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HEAD SPACE
Brain Injury Handbook
Claire Mackie
Bernadette Cassidy PhD

Foreword
by
Acknowledgements
We wish to acknowlege the generous support, direction and encouragement of the
Brain Injury Association Canterbury, both staff and members. We would also like to
acknowlege the support of; Sue Wilson, Sir Tim Wallace, Barbara Freeman, Jock Vennell,
Mike St John.............
1

Guide to the Handbook
Introduction
A brief overview of a brain injury and what
to expect following your brain injury.
Physical
Physical effects you may experience after
your brain injury.
Thinking
(Cognitive)
Problems with thinking and communication
you may experience as a result of your
brain injury.
Emotions
Changes in mood and behaviour you may
experience after a brain injury.
Life after
brain injury
Getting back into your community and
adjusting to life after a brain injury.
GUIDE TO CHAPTER CONTENTS
Headaches
Page 23
This is a visual guide
to each chapter’s
contents.
In each of the chapter contents,
there will be a picture to show
you which part of your brain
has been affected.
Guide to page number
and chapter contents.
2

Chapter Contents
1 .............. Chapter 1 - Forward and Acknowledgements
2 .............. Guide to the Handbook
3 .............. Contents
5 .............. Introduction
6 .............. Effects of a Brain Injury
7 .............. Coma and Glasgow Coma Scale
8 ............... Post Traumatic Amnesia
9 .............. Types of Brain Injury
12 .............. Left and Right Brain
13 .............. How the Brain Works
14 .............. Frontal Lobe Damage
15 .............. Temporal Lobe Damage
16 .............. Parietal Lobe Damage
17 .............. Occipital Lobe Damage
18 .............. Cerebellum Damage
19 .............. Brain Stem Damage
20.............Chapter 2 - Physical Effects of a Brain Injury
21 .............. Fatigue and Tiredness
24 .............. Headaches
26 .............. Seizures
29 .............. Movement, Balance, Co-ordination and Dyspraxia
31 .............. The 5 Senses: Touch, Smell, Taste, Vision and Hearing
33 .............. Bladder and Bowel Issues
35 ............ Chapter 3 - Thinking (cognitive) Symptoms
36 .............. Vision and Perception Issues
38 .............. Communication Issues
40 .............. Planning, Organizing and Problem-solving
42 .............. Attention and Concentration
44 .............. Memory
3

Chapter Contents
47 ............ Chapter 4 - Emotional issues
48 .............. Anger, Frustration, Depression and Anxiety
51 .............. Sexual Issues
53 .............. Behaviour and Self-centredness
55 .............. Lack of Motivation
57 .............. Emotional Extremes
59 ............ Chapter 5 - Life Issues
60 .............. Brain Injury in New Zealand - Statistics
61 .............. The Rehabilitation Team
64 .............. Family/Relationships
71 .............. Getting Back to Work
75 .............. Driving After a Brain Injury
79 .............. Nutrition / Alcohol
82 .............. Exercise / Brain Gym
85 .............. Socialising / Recreation
88 .............. Resources
92 Chapter 6 - Personal Journeys
93 .............. Mike
95 .............. Sue
96 .............. Cate
98 .............. Graeme
99 .............. Elizabeth and Merv
100.............. Paul
102.............. Cecile
(ORGANISER IN FOLD OUT AT BACK OF BOOK)
4

Introduction
Brain injury occurs when the brain’s tissue is damaged
or is not working properly. Anything that can damage
brain tissue can cause a brain injury. Brain injuries can
be the result of a blow to the head, such as from a fall,
sports injury, car accident, an assault, cycling or from
any other outside influence.
There are other ways in which the brain may suffer an
injury without a blow to the head. For example, the
brain can lose its blood supply or a blood vessel can break so that bleeding
into the brain tissue occurs. This is usually referred to as a ‘stroke’. A stroke
is one of the most frequent causes of brain injury in older people. Other
causes of injury to the brain can be a drug overdose, a tumour, an infection,
a lack of oxygen or chemical poisoning.
Sometimes the term ‘head injury’ is used instead of brain injury. This can be
misleading as a head injury can include other injuries to the head, such as jaw
or skull fractures, which may not involve the brain.
This handbook is concerned with injuries to the brain and will refer to these
as ‘brain injuries’.
Clinical identification of a brain injury includes
one or more of the following:
• Confusion or disorientation
• Loss of consciousness
• Post-traumatic amnesia
5

Effects of a Brain Injury
The effects of a brain injury are wide ranging
and may result in the following:
Physical disabilities
Sensory disabilities (e.g. sight, smell)
Personality changes
Thinking (cognitive) disabilities (e.g. difficulty thinking clearly, planning
and following through, memory problems)
Difficulty expressing or understanding language
Many people who have a brain injury continue to have ongoing
problems which may include some of the following:
Aggression
Depression
Anxiety
Impulsiveness
Mood swings
Poor concentration
Difficulty with problem-solving
Passivity
Socially inapropriate behaviour
Changes in thinking processes
Loss of memory
6

Coma and
Glasgow Coma Scale
Eyes
Glasgow Coma Scale
Verbal
Brain injuries are usually classified
according to severity. They can be mild,
moderate, or severe. When a brain injury
occurs, two assessments are used to
measure the severity: the Glasgow Coma
Scale (GCS) and the Duration of Post-
Traumatic Amnesia (PTA).
Post-Traumatic Amnesia refers to the
time between injury and the recovery of
full memory for day-to-day events. The
Glasgow Coma Scale is the most widely
used scoring system for measuring the
level of consciousness following traumatic
brain injury. GCS has three parts: an
assessment of eye opening, best motor
response and best verbal response.
1 2 3 4 5 6
Does not
Opens eyes in
Opens eyes in Opens eyes
open eyes
response to painful
N/A
N/A
response to voice spontaneously
stimuli
Makes no
sounds
Incomprehensible
sounds
Utters inappropriate
words
Confused,
disoriented
Oriented, converses
normally
N/A
Motor
Makes no
movements
Reaction to
painful stimuli
Abnormal flexion to
painful stimuli
Flexion / Withdrawal
to painful stimuli
Localizes painful
stimuli
Obeys
commands
A scoring system is used, with the lowest score being 3 and the
highest 15. For example, a score of 8 or less would be regarded as
a severe brain injury resulting in a coma state; a score of 9 to 12
would indicate a moderate brain injury; and a score of 13 to 15
would indicate a mild brain injury.
3 4 5 6 7 8 9 10 11 12 13 14 15
severe injury moderate injury mild injury
7

Post-Traumatic Amnesia (PTA)
If you are in a coma as a result of a brain injury,
afterwards you may have Post Traumatic Amnesia
(PTA). Even mild concussion can cause a short period
of Post Traumatic Amnesia.
Someone emerging from a coma does not just wake
up like in the movies, they go through a gradual
process of regaining consciousness. This stage of recovery may last for
hours, days or weeks.
This may be a very confusing time for you. You may not have any idea
of time, talking may be difficult and you may be very tired. Behavioural
changes can also affect you. For example, some people become passive,
or aggressive, abusive and agitated after being in a coma during the PTA
stage. Some people liken PTA to being in a dream-like state.
Some medical professionals believe that the duration of PTA is the best
indicator of the severity of a brain injury.
You will have little awareness of these behavioural and cognitive
impairments and usually will remember nothing of what happened
during PTA, even though you were fully awake. The good news is that
PTA does not last for ever.
Symptoms of Post-Traumatic Amnesia:
No idea of time
Talking may be difficult
You may be tired
Your behaviour may change - aggressive, abusive,
agitated
8

Types of Brain Injury
Many terms are used to describe the different types of brain injuries,
the severity of brain injuries and the causes of brain injuries. Below
are some of the more common terms used.
Concussion:
This is the most common and least serious type of
traumatic brain injury. It is usually as a result of a direct
blow to the head, or when the brain is shaken. It is not
usually associated with penetrating injuries to the head.
Concussion can also be due to a fall or sports injury
(e.g. a rugby game).
Acquired brain injury:
This term is used to describe any damage to the brain not present at birth
(for example, from a car accident or blow to the head).
Traumatic brain injury:
Anoxic brain injury occurs when the brain does not receive
oxygen for several minutes or longer. Cells in the brain
need oxygen to survive and function.
Hypoxic brain injury results when the brain does not
receive enough oxygen. An hypoxic injury is not as severe
as an anoxic injury, but brain cells can still die from a lack
of oxygen.
9

Types of Brain Injury
Mild brain injury
A mild brain injury is when there is trauma to the head.
At least one of the following symptoms needs to be
present for a mild brain injury:
A period of loss of consciousness
(no more than 30 minutes)
Loss of memory
Feeling, dazed, disorientated
or confused
Initial Glasgow Coma Scale score of 13-15
Post-Traumatic Amnesia not longer
than 24 hours
Moderate brain injury
A moderate brain injury is more severe than a mild
brain injury with a Glasgow Coma Scale score of 9 -
13. Confusion lasts from days to weeks and physical,
thinking and/or behavioural issues can last for months.
In some cases they may be permanent.
Severe brain injury
A severely brain injured person has a Glasgow Coma
Scale score of 8 or less. This person is generally in a
prolonged unconscious state and there are substantial
physical, behavioural and/or thinking issues as a result
of the injury.
10

Types of Brain Injury
Open head injury (penetration)
When an object enters the brain, such as a sharp object.
Coup/contrecoup injury
A coup injury occurs at the site of impact. A contrecoup
injury is when there is damage to a part or region to
the brain that is opposite to that at which the blow is
received, often causing rupture of the affected parts.
Contusion
A contusion is bruising (bleeding) on the brain caused by
small blood vessels leaking into brain tissue. A contusion
occurs as a result of trauma to the brain and in many
cases is more serious than a concussion.
Haematoma
A hamatoma is a collection of blood as a result of internal
bleeding from trauma or an aneurysm. An aneurysm is
a widening and possible rupture of an artery, vein or the
heart itself.
Diffuse axonal injury
A diffuse axonal injury can be caused by violent shaking
of the head. The movement of the brain inside the skull
causes extensive tearing of nerve tissue which can cause
brain chemicals to be released, causing additional injury.
11

Left and Right Brain
The brain is divided into two parts or ‘hemispheres’. The left side
of the brain controls the right side of the body and the right side
of the brain controls the left side of the body.
The right side of the brain takes visual information and interprets
it creatively. The left is the logical and analytical side. It takes the
information collected by the right side and analyses and applies
language to it.
People with right side injuries often deny having an injury as the
brain does not realise that something is missing. If you have an
injury to the left side, you may know something is wrong. You
may find it difficult to solve complex problems and consequently
you may feel depressed because of this.
Left Side of Brain
The left side of the brain controls:
Right Side of Brain
The right side of the brain controls:
Movement of right side of body
Problem-solving
Expression in words
Mathematical calculation
Seeing in black and white
Speech and language control
Reading and writing control
Organisation skills
Movement of left side of body
Holistic thought
Intuition and emotional expression
Creativity and thinking
Visual memory, drawing, and music skills
Spatial visualisation
Seeing in colour
Using pictures, not words
1 + 1
12

How the Brain Works
There are 100 billion nerve cells in your brain. On each nerve cell are
two branches:
Dendrites, which receive incoming messages from other cells
in the form of an electrical impulse.
Axons, which carry outgoing signals to other cells.
Interconnected, they provide super-fast communication, allowing the
brain to send messages from one side to the other, which lets you
move and make decisions. This is done by a chemical that is shot from
the axon across a gap (synapse) where it triggers another cell to send
a message.
An injury to your brain can destroy or damage these nerve cells, which
means that some messages will not get through or may get scrambled
along the way.
13

Frontal Lobe Damage
COMMON EFFECTS OF FRONTAL LOBE DAMAGE.
Loss of spontaneity
Personality changes
Sexually uninhibited
Inflexible thinking
Repetition of words, gestures or acts
Mood - *Aggressive and explosive anger
Initiative and planning -
*Difficulty sequencing
*Problem-solving
Motor function -
*Paralysis and loss of simple movement
Memory - *Selective attention and concentration
Language - *Decrease of verbal expression
14

Temporal Lobe Damage
COMMON EFFECTS OF TEMPORAL LOBE DAMAGE.
Language - *Difficulty recognising words
*Loss of inhibition while talking
Memory - *Difficulty recognising faces
*Difficulty identifying, locating and categorizing objects
*Short-term memory loss
Mood - *Increased aggressive behaviour
*Increase or decrease in sexual desire
Selective attention -
*Decreased recall of verbal and visual content
15

Parietal Lobe Damage
COMMON EFFECTS OF PARIETAL LOBE DAMAGE.
Limb / facial movements affected
Loss of spatial awareness
Changes in feeling / touch
Object-naming problems
Right/left confusion
Writing and maths difficulties
Difficulty with multi-tasking
Voluntary movement -
*Problems with eye-hand coordination
*Lack of awareness of body parts
Visual attention -
*Reading and drawing problems
*Inability to focus visual attention
16

Occipital Lobe Damage
COMMON EFFECTS OF OCCIPITAL LOBE DAMAGE.
Vision -
*Difficulty identifying colours and recognising drawn objects
*Blind spots
*Hallucinations
*Visual distortions
*Not seeing some words
*Difficulty reading and writing
*Difficulty recognising the movement of an object
*Difficulty visually locating objects
17

Cerebellum Damage
COMMON EFFECTS OF CEREBELLUM DAMAGE.
Difficulty with balance
Equilibrium -
*Tremors
*Dizziness
Muscle tone -
*Inability to grasp objects
*Slurred speech
Movement -
*Problems with fine movement and coordination
*Problems with mobility
*Difficulty with rapid movements
18

Brain-Stem Damage
COMMON EFFECTS OF BRAIN-STEM DAMAGE.
Problems with the physical act of talking
Difficulty swallowing food and liquid
Decreased breathing capacity
Sleeping difficulties
Problems with balance and movement
Problems with blood pressure and sweating
Digestion and temperature problems
19

Chapter Contents
Fatigue and Tiredness
Page 21
Headaches
Page 24
Seizures
Page 26
Movement, Balance,
Co-ordination and Dyspraxia
Page 29
The Five Senses: Touch, Smell,
Taste, Vision and Hearing
Page 31
Bladder and Bowel Issues
Page 33
20

Fatigue and Tiredness
Why am I tired?
After an injury, your brain uses a lot of the body’s energy to heal and
consequently it needs a lot of sleep to help it recover.
Fatigue is extremely common after a brain injury. The sleep your body
craves may be fragmented and can have little effect on the tiredness you
feel. You may find activities tire you quickly, even ones like reading which
are not that physical but require a lot of mental work.
Fatigue may be caused by damage to the part of the brain that is responsible
for wakefulness, consciousness and sleep rhythm. After a brain injury, it
may take longer to recouperate and ‘recharge’ than prior to your injury.
Ways of coping
Carefully plan activities to avoid doing too much and
be aware of too much stimuli.
Say no to the excessive demands of others. Be open
about your problems with others but don’t go on about
the issues. Beware of sounding like a ‘broken record.’
Plan periods of rest and take naps. Make naps a regular
part of your day and try to have them at the same time
every day.
21

Ways of coping
Do your most demanding activity in the morning when
you have the most mental energy.
Eating a light meal can sometimes help, and drinking
plenty of water.
8pm
Try to establish a set time to go to bed each night and
get up at the same time each day.
walk
nap
read
Vary your daily activities to avoid monotony.
Do I have the
energy?
Pace yourself, do not rush. Learn to stop and think
before you proceed to do an activity. Ask yourself, “Do
I have enough energy to finish? Do I need to break it
down or do it differently?”
Try to avoid doing too much and getting over-tired. A
really busy day can set you back for several days.
When you get tired, expect that tasks will take you
longer to complete.
22