Brain Injury


Understanding brain injuries

This page acts as your basic framework on TBI. The following information will give you a clear overview of what a brain injury is, how it is measured, the stages of recovery and the impact on function of the brain. Near the end, I have included a survivor's story on the reality of living with a TBI. For more in-depth information on the various conditions, please refer to the subpages listed above.

What is a Traumatic Brain Injury?

Traumatic brain injury is damage to the brain as the result of an injury.

Traumatic brain injury usually results from a violent blow or jolt to the head that causes the brain to collide with the inside of the skull, and is generally known as a 'closed' head injury. An object penetrating the skull, such as a bullet or shattered piece of skull, is known as an 'open' head injury.

Mild traumatic brain injury may cause temporary, or longer lasting, dysfunction of brain cells. More serious traumatic brain injury can result in bruising, torn tissues, bleeding and other physical damage to the brain that can result in long-term complications or death.

Traumatic brain injury can have wide-ranging physical and psychological effects. Some signs or symptoms may appear immediately after the traumatic event, while others may appear days or weeks later.

Symptoms

A concussion is a traumatic brain injury that alters the way your brain functions. Effects are usually temporary, but can include problems with headache, concentration, memory, judgment, balance and coordination.

Although concussions usually are caused by a blow to the head, they can also occur when the head and upper body are violently shaken. These injuries can cause a loss of consciousness, but most concussions do not. Because of this, some people have concussions and don't realize it.

Concussions are common, particularly if you play a contact sport, such as football. But every concussion injures your brain to some extent. This injury needs time and rest to heal properly. Luckily, most concussive traumatic brain injuries are mild, and people usually recover fully.

Mild traumatic brain injury
The signs and symptoms of mild traumatic brain injury (concussion) may include:
  • Loss of consciousness for a few seconds to a few minutes
  • No loss of consciousness, but a state of being dazed, confused or disoriented
  • Memory or concentration problems
  • Headache
  • Dizziness or loss of balance
  • Nausea or vomiting
  • Sensory problems, such as blurred vision, ringing in the ears or a bad taste in the mouth
  • Sensitivity to light or sound
  • Mood changes or mood swings
  • Feeling depressed or anxious
  • Fatigue or drowsiness
  • Difficulty sleeping
  • Sleeping more than usual

Moderate to severe traumatic brain injuries
Moderate to severe traumatic brain injury can include any of the signs and symptoms of mild injury, as well as the following symptoms that may appear within the first hours to days after a head injury:

  • Loss of consciousness from a few minutes to hours
  • Profound confusion
  • Agitation, combativeness or other unusual behaviour
  • Slurred speech
  • Inability to awaken from sleep
  • Weakness or numbness in the extremities
  • Loss of coordination
  • Loss of bladder control or bowel control
  • Persistent headache or headache that worsens
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • Dilation of one or both pupils of the eyes
  • Clear fluids draining from the nose or ears

Children's symptoms
Infants and young children with brain injuries may lack the communication skills to report headaches, sensory problems, confusion and similar symptoms. In a child with traumatic brain injury, you may observe:

  • Change in nursing or eating habits
  • Persistent crying
  • Unusual or easy irritability
  • Change in ability to pay attention
  • Inability to be consoled
  • Change in sleep habits
  • Sad or depressed mood
  • Loss of interest in favourite toys or activities

When to see a doctor
Always see your doctor if you or your child has received a blow to the head. Seek emergency medical care if there are any signs or symptoms of traumatic brain injury following a recent blow or other traumatic injury to the head.

Note: The terms "mild," "moderate" and "severe" are used to describe the effect of the injury on brain function. A "mild" injury to the brain is still a serious injury that requires prompt attention and an accurate diagnosis.

Causes

Traumatic brain injury is caused by a blow or other traumatic injury to the head. The degree of damage can depend on several factors including the nature of the event and the force of impact. Injury may include one or more of the following factors:

Damage to brain cells may be limited to the area directly below the point of impact on the skull.
A severe blow or jolt can cause multiple points of damage because the brain may bounce back and forth in the skull.

  • A severe rotational or spinning jolt can cause the tearing of cellular structures.
  • A blast, as from an explosive device, can cause widespread damage.
  • An object penetrating the skull can cause severe, irreparable damage to brain cells, blood vessels and protective tissues around the brain.
  • Bleeding in or around the brain, swelling, and blood clots can disrupt the oxygen supply to the brain and cause more widespread damage.

Common causes
Common events causing traumatic brain injury include the following:

  1. Falls. Falling out of bed, slipping in the bath, falling down steps, falling from ladders and related falls are the most common cause of traumatic brain injury overall, particularly in older adults and young children.
  2. Vehicle-related collisions. Collisions involving cars, motorcycles or bicycles — and pedestrians involved in such accidents — are a common cause of traumatic brain injury, particularly among adults in their early 20s.
  3. Violence. About 10 percent of traumatic brain injuries are caused by violence, such as gunshot wounds, domestic violence or child abuse. Shaken baby syndrome is traumatic brain injury caused by the violent shaking of an infant that damages brain cells.
  4. Sports injuries. Traumatic brain injuries may be caused by injuries from a number of sports, including boxing, football, baseball, lacrosse, skateboarding, hockey, and other high-impact or extreme sports.
  5. Explosive blasts and other combat injuries. Explosive blasts are a common cause of traumatic brain injury in active-duty military personnel. Although the mechanism of damage isn't well understood, many researchers believe that the pressure wave passing through the brain significantly disrupts brain function. Traumatic brain injury also results from penetrating wounds, severe blows to the head with shrapnel or debris, and falls or bodily collisions with objects following a blast.

Traumatic Brain Injury (TBI) is an injury to the brain caused by a trauma to the head (head injury). There are many possible causes, including road traffic accidents, assaults, falls and accidents at home or at work.

Effects and recovery
The effects of a traumatic brain injury can be wide ranging, and depend on a number of factors such as the type, location and severity of injury.

What happens in a TBI?

The Medical Disability Society Working Party Report on the Management of Traumatic Brain Injury (February 1988) defines traumatic brain injury (TBI) as:

'Brain injury caused by trauma to the head (including the effects upon the brain of other possible complications of injury, notably hypoxemia and hypotension, and intracerebral haematoma)'.

In other words, a brain injury is caused at least initially by outside force, but includes the complications which can follow, such as damage caused by lack of oxygen, and rising pressure and swelling in the brain.

A traumatic brain injury can be seen as a chain of events:
  1. The first injury occurs in the seconds after the accident
  2. The second injury happens in the minutes and hours after this, depending on when skilled medical intervention occurs
  3. A third injury can occur at any time after the first and second injuries, and can cause further complications.
 
The First Injury
There are three sorts of first injury - Closed, Open and Crush.

Closed Head Injuries
Closed head injuries are the most common type, and are so called because no break of the skin or open wound is visible. These often happen as a result of rapid acceleration or deceleration, for example when a car hits a brick wall, or a car is hit from behind at traffic lights. The head is rocked back and forth or rotated, and the brain must follow the movement of the skull. It can twist, and the billions of nerve fibres which make up the brain can be twisted, stretched and even torn in the process.

Even mild injuries of this sort can produce damage which is quite widespread throughout the brain. This is defined as diffuse brain injury. The front of the skull has sharp bony ridges with which the brain can also collide, causing more damage. Arteries and veins running through the brain can be damaged, allowing blood to leak.

Open or Penetrating Wounds
These are not so common. In this type of injury the skull is opened and the brain exposed and damaged. This could be due to a bullet wound, or collision with a sharp object such as a motorcycle brake lever, or being hit by a pickaxe. If the damage is limited to one specific area, outcomes can be quite good, even though the accident may have seemed horrific. In many cases, however, this type of injury may be combined with an acceleration type injury as well.

Crushing Injuries
In this type of injury, the head might be caught between two hard objects, such as the wheel of a car and the road. This is the least common type of injury, and often damages the base of the skull and nerves of the brain stem rather than the brain itself. There may be no loss of consciousness.
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The Second Injury
This happens when the brain is starved of oxygen, which makes damage from the first injury worse. It can happen for several reasons. Examples are choking on vomit after an accident, blood blocking a person's airway, or by the position which someone is lying in obstructing their airway. If other injuries are present, as they often are, serious blood loss can affect blood flow to the brain. As a result, the amount of oxygen reaching the brain can be reduced.

Understanding the relationship between the first injury and the effects of lack of oxygen has led to improvements in the kind of emergency treatment administered at the site of an accident by paramedics. They will make sure breathing is maintained and blood pressure is brought back to normal levels by emergency transfusions.
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The Third Injury
This can take place at any time after the first and second injury, in the days and sometimes weeks which follow, and could be as a result of bleeding, bruising or swelling in the brain or because blood clots have developed.

Blood leaking from torn blood vessels and other body fluids leaking into the area cause the brain to swell. This is a serious problem because the skull is a fixed space, and there is no room for expansion. It causes complications in two ways. Firstly, the walls of the skull are hard and unyielding, and damage the soft brain when it squeezes against them. Secondly, when the brain swells it can squeeze the blood vessels, limiting the brain's blood circulation. This can be fatal, so intracranial pressure is monitored very carefully once the patient is in hospital.

Measures to reduce the risk of raised pressure include putting the patient on a ventilator to ensure a good supply of oxygen, and controlling the amount of water and salts in the body to cut down on the flow of fluid into the brain.

Blood clots occur when blood has leaked from damaged veins and arteries and then pools into a clot. They can press on the surrounding brain tissue which can damage it, and they also raise pressure in the brain. Clots can occur in the brain itself (an intercerebral clot) or in the space between the brain and the skull (a subdural or an extradural clot). Blood clots, also called haematomas, can occur after quite minor injuries, and this is why patients are often kept under observation in hospital until the risk of a clot forming is likely to be over.

 

The Effects of Traumatic Brain Injury on Brain Function

Damage to the nerve fibres deep in the central part of the brain, which normally keeps a person awake and alert, results in the most obvious of symptoms - coma.

This link between damage to particular parts of the brain and a corresponding lack of brain function means, for example, that damage to the side of the brain (parietal lobes) results in weakness in the limbs on the opposite side of the body. Injury to the left side of the brain or the brain stem itself tends to cause speech and language impairment.

Coma, loss of power in the arms and legs, and speech impairment are the most visible signs of brain injury. However, traumatic brain injury causes numerous 'hidden disabilities' in that it results in changes to personality, thinking and memory. For example, damage to the brain behind the forehead (frontal lobes) results in behavioural problems, such as loss of insight and self-restraint.

Injury severity
After a traumatic brain injury, whether or not the person was actually unconscious, a state occurs where the person seems to be aware of things around them but is confused and disorientated. They are not able to remember everyday things or conversations, and often do or say bizarre things. This is called Post-Traumatic Amnesia (PTA), and is a stage through which the person will pass.

The length of PTA and/or loss of consciousness are important as they give an indication of the severity of the injury.

The term 'Coma' is often used to describe longer periods of unconsciousness.

The table below gives a rough guide to how these measures affect the severity of the injury, although it is worth noting that everyone is different and categorising injuries in this way doesn't always give an accurate measure of the long-term effects.



Minor brain injury and concussion
A brief period of unconsciousness, or just feeling sick and dizzy, may result from a person banging their head getting into the car, walking into the top of a low door way, or slipping over in the street. It is estimated that 75-80% of all head injuries fall into this category.

Post-concussion syndrome
The effects of a minor head injury can be anything but minor to the person concerned. They can include nausea, headaches, dizziness, impaired concentration, memory problems, extreme tiredness, intolerance to light and noise, and can lead to anxiety and depression. When problems like this persist, they are often called post-concussion syndrome.

Symptoms of post-concussion syndrome include:
  • Headaches
  • Irritability
  • Feelings of dizziness
  • Restlessness
  • Nausea
  • Impulsivity and self-control problems
  • Sensitivity to light
  • Difficulties with concentration
  • Sensitivity to noise
  • Feeling depressed, tearful, anxious
  • Sleep disturbance
  • Fatigue
  • Memory problems
  • Difficulties thinking and problem-solving

In most cases these symptoms will resolve themselves within two weeks. However, in some cases they may persist much longer. Try not to rush back into normal activities, as this may delay recovery. If you still have any symptoms after two weeks we suggest you see your GP and take our 'Minor head injury discharge advice' factsheet with you. It may be possible to seek referral to a head injury specialist such as a neurologist or neuro-psychologist.

A common problem is that either no scans were done at the time of the accident, or subsequent scans show no damage. This frequently gives rise to the impression that there is nothing medically wrong. The persistent problems can be misunderstood by GPs, sometimes being considered as almost hypochondria on the part of the patient. Although it is true that in some cases where the symptoms persist for months a psychological element such as depression can come into play. While this may make existing conditions even more difficult to live with, it is not on the whole true or helpful to say that 'it is all in the mind'. A second opinion should be sought from a neurologist or neuro-psychologist.


Practical issues

It is important that relatives and employers are warned about the possible effects of a minor head injury, and for plans to be made accordingly. These might include not rushing to return to work, keeping stress to a minimum in the short term, and abstaining from alcohol. One study showed that almost one third of people with a minor head injury were not working full-time three months after receiving the injury, although other studies have been much more optimistic. Difficulties are certainly made much worse if the person has a mentally demanding job where there is a low margin for error.

Recovery and further information
The general conclusion seems to be that the vast majority of people who experience a minor head injury make a full recovery, usually after 3-4 months. However there is a very small sub-group whose recovery is not so good.

Moderate brain injury
A moderate head injury is defined as loss of consciousness for between 15 minutes and 6 hours, or a period of post-traumatic amnesia of up to 24 hours. The patient can be kept in hospital overnight for observation, and then discharged if there are no further obvious medical injuries. Patients with moderate head injury are likely to suffer from a number of residual symptoms.
The most commonly reported symptoms include tiredness, headaches and dizziness (physical effects) difficulties with thinking, attention, memory planning, organising, concentration and word-finding problems (cognitive effects) and irritability (an emotional and behavioural problem). These symptoms are accompanied by understandable worry and anxiety. This can be particularly pronounced if the patient has not been warned that these problems are likely to arise. If the patient expects to be perfectly well within a few days and symptoms are still prominent after a few weeks, they may worry or feel guilty. This has the effect of creating a vicious circle leading to more symptoms and so on.

A large proportion of people find that when they return to work they have difficulties and feel that they are not functioning at their highest level. For the majority of people these residual symptoms gradually improve, although this can sometimes take 6 to 9 months.

Severe brain injury
Severe head injury is usually defined as being a condition where the patient has been in an unconscious state for 6 hours or more, or a post-traumatic amnesia of 24 hours or more. These patients are likely to be hospitalised and receive rehabilitation once the acute phase has passed. Depending on the length of time in coma, these patients tend to have more serious physical deficits.

A further category of very severe injury is defined by a period of unconsciousness of 48 hours or more, or a period of PTA of 7 days or more. The longer the length of coma and PTA, the poorer will be the outcome. However, there are exceptions to this rule and, just as there is a small group of people who have a mild head injury who make a poor recovery, so there is a small group of individuals who have a severe or very severe injury who do exceptionally well.

Coma and Persistent Vegetative State
Coma can be defined as a state of depressed consciousness where the patient is unresponsive to the outside world. Unconsciousness follows traumatic brain injury, whether for a few seconds or for a few weeks, and is the most typical symptom of a head injury.

A small number of people sustain a head injury so severe that they remain in a state of coma for months and years without recovering sufficient consciousness to make any form of communication, but can breathe without mechanical assistance. This is called 'Persistent Vegetative State (PVS)'.

Effects of brain injury

The effects of a brain injury can be wide ranging, and depend on a number of factors such as the type, location and severity of injury. Every person's injury is unique, so they will experience any number of the symptoms, which can range from mild to severe.

The effects of brain injury can be divided into three categories:

Cognitive effects of brain injury
The cognitive effects of a brain injury affect the way a person thinks, learns and remembers. Different mental abilities are located in different parts of the brain, so a head injury can damage some, but not necessarily all, skills such as speed of thought, memory, understanding, concentration, solving problems and using language.

Executive dysfunction after brain injury
Executive dysfunction is a term for the range of cognitive, emotional and behavioural difficulties which often occur after injury to the frontal lobes of the brain. Impairment of executive functions is common after acquired brain injury and has a profound effect on many aspects of everyday life.
Emotional and behavioural effects of brain injury

Everyone who has had a head injury can be left with some changes in emotional reaction and behaviour. These are more difficult to see than the more obvious problems such as those which affect movement and speech, for example, but can be the most difficult for the individual concerned and their family to deal with.
Physical effects of brain injury

Most people make an excellent physical recovery after a brain injury, which can mean there are few, or no, outwards signs that an injury has occurred. There are often physical problems present that are not always so apparent, but can have a real impact on daily life.
Hormonal imbalances and pituitary dysfunction after brain injury

Brain injury may occasionally cause damage to the hypothalamus and/or pituitary gland, which can lead to insufficient or increased release of one or more hormones.

Risk factors
The people most at risk of traumatic brain injury include:

  • Children, especially newborns to 4-year-olds
  • Teenagers, especially those 15 to 19 years of age
  • Adults over 65

Complications
Several complications can occur immediately or soon after a traumatic brain injury. Severe injuries increase the risk of a greater number of complications and more-severe complications.

Altered consciousness
Moderate to severe traumatic brain injury can result in prolonged or permanent changes in a person's state of consciousness, awareness or responsiveness. Different states of consciousness include:

  1. Coma. A person in a coma is unconscious, unaware of anything and unable to respond to any stimulus. This results from widespread damage to all parts of the brain. After a few days to a few weeks, a person may emerge from a coma or progress to a vegetative state.
  2. Vegetative state. Widespread damage to the brain can result in a vegetative state. While the person is unaware of his or her surroundings, he or she may groan or have open eyes or reflex responses. It is possible that a vegetative state can become permanent, but often individuals progress to a minimally conscious state.
  3. Minimally conscious state. A minimally conscious state is a condition of severely altered consciousness but with some evidence of self-awareness or awareness of one's environment. It is often a transitional state from a coma or vegetative condition to greater recovery.
  4. Locked-in syndrome. A person in a locked-in state is aware of surroundings and awake, but he or she can't move or speak. The person may be able to communicate with eye movement or blinking. This state results from damage limited to the lower brain and brainstem.
Seizures
Some people with traumatic brain injury will have seizures within the first week. More-serious injuries may result in recurring seizures, called post-traumatic epilepsy.

Infections
Skull fractures or penetrating wounds can tear the layers of protective tissues (meninges) that surround the brain, thereby enabling bacteria to enter the brain. An infection of the meninges (meningitis) can be especially dangerous because of its potential to spread to the rest of the nervous system.

Nerve damage
Injuries to the base of the skull can damage nerves that emerge directly from the brain (cranial nerves). 

Cranial nerve damage may result in:
  • Paralysis of facial muscles
  • Damage to the nerves responsible for eye movements, which can cause double vision
  • Damage to the nerves that provide sense of smell
  • Loss of vision
  • Loss of facial sensation

Cognitive problems
Most people who have had a significant brain injury will experience changes in their cognitive skills. 

Traumatic brain injury can result in problems with any of these skills:
  • Memory
  • Learning
  • Reasoning
  • Problem solving
  • Speed of mental processing
  • Judgment
  • Attention or concentration
  • Multitasking
  • Organization
  • Decision making
  • Beginning or completing tasks
  • Communication problems
Language and communications problems are common following traumatic brain injuries. These problems can cause frustration, conflict and misunderstanding for people with an injury, as well as family members, friends, care providers and medical personnel. Communication problems may include:

  • Difficulty understanding or producing spoken and written language (aphasia)
  • Difficulty deciphering nonverbal signals
  • Inability to organize thoughts and ideas
  • Inability to use the muscles needed to form words (dysarthria)
  • Problems with changes in tone, pitch or emphasis to express emotions, attitudes or subtle differences in meaning
  • Trouble starting or stopping conversations
  • Trouble with turn taking or topic selection
  • Trouble reading cues from listeners
  • Trouble following conversations
  • Behavioral changes
People who've experienced brain injury often experience changes in behaviors. These may include:

  • Difficulty with self-control
  • Lack of awareness of abilities
  • Risky behaviour
  • Inaccurate self-image
  • Difficulty in social situations
  • Verbal or physical outbursts
  • Emotional changes
Emotional changes may include:
  • Depression
  • Anxiety
  • Mood swings
  • Irritability
  • Lack of empathy for others
  • Lack of motivation
  • Sensory problems
Problems involving senses may include:
  • Persistent ringing in the ears
  • Difficulty recognizing objects
  • Impaired hand-eye coordination
  • Blind spots or double vision
  • A bitter taste or a bad smell
  • Persistent tingling, itching or pain
  • Trouble with balance or dizziness
Degenerative brain diseases
A traumatic brain injury may increase the risk of diseases that result in the gradual degeneration of brain cells and gradual loss of brain functions. These include:

  • Alzheimer's disease, which primarily causes the progressive loss of memory and other thinking skills (dementia)
  • Parkinson's disease, which primarily causes the progressive loss of motor skills
  • Dementia pugilistica — most often associated with repetitive blows to the head in career boxing — which causes dementia and Parkinson's symptoms

Tests and diagnosis

Because traumatic brain injuries are usually emergencies and because consequences can worsen swiftly without treatment, doctors usually need to assess the situation rapidly.

Glasgow Coma Scale
This 15-point test helps a doctor or other emergency medical personnel assess the initial severity of a brain injury by checking a person's ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues. Abilities are scored numerically. Higher scores mean milder injuries.

Information about the injury and symptoms
If you observed someone being injured or arrived immediately after an injury, you may be able to provide medical personnel with information that's useful in assessing the injured person's condition. 

Answers to the following questions may be beneficial in judging the severity of injury:

  • How did the injury occur?
  • Did the person lose consciousness?
  • How long was the person unconscious?
  • Did you observe any other changes in alertness, speaking, coordination or other signs of injury?
  • Where was the head or other parts of the body struck?
  • Can you provide any information about the force of the injury? For example, what hit the person's head, how far did he or she fall, or was the person thrown from a vehicle?
  • Was the person's body whipped around or severely jarred?

Imaging tests

  1. CT scans. Computerized tomography (CT) is a specialized X-ray technology that can produce thin cross-sectional images of the brain. A CT scan can quickly visualize fractures and uncover evidence of bleeding in the brain (hemorrhage), blood clots (hematomas), bruised brain tissue (contusions) and brain tissue swelling.
  2. MRIs. Magnetic resonance imaging (MRI) uses a magnetic field and radio waves to produce cross-sectional or 3-D images of soft tissues. Doctors rarely use MRIs during emergency assessments of traumatic brain injuries because the procedure takes too long to complete. The device may be used after a person's condition has been stabilized.
  3. Intracranial pressure monitor. Tissue swelling from a traumatic brain injury can increase pressure inside the skull and cause additional damage to the brain. Doctors may insert a probe through the skull to monitor this pressure.

These tests are effective in seeing major disruptions or damage to the brain, as is the case with open head injuries and severe brain injuries. It is common for people with mild traumatic brain injuries to receive 'normal' results. In these cases, other diagnostic tests, such as neuro-psychiatric assessment, are better able to pick up more subtle changes in functioning.

Treatments and drugs

Mild injury
Mild traumatic brain injuries usually require no treatment other than rest and over-the-counter pain relievers to treat a headache. However, a person with a mild traumatic brain injury usually needs to be monitored closely at home and with a follow-up doctor appointment for any persistent, worsening or new symptoms.

Your doctor will advise you on when it's appropriate to resume work, school or recreational activities. He or she is likely to advise a gradual return to normal routines.

Immediate emergency care
Emergency care for moderate to severe traumatic brain injury focuses on making sure the person has an adequate oxygen and blood supply, maintaining blood pressure, and preventing any further injury to the head or neck. People with severe injuries may also have other injuries that need to be addressed.

Additional treatments in the emergency room or intensive care unit of a hospital will focus on minimizing secondary damage due to inflammation, bleeding or reduced oxygen supply to the brain.

Medications
Medications to limit secondary damage to the brain immediately after an injury may include the following:

  • Diuretics. These drugs reduce the amount of fluid in tissues and increase urine output. Diuretics, given intravenously to people with traumatic brain injury, help reduce pressure inside the brain.
  • Anti-seizure drugs. People who've had a moderate to severe traumatic brain injury are at risk of having seizures during the first week after their injury. An anti-seizure drug may be given during the first week to avoid any additional brain damage that might be caused by a seizure. Additional anti-seizure treatments are used only if seizures occur.


Rehabilitation after brain injury

Rehabilitation aims to help the brain learn alternative ways of working in order to minimise the long-term impact of the brain injury. Rehabilitation also helps the survivor and the family to cope successfully with any remaining disabilities.

Continuing care after brain injury
If a person with a brain injury no longer requires intensive rehabilitation but still needs further support, there are a number of options for continuing care. This includes residential/nursing care, intermediate care and care at home.

Caring for someone with a brain injury

If you are caring for someone with a brain injury, or have a relative being treated in hospital, then the information here should help you to meet the challenges ahead and find the support you need.

Brain injury doesn't just affect individuals; it can transform the lives of entire families. Depending upon the severity of your relative's injury and its effects, you may have to make considerable changes to the way you live, such as becoming a part-time or full-time carer.

A survivor's story of brain injury - I Wanted My Brain Back


What happens when you’re a PhD economist and you suddenly can’t remember things or think straight? One woman’s story of perseverance reveals some of the mysteries of the brain.

It was a beautiful June Saturday afternoon. Anne Forrest steered her white Acura onto Memorial Bridge. The Lincoln Memorial rose before her.

Back from a business trip to Panama, Anne had picked up her cat from a colleague at the Environmental Law Institute, a nonprofit where she worked as an economist.

After crossing the bridge, she bore right at the Lincoln Memorial and dropped down toward Rock Creek Parkway. She craned her head to the left, watching for her chance to merge onto the parkway.

As Anne waited, a woman in an SUV hit her from behind. Both drivers got out to inspect the damage—Anne’s car had a dent in the back—and exchange information. A Park Police officer took an accident report. Anne felt shaken but looked fine; she got in her Acura and drove on.

“Who knew?” she says. “But that changed my entire life.”

The next day, June 15, 1997, Anne went to the Texas State Society Father’s Day picnic with Michael Crider, a man she was dating. Both Anne and Michael had grown up in Texas. One of their first dates, a year earlier, had been at this annual event.
Anne spent part of the picnic on the phone, trying to resolve a problem at work, but couldn’t grasp what her boss was saying.

Early Monday morning, she woke up feeling cold, nauseated, and with “the worst headache I have ever had.” At work, Anne would start to dial a phone number but couldn’t get through all the digits. She told colleagues about her accident and her headache. They urged her to see a doctor.

The primary-care physician thought Anne had whiplash. He wanted to see her twice a week to keep her under observation.

Two weeks later, Anne was on I-270, driving to church, when her right foot and right arm went numb.

“That was my wake-up call,” she says.

Neurologist Lewis Eberly diagnosed it as a mild traumatic brain injury.

When Anne’s car was rear-ended, it started a chain reaction in her head. The brain is made up of millions of nerve cells connected by fibers called axons. When Anne’s head was thrust from side to side and front to back, some axons—which carry messages between brain cells—were torn or twisted.

Traumatic brain injury has been called a “silent epidemic.” Each year, the Centers for Disease Control and Prevention say, 1.4 million Americans sustain a traumatic brain injury, or TBI—often in car accidents, falls, or sports mishaps. Experts believe the number of TBIs is higher because the estimate reflects only emergencyroom visits, and many patients never go to a hospital.

Three-quarters of cases are concussions or mild brain injuries. “Mild” means the patient was never unconscious or wasn’t unconscious for a long time. The results can be anything but mild.

If brain injury is an “epidemic,” why is it a silent one? “Because many of us have sustained a concussion, and two-thirds of individuals who sustain a concussion are back to normal by three months,” says Gregory O’Shanick, medical director for the Brain Injury Association of America.

But many who sustain a head injury have problems remembering things and concentrating. Accidents can be so minor that neither doctor nor patient makes the connection. Your teenage son is having difficulty at school? Must be inattention, not that hockey injury. You’re 50 and forgetting things? Must be age, not that fall off a bicycle months ago.

“Most physicians don’t have a clear understanding of brain injury,” says Dr. Ali Ganjei, director of the brain injury and stroke program at Inova Mount Vernon Hospital. “People would have a concussion, they’d be out for an hour or so, then regain consciousness, and we’d think everything was okay. If the person later had difficulties, we never linked it to that head injury.”

Susan Connors, president of the Brain Injury Association of America, is more direct: “Traumatic brain injury is the most misunderstood, misdiagnosed, underfunded public health problem our nation faces.”

First Months: A Roller Coaster

Even after the diagnosis of mild traumatic brain injury, Anne, 39 at the time, was struggling.

Bill payments lapsed because she couldn’t balance her checkbook. She had a hard time cooking; she’d lose track of what she was doing or make mistakes, like putting mayonnaise on the outside of a sandwich.

She’d wear the same outfit day after day; it was hard to match clothes. One day, instead of putting on her pants by sliding in her right leg first, as usual, she had started on the left. She couldn’t remember what came next. She sat on the bed and cried.

At work, she went on short-term disability. Her neurologist assured her that most patients are fine within six months.

Anne loved to play volleyball; she had played varsity at Yale. But her balance was shaky. She stayed away from sports.

Scared after the incident on I-270, she stopped driving. Even being a passenger in a car was hard. If a car merged into the next lane, she’d yell, “Watch out!”

“I couldn’t trust my brain,” Anne says. “You can imagine I was fun to drive with.”

She was still having headaches. Hours might pass before she realized she had one—often until a friend, noticing her discomfort, asked whether her head hurt. Anne wouldn’t think to take aspirin unless someone reminded her. She wrote herself a note: If you get a headache, take aspirin.

She likened reading to being on a roller coaster: Information was flying past, but she couldn’t absorb it. How would she go back to work if she couldn’t read?

Like many with mild brain injury, Anne looked fine. She was high-functioning in comparison with “moderate” and “severe” brain-injury patients, who might show signs of paralysis or impaired speech.

But on a trip that summer to Mohonk Mountain House, a resort in the Catskills, friend Michele Flynn, a special-education teacher, could tell Anne was having problems with short-term memory. When Anne cut short a hike to go back to the room by herself, Michele pinned directions to Anne’s shirt.

Kathy Rabin, a friend from Yale, knew Anne was having problems—she had Anne call her every day to check in. But she didn’t realize the extent of the difficulties until Anne visited her in Boston. Kathy went out and left her dog in the yard, asking Anne to let the dog in. Hours later, when Kathy returned, the yellow Lab was outside the back door.

When Kathy visited Anne, who lived alone, she discovered notes stuck all over Anne’s apartment. One affixed to the front door said take keys, wallet, call kathy.

Anne couldn’t remember anything new unless she wrote it down. “That summer’s a bit of a blur,” she says.

Her short-term memory was so bad, she says, “I could hide my own Easter eggs.”

She slept a lot, sometimes 18 hours at a time. One activity a day—going to a doctor’s appointment or to a friend’s—was all she had energy for.

Prior to the accident, Anne was energetic, fun to be with, always making friends.

Lawrence Pratt, a former colleague at the Environmental Law Institute, recalls a time when Anne gave a cranky parking attendant a cake. “She told him, ‘You are always mean to me. I don’t know what I did, but I baked you a cake to see if I could fix whatever it is.’ The man gave her a hug and wept.”

Some friends began to wonder if Anne, who had lived and worked at a fast pace, was having a nervous breakdown. “Our thought was, ‘What can we do to get Anne to snap out of this?’ ” Pratt says.

Friends didn’t connect her behavior to the accident. “We did not have the cues that movies train us to look for,” he says. “No amnesia, no head bandage.

“It was terrifying to see a person with that much talent and potential suffer from something so invisible.”

Six Months Out: A Lot of Help From Her Friends

In brain injury, the frontal lobes sustain most of the damage, says the Brain Injury Association’s Gregory O’Shanick.

The frontal lobes help us plan and follow through, part of executive functioning. They control concentration and problem-solving.

O’Shanick explains the damage using a computer analogy. “With the injury, somebody changed her processor from a Pentium 4 to a Pentium 1, and somebody reduced her RAM,” he says. “It takes her longer to process than it used to.”

Anne’s mother had died, and her father and siblings lived far away, so she relied on friends like Michael and Kathy. They talked her through phone calls she had to make to doctors and insurers. They rescued her when she locked herself out of the house or took the wrong bus. After she left a stove burner on, Michael bought her a toaster oven and a rice cooker—things that shut themselves off.

Anne tried to work, putting in a few hours a week. Interns had to read her her mail. She couldn’t use a computer. Depression crept in. “I wanted my brain back,” she says.

For months, Anne had undergone tests, including magnetic resonance imaging (MRI), an electroencephalogram (EEG), and computed tomography (CT scan). Injury to the brain’s axons usually does not show up on CT scans or MRIs. Doctors told her the test results were fine.

“Mine is the best-studied brain in Washington,” she says. Still, she says, “I couldn’t do things, and no one could tell me why.”

Accurate diagnosis is one of the difficulties in mild brain injury. “Individuals have been misdiagnosed with having depression or as malingerers,” says O’Shanick.

“Mild-injury issues are so different,” Anne says. “A lot revolves around the fact that others cannot see the injury and around trying to get back to work and life when you cannot get appropriate care.” She eventually stopped using her disabled bus pass because drivers questioned why she had one.

During appointments, doctors didn’t always notice her deficits. She wasn’t selfaware enough to see them.

“I didn’t know enough to say, ‘I can’t do this and I can’t do that,’ ” says Anne. “Your brain’s not working, so you can’t process that your brain’s not working. You have a brain injury, you think the doctor can see it.”

Money became an issue. Short-term disability had run out, and Anne’s health insurer denied her long-term disability until it knew what was wrong. She went through more tests.

Even Anne began to wonder: Was it psychological? “It’s a period where you’re vulnerable because you’re not sure what’s wrong,” she says.

The results of neuropsychological tests done by her doctors were consistent with brain injury. Still, she’d received little treatment.

“A lot of people get lost in the system,” says Annandale neuropsychologist Alec Lebedun. “People can wander around for years until they find the right person.”

One problem is a lack of programs and therapists trained to work with mild head injuries, says Dr. Yehuda Ben-Yishay, founder of a brain-injury treatment program at New York University Medical Center. Another is that insurers sometimes won’t pay for cognitive rehabilitation or pay for a limited amount.

In recent decades, everything from air bags to advances in emergency medicine have meant that people in car accidents and other traumas are more likely to survive their injuries—and more likely to need long-term services.
Thirty years ago, says Susan Connors of the Brain Injury Association of America, half of those who sustained head injuries in a car crash died at the scene. Today, less than a quarter do.

The thing Anne needed to navigate the maze of medicine and insurance—her brain—was what was impaired.

On her own, Anne had been seeing a chiropractor for headaches and neck pain. The chiropractor, Philip Shambaugh, recommended she see a developmental optometrist, Amiel Francke, after Anne complained that she couldn’t read.

Twice a week, she attended small-group sessions to practice eye exercises such as following her thumb. The idea of vision therapy is to retrain the eyes to move correctly with the brain. The signals coming into Anne’s brain were so distorted, life was like watching a foreign movie in which the English dubbing is out of sync—but you don’t know it’s out of sync.

The distortion made reading and tasks like going to a grocery store—with its bright lights and busy shelves—overwhelming. “I’d open the door to Best Buy, and she’d freeze,” says Michael. He would have to lead her out.

The driver who hit Anne had the minimum insurance then required in DC, $25,000. The insurer offered to pay Anne’s bills, but friends suggested she hire a lawyer before agreeing to anything.

Ron Simon, Anne’s attorney, worried that $25,000 wouldn’t be enough if Anne couldn’t work again. He read Anne’s policy and found she’d had coverage for underinsured drivers. But her insurance company refused to pay.

“Their argument was ‘How could you have this much damage if your car wasn’t wrecked?’ ” says Simon. “It’s not apparent she’s injured. They tried to label her a faker.”

Anne lost the case. Even her attorney admits that he didn’t see Anne’s deficits at first, but they became apparent the more time he spent with her.

“You would give her something simple to do—‘Let’s get your medical bills together’— and she couldn’t do it,” he says. “She couldn’t remember what to do from a meeting unless I wrote it out for her.”

Two Years: Some Answers

A friend’s father mentioned hearing a lecture by a New York neuropsychologist, Thomas Kay, an expert on mild brain injury. Anne made an appointment. Kay told her she needed cognitive therapy to teach her her deficits and how to compensate.

Anne called the contact Kay had given her, and in April 1999, she visited a neuropsychologist at National Rehabilitation Hospital in Washington.
The neuropsychologist said that Anne was doing too well for rehab. She suggested that maybe Anne wasn’t better because she didn’t want to get well. Anne was confused— it took such effort to process what the doctor was saying—that only later, when telling Kathy about the appointment, did she get upset.

The neuropsychologist did tell Anne that she needed to rest more. Anne’s internist at the time had told her the opposite, to “push through” fatigue.

“If you sprain your brain, one of the key things to do is rest it,” O’Shanick says. “When you have axonal injury, your brain fatigues easily—that’s why you see headache, dizziness, irritability.”

Anne had been trying to resume a normal life but was exhausted. Some days all she had energy for was getting dressed and eating breakfast before she wanted to go back to bed. If she pushed too much, Michael says, she’d hit a wall and become nonresponsive. Once Anne began to take three naps a day, frustrating days were less frequent.

Clues of Hope: Crossword Puzzles and Movies

Anne passed the two-year anniversary of her accident, painfully aware of what doctors believed: Any recovery would occur in the first two years. She fell back on optimism to get through.

Needing something to do every day, something that felt like an accomplishment, she had started doing crossword puzzles.

She canceled delivery of the Washington Post, forcing her out of the house to buy the paper. It became a game: Could she remember her wallet? She often had to turn back for money.

Anne hadn’t done crosswords, so it didn’t frustrate her when, at first, she might get just five words. She and Kathy began to do puzzles together each day over the phone. Crosswords forced Anne to scan her memory—the words were there; she just needed prompts. The puzzles got easier. Without knowing it, Anne was doing cognitive therapy.

“Part of therapy is retraining the brain,” says Melanie Reynolds, Anne’s former speech-language pathologist at Inova Mount Vernon Hospital. Broken connections can regenerate, and the brain can detour around damage and form new paths.

The puzzles proved to Anne that she could get better.

“A brain-injury counselor told me that he thought the reason why people don’t recover after two years was because they get tired of fighting the medical and disability systems and give up,” Anne says. “One of the things I think about is, what if I had given up?”

Anne loved movies. But after her accident, when she and Michael went to see The Horse Whisperer, Anne couldn’t watch—the screen looked like it was moving. She listened to the movie with her face buried in Michael’s shoulder.

If Anne could learn crosswords, could she retrain herself to watch movies?
To start, Michael wrote down the steps for turning on the VCR so she could watch videos at home. Anne would get hung up on a plot if a detail was missing; Michael would explain when the piece eluding her hadn’t been revealed yet. She relearned letting a story unfold.

She didn’t understand Magnolia—but a lot of people didn’t. She realized she couldn’t blame everything on head injury.

One film she understood all too well was Memento, about a man with severe memory damage. She and Michael walked out after 15 minutes: “It was too much of my life.”

A New Brain

Michael had moved to Austin for a job, and the relationship began to strain. He was frustrated that Anne’s recovery was going nowhere.

Anne was just as frustrated. Although the Environmental Law Institute had hired someone to do her job, she felt the door was open if she could return. In Washington, where “what do you do?” comes after “nice to meet you,” she could no longer define herself. When she visited Texas, people didn’t ask what she did for a living.

So with help—Michael got her packed; a friend helped her set up an apartment— Anne decided to move to Austin, at least for a while. There she’d be not only with Michael but with childhood friends.

“That was comforting because they knew it wasn’t me. Part of the problem being in a big city is you have people who don’t know you say, ‘There’s nothing wrong,’ ” Anne says.

In Austin, Anne eventually attended a support group. At meetings, she looked around at the quadriplegics and others with severe head injuries and felt fortunate but not always supported. So she formed her own support group, something she had watched her mother, Roz, do as Roz was dying of cancer.

In Washington, being with old friends who were doing what Anne yearned to do—advancing careers and starting families—had been hard. “People couldn’t understand my injury,” Anne says. She had been spending more time with new people she met, people who had no expectations of her. But she had been isolated from others who had brain injury and issues like hers.

With her new support network, she could joke about her situation. On one summer outing, she and friends including Kathy, who has chronic fatigue syndrome, wore T-shirts with disability camp printed on the front. On the back: it’s no vacation.

Liz Joiner, a speech and cognitive therapist, helped Anne identify her deficits and learn to work around them. Anne couldn’t organize herself, so Joiner designed a threering binder that Anne calls her “brain.” In it, divided by colored tabs, are calendars and to-do lists. Writing something down means it’s more likely to get into memory.
Anne’s brain worked better when fed smaller bits of information, so Joiner retaught her tasks by breaking them down. Paying a bill might involve ten steps, including “get a pen.” While an undamaged brain thinks through the steps automatically, someone with brain injury needs cues. Eventually, the steps can become automatic again.

Memories of third grade flooded back to Anne as Joiner retaught her how to compose a paragraph. She encouraged Anne to write about her injury.

But Anne had a bigger goal: Get back to work, get back to economics.

Anne, who once did math in her head, would have to relearn it all.

Addition and subtraction came easily. One day, as she worked with Joiner, Anne realized she couldn’t divide or multiply. It would come back, Joiner assured her.

“It was difficult to come face to face with the idea of relearning second-grade math,” Anne says. “That was a big moment in realizing your life is different.”

Anne no longer possessed the analytical skills for her old job. She made mistakes. Math was no longer fun.

It was a moment of acceptance but not defeat. If she couldn’t immediately resume her old life, Anne was determined to find ways around the paths that were blocked.

Anne had to explain her limitations to her colleagues; before rehab, she either hadn’t recognized them or had hid them. As Anne began to write and talk about her injury, Slatin invited her to speak to a class he taught on accessibility issues.

After, Anne recalls John Slatin saying, “ ‘Your speech—you still think like an economist.’ It was like finding something precious I thought I had lost.”

At Four Years: First Dance

With help—Liz coached, while Michael set up equipment—Anne got back on a computer. At first Anne could sit in front of the screen for only ten minutes, but sending or reading an e-mail made her feel connected again.

Anne worked with physical therapist Ann Katz to improve her balance. In a session, she might fix her eyes on a target while walking or sit on an exercise ball with her eyes closed.

Anne was eager to manage her dizziness so she could get back to exercise; she had gained 30 pounds. Eventually she would work up to three-mile walks and kicking around a soccer ball.

For now, she had a more immediate goal. Anne and Michael had gotten engaged. While friends pitched in on planning the wedding and Michael handled details like the cake, Anne worked with Katz on how to dance without getting too dizzy.

Although marriages and relationships often fall apart after one partner suffers a brain injury, this one had survived.

Michael had been married once before. “Going through a divorce taught me to reevaluate myself in relationships. The communication in my first marriage wasn’t that good,” he says. “I saw a lot of things in Anne I really liked. In figuring out the injury with her, figuring out the rehab process with her, it helped me understand what she was going through.” They had to listen to each other and discuss their needs. It was the most fundamental communication, and it built an intimate bond.

In October 2001, Anne and Michael took to the dance floor as a band played the George Jones song “Walk Through This World With Me.” Anne focused her eyes on the horizon as the band sang, “Walk through this world with me, go where I go. Share all my dreams with me, I need you so.”

In 2002, Michael accepted a job at America Online, and he and Anne moved back to Washington. The challenge of a new routine caused her to backslide. Exhausted, she spent a lot of that summer watching Law & Order reruns. She had seen most of the episodes before and would entertain herself by trying to remember the plots.

Anne visited her old neurologist, who surprised her by recommending further rehab, at Inova Mount Vernon Hospital. Blue Cross Blue Shield agreed to pay as long as there was demonstrable improvement.

Rehabilitation for brain injury isn’t necessarily about getting back to normal; it’s about establishing a new normal. Life had gotten more manageable because Anne knew her limitations and compensated. She might shop online or make strategic strikes in stores. She listened to books on tape. If a restaurant menu was unfamiliar, she might order by randomly pointing.
Because she was rationing her energy—and because her cognition was improving—she could handle more tasks in a day. What she really wanted back was the ability to handle more than one thought in her head. She had trouble at stores and restaurants because of distractions like noise and movement. A healthy brain filters out what’s not important so you can focus; Anne’s doesn’t filter well.

At AOL’s Christmas party, Anne was startled to realize she was having a conversation in a noisy room. She hadn’t done that in years: “I was able to think about what I was saying, not just nod.”

Brighter Days

Problem-solving was still a challenge. In Austin, Anne once vacuumed the same carpet day after day, not understanding why it wasn’t coming clean. When Michael got home from a trip, he saw there was no bag in the machine.

Her six months of rehab at Mount Vernon over—insurance would cover only so much (“It’s hard to reconcile that I am leaving the hospital but I am not well,” she would later say)—Anne was at her computer one day when her mouse stopped working. She found a new battery, replaced it, and went back to what she was doing. Then she realized she’d solved a problem.

One recent Christmas at her cousin’s house, Anne found herself following conversation, even though ten people were talking back and forth. Everyone in the room looked more in focus. She asked her cousin if the dining room had been painted. It hadn’t. To Anne, everything was clearer and brighter.

It’s a sunny day, and as Anne and I take seats at an outdoor cafe, she says: “I’ve forgotten everything we talked about.”

This is early in my reporting, and we’ve exchanged a phone call and a few e-mails. Anne points out the places in her organizer where she wrote down reminders about our lunch, and shows me the bag she carries the binder in. “I got a nice-looking ... ”—she picks up a black bag and studies it for a few seconds—“purse.”

While most of us don’t think about how our brain works, Anne is keenly aware of hers. She knows that answers to my questions might take days to percolate to the surface. It’s something she’s learned to live with.

Anne still can have trouble retrieving words, especially when she’s tired. She might call eggs “waffles.”

“We all have times we can’t finish a thought,” Michael says. “It happens all the time with her.” He admits that it can be frustrating if Anne, grasping for a word, starts her thought back at the beginning: “I try not to do what couples do and finish each other’s sentences.”

It probably helped that Anne learned to do crosswords; she and Kathy now do the New York Times Friday and Saturday puzzles, the toughest. Anytime you learn something new, it builds and strengthens neural pathways. Anne now also does sudoku.

Seven Years: Back to Work

Anne and her cousin Sandra plucked clothes off the racks at Ann Taylor—a pink blouse, a pink-and-white skirt, black pants. Anne hadn’t worked in a Washington office in years. She wondered: What did women wear?

This was spring 2004, after she had landed a volunteer position at the Brain Injury Association of America in McLean. Once a week, Anne takes a bus there from her house in Arlington.

Through BIAA as well as the Speaker’s Bureau of Brain Injury Services, another nonprofit, she’s made speeches at hospitals and universities. While Anne might need help writing speeches, many of which have been directed to neuropsychology students and rehabilitation specialists, her message comes through: Do not give up on braininjury patients.

She wants people to understand, she says, “how tough a battle those of us with brain injury are fighting just to get through the day.”

She also provides support and advice to a woman who suffered a brain injury. “Many head-injured people get upset to find that there’s such a disconnect between what they think the doctor can do and what they actually do,” she says. “They get bitter. That gets you nowhere.”

Those close to Anne are not surprised she’s driven to help others; that part of her never changed. “Anne is the kindest person that I know,” Michael says.

Anne has accepted that she’ll never work as an economist again. She loved economics because it used her brain to teach people better ways of doing things. She feels she’s doing that again.

Carol Salzman, a friend and her internist, says she understood her own sister’s brain injury better because she’d read Anne’s speeches. “I was glad to have this information to tell my sister she wasn’t nuts,” says Salzman, who is now tuned in to the subtle changes mild brain injury can cause.

Last year—almost nine years postaccident—Alec Lebedun, impressed by the progress Anne had been making, got her into speech-language therapy at Inova Fair Oaks Hospital. “The Inova system has an excellent reputation in terms of brain injury,” Lebedun says.

“They see that even though I seem high-functioning, I need help,” Anne says. “The difference between struggling on your own to keep rehabilitating and having someone say, ‘No, you should do this,’ is huge.” Insurance paid for eight months of therapy.

Today: In the Driver’s Seat

In the parking lot of Bishop O’Connell High School in Arlington, Anne sits behind the wheel of a gray Acura TL. She inches the car forward, no faster than ten miles an hour.

At Mount Vernon, Anne’s occupational therapist had worked to rebuild her eye-foot and eye-hand coordination until Anne’s responses were good enough to drive. It would take more practice for her to remember things like signaling a turn, which involves multitasking and planning.
With Michael at her side, Anne coasts around the parking lot. Her first outing lasts ten minutes, and even though she would be exhausted after, for Anne, those are ten thrilling minutes.

While she continues to practice driving, friends and neighbors are also showering her with advice on another path: motherhood. She and Michael are hoping to adopt a baby from Guatemala.

“It will push on some of my symptoms. I’ll have to take my own time-outs,” Anne says. Erin Nolan, her speech-language pathologist at Inova Fair Oaks, prepared Anne with weeks of sessions, including planning and storing meals. “With memory problems, putting things in the freezer meant they never came out, because I would forget they were there,” Anne says.

There still is much Anne cannot do that once came easily. Last summer, she got back on a bicycle again, the first time in years, and rode for 20 minutes. She would like to work more but gets tired—although acupuncture has boosted her energy.

“The healing process isn’t ever over with brain injury,” says Nolan. “You might not see any change for years, then things start to improve. It’s the mystery of the brain.”

That’s the thing about brain injury: There’s a lot of uncertainty.

“There’s a long period of time where you don’t know who you are, because your brain’s not working and your brain defines a lot of who you are. You have to refind yourself,” Anne says. “If you just look at the dark clouds, you won’t move forward. For years I didn’t feel my life was meaningful. It’s meaningful now.”


Support and Further Information

For support and further information you can contact your regional branch of the Brain Injury Association or the Head Injury Society/Headway, as below:

In alphabetical order...


Brain Injury Association of NZ (BIANZ) 

Auckland Brain Injury Association.
Phone 09 520 4791     
biaak@brain-injury.org.nz

Bay of Plenty Brain Injury Association.
Phone 07 572 4547
liaison.headwaybop@brain-injury.org.nz

Brain Injury Association (Canterbury/West Coast) Inc.
Phone 03 365 3262
canterbury@brain-injury.org.nz

Central Districts Brain Injury Association.
Phone 06 354 3540
liaison.cd@brain-injury.org.nz

Eastern Bay of Plenty Brain Injury Association.
Phone 07 307 1447
braininjury@drct.co.nz

Gisborne Brain Injury Association.
Phone 06 868 8708
liaison.gisborne@brain-injury.org.nz

Hawkes Bay Brain Injury Association.
Phone 06 878 6875
mary@braininjuryhb.co.nz

Nelson Brain Injury Association.
Phone 03 546 6656
nelson@brain-injury.org.nz

Northland Brain Injury Association.
Phone 09 459 5013
northland@brain-injury.org.nz

Otago Brain Injury Association.
Phone 03 471 6156
liaison.dunedin@brain-injury.org.nz

Rotorua Brain Injury Association.
Phone 07 350 1251
liaison.rotorua@brain-injury.org.nz

Taranaki Brain Injury Association.
Phone 06 753 3688   
liaison.taranaki@brain-injury.org.nz

Wairarapa Brain Injury Association
bia.wairarapa@hotmail.com

Wanganui Brain Injury Association.
Phone 06 347 9721
liaison.whanganui@brain-injury.org.nz

Wellington Brain Injury Association.
Phone 04 473 5004
liaison.wellington@brain-injury.org.nz



Head Injury Society

Southland Head Injury Society
Phone 03 214 4154      
Email - his-sth@xtra.co.nz
46 Kelvin Street, Invercargill

Brain Injury Waikato Inc (formerly THINK! The Head Injury Network for Kiwis)
Phone: 07 839 1191 / Fax: 07 839 5648
Address: 11 Somerset Street, Frankton
Email: admin@braininjurywaikato.org.nz

Online Support Groups

Brain Injury Forum.Org

In the spirit of sharing, “Some of the Many Sides and Challenges of Acquired Brain Injury” was created for families and individuals who wish to better understand this invisible injury, it's numerous deficits and challenges that survivors can be faced with for years after. 


Central Districts Support Groups

Levin Coffee Group

The Palmerston North Coffee Club gives a little time for a chat and an opportunity to meet new people. The Coffee Club happens the on the FOURTH WEDNESDAY of every Month at the Sponge Kitchen Cafe at 10.00AM. No need to let us know your coming, just show up! 

If you would like to know more information regarding the Coffee Club or The Brain Injury Association, feel free to send an email, or better yet, give us a call. 

Email - liaison.cd@brain-injury.org.nz
Phone - 06 354 3540

Palmerston North Carer's Support Group

Carer's Support Group is a great way to meet other individuals who are supporting someone with a Brain Injury and creates a fantastic networking group for those living with, or caring for a person with a brain injury.

The Carer's Supprt Group happens on the FIRST MONDAY of the month at Community House in Palmerston North at 6.00PM. For this event you will need to contact the Brain Injury Association to let us know you're coming. Its always handy to bring a note book to write down information that other people find encouraging and informative and don't be afraid to have plenty of questions ready!

Phone - 06 354 3540


Palmerston North Swimming group

Swimming is not only good for you, but is a social way to meet new people and get out of the house! There will be swimming EVERY FRIDAY morning at 11AM at the Palmerston North Hospital Rehab Pool. It is FREE (except for parking) 

For this event, you will need to call The Brain Injury Association to confirm a spot and make sure we know that you're coming!

Phone - 06 354 3540


Palmerston North Coffee Club

The Palmerston North Coffee Club gives a little time for a chat and an opportunity to meet new people. The Coffee Club happens the FIRST TUESDAY of every month at Capers in Downtown on Broadway at 10.00AM. No need to let us know your coming, just show up! 

If you would like to know more information regarding the Coffee Club or The Brain Injury Association, feel free to send an email, or better yet, give us a call. 

Email - liaison.cd@brain-injury.org.nz
Phone - 06 354 3540


Hawkes Bay Support Groups

Hastings Family Support Group:
A monthly support group for people who have family member with a brain injury.  First Tuesday of the month, 7 till 9pm, at Headway House, 605 Willowpark Road South, Hastings

Learn and gain coping strategies for dealing with a person with brain injury, in a safe environment that people feel confident to share their experiences.  Support each other with problems you are having with your family member.  A opportunity to get to know new people who understand. Supper will be served.

Napier Dinner Group:
First Wednesday of the Month.

Women’s Support Group
We are starting a monthly women’s support group and would like to get an idea of those that would be interesting in attending and any volunteers who would like to help with the running of the group.
If you would like to register your interest please contact the office 

Taradale Social Lunch Group
Third Monday of the Month, 12.30 at Cafe Gecko, 239 Gloucester St, Taradale
All welcome

All enquiries to:

Headway House
Phone - 06 8786875      
Mobile - 027 5366354      


Nelson Support Group 

Providing a mutual support network to people who have brain injuries and their families.

Email: nelson@brain-injury.org.nz



Ashburton Support Group 

Providing a mutual support network to people who have head injuries and their families.

Phone - 03 308 4655      




For more information on what services are available to you please see our "Things you should know about" page which includes the following: