1. Do you have to lose consciousness in order to suffer brain damage? No. The American Academy of Neurology in its guidelines for treating sports concussions recognizes three grades of concussion. Two of these grades do not involve a loss of consciousness. The American Congress of Rehabilitation Medicine states that mild traumatic brain injury includes any traumatic injury to the brain in which there is an altered state of consciousness. Thus, there are two broad categories of concussion:

• those in which there is no loss of consciousness; and
• those in which there is a loss of consciousness.

If there is no loss of consciousness, a person may see stars or be dazed, confused, or disoriented. This person often has patchy memory for the events that occurred immediately after the trauma.

2. Can I suffer traumatic brain injury even if I did not hit my head? Yes. The American Congress of Rehabilitation Medicine recognizes that three different mechanical processes can cause mild traumatic brain injury:

• the head being struck;
• the head striking an object;
• the brain undergoing an acceleration/deceleration or whiplash motion without any direct trauma to the head.

3. What type of doctors might I want to see if I suffered traumatic brain injury and I still am having problems? If you have a family physician who knows you well, this is a good starting point because this doctor may be in the best position to recognize the changes that have occurred. Specialists who you might want to see include a neuro-ophthalmologist (vision and balance problems), neuro-otologist (balance, ringing in the ears, and hearing problems) neurologist, physiatrist (doctor of rehabilitation medicine), and neuropsychologist (a Ph.D. level psychologist with special training in brain-behavior relationships). Brain injury survivors & their families, and support group members can be a good source of information about which professionals in your area are most knowledgeable about traumatic brain injury.

4. When will I get better? Most people who suffer mild traumatic brain injury will gradually recover and will have no noticeable effects of their injury after about six months. But in about 10% of all cases, the injured person will continue to struggle with their injuries and may be diagnosed with post concussion syndrome.

The period of most rapid improvement is during the first six months. Doctors believe that patients will continue to improve for about two years after injury. After that it is unlikely that there will be major improvement, although improvement has been measured in some patients eight years after their injury.

Recovery is generally not a term used in brain injury rehabilitation. This is in part because brain injury and the return to more normal function are processes and not events. Once the trauma has occurred, a cascade of events is set in motion. Inside the brain, physical forces stretch and tear the connections between the brain's neurons. The chemistry of the brain changes, which in turn can cause additional damage. The brain attempts to repair itself by rewiring the connections between the neurons. If a neuron is unable to reconnect with its neighbors, then it shrivels up and dies. Sometimes a neuron will hook up with some of its neighbors but not with all of them. This neuron will not work as efficiently as it could before injury. In other cases a neuron may hook up to the wrong neighbors leading to episodes of miscommunication. Fortunately a fair number of the neurons do succeed in rewiring themselves. Most of the rewiring process takes place during the initial six months, which probably explains why most improvement occurs during this period.

We also know that the brain can be trained to learn new skills and information. Often the brain develops new connections during this process. Rehabilitation specialists take advantage of this fact when they provide various types of therapy to people who have suffered brain injury. They hope that the therapy will aid in developing new connections among the neurons that will help the brain compensate for the connections and neurons that it has lost.

5. Why did I start having a lot more problems when I returned to work? The answer to this question is complex. Usually a number of factors explain why this happens.

a) Until a person with brain injury returns to work, much of the structure that life requires has been provided by medical professionals and the family. For the first time since the injury, the person may be facing situations with little structure and she is expected to provide that structure. People who have suffered brain damage may have problems when structure is not provided for them. Often it is work that makes this apparent.

b) Many jobs require the worker to handle a number of tasks at the same time. Work may be the first setting in which the injured person has been required to handle multiple tasks. We know that many people with brain damage may have difficulty in this area.

c) The memory of a person who has suffered traumatic brain injury generally stays intact for knowledge acquired before the injury. Acquisition of knowledge tends to be the problem. If this person has a job that requires him to learn new information, a deficit in acquiring new knowledge quickly will become apparent.

d) For most people, work is filled with some stress. Many people who have suffered traumatic brain injury do not cope well with stress.

e) A common and persisting complaint of people who have suffered traumatic brain injury is fatigue. In part this is because a person with an injured brain does not process information as quickly as before the injury. Work places a premium on efficiency and is likely to unmask workers who have problems efficiently processing information.

f) A commonly injured part of the brain is the orbital-frontal area. This area is responsible for successful interactions with others. Injuries to this area do not show up on formal neuropsychological tests. But putting an injured person back to work often uncovers this deficit because work means working with people.

g) When a person goes back to work, she may be confronted with her deficits for the first time. She may be able to do everything she could before, but she just can't do it as fast. If she recognizes that she is not the worker she once was, she may become anxious and depressed. This in turn leads to further decline in her ability to perform.

6. Can a person suffer a mild traumatic brain injury that has catastrophic consequences to his or her life? Absolutely. There really is no such thing as a mild or minor brain injury. Our brain controls almost every aspect of our lives. By definition any injury to the brain is serious. Hippocrates recognized this fact in the 4th Century B.C. when he wrote: "No head injury is too severe to despair of, nor too trivial to ignore."

The term mild head injury originates from the classification scheme of the Glasgow Coma Scale. This is a test that evaluates a patient's state of consciousness and may be used to predict whether the patient is likely to survive. The scale was never intended to predict functional outcome following traumatic brain injury.

The brain is the body's central processing unit and its system software. It regulates attention, cognition, language, memory, conduct, movement, and all the autonomic functions. Minor damage to a computer's CPU or system software is likely to lead to the computer working a lot slower or crashing. Similarly, even minor damage to the brain can cause a person to function less efficiently.

7. Is it possible to have brain injury even when all the medical tests (neurological exam, EEG, CT scan, and MR scan) are normal? Yes. In fact in most people with mild brain injury, these tests will be normal.

The gross neurological exam is neither designed to nor sensitive enough to measure neuropsychological deficits.

The EEG is another test that is not sensitive enough to detect all but the most severe brain injuries. For example, a high percentage of the people who have known seizure disorders are likely to have normal EEGs.

CT and MR scans show the structure of the brain, but not at a microscopic level. These scans also do not show whether the brain is functioning correctly. Brains that have suffered mild injuries are damaged neurochemically and at the microscopic level. It is not surprising that mild traumatic brain injury rarely shows up on these scans.

Functional imaging is the only group of medical tests that is likely to pick up mild traumatic brain injury. These tests look at the brain's metabolic functioning. The best known test is the PET scan (Positron Emission Tomography). It has a good track record for identifying abnormal brain function. It is a fairly expensive test that is appropriate in some situations. Other functional imaging tests include SPECT and functional MRI.

8. Is it possible to have brain injury even if the neuropsychological tests are normal? Yes. Neuropsychological tests cannot test all of the functions of the brain. The tests do not measure behavioral and emotional changes that follow head injury. They do not measure damage to the orbital-frontal region of the brain.

In intelligent individuals who suffer traumatic brain injury, the tests may be normal precisely because of the person's high level of intelligence. Nonetheless, these normal test results may in fact represent a significant decline in the person's pre-injury abilities.

9. What is a neuropsychologist? Neuropsychology is the study of the relationship between the brain and behavior. Neuropsychologists are psychologists who hold Ph.D. or equivalent doctoral level degrees. They conduct extensive evaluations of patients to determine the strengths and weaknesses or deficits in the functioning of their brains. These evaluations almost always include special psychological testing known as neuropsychological testing. Division 40 of the American Psychological Association defines a neuropsychologist as:

"A Clinical Neuropsychologist is a professional psychologist who applies principles of assessment and intervention based on the scientific study of human behavior as it relates to normal and abnormal functioning of the central nervous system. The Clinical Neuropsychologist is a doctoral-level psychology provider of diagnostic and intervention services who has demonstrated competence in the application of such principles for human welfare following:

A. Successful completion of systematic didactic and experiential training in neuropsychology and neuroscience at a regional accredited university;
B. Two or more years of appropriate supervised training applying neuropsychological services in a clinical setting;
C. Licensing and certification to provide psychological services to the public by the laws of the state or province in which he or she practices;
D. Review by one's peers as a test of these competencies.

Attainment of the ABCN/ABPP Diploma in Clinical Neuropsychology is the clearest evidence of competence as a Clinical Neuropsychologist, assuring that all of these criteria have been met."

10. What is a physiatrist? A physiatrist is a doctor of rehabilitation medicine. This physician evaluates the effect of the brain injury on the functioning of the patient's entire body. The physiatrist is the captain of the team of doctors and specialists who help rehabilitate survivors of TBI. This doctor writes the orders that lead to the patient receiving respiratory therapy, speech therapy, occupational therapy, physical therapy, recreational therapy, neuropsychological evaluation, psychological services, and social work services.

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