Traumatic brain injury (TBI)

Most TBIs are mild, and these are often called concussions. Most people recover fully, though symptoms can last weeks or months.

See the “Concussion” guide for signs, recovery and returning to school, work and sport.

Moderate and severe TBIs can cause long-term health problems that touch every part of life, much like a chronic illness. People often need rehabilitation and ongoing care, and the whole family is affected.

Falls are the most common cause, followed by car crashes and assaults.

Some damage happens at the moment of injury, such as bruising, bleeding, or stretching and tearing of the brain’s wiring. Other damage can develop over the next few days, often from swelling or low oxygen. Much early hospital care aims to prevent that second wave.

After an injury, the brain can form new connections. This change is slow and needs practice and stimulation, which is one reason rehab matters and why recovery can keep going for months or years.

Hospital teams use the Glasgow Coma Scale to check eye opening, movement and speech. A score of 3 means the deepest coma. A score of 9 or more means the person is out of coma but not fully alert. A score of 15 means fully awake.

As swelling and brain chemistry settle, a person may start to open their eyes, have sleep-wake cycles and follow simple commands. Doctors may use terms like “vegetative state” or “minimally conscious state” for in-between stages.

Many people go through a confusion stage, also called post-traumatic amnesia. They may not form new memories, repeat questions, be restless or agitated, sleep poorly, or sometimes see things that aren’t there. It can last days or weeks.

Ups and downs during this stage are normal. It can be very upsetting for families to see, but it is often part of the brain healing.

How families can help

• Keep the room calm, with one or two visitors at a time
• Speak simply, one person at a time
• Stay nearby. Confused or agitated people shouldn’t be left alone
• Work with nurses and therapists on how much help to give

The frontal lobe, behind the forehead, helps with starting activities, judgment, controlling emotions, planning, flexible thinking and problem solving. Injury here is often linked to emotional and behavior changes.

The temporal lobes, near the ears, help with hearing, forming new memories, recognizing faces and objects, understanding spoken language, and emotion.

The parietal lobes help with touch, visual attention, purposeful movement and combining information from the senses. The occipital lobe, at the back, handles vision.

The cerebellum helps coordinate movement and balance. The brainstem controls basics like breathing, heart rate, swallowing, alertness and sleep.

People may think, talk and solve problems more slowly. Noisy or busy places and sudden changes in routine can be confusing.

What helps

• Give extra time to answer
• Keep routines steady
• Talk in quiet places
• Use short, simple sentences

Trouble paying attention and remembering new things is common, especially after a moderate to severe injury.

Memory helpers

• A big visible calendar
• Labeled photo albums
• Notebooks and checklists
• Phone alarms and reminders

The skills used to plan and manage daily life, sometimes called executive functions, can be affected. People may find it hard to switch tasks, or jump to the first solution without weighing others.

What helps

• Break tasks into small steps
• Do one thing at a time
• Use a simple problem-solving plan (see the worksheet)

Some people have trouble finding the right word or understanding others. Speech-language therapy can help.

• Acting in ways that don’t fit the situation
• Irritability or aggression
• Low motivation or low energy
• Mood swings
• More dependence on others
• Restlessness

These changes can be very distressing for the person and the family. With rehab, therapy and support, people can learn to manage them.

Lack of self-awareness is common after a TBI. A person may not realize they have changed or are having problems. This can come from the brain injury itself, or from denial.

It isn’t stubbornness. Gentle, specific feedback and a rehab team that understands brain injury can help.

Depression is much more common after a TBI, especially in the first year. About a quarter of people have major depression 2 years after a moderate to severe injury.

TBI can also lead to anxiety, PTSD and substance use problems. Mental health counseling can be part of a TBI care plan.

The overview guide “Brain injury & concussion” has more on the “short fuse,” fatigue and grief after a brain injury.

• Get support from family, friends or recovery groups
• Know your triggers and plan how to cope
• Reward yourself for progress, and have a backup plan
• Set a clear goal and a plan to reach it
• Talk with your clinical provider about treatment options

SAMHSA’s National Helpline, 1-800-662-4357, is free and confidential and can connect you with local treatment and support.

Rehab can include

• Assistive devices
• Coping skills for thinking and behavior
• Driver rehabilitation
• Mental health counseling
• Occupational therapy (daily living skills)
• Physical therapy
• Speech-language therapy
• Vocational therapy (getting back to work)

Most people walk and use their hands within 6 to 12 months. Lasting weakness, balance problems or tiredness may remain, but in most cases physical problems don’t stop a return to independent living, including work and driving.

About 30% of people have a job 2 years after a moderate to severe TBI, which may be different from their old job. Vocational rehabilitation counselors can help find a good fit.

Purpose doesn’t only come from paid work. Volunteering, faith, creativity and caring for others count too.

Recovery numbers describe groups of people, not what will happen to any one person. Recovery can continue past 2 years. Healthy habits, like exercise and avoiding alcohol and other substances, support the brain for life.

• Avoid crowds and keep visitors to one or two
• Give one instruction at a time
• Include them in family life and treat them as an adult
• Keep a daily routine with frequent rest
• Point out progress, and avoid comparing to life before
• Try not to overwhelm with false cheerfulness

Clear walkways and stairs, keep good lighting, and remove dangerous objects. Driving, contact sports, swimming, power tools, firearms and alcohol all need a clinical provider’s OK first.

Long-term stress can wear down patience, focus and mood. Rest, a daily walk, support groups, humor and asking clearly for help all make a difference.

See “Family caregivers” and “Caring for yourself as a long-term carer” for more.

VA has a Polytrauma System of Care, a network of specialized TBI programs at many VA medical centers. If you think you have a TBI, talk with your VA primary care provider or local VA facility. Veterans not yet enrolled can apply.

The Defense Department’s Traumatic Brain Injury Center of Excellence shares education materials, a Family Caregiver Guide and resources. It doesn’t provide medical care itself. Vet Centers offer free readjustment counseling, including for TBI, without needing to be enrolled in VA health care.