Recovery from Head Trauma

Recovering From Head Injury

A Guide for Patients
Wiley Mittenberg, Ph.D - Renee Zielinski, Ph.D. - Sharon M. Theroux, Ph.D.

What Happens in a Head Injury?
A blow to the head can occur in a motor vehicle accident, a fall, when the skull is struck by a blunt or heavy object, or in other ways. In most cases, there are no lasting symptoms or ill effects from an injury to the head. This is because the brain is surrounded by shock absorbing liquid and covered by the skull. Often these are enough to protect the brain from any damage.

Sometimes the force of impact is more severe. This can cause the skull to break or fracture. When the skull fractures, this absorbs some of the force of the blow and protects the brain. This is the same way that a crash helmet works.

When the head is hit, the brain may be shaken around inside the skull. This can sometimes cause the brain to get bruised if it hits the inside of the skull hard enough. Like a black and blue on your arm or leg, this will recover with time. If there are many bruises on the brain, there will be some swelling that can take a while longer to return to normal.

The brain is made of many thousands of long, nerve fibers. Some of these nerves can snap or break if a blow to the head is severe enough. Although these nerves cannot be seen without a microscope, we know that they can recover because many patients recover completely in time.

Like any other part of the body, the brain has blood vessels in it. If a head injury is very serious, some of these blood vessels can tear and bleed. This happens soon after
the injury. The bleeding often stops on its own and the blood vessels heal like any cut
will.

Bruises, swelling, snapped nerves and broken blood vessels are the causes of symptoms after a head injury. Your doctors have examined you for any signs of injury to the brain and prescribed treatment if you need it. Most people who suffer a head injury recover completely in time because the damage is minor and heals.

How Serious Was The Head Injury?
One way to tell if a head injury is serious is the amount of time the patient is unconscious
afterwards. If you weren't knocked out at all or if you were unconscious for less than an hour, then the injury was minor or mild. Although you may have some symptoms, there was probably little injury to the brain and complete recovery is expected. Most people who have a head injury fall into this category.

The longer you were unconscious, the longer recovery usually takes. If you were knocked out for more than an hour but less than a day, your injuries were most likely moderate. Return to normal will probably take a while.

Patients who are unconscious for more than a day have suffered a severe injury.
Although many patients make a good recovery even after a severe head trauma, symptoms can often last for some time. In very severe head injury, many symptoms can be permanent. Treatment at a rehabilitation hospital is usually recommended and can help recovery.

How Long Will the Symptoms Last?
You have probably gotten a lot better over the last few days. The most rapid recovery occurs in the first 6 months after head injury, and most patients will be back to normal by 3 months.

If you still have some symptoms after 6 months, these will most likely disappear altogether or be greatly improved within a year after the injury. If you suffered a severe injury, recovery can take as much as two years. During the second year, improvements will be more gradual.

Not everyone recovers at the same rate. People who are under 40 recover faster and have less symptoms during the time they are recovering. If you are over 40, you won't get better as quickly and you may have more symptoms at first. Patients who are older or who have been hospitalized for head injuries before should expect full recovery to take 6 to 12 months even after a mild head injury.

Most doctors who treat head injuries agree that recovery is faster when the patient gets enough rest during the weeks after they leave the hospital. Work, exercise, social activities, and family responsibilities should be started gradually, not all at once.

What Symptoms Can I Expect?
The most common symptoms after a head injury are known as the post-concussion syndrome.
Eight out of 10 patients with a mild head injury show some signs of the syndrome during the first 3 months after the accident. These symptoms are part of the normal recovery process and are not signs of brain damage or medical complications. Like the itch of healing stitches, these symptoms are expected as you get better. They are not a cause for concern or worry.

Postconcussion syndrome is more common after mild head injury. The symptoms are less likely to trouble a patient with severe head injury. If you have these symptoms, this is a sign that your injuries were probably mild or minor. The majority of patients with post-concussion syndrome recover completely in 3 to 6 months. If you are older than 40, it may take a bit longer to return to normal.

Most patients don't develop the symptoms until days or even weeks after the accident, but the syndrome can begin sooner. Either way, the symptoms often disappear without any special
treatment.

A list of the symptoms that you can expect is shown below, along with the percent of head injured patients who experience each symptom at some point in their recovery.

Symptoms of Postconcussion Syndrome
Symptoms of Everyday Stress

Symptom                                                   Percent of People
Poor concentration                                      14%
Irritability                                                   16%
Tired a lot more                                          13%
Depression                                                20%
Memory problems                                       20%
Headaches                                                 13%
Anxiety                                                      24%
Trouble thinking                                           6%
Dizziness                                                     7%
Blurry or double vision                                  8%
Sensitivity to bright light                              14%

The reason that the symptoms of postconcussion syndrome are so much like the normal signs of daily stress is that one main cause of these symptoms is exactly the same: everyday stress. Of
course hitting your head also has a lot to do with it. But having a head injury adds more stress to your life, not just bumps and bruises to your head.

The accident itself, being in the hospital, and going back to work or school are all things that add stress to most patients' lives. Bills can pile up, time is lost, there may be injuries to other parts of your body. And just like a pulled muscle or a bruised leg, your brain takes some time to
recover. You can have some trouble with work or school at first, and this is stressful also even though it is normal. Trying to do your regular work right after a head injury is something like trying to play baseball or swim with a pulled muscle. You can't see it, it isn't really serious, but it takes some time to get better.

Another main cause of stress after a head injury is worry about the symptoms you have. Scientific studies by neurosurgeons and neuropsychologists in New Zealand show that patients who get an information booklet like this one recover faster and feel better during recovery than patients who don't know what to expect. That's why we gave you this booklet! Doctors in the
United States who treat head injuries agree that the single most important factor in recovery is that you know what to expect and what to do about the symptoms.

Of course, talking to a doctor about your symptoms is also important. Your doctor can prescribe medication that can help you if you need it. You can also call us at the number listed in this
guide.

More About the Specific Symptoms

Poor concentration. The main cause of poor concentration is tiredness. When it becomes
difficult to concentrate on what you are doing, take a break and relax. Between 15 and 30 minutes should be enough. If you still continue to have problems, your workday, class schedule, or daily routine should be temporarily shortened. Trying to "stick to it" won't help, and usually makes things worse.

Reducing distractions can help. Turn down the radio or try to work where it's quiet. Don't try
to do too many things at once. Writing while you talk on the phone or taking notes as you listen to someone talk are examples of doing two things at the same time. It may be difficult to concentrate on more than one thing at first. You will be able to concentrate better when you have had enough rest.

Irritability. One of the most frequent causes of irritability is fatigue. People lose their tempers more easily when they are tired or overworked. Adjust your schedule and get more rest if you notice yourself becoming irritable.

Everyone gets angry from time to time, often with good reason. Being irritable only becomes a problem when it interferes with your ability to get along with people from day to day. If you find yourself getting into arguments that cause trouble at home or at work, try to change the way you think about things. Thoughts often make us more angry than what actually happened. You can see this for yourself by imagining an irritating situation and why it would make you
angry.

There is usually a reason why irritating things happen. When something makes you angry, ask yourself what caused it. Family, friends, or co-workers can do things that bother us at
times. Try to think of why they did whatever it was that irritated you. What would they say the reason was? Thinking about what caused a problem is the first step to solving it.

Problems can usually be solved better if you stay calm and explain your point of view.
The steps you need to take to solve a problem will be the same when you are calm as they would be if you were irritated. Try to remind yourself of this when you find yourself becoming irritable.

You can usually come up with several ways to solve a problem. Try to think of at least 5 different ways, and then decide on which is best. Just realizing that there are several things you can do to solve a problem will make it a lot less irritating.

Fatigue. It is normal to be more tired after a head injury. The only sensible treatment for being tired is rest. Avoid wearing yourself out. Gradually increase your activity level. Most patients have more energy in the morning than later in the day. You may benefit from scheduled rest breaks or daytime naps. If your symptoms get worse, this means that you are pushing yourself too hard.

Depression. People become depressed when unpleasant things happen to them, and a head
injury is unpleasant. We feel good when good things happen to us. An effective way to treat depression is to make sure that good things happen. One way to do this is to plan to do
something enjoyable for yourself every day. Make your plan specific, and then be sure to stick to it. Decide on something you like and exactly when you're going to do it. That way you can look forward to it. Anticipating and doing enjoyable things each day will improve your mood.

Thoughts can make us depressed. Thinking that things are bad or terrible will do it. Bad
situations are often not as terrible as they may seem at first. Think back to an unpleasant moment in your own life and you will see that this is so.

Chances are that if you are depressed, you are telling yourself things that are depressing. Thinking that the situation is terrible, that there is no end to it in sight, that you aren't
able to do anything about it, and that it is your fault are all depressing things to tell yourself. Thinking this way can become a habit if you do it enough.

Usually, when people tell themselves unpleasant things all the time it is out of habit, not because those things are really true. If you find yourself thinking depressing thoughts, stop.
Simply stopping a depressing thought can make you feel better. See if what you are telling yourself is really true.

Memory Problems. Memory difficulties have several causes. The part of our brain that stores
memories is called the temporal lobe. This is the part of the brain that is most likely to be bruised in a head injury. Some memory difficulties can be caused by the bruises, which is why you may not remember the accident very well. Like a black and blue on your arm or leg, these bruises will recover with time. Your memory will improve as this happens.

If you can remember the accident, chances are that your brain was not bruised. Most of the memory problems patients notice after a head injury are not caused by bruising. They come from poor concentration and being tired.

For you to remember something, you have to pay attention to it first. If you don't concentrate long enough the information is never stored in your memory. Concentration problems are a normal part of recovering from a head injury, and some memory trouble is a normal side effect of this.

You will be able to concentrate and remember better when you get enough rest. Memory problems can be a sign that you are pushing yourself too hard. Writing things down or using
a pocket tape recorder are another excellent ways of coping with temporary memory difficulties. They will help recovery and not slow it down.

Of course, nobody's memory is perfect anyway. After a head injury it can be easy to forget that we sometimes had trouble remembering things even before the accident. Some of the symptoms you notice may actually have nothing to do with your head injury. A list of common memory 'problems' is shown below, along with the percent of people who experience each
"symptom' even though they didn't have a head injury.

Things We Normally Forget

Symptom                                              Percent of People
Forgets telephone numbers                            58%
Forgets people's names                                 48%
Forgets where car was parked                        32%
Loses car keys                                             31%
Forgets groceries                                          28%
Forgets why they entered a room                   27%
Forgets directions                                         24%
Forgets appointment dates                            20%
Forgets store locations in shopping center      20%
Loses items around the house                        17%
Loses wallet or pocketbook                            17%
Forgets content of daily conversations             17%

Worrying about remembering things that you would normally forget can make your memory seem worse to you. If you can remember your memory problems, you probably don't have much of a memory problem! People with serious memory difficulties are not upset by their
symptoms. They don't remember that they have any memory trouble.

If you are concerned about your memory, have it tested. Your doctor can send you for these tests if you need them. You can also ask the person who gave you this booklet or call us at the
number listed on the last page of this guide.

Headaches. Headaches are part of the normal recovery process, but that doesn't make
them any less bothersome. Headaches are another cause of irritability and concentration problems after a head injury. This guide cannot replace the medical advice that you should get if you are bothered by headaches. Headaches can have many causes, and your doctor will want to diagnose the problem and prescribe medication that can help if you need it.

One of the most common causes of headaches after a head injury is stress or tension. This is usually the cause when the headaches start for the first time several weeks after the injury.
These headaches mean that you are trying to do too much. They will disappear if you take a break and relax. Your workday, class schedule, or daily routine should be temporarily
shortened if you continue to have headaches.

Stress or worry cause tension headaches by increasing muscle tension in your neck or forehead. These muscles become tense and can stay tight without you knowing it, out of habit. They can become even tighter once a headache starts, because muscles automatically tense in reaction to pain. This muscle tension makes the headache worse.

If you have tension headaches, relaxing your muscles can help. One way to do this is with a method called progressive muscle relaxation. Start by clenching your hand as hard as you can.
Harder. Notice how the muscle tension feels. Now relax your hand completely, and notice the
difference.

Now clench both your hands as hard as you can and hold them that way for a moment or two before letting them relax completely. Notice the difference. Now, continue to tense
and relax more muscle groups together by adding a different set each time. Face, chest, stomach, buttocks, feet. This method works best if you are lying on your back.

Finally, tense all the muscles in your body at once as hard as you can, and then let them relax. At this point all your muscles will be very, very relaxed.

Progressive muscle relaxation can help prevent tension headaches by relaxing your muscles. This works best if you practice it once a day at about the same time for 5 minutes or so. Do not do this while you are having a headache.

Anxiety. Worry about symptoms and problems at work are the main causes of anxiety
for most patients. Anxiety should not be a problem for you if you understand that your symptoms are a normal part of recovery, get enough rest, and gradually increase your responsibilities at work.

If you are anxious, chances are that you are telling yourself things that are making you that way. Usually, when people worry all the time it is out of habit, not because the things that they are telling themselves are really true. The steps you need to take to solve a problem will be the same when you are calm as they would be if you were anxious. If you find yourself thinking anxious thoughts, stop. Simply stopping an anxious thought can make you feel better.
See if what you are telling yourself is really true.

Trouble thinking. This problem is a side effect of other symptoms. Concentration problems,
being tired, headaches, and anxiety can all make it hard to think clearly. Like these other symptoms, trouble thinking is a sign that you are doing too much too soon.

Dizziness, Visual Difficulties, and Light Sensitivity. Dizziness and visual difficulties should be checked by your doctor. These symptoms usually go away by themselves in 3 to 6 months or less in most patients. If you find these symptoms troublesome, your doctor may want to prescribe medication for motion sickness or eyeglasses. Some motion sickness medications are
very effective for dizziness, but can make you drowsy or reduce your attention span as side effects.

You may notice some increased sensitivity to bright light or loud noise, particularly if you have
headaches. Some increased sensitivity is normal after a head injury. But scientific studies by neurosurgeons and neuropsychologists in New Zealand show that someone's actual sensitivity to
light and noise has nothing to do with how much light and noise bother them. Paying attention to these symptoms makes them seem worse, because paying attention to a feeling seems to
magnify or increase it. The less you think and worry about your symptoms, the faster they will go away.

Summary
The most common symptoms after a head injury are known as the postconcussion syndrome.
These symptoms are part of the normal recovery process and are not signs of brain damage or medical complications. They are not a cause for concern or worry.

Postconcussion syndrome is more common after mild head injury. Few patients will experience all of the symptoms. The symptoms may not develop until days or even weeks after the
accident. Most patients will be back to normal in 3 months without any special treatment.

Most doctors who treat head injuries agree that recovery is faster when the patient gets enough rest and resumes responsibilities gradually. If your symptoms get worse, or if you notice new postconcussion symptoms, this is a sign that you are under too much stress. Your workday, class schedule, or daily routine should be determined by what you are comfortable with.

About This Guide
The information presented here is based on published scientific research and clinical studies.
If you have any questions, comments, or would like more information, contact Dr. Sharon M. Theroux at (561) 395-0243.