Physical Aspects of Brain Injury

Physical Aspects of Brain Injury:

Although most of the physical aspects of brain injury are beyond the scope of this site because they require a comprehensive evaluation from your physician, we will offer a brief overview and suggestions about some of the more common physical challenges after head injury. If I could identify one central recommendation that pertains to all of the physical aspects of MTBI, it would be to seek medical advice about your symptoms immediately. These physical signs are your body’s way of telling you that something is wrong, so don’t hesitate to consult your physician.

HEADACHES:

One of the most common symptoms experienced after an MTBI is headache. For patients with the least damage, headaches are often the most severe symptom. Headaches can range in both intensity and the type of pain (from mild to severe and from dull to sharp). There are more than a dozen classifications of headaches; however, there are five types that are primarily associated with MTBI. We will review these types of headaches and the associated symptoms. Use this section to identify the type of headache you experience so you can relate this information to your neurologist or primary-care doctor.

The five types of headaches most likely to affect you as a result of MTBI are:

migraine

post-traumatic

tension

cluster

analgesic rebound

MIGRANE HEADACHES:

Migraine headaches normally last from four to seventy-two hours. The pain is located at the forehead or temple and is characterized by a throbbing. This throbbing pain may be accompanied by nausea, vomiting, numbness, muscle weakness, and sensitivity to light, sound, or smell. Intensity may increase with activity, and the headache can often be resolved with sleep. Migraines can be triggered by emotional stress, physical activity, the menstrual cycle, irregular sleep, irregular meals, and trigger foods. Some migraines are preceded by an aura consisting of blurred vision, flashing lights, or a brightness. Onset may also be signaled by mood swings, fatigue, and an increase in thirst, food cravings, or energy.

POST-TRAUAMATIC HEADACHES:

Post-traumatic headaches can occur months or years after an MTBI. These headaches may resemble tension headaches or atypical migraines. They are associated with a burning or tingling sensation and pain that increases in intensity with even a light touch. The rigorous diagnosis criteria for these headaches are too extensive to list in their entirety here. For more information, contact your physician.

TENSION HEADACHES:

Tension headaches are typically the result of facial or back pain, often the result of whiplash. Tension headaches associated with MTBI are frequently the result of injury to the vertebrae, ligaments, neck tendons, or jaw. Because they cause intense pressure in your head, they are considered pressure headaches. Typical triggers include worry, stress, overwork, poor posture, and poor ventilation. Onset is normally late in the day, so these headaches may prevent sleep. Degree of pain varies and often these headaches are not debilitating. Tension headaches may be episodic, occurring less than fifteen times per month, or chronic, lasting from fifteen days to six months. Chronic tension headaches are often associated with depression.

CLUSTER HEADACHES:

Cluster headaches are related to migraine headaches. These headaches are extremely severe and are associated with injury to the back of the neck and nerve damage. Pain is intense and often penetrates behind the eye and affects one side of the face. The headache duration is between fifteen minutes and three hours and the pain may move from one side of the face to the other during the course of the headache. The headache may be triggered by nicotine, alcohol, overwork, or extreme emotion.

ANALGESIC REBOUND HEADACHES:

Analgesic rebound headaches are associated with withdrawal from extended usage of pain relief medications (analgesics). These headaches can be severe and not limited to a specific area of the head. Symptoms include nausea, difficulty concentrating, depressive symptoms, irritability, and restlessness.

CAUSES AND TREATMENT:

Headaches are often the result of other conditions, including whiplash, depression, vertigo (loss of balance), and cognitive difficulties. Headaches after an MTBI cannot necessarily be linked to psychological symptoms prior to the accident. Additionally, there is often symptom overlap with headaches. You may experience multiple headache types simultaneously or may alternate headache types over the course of a week or a month. Your treatment team may include your neurologist, orthopedist, dentist, ophthalmologist, physical therapist, and psychologist. Treatment may include medications or you may opt to try cognitive behavioral therapy, hypnosis, or biofeedback. Always discuss your headaches with your neurologist or primary-care physician.

WEAKNESS:

General weakness in the arms or legs is a common result of MTBI. This effect is similar to the effects of a stroke. You may experience hemiplegia, which translates to “half paralysis.” Essentially, this means that there is damage to one side of the brain. The result of the damage to this one side of the brain is that the opposite side of the body is weakened. For example, if the left side of your brain sustains damage, whether bruising or a blood clot, your right arm and leg will exhibit signs of weakness. In this example, your right arm and right leg will be weak because the left side of your brain has suffered injury.

In cases where damage to the brain is more widespread and deeper in the cranium, triplegia may be experienced. Triplegia means that three limbs are affected by the brain damage. The damage will occur in one arm and both legs. Initially, both arms may exhibit signs of weakness; however, after some recovery, one arm will be nearly normal while the other arm and both legs remain weak and spastic. Typically, the hand is more strongly affected by brain injury than the elbow or shoulder. The hand may continue to be weak and somewhat clumsy after good recovery elsewhere in the body. Your muscles may remain strong, but the joints may not cooperate in moving the muscles. Active reflexes may result in clonus, a spastic movement of the muscles. For example, after you make a sudden movement, your hand or foot may continue to move about involuntarily. This spastic movement may cause your joint to slip into an abnormal position. If the joint does not return to a normal position and stiffens, it may affect the future functionality of the muscle.

The weakening of muscles results in stiff arms that are either straight or sharply bent at the elbow joint. The legs are typically straight with the toes pointed. This positioning may result in stiff joints and the rehabilitation team must take great care in preventing or relieving this stiffness so as not to cause further damage. Most likely you will be involved in either physical or occupational therapy to cure the muscle weakness in the arms and legs.

POOR BALANCE:

The coordination of movement is controlled by multiple brain systems (see chapter 2). Compared to a stroke, which is normally localized, trauma tends to be more widespread. For that reason, brain injuries usually affect coordination and strength by traumatizing various sections of the brain that normally work together to coordinate movement. Sometimes the impact is restricted to coordination. If you have both weakness and clumsiness, it’s difficult to do something as ordinary as rising up from bed. The lack of balance causes your head to fall forward or slip to the side as soon as you rise. Simultaneously, the body slumps. As muscle tone improves, you regain the ability to hold your head up, then sit. Eventually the muscle tone improves in your legs and your trunk, enabling you to first stand and then relearn to walk. As mentioned, balance is impacted by multiple systems of the brain. One of the primary issues related to balance is limb perception, or proprioception. Prior to your injury, you were completely aware of where your body was positioned in relation to the world around you. Now, it may be difficult for you to know how far to reach your arm out to pick up your drink or how far to extend your foot forward when taking a step. This loss of perception has a dramatic effect on balance.

Also, balance is tied to the vestibular system. The vestibular system is made up of the balance organs located under the thick part of your skull close to your ear. Included in this area are your hearing organs. These organs are delicate and easily impacted by brain injury. When your vestibular system is injured, sudden movement of your head results in dizziness. The lack of functionality of this system inhibits balance and thus your ability to sit, stand, and walk. You can relate this to a time when you have had an
ear infection—the world seems out of balance and your gait uncertain. A similar but less dramatic comparison may be the sensation you experience when changing altitudes or just after landing from a flight or even the sensation you feel after an extended cruise.

A physical therapist will work with you to regain your strength and coordination. As you relearn to walk, you will rely on your therapist for physical support. You’ll use a wheeled frame, sticks, and possibly splints for your joints and feet. Your recovery will be dictated by your perseverance and regained muscle strength. This may be a slow process and it will be critical to build your endurance but not strain your muscles. Your physical therapist will be your coach in this portion of your rehabilitation.

SEIZURES:

Seizures are characterized by a sudden discharge of electrical impulses and may be isolated to one area of the brain or generalized and diffuse. If seizures occur only after brain injury and are recurrent, the diagnosis is post-traumatic epilepsy. Typically, seizures are not associated with mild traumatic brain injury, but rather moderate to severe brain injury. As a result, this discussion of seizures is limited. Seizures are normally associated with damage to the temporal lobes, but they can also occur with damage to the
frontal, occipital, or parietal lobes. Seizures are more frequently exhibited in those with a familial disposition to seizures, childhood meningitis, or a history of alcohol or drug abuse. It is absolutely imperative for your neurologist to be involved if you suspect seizures. While seizures cannot be cured, they can be controlled with medication. Additionally, you can limit your exposure to alcohol and caffeine and ensure that you do not become fatigued. You must be compliant with your prescribed medications, and it is imperative that you discuss driving with your neurologist. Again, it is absolutely essential that you work with your neurologist if you suspect any seizure activity.

SEXUALITY:

As unromantic as it may sound, sexuality originates in the brain—specifically, the hypothalamus and the brain stem. If you sustain an injury to these areas of the brain, you may find that your sexual desires are repressed or nonexistent. Conversely, you may experience heightened and inappropriate sexuality if you sustain an injury to the frontal lobe. This type of injury is less common than damage to the hypothalamus and is usually associated with moderate to severe brain damage. Sexual interest may also be impacted indirectly by brain injury. That is to say, a loss of concentration, emotional stressors, fatigue, medications, and so on may cause sexual dysfunction. Nerve impulses may be misinterpreted or not interpreted at all. Touch to the breasts, genitalia, and other erogenous areas may be unbearable due to heightened sensitivity.

This topic may be somewhat uncomfortable for you to discuss with your doctor. However, you can link this particular symptom with other symptoms you may be experiencing (fatigue, stress, lack of concentration) and to medications you are taking. Your doctor may refer you to a psychotherapist, urologist, or gynecologist for further evaluation. It is important to discuss this issue openly with your partner. Eliminating the stress of sexual disinterest and the impact on your partner will help relieve some of your anxiety. You may also want to consider marital therapy to facilitate discussing this issue openly and work on restoring your sexual interest. Together with your partner, you can explore relaxation techniques to use as a couple or create a romantic environment to stimulate sexual arousal.

FATIGUE:

Another common symptom or side effect of MTBI is fatigue. Diagnosing the cause of your fatigue is difficult if not impossible since this symptom correlates to so many other symptoms associated with MTBI. In addition, we live in a chronically fatigued society that has become defined by the do-it-all syndrome. Regardless of the cause, fatigue associated with MTBI seems to leave none of the reserve energy that you previously relied upon when you were exhausted. With MTBI, reserve energy is nonexistent.

To compound the fatigue problem, sleep disturbance may be a new problem for you since your injury. When you are overtired, it is often more difficult to fall asleep and to stay asleep. Additionally, pain associated with your injury may awaken you. Other disturbances, like noise, may also disrupt your sleep. You may attempt to overcome your fatigue by using caffeine, which ultimately compounds your sleep woes. In the past, you may have gotten an energy boost from sugar, exercise, or naps, which now only serve to heighten your fatigue.

Fatigue tends to exacerbate the other MTBI symptoms you are experiencing. Your cognitive processes are further slowed by fatigue, and your memory and concentration are also hindered. You will notice decline in efficiency and an increase in irritability when you are fatigued. Consider the medications you are taking and at what time of day you take each one. Your physician may be able to help you schedule your medication times to minimize sleep disturbance. Or there may be some flexibility in medications so that you can switch to a medication that has less impact on your sleep patterns and tiredness.

You can minimize the effects of fatigue by concentrating on your most intense responsibilities during your most energetic times (typically mornings). It’s also very important to learn your limitations and take rests prior to becoming overexhausted. Although it may be hard for you to admit, it takes significantly longer for you to overcome extreme exhaustion than it did prior to your injury. It’s critical that you learn to stop and rest before reaching this state. Naps may be useful to keep you energized during the day and may actually improve your night sleep.

There are tricks that can help to work around your fatigue. Don’t hesitate to elicit help from your family in managing tasks. Find ways to minimize the complexity of everyday activities. For example, use automated bank systems to pay regular monthly bills. This not only eliminates the risk of forgetting the bill, it also helps ensure the correct amount is paid and gives you one less thing to worry about as you concentrate on healing. There are many strategies that you and your family can enlist to help minimize your fatigue. Eliminating fatigue as much as possible is key to minimizing the other physical symptoms described in this section.

SLEEP TIME AND QUALITY:

In regards to fatigue, one of the most important things to take into consideration is the amount of sleep you are getting and the quality of that sleep. It is important to stick to a schedule for bedtime and waking up. Fatigue will compound the problems you are suffering from. A lack of sleep will compound your fatigue. There have been many volumes written on sleep because it is such a problem for so many people in our modern society. If you are having problems with sleep, I would recommend that you speak with your physician. Undoubtedly there are suggestions he or she can make to help you. However, there are several bits of advice I can give you here to help alleviate your symptoms in the meantime. For the most part, it is best to avoid sleep medications if at all possible. Studies have shown that your body has a more difficult time entering REM (rapid eye movement) sleep when you take medications. REM sleep is very important, as it is during this stage of sleep that your body enters into a deep restful state. Without enough REM sleep, you are guaranteed to continue feeling tired. Relying on sleep medications can also turn into a habit that is difficult to break. It is far better for you to try to put yourself on a reliable sleep schedule. Speak with your physician about developing this type of routine. You should also avoid the use of alcohol as a means of getting to sleep. In fact, it is better if you limit your intake of alcohol throughout the process of your recovery. While recent studies have shown that a limited intake of alcohol has certain health benefits, people suffering from an MTBI should really try not to drink too much. Alcohol has a very pronounced effect on your cognitive function and it should be avoided for the most part. In terms of sleep, alcohol does more harm than good. It may be that you feel it is easier to get to sleep after you have had a drink. Unfortunately, your body doesn’t rest nearly as deeply when it is busy trying to process the alcohol. If you are going to drink at all, I would recommend drinking several hours before you plan to go to bed.Again if you are experiencing any of these symptoms seek help immediately.

EXERCISE:

With your recent injury, your body’s metabolism has probably changed. You may find yourself gaining weight due to decreased activity, or you may require more nutrients and calories to assist your brain in healing. But remember, calories do not necessarily equal nutrition. To help your body heal, eat mostly nutrient-dense, minimally processed foods. Your essential organs, such as your liver and pancreas, may have more difficulty in processing nutrients right now. Exercise is not only a good way to strengthen your body and improve circulation, but it will also assist your body in reestablishing its normal metabolism. It increases your metabolism so that food is processed by the body more quickly, thus absorbing more nutrients. This will greatly enhance your recovery process.

Excerpts from the Mild Traumatic Brain Injury Workbook, Mason, D.J.; New Harbinger Publications