What is traumatic or acquired brain injury?
Traumatic brain injury (also known as acquired brain injury) refers to an impact injury to the brain which can happen in raod accidents or falls as well as other situations such as gunshot injuries to the head.
It happens suddenly and unexpectedly and the forces acting at the time of the impact are violent as the head of the person is thrown around and hit by objects, sometimes causing skull fractures.
These impacts can cause damage to the soft brain tissue inside the skull even without skull fracture. The impact injury can cause bruising and bleeding of the brain inside the skull. This may lead to permanent damage to the brain cells and leaves many survivors alive but permanently impaired.
Can I make a brain injury compensation claim?
If you have suffered a brain injury in a road accident, even if the accident was your fault, you may be entitled to injury benefits or compensation through the Lifetime Care and Support (LTCS) Scheme and/or CTP Insurer .
All reasonable and necessary treatment and care for moderate to severe brain injuries are covered by the Lifetime Care and Support (LTCS) Scheme. Those with serious brain injuries frequently require extensive medical treatment and incur large rehabilitation expenses, and it is important to ensure that you maximise your entitlements, including the provision of medical treatment.
If the other driver was wholly or partly at fault, you may also have rights to compensation for pain and suffering and impairment and for wage loss.
Extent of the problem
The leading source of acquired brain injury is the traffic accident. In most industrialised countries there has been an increase in the proportion of the population who can expect to suffer from this disorder.
Statistics show (The Age, 22 April 2006) that apart from the tragedy of roughly 1750 people killed on Australian roads each year, there are around 8000 people who go on to suffer disabling brain injury effects for many years and about 2500 people are so disabled that they are dependent for life.
The at-risk group
Although it can happen to people of any age, many of those at risk are young adults, previously healthy, with a long life expectancy. The average age of this group is around 28 and there are disproportionately more males than females (3.5 to 1).
Traumatic brain injury has a major responsibility for invalidism and lay off from work during what should be the most productive period of a person’s life. Every person is different in the way they recover but the more severe the brain injury the more likely it is that there will be serious long term problems with brain function.
What happens after an accident?
The ambulance services take the injured person to hospital for treatment. The family will usually be notified by the police or others. When family members arrive at the hospital they may be overwhelmed to find that the injured person is not able to talk to them or is in a coma or unconscious or so confused that they do not recognise the family.
- There may be severe bruising, lacerations or injury to the head and face and the patient’s appearance can be very disturbing for the family.
- There may be the need for neurosurgery or operation on the brain which can be a frightening prospect for family members. At this early stage it is very difficult for the specialist medical staff to predict how the patient will recover.
Frequently in traffic accidents the person suffers bodily fractures and internal bodily injuries and in such multi-trauma situations there are many different medical specialists involved in treatment. Depending on the extent of all injuries including the head injury, the patient may remain in hospital for days or weeks until all treatment is concluded.
There will be x-rays and scans of the brain to determine the presence or otherwise of brain damage. Social workers help the family to cope with this crisis situation. Most patients do not remember the accident. There will be a memory loss for a period following the accident which may be as short as minutes or as long as weeks. During this time the patient will not remember ongoing events.
They may talk to their visitors but not remember that they came to visit. The patient gradually improves and begins to remember but it can be worrying to family members at the time.
Rehabilitation - the next step
When the treatment needed in the acute hospital is achieved and the injured person is considered to be ready, they will be transferred to a rehabilitation centre for rehabilitation treatment. They may live in the centre or be treated as an out patient. Much depends upon the nature and severity of the overall injuries and future treatment required as well as the geographical location of the patient’s home relative to the rehabilitation centre.
In rehabilitation the patient will have the benefit of all therapies to treat any physical injuries, any speech, language, memory problems and to help the patient cope better in daily life such as deciding whether the patient is competent to drive. Psychological counselling and psychiatric assessment are available and all medical needs of the patient are met.
The duration of rehabilitation may be as little as weeks or much longer. In some cases where therapy is available locally the person can return home and be treated in the area. The more severe the head injury and the more widespread and severe other injuries, the longer rehabilitation will last. Formal rehabilitation will conclude when the rehabilitation staff considers that all reasonable progress has been made. Social workers will usually liaise with the patient and family to assist in these stages.
There may be attempts by vocational counsellors to help the patient try to return to work if this is considered to be appropriate. There may be recommendations to the patient to try to undertake retraining in a new area for future work if this is considered to be appropriate. At this stage the patient is usually discharged home to the family or to whoever can provide the level of care needed.
Outcomes of traumatic brain injury
What is the effect of traumatic brain injury on brain function?
The immediate effect apparent in hospital is that the patient suffers from disturbances in memory function. They cannot remember the accident. In the hours or days or weeks following the accident they cannot remember ongoing events in hospital. They may be alert enough to talk but they do not remember.
This period of confused memory following head injury is known as post traumatic amnesia. It provides an indicator of how the brain is functioning. It may last for hours in cases of mild head injury or for days in moderate head injury.
In severe head injury it is not unusual for it to endure for weeks. The general principle is that the longer the period of post traumatic amnesia the more likely it is that there will be long lasting problems with brain function.
The first and most immediate evidence of the effect of brain injury on brain function is that the person’s brain has difficulty in organising memory functions.
These problems in thinking are frequently reported by persons with brain injury but not all persons experience all of these problems or to the same degree:
- Forgetfulness and memory impairment
- Slowness in mental processing–the person does not think as quickly
- Decreased attention and poor concentration with easy distractibility
- Impaired verbal processing ability and use of complex language
- Impaired executive control and regulation of thinking and behaviour
- Difficulty in organising their work or daily life activities
- Need for reminders to attend appointments or to do activities
- Need for assistance with financial matters.
On the positive side and in cases of mild to moderate head injury the patient will usually have good recovery of formal intellect. This means that the person has not lost their intellectual skills or knowledge from the past but they find that they cannot always use that intellect effectively. When they go to do things their inefficient short term memory systems and poor concentration cannot support or work efficiently with their preserved intelligence and this leads to failure.
This is the enigma of head injury that the person can recall their past knowledge but their ability to use it effectively can be impaired by defective memory and poor mental organisation.
Practical effects of cognitive impairment
Disorders of thinking (sometimes called cognitive disorders), may not become apparent until the person has returned home after rehabilitation and finds that they have to think for themselves and then finds that they cannot manage in the way that they did before the injury.
As a general rule, the slower the rate of recovery in the early months, the more likely it is that there will be a permanent impairment of brain function and therefore that cognitive disorders will be enduring. However there are always cases which defy these general rules where people go on to make a better than expected recovery.
Problems with memory and concentration are often reported. People who were competent workers before the accident will complain that they cannot do multitasking and are so distractible that it is often hard for them to do even one thing at a time let alone have lots of activities on the go.
They will be forgetful and not remember what they are told which can have distressing consequences in relationships because they often do not believe that they forget. If their partners think that the head injured person doesn’t listen or doesn’t care, then irritability and mood swings can be prevalent.
The frustrating aspect for the head injured person and for their family and friends is that so often their communications appear to be normal yet when they try to do things their inefficient memory systems let them down. Generally their thinking is slowed down by the acquired brain injury. They cannot keep up with normal conversations and tend to withdraw.
They find it difficult to be in crowds such as supermarkets and are often over sensitive to crowds and noise and they avoid such places. They may drive the car but find it hard to concentrate if passengers talk to them or the radio is on. In practical terms the brain injured person may find that if they have returned to work they are not coping and lose their employment because of forgetfulness or slowness or errors.
Typical areas of mood and temperament impairment
As well as the cognitive problems described there are frequently disorders of mood or temperament not present before the acquired brain injury:
- Increased irritability and frustration, mood swings
- Short temper, self centred, insensitive to others, inconsiderate behaviour
- Discomfort from chronic pain
- Anger about the accident
- Loss of confidence, loss of motivation
- Depression, withdrawal from social contact.
The combination of mood changes and forgetfulness can be associated with problems of depression and withdrawal. Head injured people often lose confidence in themselves and are reluctant to participate socially. They frequently cannot keep up with conversations and can be embarrassed by their forgetfulness and inability to participate preferring not to attend social outings.
If there are small active children in the family the person may find it difficult to cope and may be unduly short tempered with the children which can impair family relations generally.
- They may find it difficult to cope with the discipline of the work place, to take criticism or to use the feedback to improve their performance.
- They tend to be over sensitive and to take criticism personally so that they may be considered to be difficult employees.
- They tend to be fairly rigid in their thinking and often unable to take a flexible approach to situations.
- They tend to focus on single aspects of situations rather than being able to see the broad picture. Despite well preserved intelligence they fail to reach the level of performance expected and tend to make poor decisions and to be unable to cope with responsibility.
- They frequently lack the depth of insight needed to appreciate these problems.
A special case - mild head injury
These are people who may only stay briefly in hospital and may not have formal rehabilitation because the head injury is not considered severe enough to warrant it. These are people who appear to have made a good recovery and in social contexts show little if any sign of a thinking disorder as a result of the head injury.
They may be told that they have made a great recovery and asked why they cannot get back to work. Even worse it may be suggested to them that the problem is all in their mind and that if they try, they should be able to recover. This can erode even further the morale of a person who knows that no matter how hard they try to concentrate or learn new information, they always have problems.
Summary of outcome problems
The memory problems apparent immediately after the accident may not completely recover. They will be associated with at least some of the following disturbances to mental function namely poor concentration, easy distractibility, poor sequencing and organising of activities, poor multi-tasking together with fatigue and slowness in thinking.
These problems may not become apparent until the person tries to return to work or to study or to their previous lifestyle activities. Relationships with family members and other workers can be impaired and the person may go on to develop psychological problems with depression, loss of confidence and increased anxiety.
Frustration increases because everything has become so difficult. An inability to complete a simple task that was once routine can lead the person to a level of emotional distress that was never the case before the accident. The injured brain can be overwhelmed by the person’s physical limitations and emotional limitations as the brain tries to deal with the combination of chronic pain, fatigue and emotional distress on their thinking.
Long term recovery from traumatic brain injury
Unfortunately there is no magic medication or operation that the person can have to remedy the problem. The brain damage is enduring and the problems that the person has with memory and thinking will continue. Much depends upon how the person can adjust to these changes in brain function.
Some persons, especially those who have severe head injury, frequently do not have much insight or awareness into their problems and cannot use methods to help themselves.
- They will be described as having a loss of executive functions which means that they cannot plan and organise their lives, cannot manage their affairs and will always be to some degree dependent on others to make life decisions for them.
- They will always need someone “out there” to be their memory/planner/organiser of their life.
Others with less severe head injury may appreciate that they have a problem and can be helped to learn ways to get around their problems but it is difficult for people with memory problems to learn, remember and utilise new ways to cope. These techniques do not cure the brain damage but they may assist the person to cope better with a fixed underlying disability or perhaps help the person to understand better how the brain injury has affected their thinking.
Return to work or pre-injury activity
Some people are able to return to the work force but it may be to a lower level of responsibility with less need for decision making.
- They may find that they need to adapt the work environment to their needs.
- They may need to write notes as reminders and to be careful when they are interrupted not to lose track of what they are doing. If they have returned to a well known workplace where procedures are remembered from the past, they may adapt fairly well.
- They will prefer a slower moving workplace where the work is fairly routine.
- They will not cope easily with the stress of a fast moving work environment that requires rapid decision making or an ability to cope with information overload.
- They will probably need to return on a part time basis because of the fatigue.
Many survivors of head injury will not be able to find a suitable workplace and will be dependent on community activities for stimulation. Many of these people have sustained fairly severe head injury and do not have good insight or awareness of their problems; they find it very difficult to understand why they cannot find work.
Lack of insight together with mood, temperament and behaviour problems as well as memory difficulties can make it very difficult for these victims of head injury to lead satisfying lives and very difficult for family members to cope with the changes due to brain injury.
Such persons are dependent on others to organise their affairs and to manage their lives.
Life after brain injury
Where there is support and encouragement and understanding of the problem of head injury from family or friends the victim can often achieve significant levels of recovery.
The head injury damage will not be cured but the capacity of the person to cope with underlying fixed disability may be improved.
If self confidence and morale can improve then a happy lifestyle may be achieved by the victim even if they are not able to return to the work force. Psychological counsellor for the victim and family may assist all in adapting to life after brain injury.
- Muriel Lezak, Neuropsychological Assessment (1995).
- Glenn Larrabee, Forensic Neuropsychology (2005).