It is natural at this stage for relatives and friends to be anxious about the prospects for future recovery. The effects of brain injury differ widely from person to person, depending on how severe the injury was and what parts of the brain were damaged. Any one patient’s condition will be made up of a mixture of these effects, in varying degrees of severity.
People with less severe injuries may spend a short time in coma and may go quickly through the stages of rehabilitation and be back at work in a month or two. Those more severely affected are likely to still need care and treatment a number of years after the accident. Fortunately, the brain seems to have a remarkable capacity for re-learning many skills that have been lost and even people with severe injuries can often make a reasonable recovery.
In the very early stages, even when the patient is still unconscious, physiotherapists will be involved in the care of the person with a brain injury. This is to prevent unnecessary complications arising, such as developing a chest infection, skin breakdown (pressure sores), or contractures of the limbs as a result of muscle spasm.
Once the person regains consciousness, it is important to get them to sit up in bed or in a chair as soon as possible. Later, by using a ‘tilt table’ that can be tilted until upright, the patient can become gradually used to standing and taking their weight on their feet. As they become used to doing this, they may then start to take steps – at first with the help of staff, then a mobile frame and then, as their balance improves, with less and less support. Some people may not be able to walk independently and will need to use a wheelchair.
Movement in arms and legs
The areas of the brain that control movement of the arms and legs are often affected by brain injury. Even when the person is still unconscious you may be able to see that one arm or leg is not moving like the other one, or is lying in an unnatural position. The muscles may not be working at all, which makes the limb loose and floppy. Alternatively, the muscles may contract unnaturally, causing stiffness or ‘spasticity’.
If a joint is being pulled out of place by muscles that are over-contracting, a splint may be needed to control the movement. This may be worn all the time or just at night. Until movement returns it is important to make sure that the joints are not allowed to stiffen, either from lying still or by being pulled into an abnormal position by the muscles.
The physiotherapist will begin by trying to relax the tight muscles and will try to move the joints through their full range of motion. This must be done carefully, since too much stretching can damage the joints and ligaments. Once some movement returns, exercises will then be carried out to develop and strengthen the movement and to correct any problems.
Posture, balance and knowing where the body is in space
When the patient first starts to sit up in bed, they may be unable to hold up their head and their body may fall to one side if not supported by pillows. This is because they need to regain strength in their trunk muscles and re-learn how to use these muscles to control posture. The balance organs in the inner ear can also be damaged by brain injury, causing dizziness and balance problems.
Another difficulty for the patient is in knowing where their body is in relation to the things around them. After a severe brain injury, the mechanisms that regulate this process tend to be faulty. As a result, the patient may have no idea of what their position is, whether they are sitting safely or are about to fall off the edge of the chair, or whether an outstretched hand will meet the bed, the wall or empty space.
Exercises will be needed to help the patient begin to recognise where their arms and legs are in relation to their own body and the space around them.
Memory and concentration
One of the immediate things you may notice when your relative first regains consciousness is that they can only concentrate on what you are saying for a very short time. They may soon forget what you tell them and may ask the same questions over and over again. They may also become tired very quickly, which makes their concentration and memory even worse.
While the person’s memory for the past before the accident may be quite good, their memory for what has just happened is often the last thing to recover. Dealing with any new situation is likely to confuse the person and they may have great difficulty in learning from recent experience.
The first things the person may recover might be their memory for familiar and automatic activities, like repeating the days of the week and counting. It may be helpful to try to get the person to talk about other things they may remember, such as family history, friends or their job.
Managing fatigue is often one of the most important areas in helping people after brain injury. If the person becomes tired during rehabilitation exercises and their progress slows down, this is a signal that they need to rest straight away. It is not helpful to push them to do more, as they will only become exhausted and will need to rest more than ever.