Some Information on Head Injury Effects

[LucasM]

NOTE: I initially wrote and edited this as best I could at the time, but I inadvertently left out some important things.  Because of that, I have revised it multiple times since I first posted it, sometimes to clarify what I'd written, sometimes to add new information.  [Although even when initially written, I massively surpassed the board's 20,000 word post-size limit, so I had to break this 'first' post into three.  That post-size upper limit, plus forgetting things needing longer explanations until later, meant that some of that additional important info was later added in subsequent posts I wrote, after others' responses to these first three posts.]


I initially started writing this in response to the thread To Our Friend, Bob...    When I started it, it was intended to give Bob a 'heads-up' (so to speak) about some things to keep an eye out for following his head injury, so that he could get the help needed to recover as best he could, as quickly as he could.  I also initially was writing it to possibly help people understand some of what Bob is going through, since he's 'one of us'.  [EDIT: since Bob says he is doing much better, and to reduce the 'required' reading, I've moved the information specific to him into 'spoiler' areas.]

As I wrote more (and more, and more), I realized that everyone should have some level of knowledge of head injuries.  This is to hopefully dispel some of the incorrect knowledge of what 'a bump on the head' can do, as virtually all media gets it massively wrong.  Think of this the next time you consume some fiction in which someone gets knocked unconscious, and, when they wake, they are the same as before.  Or think of this the next time you hear about someone around you who has been hit in the head.  And, for anyone who hasn't yet had a head injury, think of all of this and keep it in mind when there is something you might be doing that could result in a head injury.  e.g. Soccer and football players - even those just playing in high school or for fun - suffer repeated head injuries even one of which can potentially ruin their life.  Things as 'minor' as hitting a soccer ball with one's head is sufficient to cause measurable brain damage, as well as potentially things like lifetime depression that because its symptoms originate from injury, is not as easily treated by medication and therapy as is non-injury-related depression.


Sadly, from my experience, most people in the general public do NOT understand that something is wrong after a head injury.  There are a multitude of reasons for this, but I think the largest is simply: media.  Cartoons, comics, books, TV shows and movies ALL have people repeatedly getting knocked unconscious with no effects on their functioning whatsoever afterwards.  ANY impact that disturbs the brain's functioning enough to disrupt consciousness (or even just briefly altering perception; hell, even some impacts that do neither) is causing some degree of permanent damage.

Unfortunately, that results in what can be inconsiderate treatment of the head injured by a large number of people.


Spoiler directed to Bob:

Spoiler (click to show/hide)

Bob, this is - I know - MASSIVELY long.  I wanted to give you an overview of just some of the major things that happen with head injuries, so that you'll have a framework to look at your new life in.  My suggestion would be to print out a copy of this and keep it handy.  But read it slowly, and possibly only one small section at a time.  You may want to make notes in the margins if you notice something that sounds like what you are experiencing.  Then share the things you notice with your rehab team.  [You may wish to give a copy of this to your sister and close friends who see you frequently, so they can start to understand some of what you may be experiencing, as they can help you also.]

Disclaimer: this is not meant to replace the information given to you by your doctors and other treatment professionals, but is meant to be a supplement to them, and possibly provide additional information that only one who has both studied neuropsychology and lived with head injuries might be aware of.

Bob, when I use 'you' in the following, it is you specifically that I'm speaking of (as opposed to the generic 'you' people use while writing).

In case the people reading this haven't seen it mentioned in my posts elsewhere on the boards, I was a trained Neuropsychologist, having studied neuropsychology in a doctoral program (when there were only 10 accredited universities in the country offering that special focus), and then I did my APA-approved Internship under the then-director of the International Neuropsychological Society.  My undergrad degree was pre-med (Biology major with Chemistry minor), and then in the doctoral program I had a minor in Biopsychology/Physiopsychology.  Because of that, I learned what happens on a cellular level what my Clinical Neuropsychology training showed on a behavioral level.  But in addition to all that, I've had three head injuries of my own [auto accidents, none my fault, in '95, '96, and '99].  My life was affected differently by each of them.  And each was more damaging than the last.  Those gave me an insider perspective that I was able to understand because of my training, but that also expanded my awareness in different ways from what my training had given me.

To write this out has taken effort by me during the course of over two weeks.  That is because of both its length and detail, as well as the mental drain (and recovery time) it takes for me to write (coherently, at least: I can write incoherently with relatively little effort ).


The following may be WAY more than you wanted to know.  But I felt it was all important, and information that you might want to keep an eye out for.  Though if they are occurring, you may not notice these things even if you know they are possible.  I know that I am too often so overwhelmed I cease to notice large sections of my environment, as it is so exhausting to even attend to the things I have to (you know: little things like 'remembering to eat', 'resting when I am tired', 'shifting my position when my soft tissue spinal injuries flare up').

Spoiler directed to Bob:

Spoiler (click to show/hide)

When first hearing about your accident, I went to your profile and followed the 'read most recent posts' link, and read all of your posts starting from a week or so before you disappeared from the site.  There are two things I noticed right away.  First, the complexity of thought seemed more limited after you came back.  The second is your posts since the return to the forum show signs of language problems (missing words, substituting words, or typing homonyms rather than the word you actually wanted).  How much of that was auto-correct on the iPad, or whether some of that is from actual language impairment, or reduced fine motor coordination isn't clear.  [[Typing homonyms can be an event of 'more-often-typed' letter combinations overriding what is actually desired to be typed, rather than a language problem per se ['motor routines' are stored in the cerebellum, if the brain's control of - or connections to - the actually desired cerebellar motor routine is impaired, a 'similar' one may be activated; general confusion or overwhelm (or seizure activity) can also result in such 'misfirings'].  However, I noticed that you did NOT edit those errors to correct them, as you must have with such things prior to your absence.  (That could possibly be from overwhelm, or could be a frontal lobe effect, as described below.)]]

In particular, with your first couple of personally-typed messages after you came back to the forum, there were many unrelated letters in them and so I typed them myself to see if I could figure out what was happening with hand-based motor coordination.  It appeared that, at least for one, you were typing 'all around' the letter you actually wanted [it was clear the letter you wanted was 'd' and you repeatedly typed 'a' 's' 't' etc.  If you are a touch-typer, then it would be that all the fingers except the one you wanted were activated].  How much of that was from using the iPad screen, rather than a more typical keyboard is a question, but since it seemed localized to particular letters [and 'all the keys hit by all the fingers but one'], it would seem not.

As wurwolf mentioned, many of your sentences following your return, moreso earlier than recently, seem incomplete, with connective words missing.  [Which is better than the problem I had early on, and still have when overextended, which is to leave out little things like 'nouns' and 'verbs'.]

I must say, I winced at some of the comments made by some on the forum, jesting about your less-than-coherent comments and mis-spellings/stray letters in your first couple of posts.  From both my hospital work with head injured patients, and my personal experience, I know that a person freshly head-injured can become VERY self-conscious about what they say and do, and they may withdraw because of such comments.  Particularly if the head injured person is thinking concretely, they can take such comments as ridicule and attack, or feel shamed by them, rather than them being seen as 'good natured ribbing', or even just 'observation'.  I wondered if that was why the third - the longest - comment that was posted via your account after your injury was from someone else typing your thoughts for you.

How Impacts Affect the Brain
Now it is important to remember that the brain is far softer than any other organ.  It has the consistency of Jell-O or room-temperature butter.  So one can understand how very easy it is to damage it when it comes into contact with the hard, and often rough or sharp, interior of the skull.

The brain's movement with an impact to the head:

The rough and sharp interior of the skull that cups the underside of the brain:

Obviously the area directly under the impact site receives the most damage, and the most focal damage.  That can result in a disruption of most any functioning, depending upon where that impact was.

With every head injury, the area directly opposite to the impact site has almost as serious damage, but somewhat less focal.  This is called the 'contra-coup' [and has nothing to do with US Presidents illegally trading missiles to Iran to help groups of Central American rebels].  The reason that that opposite side of the brain gets damage is because the brain bounces off the inside of the skull at the impact site, and then rebounds off the opposite wall.  "The area directly opposite" would factor in the direction of the force of the impact, like a cue ball being hit, then hitting another ball at the opposite side of where the force was administered.  That includes things like 'english' being put on the ball and such.
Spoiler directed to Bob:

Spoiler (click to show/hide)

If your head was forced to turn as you fell and hit whatever it was, then the rotational complications would affect you.  Rotational impact to a brain is far more damaging than 'straight-on' impact because of what I discuss next.

On top of the contra-coup, the difficulty with any head injury is that ALL of the outer parts of the brain are likely to get damaged to some degree, as the brain scrapes against the very hard, and quite rough protrusions on parts of the interior of the skull.  The temporal lobes, the frontal lobes (particularly the area directly above the eyes), and the base of the brain (near the brainstem) are all particularly susceptible to such scraping.

The scraping of the brain on the inside of the skull injures or kills off the most 'superficial' (top) layer(s) of neurons in the areas affected.  The more intense the impact, the more layers are likely to be killed off.  Unfortunately, the superficial neurons do much of the final coordination of signals.  They assemble the information that the deeper layers of neurons have analyzed and so they do some of the final synthesis of thoughts or perceptions.  For example, at the back of the head (the occipital lobes) is where visual information is processed.  The deeper layers of neurons will analyze things like "straight line-horizontal", "straight line-vertical", and "movement left-to-right", subsequently higher layers of neurons will ultimately process those into - say - perceiving a car moving towards oneself.

Though I have never read it proposed anywhere, I believe that may contribute to why those with head injuries are far more concrete in their thinking [have less capacity for abstract thought]: because the top layer of neurons that would do the 'final comparisons' in the areas responsible for dissecting different but related concepts and thereby interpreting abstract thought have been injured.  Having concrete thinking was very true of me closer to my accidents, but has improved since [though the more I am exhausted past my limits the more I get concrete in my thinking again].  This difficulty with abstract thought often results in disruption of interpersonal relationships, as subtext and subtle social cues are often misinterpreted, or lost completely.


Effects of the Top Layer of Neurons Being Injured
The next two things are considered to be the result of the damaged 'superficial' neurons, and the damaged connections and need for rerouting.

People with head injuries are often overwhelmed by tasks they are so familiar with they used to be able to do them in their sleep... much less new tasks requiring different thinking or perceptive patterns.  Driving, going out to a grocery store, things like that all require processing power.  With the brain having to reroute so much, that becomes overwhelming with the number of things that need attending to ALL having to basically be rerouted to some degree or another.

The other is confusion.  It is likely obvious by the above why confusion takes place: if there are so many things that need attending to, and the usual patterns of responding are blocked, confusion is the result.  It can also be caused simply by being somewhere with multiple choices, and your 'too many choices' can be as simple (to the non-brain-injured) as a fast food restaurant menu.

The above two things can be caused by, or massively aggravated by, the reduced ability to separate what may be 'relevant' input from 'irrelevant' input.  The head-injured often have to consciously rule out non-relevant perceptions (or thoughts).  That, obviously, results in slower processing of what is happening, and a lot more mental energy being used to process it [when a healthy brain already uses about 25% of all calories burned].  That, of course, results in the head-injured person being easily fatigued.


Interior Damage to the Brain: Connections
But it isn't just the outer parts of the brain - the neurons as a whole - getting damaged that cause problems.  The axons (and dendrites though those are rarely mentioned because they aren't as susceptible because they are much shorter), ALL the 'wires' connecting neurons are incredibly sensitive to tearing during any head injury.

Axons are the 'outgoing' connections a neuron makes.  They are incredibly thin and can be up to two to three feet long.  Dendrites are the threadlike protrusions for input to a neuron (tho neurons can receive signals all over their surface from the axons of other neurons, dendrites 'reach out' for important 'wanted' incoming connections).  Dendrites are MUCH shorter, so less affected by the tearing occurring in head injuries.

The damage to the connecting 'wires' results in two major things (and a multitude of others).  The primary one is that the loss of connections between neurons means that any task governed by those connections is disrupted.  The brain has to work harder to do things that at one time were simple, even automatic, if it can do them at all, because it has to find another, less direct, path from one neuron to the other.  And this is often with dead or scar tissue blocking the way.  So in addition to actions and thoughts being slowed, the person is very likely to get fatigued far easier than they used to.  [Think of it as driving from Michigan to Mexico via Anchorage, Alaska.  It takes a LOT more time and gas to do so, than by going direct.]  The second major thing that axonal tearing can cause is almost as devastating, and that is that the brain, having lost so many connections, tries to rewire itself, but with all the damage present, and the speed at which it tries to repair itself, it can rewire itself wrong.  So there can be new problems from a head injury starting as late as six months or more after the injury itself, as those incorrect connections start to cause further disrupted behavior.  That is why early therapies for lost abilities are very important: they help the brain make many more correct connections than wrong ones.

Memory and impulse-control problems are very common effects of head injuries.  [To Bob:] I haven't seen enough in your comments since returning to the forum to tell just how much you were affected by such things, though I did notice in the course of just a few days you repeated, nearly verbatim, that your doctor was pleased with your weight loss.  [And s/he has good reason to be: not only did it signal that you had had great follow-through on your own prior to the head injury (which may bode well for your cognitive rehab following the head injury), but according to SPECT studies by Dr. Amen http://www.amenclinics.com slimmer people have better functioning brains (thanks, in part, I would guess, to better blood flow).  http://www.amenclinics.com/newsletter/article/?articleID=320]

[LucasM]

Movement
Bob: Your injury was described by someone (in a post I can no longer find) who said it fractured your skull and cheekbone on the right side.  With the location, with that description, it could have hit anywhere from more in your face to the side nearly back by your ear.  Almost all of the area likely to have been directly hit would be the frontal lobe, but different parts of the frontal lobe do different things.

If more to the side of your head, it might have hit the motor strip which would disrupt movement on the left (opposite) side [that would explain your typing 'around' the letter 'd' as mentioned above, but also could affect walking and other movements, where I do not know if that is the case].  Just to the rear of that (at the back-most part of the frontal lobe) is the sensory strip, which could also impair movement because it would limit the reception of feedback from the nerves which tell one what their body is feeling.

While damage to the motor area might cause difficulty walking and other movements that would be more obvious to onlookers, if the injury was closer to the front it may be far more disruptive to behavior than awkwardness in movement.  It would make others' seeing someone's head-injury-related problems MUCH more difficult, because there is no obvious problem like a limp or 'dead' arm to cue someone to the fact there had been an injury.  [My injuries were pretty much all like that: not obvious to onlookers.]


The Frontal Lobes
The frontal lobes are nearly universally damaged in any impact.  Bob: they would be likely to have been more injured than usual with your impact where it was, particularly if it was more towards the front (nearer your face).

The frontal lobes control many things, a few of which I'll mention here.  They play a great role in the ability to pay attention to things (many, if not most, head injured people have difficulty with distractability).  They play a large role in sequential thinking and being able to put memories in proper order for which happened first.  They also govern impulse control and self-monitoring; being able to tell what condition you are in and what is happening with yourself.  That can result in difficulty assessing personal safety.  (Bob: That is likely why the program had you retested for driving, as they could not be sure your assessment of your remaining abilities were accurate.)  The frontal lobes control some of the ability to process and express emotion.  And they regulate the initiation and cessation of action [inability to stop an action is called 'perseveration'].  The inability to start particular actions can be misinterpreted by uninformed doctors after head injuries as depression about an injury and inability to get things done from that, rather than the organic problem that it actually is.  Depression and head-injury-caused inability to initiate actions have VERY different treatments.  [Antidepressants usually have a sedating effect.  If they are given when not needed - e.g. following a head injury - they can make initiating actions that much more difficult.]

The frontal lobes are believed to be central in decision-making.  Following a head injury, what used to be a simple choice can become overwhelming.  [For an example here's something from just after my first head injury, while I was still working.  At the end of a day's work I had three things to do before I could go home.  They were: write the progress note for the last person I saw, prepare the billing for that person, and to prepare the next day's materials.  They all had to be done before I left.  None of them was 'urgent'.  But I sat for a minute or more, near tears, because I could not figure out which to do first.]


Personality
Head injuries most often include a change in overall personality.  This can be subtle, or it can be dramatic.  That personality change includes the way a person feels and expresses their emotions, but also the things I mentioned before (difficulties with social situations often occur as social cues, and subtlety, and hints, may be missed).  But the person may overreact (or underreact) to emotional events in their environment.  They may 'hyper-respond' to emotional cues, such as crying easier than previously or getting angry easier (e.g. if one runs into difficulties putting dishes away, one may start crying about it, or one may get angry and break things [I've done both at one point or another since my head injuries; a few years back I actually stomped a VCR into rubble because it was messing up]).


Those With Head Injuries Functioning in Crowds
After a head injury, until one knows that they can handle them without stress, crowds are generally to be avoided, particularly right after a significant head injury (especially during that first 6 mos), as overwhelm is likely.  That is because the head injured usually can't filter out things like other conversations, stray noises, lights, movement, so it is often very difficult for them to focus on what they need to do, or intended to do.  [One of the ways I developed for myself is to ALWAYS wear an iPod and headphones when I was out, and play familiar music.  The muffling of surrounding sounds helped reduce the demands on my brain when grocery shopping, for instance.  Another thing I worked out was that I also wear sunglasses whenever I am out during the day, or in stores at night, as the dimming of the light reduces the amount of processing my brain has to do.]

Bob: because of that difficulty with crowds, I was rather concerned when I read your comment that you were "missing meetings", as I believe it was referring to your job.  Such things may be overwhelming and extremely hard to process.  DO NOT be afraid to accept and mention that to the people working with you in the rehabilitation program.  They may help you interact with your employer about it.


Desire for Life to 'Return to Normal'
Unfortunately, the freshly head injured just want 'things to get back to normal' so they most often push themselves to do everything they were doing before the injury.  The difficulties freshly head injured people run into with that often cause both functional problems and emotional problems.  And very often, because of the memory problems which occur regularly with head injuries, it is possible for them to not remember how much difficulty it causes them from one day to the next (or one minute to the next).  So they just continue doing whatever, and they cannot remember enough to report it to the cognitive therapist who could potentially help them learn strategies to help them process it.  Often the freshly head injured end up doing nothing about a problem they've noticed, or worse, devising their own ways of trying to manage whatever it is, which, because of their injuries and not understanding what is happening, can often be maladaptive.


Recovery
What someone freshly head injured may be wondering is, "will I recover, and if so, how much?"

The truth is, there's no guaranteed way to gauge that.  But there are some things that may be helpful to know.

1. It used to be believed that length of coma related to the degree that previous functioning might return; the longer the coma = the less recovered functioning.  [Bob: if your coma was induced to reduce damage from swelling, then that doesn't apply.]  And, there are exceptions to most any health-related rule: some people have been in comas for long periods of time and recovered most of their functioning.

2. The largest amount of functional recovery takes place in the first six months.  During that period it is because of the hyperactive axonal formation, and while the injured, but not dead, superficial neurons heal.  This is the same time period as the delayed functional problems from a head injury occur (and partly for the same 'healing' reason: axonal formation, but also because this is when scar tissue can form).  But - particularly when receiving appropriate cognitive rehabilitation - the good connections far outweigh the bad, so there's a net increase in function, even though some new problems may still occur.

But especially during this six month period with the rapid brain repair going on, it is ESSENTIAL that things like alcohol and tobacco be avoided, as they put stress on the neurons.  If the neurons are injured, alcohol and the anoxia (lack of oxygen) caused by cigarettes can very well kill them (one of the main outputs of cigarettes is carbon monoxide: the same thing people die of from concentrated car exhaust).  That results in lost functioning that could have been retained.  Unfortunately, many, many freshly head injured people self medicate with alcohol (or drink to forget the functioning they can tell that they've lost).  [Even I, who learned all this about the brain and injury, self-medicated for a time after the first one; every day that I worked I was so far past capacity that I'd come home and need to shut my brain off, and I drank hard liquor to 'shut down'.  I had help stopping that.  I have now had very little alcohol in the last 16 years, and none since getting on the proper anti-seizure meds.  And between those meds and reducing what I try to do during the day so I'm not as intensely over-taxed, I have not wanted any more.  That is because the anti-seizure medication keeps me functioning at a relatively normal pace (well, 'post-head-injury' normal, at least), but I also avoid it because, with the alterations in my functioning from the head injuries, I treasure every bit of consciousness I can get.]

It is also important to eat properly, and according to research [http://www.amenclinics.com/], make sure to take a multivitamin (the B complex is especially important), and get a lot of good quality Omega-3 fatty acids (about four grams a day).  Taking the Omega-3s as fish oil is far preferable to flax-seed oil, as only 1/34th of flax-seed oil is usable by the brain and body, when compared to fish oil.

3. Additional fairly easily noticeable increases in functioning continue for the next roughly two years.  During that time it is possible to see functional improvement with some speed.  Although it can be helpful for resolving functional difficulties at any time post-head injury, this first two years is when most focal neuropsychological/cognitive rehab has the best effects.

4. Some functional increases can continue for a decade or longer after a head injury, but during this time span (2 years to 10+ years) it is usually VERY slow, and can only be seen when comparing one's functioning to how one functioned, say, 6 months to 1 year before.  [I still have little improvement 'bumps' that occur.  They are never major things, but every bit of functional improvement helps.]


One uses the functioning and brain areas that are retained to work around those that were damaged.  But the unfortunate fact is, despite what some may say (especially those who have been head injured), there is NEVER a full return to previous functioning after a head injury.  [People's claims that they are back to normal are generally a combination of the self-monitoring parts of the brain being injured and psychological denial from being unable to emotionally process the lost functioning.]  The inability to return to full previous functioning is particularly true for a moderate to severe head injury (one causing a coma, or requiring an induced coma).  People may get 'close' and appear 'back to normal' in the way they act.

Because there is no part of the brain that is not used in everyday life, there is no part of it that is expendable.  So any damage will have some permanent results.

Appearing 'back to normal' is just that: appearance.  How the person thinks, and how they manage to do particular tasks mentally, will never be the same.  [I am just over 17 years post-my first head injury, and 13 years post-my third/final one, and I STILL miss my premorbid (i.e. "pre-injured") personality and functioning, though I have learned to accept and work around most of my limitations.  In face-to-face and phone conversations with people, they've told me, "you sound perfectly fine!" (as if that is meant to be reassuring).  The thing is, they don't get that it may take me up to two weeks to recover from a one-hour in-person discussion (or a 20 minute phone call), and it has taken over a month to recover from interactive evenings lasting a few hours.  It takes two weeks to recover from a quick doctor's appointment or just going grocery shopping.  During that recovery time, I may not be able to follow a TV show plot (even as predictable as they usually are), hearing words may give a spike of pain in my head with every syllable, reading is out of the question, and so forth.  (So, "you sound perfectly fine," is - at best - an irritant, but often angering because it ignores the devastating consequences of an interaction for me.)]


Other Things to Look Out For
Memory is very frequently, if not universally, affected by head injury.

'Lost time' is possible.  That is where you become aware that you were not aware of your surroundings for a time (and is about as difficult to recognize as seeing an invisible man; one can only tell this from things like noticing that the last thing one remembered, they were in the middle of a TV show and now they are in the middle of a commercial, with no memory of anything in between).  This needs to be followed up on, as it can be a sign of what is called 'subclinical' seizure activity.

The drug Neurontin has been found to be helpful to those with head injuries for a number of problems (attention, memory, lost time, and more).  Sometimes it is routinely prescribed.  But, since the brain can be much more responsive to most all medications following a head injury (particularly medications with brain side-effects, such as making one tired), the dosage may require significant adjustment to be truly helpful.

Sleep disruption, or appetite disruption (the ability to tell when you are either hungry or full), or what seems like a balance issue (walking on an angle such that one may hit walls or people), or double-vision can occur with brain-stem damage.  This can happen since the brain-stem is at the base of the skull.  So not only abrasions from scraping the skull, but 'tugging' on the brainstem can also damage it, as the brain moves during impact, but the attached spinal cord at the other end tries to hold the brain in place.  The brainstem, being between the two, takes the brunt of that tug-of-war while being encircled by the foramen magnum (the hole in the skull the spinal cord passes out of).

But walking on an angle and double vision can also be from a specific type of brain damage that results in Vertical Heterophoria Syndrome.  That is a misalignment of the images produced by the two eyes.  It occurs with some frequency with head injury, and can often be fixed very simply by getting glasses with prisms in them, to take the strain of trying to realign the images off of the brain.  [I have a pair of these each for reading, computer, and distance viewing.]  To those having a head injury, one of the foremost researchers in that area is at this site, with an online test that helps decide if that may be a problem for you: Vision Specialists of Birmingham


Treatment [Overwhelm], and Recovery
Proper medication (if needed), and proper cognitive rehab can help tremendously, especially in the earliest stages: right after injury to two years-post.  But that rehab can ONLY be helpful if it truly takes into account the current functioning of the injured person, and is tailored to not overwhelm them.  That generally is not the case with most outpatient cognitive rehab, as the 'simple' act of just GETTING to the facility may be more than enough to wipe out the functional capacity of the person for that day.  [That was the case with me, but, knowing I 'should' do it all, I did it, and it - instead of helping - made some things worse and likely slowed my recovery.  Overextending myself past my capacity may have also amplified my 'abnormal electrical activity in the left temporal lobe' [the quote from my EEG report...  'abnormal electrical activity in the left temporal lobe' = seizure activity].]

Bob, when you mentioned that the program you are in was testing your ability to make burgers, or your ability to drive, it was clear that one of the things it sounds like the program is doing is testing 'daily living skills'.  This is a very good thing.  When someone has had a head injury, particularly one as severe as this one must have been [a coma and a metal plate replacing broken skull], testing to make sure that someone can still do tasks that are required to function on a daily basis is necessary (things such as making themselves food to eat, or driving safely so as not to endanger themselves or others).


Important Point to Remember
Rest when you are tired.  Accept that your brain - which, when NOT injured, consumes about 25% of all the calories your body takes in - is going to need extra rest and is going to consume more of your energy, leaving you more tired than usual.  It is just like someone who was a runner prior to a knee injury: if they start back by doing a marathon, they will, inevitably, stay injured and take longer to heal.  One needs to start recovering slowly, and build up again, going just a tiny bit beyond current functioning.  Only then can recovered functioning be retained.  [The thing that was hardest for me to accept was that repeatedly pushing myself well past what my capacity was was actually slowing my recovery.]


If someone ends up with a bruise or a bump that one can see on their head from an impact, most likely their brain was damaged to some degree as well.  One can work around that damage, or create alternative pathways in the brain to bypass it, but that doesn't mean that it 'goes away'.  A dead neuron is a dead neuron: it isn't resuscitated.  A broken axon is a broken axon: it MIGHT be regenerated if JUST the right combination of effort is exerted, but most likely that pathway is gone for good and a more roundabout path is generated.

[LucasM]

What comes back first, or last, or not at all, depends on many things: what functioning is most damaged, and how much effort is placed on recovering that functioning.  The brain is very resilient up to a point.  Sometimes those who have lost eyesight can later hear better or their sense of touch can be more sensitive.  That is directly related to that resilience.  When there is effort placed toward certain functioning, the brain can rewire areas that weren't originally designed to do a particular task to do it following injury or damage to the brain.

With all the broken axons, the brain rewiring itself following a head injury requires more effort to perform whatever task that one wants to get back than one is used to giving to that task [remember the Michigan-to-Mexico path, via Alaska].  It requires at least the amount of effort it took to learn it in the first place, possibly more than that, and always requires more mental energy to manage and sustain the roundabout way.  Needing more effort and energy for the brain to perform tasks as it rewires itself is responsible for the incredibly common effect of head injuries resulting in people getting tired more easily than they used to.  [After my first head injury I went from being able to manage occasional ten hour days at work to being exhausted and stressed by working three hour days.]

After a head injury there are no 'spare' neurons to take over for the injured brain tissue.  Contrary to belief even 10-20 years ago, the brain can actually form new neurons later in life.  But it is unlikely in the time remaining in one's life for it to replace all those that were lost.  Beyond that, the lifetime of experiences that resulted in the brain being wired the way it was simply can't be replicated.  So one will never be exactly like they were before a head injury.


Example of my functioning/recovery:

Spoiler (click to show/hide)

With my recovery: since after my third (most damaging) head injury I could no longer tolerate phone calls, or even face-to-face contact with people, most of my contact with 'the outside world' has had to be through writing in newsgroups, message boards, and e-mails.  So my writing was VERY important to me, to not feel isolated.  So I've focussed heavily on getting my writing skills back over the last 12+ years.  For most things I am a much slower writer, but with all the effort I've put in over the years I believe I write as well as I did before the head injury now.  (In some ways my writing is possibly smoother, because I've had to restudy 'the basics' of writing all over as an adult.)  But depending on how I'm doing any given day, a two or three paragraph communique' can sometimes take me a couple hours to write and edit until I am sure it says what I intended it to.

I lost many friends, especially in the early days after my head injuries, because I could not tell that what ended up in an e-mail was not what I thought I was writing.  In editing I may still find that sentences are simply in the wrong place, or that paragraphs are out of sequence, or that I've left out words or ideas that render what I've written less comprehensible or completely unreadable.  So I edit, and re-edit, and re-edit what I write.  That is the only reason that this (hopefully ) was coherent and makes sense.

But in order for what I write to make sense and feel 'complete', I still have to work a LOT harder on writing than I used to, and it takes more out of me than it did before any of my head injuries.  And I have to focus more intensely than I used to because I can't remember things like I could before, so I may repeat things, or leave them out, because by the time I've written a certain amount I can forget what I've already stated.  And for something of this length, even when editing, by the time I reach the end I've generally long since forgotten what I said early on.  So I usually go back and re-read, and re-read, and re-read what I've written to make sure that repetition is minimized, and that the sequencing of ideas is optimal for clarity.

Believe it or not: what I've written here is just scratching the surface of what is involved with head injuries.  But I tried to cover as broad a range of functioning as I could, in enough depth to make sense.


Directed to Bob:

Spoiler (click to show/hide)

Bob, with your recent head injury, I tried to address what I could see directly, then I wanted to give you a heads-up on a few of the things that you might want to keep an eye out for.  And, when it (hopefully) wasn't too distracting, I wanted to include personal experiences to help show some of what can occur with a head injury.

Of course, anything that you now feel or experience that is different than what you used to feel or experience, write it down (for yourself) and report it to the people working with you at the clinic.  Even things that might seem small to you, could be very important to helping you get better.

Reiterating: Four Important Points to Remember Immediately After A Head Injury, to Help Recovery
1. Try as hard as you can to avoid alcohol and tobacco, especially for the first six months.
2. Try to eat as well as possible, with a multivitamin and about four grams of Omega-3 [fish oil] supplements every day.
3. Pushing yourself too far, too fast, will only slow your recovery.
and 4. Rest, any time you feel tired.


If there are any questions you have (or anyone else has) on any of what I've written, please post below and let me know what you'd like clarified or explained, and I'll do my best.

Take care.


EDIT:  Note to readers, there are a few posts I made below others' comments that further describe head injury difficulties.  I talk about things such as memory and sleep disruption.

[Tripe]

 

[Bob]

Thanks from me too!

[LucasM]

Thank you for the responses Tripe and Imrahil and Bob.  You are very welcome.  It is nice to know that at least a few people that looked in on the thread made it through the whole thing and that it was appreciated.  Given the opportunity that was presented, both to help Bob, and to educate anyone who would 'sit' through the entire thing, I felt it was important to use my writing capacity for the last couple weeks composing it.

A simple addition to what I wrote above is this: head injuries are often referred to as "TBI"s.  That stands for 'Traumatic Brain Injury'.  [A friend once asked, "and there are brain injuries that are NOT traumatic?!"]


[As tends to be the case when I've gone past my limits... this next addition is WAY longer than intended (I thought it would be about two average-size paragraphs when I got on here to write it  ).]


I forgot something important about head injuries that - ironically - was demonstrated by being able to write all this without any research (i.e. it was off the top of my head, just needed organizing).  And that is related to memory following a head injury.

Memory
In the vast majority of cases, memory for things happening, or learned, prior to the injury is largely unaffected.  This is especially true of vocabulary, which is the least affected of any prior learning.  This leads many with head injuries to believe there is nothing wrong with their memory, and can result in people who interact with someone who is head injured saying things like, "you seem fine" [which can result in both denial of any real problems, but if one recognizes the damage that one sustained, it can be angering].  But despite the nearly-unaffected prior learning, completely new learning can often be difficult, with either retention or retrieval affected.

Retention is the ability to encode new learning [form new connections and associations between neurons] and the brain holding onto that.  Retrieval is the ability to access that memory, once it has been encoded.  Often the two are, very superficially, identical, because both show up in daily life as 'not remembering'.  The difference is that with memory cuing [being reminded of some aspect of the learned thing] the memory can be retrieved if the brain was able to encode it.  But if the brain areas governing retention for that memory were damaged (or if distractability prevents attention being maintained on something new long enough for it to be encoded clearly), no amount of cuing can bring back the memory.

From my history, a good example of this occurred within three days of my third - most severe - head injury.  My left knee was bothering me right after the accident, but I was so overwhelmed that I didn't mention it to the EMS or ER people, so nothing was checked with it when I was taken to the hospital.  I did not have any conscious memory of that for years.  It was only three to four years later, when I was required to go through all my receipts and itemize them [luckily I had help with that] that I was reminded of the event.  During that, I found a receipt dated two or three days after the accident for a visit to the Internist I've seen for the last 26 years, and a receipt for X-Rays at a nearby hospital.  At first I couldn't remember anything about it, and, honestly, I believed it was a mistake!  But, with some struggle I was able to gradually remember the knee problem.  I still cannot remember anything from the visit with my Internist, but with significant effort I was able to get a single 'still picture' of the waiting area for the X-Ray in my mind.  I also was able to recall an 'objective' awareness that I had been told that the X-Ray area for the hospital had changed since I'd last been there and that I'd been given a map for how to get to it in the hospital complex.  But no clear memory of either of those things actually happening (no visual memory for them, awareness of whether I was told that in person or over the phone, by whom I was told it, or clear trust in my memory that they actually happened).

However, I have found that, if I remember an event clearly, then what I remember is very accurate.  My attorney told me once that it was 'scary' to him how accurate my memories were for some things.  That is, actually, how my memory was for most things prior to the head injuries, and I sorely miss that, since that extreme clarity of memory is the exception now rather than the rule.

With both, I have improved consistently since the head injuries took place.  Hopefully from these examples, what I was saying about memory problems can be better understood.  From what I wrote, it can also be seen that I have difficulties with both retention and retrieval (for things following the accidents, particularly the third).  For things closer to the head injury like the X-Ray events, my retention was almost non-existent, as I could not remember most of what occurred.  But since it took so much conscious effort for those little bits that I was able to get back, even when reminded of the events by the receipts, my retrieval was clearly impaired.


Sleep Disruption
Another thing I just breezed by under "Other Things to Look Out For" (again, somewhat ironically, because of how central it is to my day, every day), is that sleep can be disrupted.  One's sleep schedule can be thrown off significantly, and one's brain may consistently require more than one sleep period during a day.

To give you an idea of how this may play out, within the first few years of the third head injury I had a sleep study done (partly because brain-injury-caused sleep apnea was suspected; luckily that was not the case).  But in the sleep study they found that it took a long time for me to get to sleep.  [I could've told them that!  ]  Ultimately, since sleeping pills didn't work past about three days, I just had to accept that I wasn't going to be able to get to sleep until my body 'allowed' it, and my bedtime gradually moved to 6am, where it has remained relatively stable since.  Now, my current schedule is generally: wake up at about 1:30 to 2:30 in the afternoon and remain awake until 6pm at which point I am already exhausted and need to sleep again.  I usually sleep about two hours then, and am then awake from roughly 8-9pm until I have to start getting ready to sleep at 4am, usually getting into bed and to sleep at about 6am.  [Later edit: I have since figured out the possibility that my brain also may have partially made this day/night change to reduce sensory input.  The world is now dark and quiet when I am awake the longest, when unexpected sounds, and light, cause difficulties and excessive mental drain for me.]

If my afternoon/early evening crash is missed, I end up losing virtually all of my frontal lobe self-monitoring, and generally can do things that are not in my best interests (e.g. write too much without stopping thereby pushing myself past my limits, moving or keeping poor posture or lifting things that result in aggravation of my soft tissue spinal problems, or inability to recognize that I'm full when I eat, etc.).  [It is, I figured out after a time, much like a toddler who misses their afternoon nap: irritability and poor overall control of themself.]  When that happens, it often takes as much as a week for me to recover from the sleep disruption (i.e. before my sleep normalizes again), and sometimes it takes longer than that for the functional consequences of what I did while my frontal lobes were 'off-line'.

If I am able to sleep restfully during that 6-8 or 9pm time, I've found that my best functioning - when my brain works the best - is during the 9pm-midnight time period.  [If someone takes a look at my stats here on the boards, they will show a very significant 'pooling' of when I post, most of which are during that time (when corrected for time zone).]  But to keep myself functional day to day, I still can't focus intently on anything for over an hour or so.  But it took me a long time for this to stabilize and for me to figure out when the best times to do things were.

[Bob]

Stupid hospital that was supposed my follow up meetings done all last week on Monday has not done them yet and can only tell me they will have "something" worked out for me all next week (and hour plus from my house) worked out by Friday.   They cannot say what will be in them yet.

This pisses me off since I have ZERO memory or ANY physical issues.  It cannot go on for weeks as I need to go back to work NOW!

 

Their lack of work is pissing me off.

[RVR II]

Stupid hospital that was supposed my follow up meetings done all last week on Monday has not done them yet and can only tell me they will have "something" worked out for me all next week (and hour plus from my house) worked out by Friday.   They cannot say what will be in them yet.

This pisses me off since I have ZERO memory or ANY physical issues.  It cannot go on for weeks as I need to go back to work NOW!

 

Their lack of work is pissing me off.

Don't blast one of those plates off your head..

[Bob]

Sigh, they are now telling me I will have all day classes on Monday, Tuesday, Thursday and Friday.   And then some more.  I better have this as last week or my lawyer is getting called............

[RVR II]

Sigh, they are now telling me I will have all day classes on Monday, Tuesday, Thursday and Friday.   And then some more.  I better have this as last week or my lawyer is getting called............

I'd have been in touch with him anyway about the incorrect prescription drugs you were given, but that's your call..

[LucasM]

[EDIT: As has consistently been the case recently, my frontal lobes aren't quite functioning right now, so while I thought this would be brief, it is not.  I have to stop and go get breakfast now.]

For those reading this for general knowledge: most of this can be applied to head injuries in general, not just to Bob.

Sigh, they are now telling me I will have all day classes on Monday, Tuesday, Thursday and Friday.   And then some more.  I better have this as last week or my lawyer is getting called............

The thing is, if you need additional therapies for the head injury's effects, then this first six months after the accident can be very helpful.  Partly because they will teach you how to work around some of the major problems.  But it is possible that with it being so close to the head injury that you haven't had time to recognize the difficulties you have been left with, so aren't motivated to either be there, or to work on the difficulties that they have found through testing, that you can't see yet.

One of the things that is very difficult for people who are freshly head injured, who are not back in their usual environment (home, work, etc.), is that they cannot as easily see the difficulties that they are having.  The new daily tasks of, for instance, a head injury rehabilitation program are so foreign, and often so overwhelming, that it is difficult to tell how one is actually doing, because the usual reference points for functioning that one has through being at home, with friends and family, and at work, are not there.  Until someone is back in their usual patterns, and not doing as well at them as they used to, they may not realize the effects that the head injury actually had.  Even then, some people, through both organic ['injury-related'] and defense-mechanism-based inability to recognize difficulties, have to have a lot of difficulty in their regular home life before they begin to see that they need help.  Hopefully this won't be the case for you.


You said

...since I have ZERO memory or ANY physical issues.

With the phrasing, I am unclear if you meant, "I have zero memory [function] and no physical issues," or if you meant, "I have zero memory... issues".  [The way it is phrased is unclear.]

If it is that you have limited memory function, then training yourself to reliably use a notebook you carry with you everywhere is a key point before returning to work.  If you meant you have zero memory issues, then you will be a step ahead in learning to compensate for the other difficulties you are having, and learning to compensate for difficulties is quite important.

If you feel that your memory is unaffected, then test yourself with it: write out everything you can remember happening from Monday; both everything you did at home before you left, everything you did during every therapy through the day at the rehab program, and everything you did that night.  That was only three days ago, and - as a 'first or last' day of the week, would stand out more in memory than a 'mid-week' day.  Then do the same for last Friday.  Then last week, Monday.  Then take those with you to the rehabilitation program.  That will either do one of two things: it may show you that there are gaps in your memory that you were not aware of before, or it will show the rehab program that your memory is intact for new learning and that you don't need additional focus on it.

Programs like that one don't keep people just because they can, they have more than enough applicants to keep them busy.  So the only reason that they would have you come in so often is because they are seeing difficulties that you aren't able to at this point.  [Whether the inability to see difficulties is the emotional defense mechanism of denial, or whether it might be from the frontal lobe damage isn't clear, and likely wouldn't be to anyone.]


But I realize there may be other reasons why you want to finish with the program and get back to work.  The first one that came to mind is financial.  If you are having monetary difficulties from being off of work for a long time, that is clearly something that the program needs to work with you on.  To get help that, because you are not working, leaves you unable to pay things like mortgage, utilities, etc. is not helpful, and can be very stressful.  [And stress is damaging to the functioning of even healthy brains.]  The second thing that came to mind was what I wrote about above: the "Desire for Life to 'Return to Normal'".  [In about the middle of this post Part 2 of the original 3 posts.]

I'd have been in touch with him anyway about the incorrect prescription drugs you were given, but that's your call..

I hadn't heard this anywhere.  What medications have been given, and what was the reason given for them?  Which ones were considered "incorrect", and was there a reason given for that?  [It is best to ask them why they gave them and what they were hoping they would do for you.  And I will not weigh in as to their appropriateness to you specifically, but I may be able to give more details as to what head injury effects they might have been trying to accomplish something with for any I'm familiar with.]

Some medications that don't seem to be correct may actually be appropriate.  And unfortunately, following a head injury in particular, there is no guarantee that medications that are known to help following a head injury will be helpful to you, personally.  It is also possible that the side effects of some medications may outweigh any functional gains you may get from them.  So there is a need for a knowledgeable doctor to experiment with which medications work for you.  That may take some time, and may take going through a number of 'wrong' medications before the right ones for you are found.  [It took until nearly six years after my third head injury to find just the right 'cocktail' of meds that was most helpful to me.]


Since we are discussing medications, I want to reiterate: Because of damage to the brain, the brain is likely to be far more sensitive to medications of any type that affect brain function.  That includes both medications that are supposed to affect the brain, as well as those that have brain effects as side effects (e.g. drowsiness with antihistamines).

[LucasM]

I think RVR is talking about the pills which originally caused the fall, but I may be wrong.

Thanks, Imrahil.  I didn't remember that it was medications that caused the fall (or may never have heard that in the first place; I don't know which).

Yeah: if RVR was referring to medications that caused the fall, particularly if they were not appropriate to Bob at the time, I'd at the very least consult an attorney about them.  Though there are sometimes so many disclaimers on medications that it's hard to get anything legal to 'stick', it'd still be worth a consultation given the devastating effects they had.

[RVR II]

I think RVR is talking about the pills which originally caused the fall, but I may be wrong.

Thanks, Imrahil.  I didn't remember that it was medications that caused the fall (or may never have heard that in the first place; I don't know which).

Yeah: if RVR was referring to medications that caused the fall, particularly if they were not appropriate to Bob at the time, I'd at the very least consult an attorney about them.  Though there are sometimes so many disclaimers on medications that it's hard to get anything legal to 'stick', it'd still be worth a consultation given the devastating effects they had.

Exactamundo!

[Variety of Cells]

I just read everything and wanted to say that it was a very interesting and engaging read. The order made sense and I learned a lot. Thank you.

[Bob]

Well, the good news:

1.  My memory is 100% and my co-workers and pals all agree.
2.  My physical is 100% and I get to lift weights every other day and am 6 foot and 175 pounds as a normal person.
3.  Back at work 100% normal and all is well there.
4.  Basically, I am 100% with zero problems.
5.  My doberman enjoys the full energy power walks she takes me on daily.

I am sure if I broke my skull and brain 20 years ago this would NOT be such a good thing!

I am 100% now and living life normally.