TV or read (if easy to do without assistance) until he or she feels tired and is ready to try again.
• Talk with your service member/veteran’s doctor about temporarily using sleep medication or complementary/alternative therapies to help establish a sleep schedule.
• Make sure to tell your doctor if your service member/veteran is taking an over-the-counter medication.

Fatigue/Loss of Stamina

Fatigue is a common complaint among people with TBI. The body needs a vast amount of energy for healing after traumatic injuries. Sleep is often disrupted in the hospital. Usual patterns of rest and activity are often very different for many weeks to months after TBI. Confusion can make fatigue worse. Central fatigue is the major type of fatigue in TBI patients. Central fatigue affects thinking. Working harder to learn and stay focused can make your family member mentally tired. In some people, central fatigue causes them to be irritable or have headaches.

Peripheral fatigue is also reported by many. Peripheral fatigue is physical. It can make pain, thinking, and mood worse. Fatigue reduces the speed and quality of rehabilitation. Fatigue can also slow down the return to normal life activities, such as school or work. For most people, fatigue gradually lessens over time. Stamina and endurance improve. However, some people with TBI say that for the rest of their lives, their endurance is just not what it used to be. They have to pace themselves more than they used to.

What you might see:

• Frequent comments about being tired
• Need for sleep after a short activity, lack of energy
• Poor stamina
• Extreme fatigue after a busy stretch of hours
• Slurred speech
• Irritability
• Slower thinking speed.

How you can help:

• Set up a daily schedule for your family member. Make sure it includes enough rest/sleep. Use a calendar to help your service member/ veteran follow the schedule.
• Reduce family and social demands.
• Help your family member to pace him or herself.
• Ask your family member to conserve energy for important tasks in the day.
• Help your family member to have an active lifestyle. Regular exercise increases stamina. The physical therapist can develop a safe exercise program.
• Allow time for undisturbed rest during the day. A nap is usually 30-60
• minutes.
• Schedule important appointments for times of the day when your family member is most awake.
• Learn the signs of fatigue in your service member/veteran. Ask him or her to do the same. Make a list of the signs and keep it in his or her calendar/memory notebook.
• Inform the health care team about changes in sleep patterns or stamina.
• Ask the health care team to rule out other causes of fatigue. Common causes of fatigue are endocrine abnormalities, sleep disorders, mood disorders, diabetes, substance abuse, electrolyte imbalances, and nutrition deficits.

Dizziness

Dizziness is a term used to describe everything from feeling faint or lightheaded to feeling weak or unsteady.

Under normal circumstances, your sense of balance is controlled by a number of signals that your brain receives from several locations. A TBI can disrupt this.

The greatest concern about dizziness is the increased tendency to fall when dizzy or lightheaded.

Dizziness is often an early effect. It frequently goes away during the first weeks following injury.

If dizziness does not go away on its own, there are therapies and medications that may help. These must be used under the supervision of the health care team.

What you might see:

• Complaints that the surroundings are spinning or moving (vertigo)
• Loss of balance, unsteadiness
• Nausea
• Wooziness, lightheadedness
• Blurred vision during quick or sudden head movements.

How you can help:

• Be aware of the possible loss of balance. This can lead to falling and serious injury.
• Fall-proof your home: Remove area rugs and electrical cords that someone could slip on. Use non-slip mats on your bath and shower floors.
• Have your service member/veteran:
  • Sit for a few minutes before walking. This gives the brain time to adjust.
  • Sit or lie down as soon as he or she feels dizzy.
  • Avoid driving a car if frequent dizziness or lightheadedness is present.
  • Use good lighting when getting out of bed at night.
  • Walk with a cane, walker, or other assistive device for stability.
  • Avoid sudden movements or bending over.
• Work closely with the health care team to manage symptoms effectively.
• Talk with the doctor about therapies or medications that improve symptoms.

Balance Problems (Tendency to Fall)

The brain controls our physical movement and our balance. A TBI can affect balance.

Balance problems are often an early effect after TBI. They go away over time and with physical therapy.

What you might see:

• Unsteadiness when walking
• Inability to walk or sit without assistance
• Falls
• Holding onto furniture, walls, other objects when walking.

How you can help:

• Encourage proper use of aids such as walkers or canes, if prescribed, in all settings (community and home).
• Remove throw rugs from your home.
• Work with the physical therapist to learn how to assist your service member/veteran while he or she is sitting or walking.
• Falls are the leading cause of non-combat TBI. Provide or arrange for supervision once you are home to prevent falls and another TBI.

Sensory Changes

The brain is the center for all five of our senses: sight, hearing, taste, smell, and touch.

When the brain is injured, each of the senses is at risk for change. There is often not much to be done about these changes in the first year after injury.

Doctors often use a “wait and see” approach with the hope that sensory changes will go away on their own.

For some sensory changes that don’t go away over time, surgery may help. For others, therapy and learning to live with the effect will be in order.

What you might see:

• Vision changes, such as blurry vision, double vision, or sensitivity to light
• Hearing changes, including muffled hearing or ringing in the ears (tinnitus) in one or both ears
• Changes in taste and smell. This could be a complete lack of taste and smell or an altered taste, such as a metallic flavor in the mouth.

How you can help:

• A neuro-ophthalmologist can evaluate visual changes. A neurologist can evaluate other sensory changes.
• Reinforce wearing of an eye patch or special glasses if ordered for double vision.
• Ask your service member/veteran to avoid alcohol. It may increase sensitivity to light and noise.
• Seek professional advice about whether or not it is safe for your family member to drive if he or she is having a change in vision.
• Have his or her hearing checked. Use hearing aids, if needed.
• Ask a dietitian about tips for eating if taste and smell are lost or altered.
• Make sure you have a working smoke alarm in the house if his or her sense of smell has been lost.
• Try to be patient. Sensory changes can improve over the first several months or years after TBI. Work with the health care team to track how the senses are working. Seek further evaluation and treatment options as needed.

What Physical Effects May Be Less Common?

Spasticity

An injury to the brain can cause an abnormal increase in muscle tone called spasticity. A spastic muscle does not easily relax the way a normal muscle does.

This effect is most common with a severe and/or penetrating head injury.

Regular stretching, splints to keep limbs in proper position, and medications are common treatments.

Severe spasticity can be painful so pain management may be in order.

What you might see:

• Involuntary muscle tightness and stiffness
• Muscle contractions
• Decreased range of movement and abnormal posture.

How you can help:

• The physical therapist will develop a stretching program for your family member. Ask the physical therapist to teach you this program.
• Post diagrams of the stretches. Help your family member do the recommended stretches.
• If splints are used, learn how to apply them. Find out how long they are to be worn each day.
• Monitor your family member’s skin for pressure points from the splints. Alert nurses to areas of redness and breakdown.
• Tell the health care team if the spasticity gets worse. This could be a sign of an underlying problem.
• If spasticity is so severe that it interferes with comfort, positioning, and general functioning, ask the doctor about treatment options. These include implanting a muscle relaxant pump.

Hemiparesis, Hemiplegia

Muscle movement originates in the brain. A TBI can affect movement.

You may remember from Module 1 that movement of the right side of the body is controlled by the left side of the brain, and movement of the left side of the body is controlled by the right side of the brain.

What you might see:

• Muscle weakness on only one side of the body (hemiparesis).
• Total paralysis of the arm, leg, and trunk on one side of the body (hemiplegia).

How you can help:

• Your service member/veteran’s physical therapist and occupational therapist will develop leg and arm exercises. Ask to learn these exercises.
• Realize that your family member may take longer to move around. Allow extra time to get places.
• Encourage use of prescribed assistive devices, such as a walker or cane.
  They help your family member stay safe and independent.
• You may notice decreased sensation in affected limbs. Monitor skin
  for pressure points from the splints. Alert the team to areas of redness
  and breakdown.
• Therapists may recommend certain sleeping positions that are best for
  the affected limb(s). Follow their suggestions.

Bladder/Bowel Changes

Even bowel and bladder functions are controlled by the brain. For many people with TBI, bowel and bladder functions are impaired in the early days to weeks following injury. Health care providers expect this and are prepared to help. Urinary catheters and use of diapers or pads may be needed. Bowel and bladder retraining is part of the rehabilitation process. Fortunately, with time and practice, most people with TBI regain control of these body functions.

What you might see:

• Loss of bladder or bowel control
• Increased urgency to urinate
• Incomplete bladder or bowel emptying
• Increased bladder infections
• Constipation
• Memory and cognitive problems such that the person does not recognize the need to urinate/defecate or recall when he or she last did so
• Skin problems due to incontinence.

How you can help:

• Indwelling urinary catheters followed by the use of pads or diapers are common early on. Reassure your service member/veteran that these are nearly always temporary.
• The rehabilitation nurse will teach bladder “training” which often includes a specific fluid schedule, limiting fluids in the evening, and timed attempts to empty the bladder. Help your service member/ veteran adhere to the recommended schedule and interventions.
• Bowel “training” often includes scheduled attempts, a high fiber diet, adequate fluids, physical activity, eating meals at regular times, and possible use of medications, including suppositories. Help your service member/veteran to adhere to the recommended schedule and interventions.
• Monitor for skin breakdown and report it to health care providers.

Changes in Swallowing and Appetite; Weight Loss or Gain

Many people with traumatic injuries do not drink or eat for a period of time. As a result, they lose weight.

Once the person is fully awake and able to follow directions, swallowing can be evaluated. It is important to fully evaluate swallowing before the injured person drinks or eats.

The purpose of evaluating the person’s ability to swallow is to make sure that what he or she eats goes into the stomach, not into the lungs. When food or fluid slips into the lungs, it often results in pneumonia.

A speech or occupational therapist evaluates swallowing. This may be done in the person’s hospital room.

If not, the therapist may escort your family member to the x-ray department for a video fluoroscopy. Your family member will consume a barium-laced liquid or food that will light up on an x-ray. The x-ray helps the therapist to see precisely where it is going.

Once your service member/veteran is cleared to drink or eat, he or she may only be able to consume certain types of liquids and foods. Most people do best with medium consistencies, rather than thin fluid or very chewy, tough foods.

With practice, most people will return to a normal diet.

Appetite can be affected. Some people with TBI complain of a reduced appetite. Others gain weight due to boredom, memory problems, and an increased appetite.

Work with the health care team to learn how to help your service member/veteran have a healthy diet and a healthy weight.

What you might see:

• Choking or coughing during meals
• Pocketing of food inside the mouth and/or drooling
• Decreased interest in eating
• Weight loss, without trying to lose weight (possibly due to loss of taste and smell)
• Overeating, resulting in weight gain
• Memory problems: failure to remember when to eat or when last ate.

How you can help:

• Do not offer fluids or food until your service member/veteran has been cleared to drink and eat.
• If on a special diet with restricted fluids and foods, work with the therapists and dietitians to learn what foods are allowed. Learn how to assist your family member to drink and eat if special strategies are needed (i.e., eat slowly, chin tuck during swallow, double swallow, follow every bite of food with fluid).
• Short term changes in appetite are common. Don’t worry about early weight loss. Most often, the weight is regained once the person is home.
• Monitor your service member/veteran’s body weight and learn what his or her ideal weight range is from the dietitian.
• Report appetite changes to the health care team. These may be a sign of depression, general emotional distress, medication problems, or other medical conditions.
• Ask for a dietitian to review dietary intake and to learn more about meal preparation and a balanced diet.
• It is common to have reduced taste and smell following TBI. Talk with the dietitian about how to use spices and flavorings to perk up the taste of food.
• Weight gain following TBI is common. It is usually due to lack of physical activity. But sometimes it is due to boredom. Work with your service member/veteran to remain physically active and engaged in outside activities. Establish set meal times. Discourage overeating or too many snacks.
• Encourage your service member/veteran to be involved, as able, in grocery shopping and meal planning/preparation.
• Write meal times in the planner/memory book. Check off meals when finished.

Visual Spatial Problems

Visual spatial abilities begin in the brain. They include blind spots and/ or changes in the brain’s ability to understand what the eyes see.

The ability to perceive where you are in space and in relation to other items in the environment may also be affected by TBI. This is called spatial awareness.

Injury to the right side of the brain in particular can lead to difficulties in these areas.

What you might see:

• Tendency to ignore things on one side of the body
• Bumping into things on the affected side
• Difficulty finding his or her way around, especially in new places
• Difficulty recognizing shapes and telling the difference between shapes
• Turning head towards the unaffected side
• When reading, cutting words in half or beginning to read in the middle of the sentence or page
• Mistaking the location of a chair when sitting down
• Misjudging distance; for example, missing the cup when pouring
• Standing too close or too far from others in social situations
• Confusion between right and left
• Reports of impaired vision.

How you can help:

• Ask for a neuro-ophthalmologist to identify your service member/ veteran’s specific visual and/or visual spatial problems.
• Stand on and place objects on the affected side. Encourage your service member/veteran to look to that side (this is called visual cueing).
• Remind your service member/veteran to frequently look around the environment, especially toward the affected side (this is called visual scanning).
• Use visual cues (e.g., a dark line) on one side of a page to encourage visual scanning of the entire page.
• Arrange your house to make tasks easier. For example, have items to
• accomplish a task organized in one place.
• Show your service member/veteran around new places several times. Avoid sending him or her to new places alone.
• Limit clutter in the house. Try not to move items around.
• Remind your service member/veteran to use handrails when available.
• Provide gentle reminders that he or she is standing too close or far away during social encounters.
• Seek professional advice about whether or not it is safe for your service member/veteran to drive (see Module 3).

Apraxia

A person with apraxia can often understand what to do and has the physical ability to do the task. However, his or her body simply has trouble cooperating with his or her best intentions.

This is a direct result of injury to the brain, often to the parietal lobe.

People with apraxia may have trouble using items correctly.

What you may see:

• Trying to use a toothbrush to comb hair or a fork to eat soup
• Unable to follow spoken directions accurately. For example, he or she may not give “thumbs up” when asked.
• Putting clothes on backwards, upside down, inside out.

How you can help:

• Guide the person to complete the task the right way. For example: Place your hand over your family member’s hand and move it through the correct motions to perform a specific task.
• Redirect your service member/veteran to perform other common tasks in the correct order, one step at a time.Write down instructions for your service member/veteran.
• Write down instructions for your service member/veteran.
• Post a daily routine or schedule for hygiene and other daily tasks (e.g., dressing) and write the routine down in your service member/veteran’s calendar/memory notebook.

Seizures

Seizures happen when the electrical system in the brain misfires.

Seizures can be frightening to watch.

Two kinds of seizures may occur following a severe TBI:

• Early seizures—also called “generalized seizures” or “Grand Mal seizures” — typically happen during the first week after an injury.
• Later seizures usually occur after the first week of injury in individuals who have never had a seizure before. People who have late-onset seizures are more likely to have a penetrating injury or one that causes a large amount of bleeding in the brain.

Seizures can be temporary or chronic. Late-onset seizures carry a greater risk of future seizures than do early seizures.

A neurologist is the member of the health care team who usually diagnoses seizures. He or she will treat seizures with medications.

What you may see:

• Generalized shaking or jerking of the arms and legs
• Loss of consciousness
• Altered attention, emotion, sensation, or movement
• Strange odors or sensations.

Late-onset seizures can also cause changes in smell, behavior, or personality. Sometimes, people mistake a seizure as a psychiatric disorder.

Ask your doctor early on about how to recognize a seizure and what to do if one occurs.

How you can help:

• For a first seizure, call your doctor as soon as possible.
• If not a first seizure, alert the doctor. Make an appointment to have anti-seizure medication and blood levels checked.
• Talk to the doctor before adding or stopping medications or herbal treatments. These can change the blood level of the anti-seizure
• medication and make it ineffective.
• During a seizure:
  • Keep calm.
  • Don’t hold your family member down or try to stop his or her movements.
  • Loosen ties or anything around the neck that makes breathing hard to do.
  • Clear anything hard or sharp from the surrounding area.
  • Put something flat and soft under the head.
  • Turn the person gently onto one side. This helps keep the airway clear.
  • Do not try to force the mouth open.
  • Stay with the person until the seizure ends.
• CALL 911 if your service member/veteran experiences:
  • Difficulty breathing during or after a seizure
  • Seizure lasting more than five minutes
  • Second seizure that happens immediately after the first seizure
  • Difficulty waking up from the seizure or a second seizure without waking up in between.

Some things are triggers for seizures. These include:

• Stress
• Overuse of alcohol and/or other drugs
• Being overworked and/or tired.

Help your service member/veteran to avoid these triggers.

Driving laws for people with seizures vary from state to state. Check with your Department of Motor Vehicles to find out what the rules are for your family member if he or she has a seizure disorder.

Heterotrophic Ossification

Heterotrophic ossification (HO) happens when bone forms in an unnatural location, such as in soft tissue or muscle.

What you may see:

• Swelling, warmth, limited range of motion, pain in soft tissue areas or a muscle.

How you can help:

• Rest the arm or leg where the pain is. Ask for physical therapy to maintain range of motion.