Category: Professionals

 

Over 1.5 million Canadian’s live with acquired brain injury (ABI).  ABI is unique and complex and can impact every aspect of a person’s life.  As an often invisible disability, it is essential that health care workers and providers understand both the nuances of brain injury and how it intersects with all facets of daily living.

The Foundations of Brain Injury for Health Care Professionals is the affordable self-paced course designed specifically for health care and service professionals to enhance their knowledge of brain injury, enabling improved, customized and informed care. 

What you will learn

• Causes and types of brain injury;
• How injury affects the brain;
• Physical, cognitive, behavioural, and emotional effects;
• Dealing with challenging behaviours;
• Focus on person-centered care;
• Intersectionality and brain injury;
• Cultural intelligence in care:
• Supporting families;
• Self-care and preventing burnout and compassion fatigue

This course is multi-modal for the best possible self-directed learning experience, including:

• Videos from experts in the area of brain injury to provide an evidence-based, research-supported lens
• Videos from individuals sharing their personal accounts of living with the effects of brain injury, ensuring a valuable educational resource powered by lived experience
• Downloadable resources & further educational opportunities for deeper learning

Who should take this course:

…And any one else working in the brain injury sector.

All course content is evidence-based and has been developed under the guidance of our Scientific Advisory Committee, comprised of researchers and clinicians from across Canada.

Course registration details:

• Course Length: 8-10 hours
• Registration fee: $65.00

Included in your registration fee:

• Access to online course modules for a one-year period
• Downloadable resources
• Electronic certificate of completion

Cancellation/Refund policy

All cancellations must be submitted in writing to [email protected]

We will provide a partial refund less an administration fee of $25 for written cancellation requests received within 7 days of purchase for any self-directed online course which has not been accessed and/or opened.

No substitutions or transfers.

Health literacy is the language spoken by health care providers. They are tasked with having to maneuver quickly between what seems to be two different languages. The medical terminology represented in communications with other medical professionals and medical charts and files, and the use of plain language used to translate this medical information to the patient and their families.

What is plain language?

Plain language is described by Health Quality Ontario as “the practice of communicating – verbally or written – in clear, simple terms that a majority of audiences can easily understand” [1].  Using plain language ensures information passed to the patient is easily understood. A lack of health literacy can affect the patient’s health care outcomes and increase costs to the health care system [2].

Importance of using plain language

The use of plain language is important for several reasons.

“Roughly 60% of Canadian Adults and 88% of Canadian Seniors have low health literacy” [3]. Health literacy is “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” [4]. Additionally, there can be language barriers to be aware of as well.

A patient’s understanding and comprehension of their health will drive their decision-making process and influence their participation in rehabilitation [5]. It is important to note that in many cases, family members, friends and community members may be included in the decision-making process. Therefore, it is important to be able to communicate with all members effectively.

Health illiteracy is “associated with reduced access to health information, poorer health status, limited understanding and use of preventive services, medication errors, increased health care costs and hospitalizations, increased mortality, decreased self-efficacy, and inadequate knowledge and self-care for chronic health conditions” [6]. Because of these disparities, the use of plain language is an important part of patient-centred care.

Communicating with individuals with brain injury

Many brain injury survivors, regardless of severity, experience some form of cognitive impairment. This can impact comprehension of new information as well as decision-making abilities. It is important to note that cognitive disability does not equate to lack of intelligence. The patient’s intelligence has not been impacted by the brain injury or cognitive impairment.

There may be difficulty in processing and understanding language including verbal, visual, and written communication styles. Comprehension can also change from day to day. They may be aware of a word meaning one day and unaware the next [7]. Communication difficulties due to brain injury can also be seen in “word finding difficulties, excessive talkativeness, difficulty staying on the topic, difficulties thinking of questions to sustain a topic, tactlessness, repetitiveness, and difficulties keeping track of topics in group situations [8].

Keeping in mind the patient-centred care model, health care workers should demonstrate patience and compassion when having to repeat instructions or information.

Tools to communicate with patients effectively and respectfully

Because families and caregivers are instrumental in the patient’s rehabilitation program, including them in the communication process and ensuring they are provided the opportunity to ask questions is important [9].  To maximize patient communication and accessibility to health literacy, Health Quality Ontario suggests that healthcare worker follow these practices [10]:

• Focus on communication
• Be concise
• Speak and write at a grade 8 level
• Use bullet points
• Use images
• Avoid using jargon – language that is specific to you and co-workers
• Avoid using acronyms

In Health Literacy Manual for Clinicians, B.D. Weiss offers the following strategies for simple language and accessibility in communication [11]:

• Slow down
• Use plain, nonmedical language
• Show or draw pictures to enhance patient understanding and recall
• Limit the amount of information given at each visit — and repeat it
• Use the teach-back and show-me techniques
• Create a shame-free environment: Be respectful, caring, and sensitive
• Creating and using patient-friendly written materials

Assistive technology can also be utilized to assist patients with communication. “Augmentative and Alternative Communication involves the use of external materials, such as pictures, electronic devices, books, or boards with text, to assist the person in expressing his or her wants, needs, and opinions” [12].

Assistive technology for communication can come in many forms and will be determined in collaboration with the patient, families, caregivers and health care providers. It’s important for the health care provider to be knowledgeable about communication devices and to encourage their use to maximize effective communication between all parties.

Health illiteracy is an ongoing concern with real implications. Patients and their families require plain language to be used to educate and communicate effectively with the health care team. The communication and information network may differ depending on the patient’s communication style and abilities. However, it is the health care providers’ responsibility to understand the best method of communication and provide materials which deliver the information to the patient and their caregivers, so they may best participate in their rehabilitation plan.

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After a brain injury, the road to recovery can be challenging and filled with emotions. Caregivers are faced with additional “stress, anxiety and depression [1]. Families and caregivers may be overwhelmed with the circumstances. There may be situations where they become agitated or even argumentative with the health care providers or clinicians.

Understanding how to manage this conflict is important for maintaining communication and trust with families and patients.

Why do conflicts occur?

After a serious injury, families and caregivers often feel intense emotions, including fear and anger. Coupled with a lack of control over the situation, it is easy for these emotions to spill over.

There are several reasons why family members may become agitated. Some family members feel that their input is not properly acknowledged or considered when making decision about their loved one’s treatment or care plan [2]. Many are also dealing with a swarm of emotions such as grief, anxiety, uncertainties, financial and emotional stresses, added responsibilities, and a change in families dynamics which may affect their cultural norms.

Some families may feel they have not been provided enough information or that the healthcare system is not providing enough support [3]. Sometimes there may be conflicting information provided by a lack of interdisciplinary collaboration. The families are provided with inconsistent information regarding the treatment or expected outcomes [4].
Understanding the struggle faced by the family is an important step in providing conflict management. There should always be a focus on person-centred care principles, including respect and dignity for the patient and the family members, participation and providing continuity of information.

If conflict arises between the family and the health care provider, try the following:

• Listen actively
• Do not take it personally
• Speak in a calm and neutral tone
• Repeat to the families the concerns they vocalized, so they feel heard and you are clear on their concerns
• Acknowledge and be empathetic
• Be honest and consistent in your responses or when relaying information

Managing conflict with patients

Managing conflict with brain injury survivors is substantially different than dealing with their families. There are neurobehavioural changes that may limit communication and comprehension abilities [5]. These factors can be a great source of frustration for the patient and lead to outbursts, anxiety and depression. Understanding the patient’s personal situation, the impact of the brain injury, and that they may lack self control can help the health care worker provide better care.

The TBI Model System [6] suggests the following tools to manage outbursts and conflicts with patients:

• Remain calm
• Don’t take things personally
• Be empathetic and acknowledge their feelings
• Listen
• Do not engage in combative behaviour
• Speak calmly and in a neutral voice
• Redirect the conversation or leave the room for a short time to allow the patient to calm down

Many individuals with brain injury may have trouble with reasoning, problem solving, information processing and concentration [7]. Finding a suitable solution may be challenging. If the situation becomes aggressive or has potential for violence, you may need to ask for assistance or use a non-violent crisis intervention.

Navigating difficult conversations

Difficult conversations can include anything from telling a patient that they may never walk again to explaining how a brain injury will change a person’s lifestyle. Whatever the situation, having these difficult conversations with families and patients is never easy. “Patients and family members highly value effective communication and empathetic relationships with their healthcare providers” [8].

Here are suggested steps for navigating difficult conversations [9]:

• Pick a quiet and private location to have the conversation
• Prepare ahead of time – practice the conversation
• Use simple language
• Have some additional support services (pamphlets, websites, or contact numbers) prepared
• Be encouraging and empathetic

Additional strategies to assist with the initiation of the conversation can include:

• Start off the conversation with an introduction. And remember – always use the patient’s name
• Ask the family if they have any concerns
• Sit rather than stand
• Listen actively
• Discuss the stated concerns and use this opportunity as a starting point
• Use plain language
• If there are moments of quiet, allow it. Families and patients need this time to process their emotions
• Be empathetic

There are several different ways to approach these conversations [10], but the most important aspect is simple, clear communication.

Brain injury survivors and their families/caregivers all face what seems to be an insurmountable amount of stress and anxiety. These emotions can become outbursts or evolve into conflict.

Do not take it personally. Having difficult conversations with the patient and their families is always uncomfortable. Preparing and practicing can help ensure you are using the proper language and providing the most accurate information and supports.

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Communication and collaboration are key to a successful rehabilitation plan. It is also imperative to minimize health care costs, duplicated efforts and testing, and maximize efficiencies in the health care system.

Collaboration in health care is defined as working together to improve patient outcomes [1]. There are two facets of collaboration: collaboration between the clinicians; and collaboration with the patient and families/stakeholders. Both are equally important and serve to better the patient’s health outcome.

Communication & collaboration with patients & families

Communication styles develop based on various factors, including culture; ethnicity; and socioeconomic background. However, survivors of brain injury are faced with additional barriers Most individuals with brain injury face challenges with “language functioning, cognition and executive skills” which effect their ability to communicate their needs and goals [2].

Collaboration involves health care providers working with the individuals closest to the patient, such as their caregivers, families and friends to provide them with strategies for effective communication. The communication is bilateral, as these individuals can provide the health care team with valuable information about the patient. “The partnership between providers, patients and their families in shared decision making, coordination, and cooperation has been defined as interprofessional collaborative practice” [3]. Collectively, this partnership will drive the rehabilitation process and promote more efficient and patient centered goals.

Collaborative communication emphasizes strategies of “positive” and “rewarding” communication skills [4]. It promotes an atmosphere of respectfulness and transparency while allowing each team member to feel valued.

There are many ways collaboration with the patient and their respective family members/stakeholders. This can be accomplished through team meetings scheduled to include the patient, family, stakeholders, as well as ongoing therapeutic representatives. It can also be accomplished through group emails or online virtual meetings.

Patients and their families should be made to feel comfortable enough to ask questions and discuss alternative treatments without judgement. It is a team effort, and “team diversity should be viewed as a strength; it can bring about different viewpoints, facilitate innovation and problem solving and have the potential to result in amazing outcomes” [6].

Mitchell at all, from the The Institute of Medicine, in their discussion paper Core Principles & Values of Effective Team-Based Health Care [7] outlined what they found, through research, to be the Principles of Team-Based Health Care. They are as follows:

• Shared goals: The team – including the patient and, where appropriate, family members or other support person – works to establish shared goals that reflect patient and family priorities, and can be clearly articulated, understood, and supported by all team members.
• Clear roles: There are clear expectations for each team member’s functions, responsibilities, and accountabilities, which optimize the team’s efficiency and often make it possible for the team to take advantage of division of labor, thereby accomplishing more than the sum of its parts.
• Mutual trust: Team members earn each others’ trust, creating strong norms of reciprocity and greater opportunities for shared achievement.
• Effective communication: The team prioritizes and continuously refines its communication skills. It has consistent channels for candid and complete communication, which are accessed and used by all team members across all settings.
• Measurable processes and outcomes: The team agrees on and implements reliable and timely feedback on successes and failures in both the functioning of the team and achievement of the team’s goals. These are used to track and improve performance immediately and over time.

 Interdisciplinary collaboration

It is beneficial for an individual to be “treated as a whole patient rather than just chief complaints,” [8]. This statement is especially true when dealing with individuals with multiple comorbidities, such as in brain injury. Interdisciplinary collaboration occurs between health care providers and the interdisciplinary team has a “common goal of optimizing patient care” [9].

Through various studies, The Government of Canada has identified several factors as important in collaboration. These include [10]:

• Co-location and amount of time spent at a site;
• Understanding of roles and responsibilities;
• Trust and respect of each professional;
• Ability to share patients/clients;
• Sharing information about structures and procedures;
• Regular face-to-face contact;
• Joint work on local projects or specific topics; and
• Support from senior management

The incorporation of various communication tools for collaboration is determined by the organization and/or the health authority. Interdisciplinary collaboration requires each participant to understand their role and responsibilities in way of communicating and attaining the patient’s goals.
Unfortunately, we are still faced with numerous challenges in working collaboratively in the health care system. Staff shortages and an increasing number of health care disciplines may contribute to more fragmented health care plans [11]. This therefore emphasizes the need for an increase in collaboration and collaborative tools and systems to be put in place.

Interprofessional and interdisciplinary collaboration are important elements for “Improved healthcare outcomes, […] the transfer of knowledge, sharing of information and enhanced decision making” [12]. It has been acknowledged that through this collaboration, the patient and their families will have better knowledge and communication which increases engagement and positive health outcomes. This collaboration is known for its “reduced length of hospital stays, improved compliance with standards of drug prescription, improved symptom and psychosocial management” [13]. Many organizations have embraced interdisciplinary collaboration for the patient’s best outcome. “It must be the duty of health care professionals, physicians, nurses, pharmacists, social workers and researchers to collaborate in order to reduce the health disparities and better the overall health among people” in our communities [14].

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While most health care providers who work with individuals with brain injury are not directly involved in immunization programs, the COVID-19 vaccine has become an important topic.

There is a large portion of Canadians that still have not made up their mind about the COVID-19 vaccine. They are in a state called vaccine hesitancy. The Vancouver Sun published an article on how doctors in British Columbia are working together to address vaccine hesitancy in their communities. It highlights that no matter the discipline, health care providers can play a large role in helping a patient come to an informed decision.

When the topic of COVID-19 vaccines is brought up, there are a few things you should keep in mind during the discussion with your patient(s).

Ask open questions to help discover a patient’s views

The topic of vaccination can be a challenging one to bring up without sounding bossy or confrontational. To help you discover a patient’s views and concerns, ask open-ended questions. Some examples include:

• What are your thoughts on the COVID-19 vaccine?
• Do you have any questions about the COVID-19 vaccine?
• Are you ready to talk about vaccination?

It can be helpful during these questions to paraphrase the person’s responses, provide praise for the thought they are putting into their decision, and tips for additional protective measures.

Address misinformation

There is a lot of misinformation about COVID-19 and the vaccines that is circulated on the Internet. Many people may take it as fact, particularly if it comes from a person they trust (like a family member). If COVID-19 vaccine misinformation comes up, it’s important that you address the misinformation.

Ask if you can share information with the patient

When a patient does bring up their concerns or misinformation, ask if they are okay with you sharing information with them. This is when you would be able to provide some fact sheets or refer to research on COVID-19 vaccines.

When sharing information, make sure you use clear, simple and respectful language.

Be empathetic

It’s hard when you care deeply about something, and other people don’t have the same views. Many people are coping with different opinions on vaccinations within their own families.

This can be even harder when you’re a health care professional who sees and knows firsthand the impact of COVID-19. It can feel like a patient doesn’t care or doesn’t understand. And the truth is, they may not fully understand. Or they may have fears/concerns that are very real to them.

It’s important to be empathetic when talking about vaccination. Telling the patient that you understand their concerns can help keep the conversation calm and professional. When you give your recommendation in an empathetic manner, a patient is more likely to take your recommendation seriously.

Be honest about the COVID-19 vaccine

When a patient has a question about side effects or the differences between vaccines, don’t dismiss those fears or say something like ‘the benefits outweigh the risks’ without first addressing their concerns. Use vaccination rates in your area, potential side effects, and any other information that has been made available to you to talk about vaccination with your patient.

Give your recommendation respectfully

As a health care professional, patients look to you for recommendations. But your recommendation shouldn’t sound like a command or disrespect their concerns.

Tell the patient your recommendation respectfully, and if they ask, give them the reasons behind your recommendation.

This may be an opportunity to present your own situation as an example if that’s something you’re comfortable doing. I.e., you can tell them that you got vaccinated and you recommend it to every patient.

Listen to their concerns – and don’t pass judgement

COVID-19 has been incredibly scary for all of us. The vaccines can be equally unsettling for people who don’t understand them; who are scared of needles; or who have concurrent conditions.

You often don’t know what past experiences or influences people have in their lives. These experiences could inform their present reactions and decision-making.

Start by asking your patient if they have considered getting the COVID-19 vaccination (if they haven’t already). If they start sharing their concerns, listen actively and don’t pass judgement. They may not have the same views as you, but that doesn’t mean their feelings aren’t valid.

Take breaks for yourself

When you work in health care, it’s important to take breaks to give yourself some time to recharge. This is particularly true when you’re talking about a subject where people don’t share the same views as you. While the majority of people you speak with will be able to discuss it respectfully, there will be some people who react quite strongly.

While these conversations are important to have with your patients, it is equally important to give yourself a reprieve and engage in some self-care.

• Information about self-care as a health care provider

Help with next steps for vaccinations

If a patient is ready to take the next step and book a vaccination appointment, make sure they have what they need to do so. This may include informing their caregiver or telling them about the provincial/territorial booking system.

Patients/clients in recovery often neglect their diet, but it is important they are encouraged and reminded how important nutrition is to their recovery. The food we eat supplies us with energy and nutrients that our brain and body use to complete physical, cognitive, and mental activities. When we eat well our body obtains all the protein, vitamins, and minerals we need, improving both our overall health and our brain function.

Healthy eating means eating a variety of high-nutrient foods and drinking plenty of water. Vegetables, fruits, legumes, meats, milk products, and whole grains contain the important nutrients the body needs to heal and stay healthy. Foods and drinks that are high in salt, sugar, or caffeine should be limited.

Please note: Dietitian is a protected term in Canada, which means they need to have professional certification. Nutritionist is only a protected term in Alberta, Quebec, and Nova Scotia. This means that someone may be a nutritionist in British Columbia but not have the same credentials as someone in Alberta. Dietitians of Canada has an explanation and a chart of protected titles by province/territory that can help identify what kind of health professional to consult for dietary needs.

How nutrition can impact brain injury recovery

The brain uses approximately 20% of daily caloric intake. After someone sustains a brain injury, they need to be eating enough calories to help the brain function well [1]. Good nutrition will be important for the rest of their life. In addition to getting enough calories, it is important they also get the specific nutrients that will help the brain recover. The brain needs amino acids, protein, omega 3 fats, vitamins and minerals, and many other nutrients to keep the brain working well.

Are there brain healing foods?

Studies have shown that specific nutrition-based diets and exercise can impact the brain in positive ways, such as improving cognitive function [2]. There are foods that are better for brain health than others because they contain important nutrients – but there are no foods that will heal a brain injury. Brain injury recovery takes time, patience, rehabilitation, and a commitment to learning coping strategies. This includes proper nutrition.

Here is a brief overview of the components of a healthy diet that you can share with your patient/client [3]. If they have more questions, you should refer them to a dietitian or nutritionist.

Caloric intake

How often a person eats and how many calories they take in have been shown to contribute to brain function. This is entirely dependent on the person and their dietary needs. A dietitian can work assist to identify an appropriate eating schedule.

Anti-inflammatory foods

Inflammation can occur following a brain injury. Studies have shown that anti-inflammatory diets can be helpful in improving pain, mood, and sleep [4]. Anti-inflammatory diets are made up of foods like fatty fish, healthy oils, flaxseed, fruits, vegetables, and lean proteins. For a more comprehensive anti-inflammatory diet plan, speak with a dietitian.

Healthy fats

Studies have shown diets with a lot of saturated fats aren’t good for the brain [5]. Diets should be higher in good-quality fats (unsaturated fats). Foods such as oils, nuts and natural nut butters, and some fruits and vegetables (such as avocados) have unsaturated fat that is better for us (in moderation).

Omega-3 fatty acids, a special form of fat most commonly found in fish, has been shown to improve cognition and recovery of neurons after a traumatic brain injury. Evidence suggests that docosahexaenoic acid (DHA), an important form of omega-3 fatty acid can help improve neuronal function [6]. The body does not naturally produce DHA, so this needs to be included in a diet.

A dietitian will be able to assist with what kinds of foods they should be eating (and how much) to supplement their diet with healthy fats.

Proteins and amino acids

Amino acids, the small components of protein, are used for the growth, repair, and maintenance of nearly every tissue in the body. The brain needs amino acids as well. Protein can come from fish, lean chicken and meats, eggs, legumes, nuts and seeds. A dietitian can recommend ways to incorporate protein into meals and snacks.

Fruits and vegetables

Fruits and vegetables are the best source of the vitamins and minerals the body requires to become and stay healthy.  Each type of fruit and vegetable contains a unique blend of vitamins and minerals, so it is best to try to get a variety of each throughout the day.

Whole grains

Whole grains contain a lot of the B vitamins that the body need to keep the brain functioning well. They are important for sending messages to and from the brain, controlling muscles, and allowing us to function. Whole grains, like brown or wild rice, multigrain breads, and cereals should be eaten more often than more highly processed breads and cereals.

Blood sugar (glucose) balance

Proper glucose (blood sugar) levels are extremely important. In some cases, the brain’s ability to convert glucose into energy doesn’t work as well after a brain injury. The brain needs more energy than usual, and this can result in more damage to the brain [7].

Food such as fruits with naturally high sugar (such as grapes or raisins) or fruit juices can help. There are also glucose medications available by prescription. Patients/clients will need to work with a dietitian or healthcare specialist that is able to identify what is causing the problems in blood sugar levels. Once that problem is identified, treatment can be recommended.

Water

Water is an important part of healthy living for everyone. Dehydration can impair brain function and can even change the brain’s structure. Drinking water regularly throughout the day can reduce the risk of becoming dehydrated. If remembering to drink water is a challenge, patients/clients can use a large water bottle with time markings or get a smartphone app that sends reminders.

There is also some evidence that Vitamin E and curcumin may also be helpful. Vitamin E is found in certain oils, nuts, and spinach. Vitamin E functions as an antioxidant, which helps make sure neurons can function as well as possible. Studies have shown a link between Vitamin E and neurological performance [8]. Curcumin is a yellow curry spice that has also been suggested to help recovery after brain injury, particularly in helping preserve cognitive abilities [9]. Although they would need a lot to have the results shown in the studies, even small amounts may help.

Patients/clients should work with a dietitian for best results

Rehabilitation schedules, cognitive struggles, fatigue, and other effects of brain injury can make planning out a nutritious diet difficult for someone with a brain injury. A dietitian is the best person to help develop a specific and effective nutrition plan after injury. Each person’s body will have different needs than someone else based on factors such as age, weight, gender, and activity, and a tailored plan is the best way to ensure that they’re getting the nutrients they need.

Factors that can impact nutrition after brain injury

Changes in taste and smell

Some individuals living with brain injury experience sensation changes, including to their senses of smell and taste. These senses can be altered or lost on a temporary or permanent basis. This can be a difficult adjustment: it can change the kinds of foods and beverages a person wants to eat and can greatly impact their enjoyment of food and eating. Working with a dietitian to create a tailored meal plan can help address these changes.

Memory problems affecting eating

People with a brain injury may experience memory problems. This can make it difficult to remember to eat, or all the steps needed to make a meal. If your patient/client is forgetting to eat or drink, they may not be getting the proper nutrients they need. Alternatively, if they can’t remember if they ate and make another meal, they may be eating too much.

Ways to cope with memory problems in relation to eating include:

• Creating a meal plan, including step-by-step instructions for preparation
• Setting alarms for when to start meal preparation
• Keeping a food journal to document when and what they ate

Not feeling full or hungry

In some cases, a person may not be able to feel the sensations associated with being full or being hungry. This can impact eating habits, which in turn can impact nutrition. Some ways to help patients cope with these changes are:

• Identify the problem. While some people don’t feel hungry because their brain doesn’t process that sensation, others may be experiencing false fullness because of something such as constipation. By identifying the cause and addressing it, they’ll understand why it’s happening.
• Scheduling meal times, including portion sizes so they won’t eat too much or too little
• Keeping a food journal to document when and what they ate

Even when they don’t have much of an appetite, it is important they try to eat.  Remind them that food is like medicine and they need it to recover and heal.

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Sleep disturbances and lack of sleep are common problems that many people with a brain injury face. Multiple effects of brain injury make it harder for people to get the sleep they need. This can include but is not limited to:

• Depression and anxiety experienced because of the injury
• Chemical changes. The brain moderates the release of chemicals that help with sleep, and this can be impacted after brain injury
• Sleep disorders and sleep syndromes
• Changes to breath control
• Physical pain/discomfort

Sleep problems can also come from sleeping too much, causing mixed-up sleep cycles. In general, people with a brain injury do need a bit more rest after their injury, which can make some sleep problems difficult to spot. Addressing sleep problems can be done by developing a sleep routine made up of good habits (also called sleep hygiene) and by working with a healthcare team if the sleep problems are medical in nature.

Topics in this section include:

• The importance of sleep in brain injury recovery
• Common sleep problems after brain injury
• Effects of poor sleep

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The importance of sleep in brain injury recovery

Sleep problems can make recovery more difficult. If a person isn’t able to focus, gets tired at a faster rate or is unable to complete rehabilitation exercises, progress in recovery can be slower.

A great way to monitor sleep and understand how it is affecting the individual is to ask them to keep a sleep journal. 

• Here is a sleep journal template that can be shared with patients/clients 

The individual can also keep track of sleep through technology specifically designed to help monitor sleep. For example, some fitness trackers have sleep functions. They are designed to be as easy on the eyes and brain as possible (little-to-no blue light) and can tell important information about periods of sleep, if they were restless, and if they woke up. Some even monitor heart rate.

Sleeping problems can become a cycle that can be difficult to break. But as sleep improves, so does brain injury recovery, and vice versa. The key is finding ways to understand the relationship with sleep and developing methods to support healthy sleeping patterns.

Common sleep problems after brain injury

Changes in breathing

The brain helps regulate breathing, and damage to the part that controls the breath can lead to challenges. In some cases, a person with affected breathing control may actually stop breathing for short periods of time. This is commonly called sleep apnea and can also cause snoring problems. There are sleep apnea machines (such as continuous positive airway pressure (CPAP) machine) that a person can wear to bed to help control breathing.

A common challenge faced by people with sleep apnea is that they don’t know they have it. There are some signs they may notice: they wake up choking, gasping, or with shortness of breath. Other signs such as snoring or stopping breathing are only noticed by partners. Sleep apnea may also cause insomnia.
You may want to inquire if the person (or their partner if relevant) has noticed these symptoms of sleep apnea. They may need to be referred to a sleep specialist who can run more tests. Successful treatment for sleep apnea can be a game-changer.

• Information about sleep apnea

Chemical changes

Parts of the brain control chemical levels in the body that help a person fall asleep. For example, the pineal gland in the brain regulates melatonin, which plays a role in falling asleep [1]. When there is damage to these brain functions, a person may have trouble falling asleep or experiencing disrupted sleep patterns because the chemicals no longer affect the body in the same way.

Depression or anxiety

When a person is experiencing mental health struggles such as depression or anxiety, it can affect their sleep. This can in turn lead to feelings of fatigue and tiredness that can actually impact depression and anxiety more. Taking care of mental health and practicing proper sleep hygiene will help with the related challenges.

Medications

Some medications have the side effect of interfering with sleep. They may also cause drowsiness during the periods of time the person is awake. If the patient/client shares side effects with you, you may be able to help recommend ways for managing them. 

Pain and discomfort

Physical pain and uncomfortable positions may contribute to a person not being able to fall asleep or stay asleep. Before going to bed, remind them to take any pain medications (following the instructions) prescribed, lay in a comfortable position, and use a supportive mattress, pillows, and bedding. Additional common pain management strategies include physiotherapy, medication, meditation, or even special pillows or mattresses to provide more support to affected areas.

Sleep disorders and syndromes

Studies have shown that brain injury and sleep disorders go hand in hand [2]. When looking at a successful sleep-wake cycle, a person gets uninterrupted rest at night and is awake during the day. Sleep disorders make it difficult to rest, and brain injury recovery can suffer as a result. It’s difficult to recognize a sleep disorder or a related sleep problem because it can include resting too much as well as not resting enough. Types of sleep disorders include:

• Circadian rhythm sleep disorders. These disorders make it difficult for a person to follow a normal sleep pattern
• Hypersomnias. These are disorders that make the person extremely sleepy
• Insomnias. These are disorders that make it difficult to fall asleep or stay asleep
• Parasomnias. These are disorders that include unwanted events during sleep. This can include sleep walking, talking, and bedwetting
• Sleep related breathing disorders. These are disorders that cause difficulty breathing while asleep
• Sleep movement disorders. These are disorders that cause unwanted movement, which can make it difficult to fall or stay asleep

Sleep disorders/syndromes are challenging to cope with but can improve over time by committing to good sleep hygiene/routines. 

Too much napping

A person coping with physical and cognitive changes after a brain injury may need to take more rest periods or naps. This is normal, as they’re using a lot of energy to complete tasks and may need to take more breaks than they did before their injury. But too much napping can make it difficult for a person to fall asleep at night, when they are supposed to be doing the bulk of their recharging for the next day. This leads to mixed up sleep patterns or poor sleep.

Part of a good sleep hygiene routine is listening to the body, and sometimes the body and brain do need a nap. But naps should be limited during the day and should be kept short. An alternative to napping is practicing meditation.

[3]

Effects of poor sleep

If a person isn’t getting a lot of sleep, they may experience:

• Bad moods or emotional lability (mood swings)
• Depression/anxiety
• Fatigue
• Headaches
• Increased difficulty thinking or remembering. Any cognitive challenges they are coping with may be worse on days when they aren’t getting enough sleep
• Physical discomfort, including aches

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See sources

Alcohol & drug use

[1] Corrigan, J. D. (1995). Substance abuse as a mediating factor in outcome from traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 76 (4), 302-309

Information and content on this page provided in part by the Acquired Brain Injury Partnership Project of Saskatchewan. 

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Nutrition

[1] Keatley and Whittamore, Understanding Mild Traumatic Brain Injury

[2] Gómez-Pinilla, F. (2008). Brain foods: The effects of nutrients on brain function. Nature Reviews Neuroscience, 9(7), 568-578. doi:10.1038/nrn2421

[3] The OCF-18 Adjusters Guide

[4] Allison, D. et al., (2016). Targeting inflammation as a treatment modality for neuropathic pain in spinal cord injury: A randomized clinical trial. Journal of Neuroinflammation, 13(1). doi:10.1186/s12974-016-0625-4

[5] Molteni, R., Barnard, R., Ying, Z., Roberts, C., & Gómez-Pinilla, F. (2002). A high-fat, refined sugar diet reduces hippocampal brain-derived neurotrophic factor, neuronal plasticity, and learning. Neuroscience, 112(4), 803-814. doi:10.1016/s0306-4522(02)00123-9

[6] Salem, N. (2001). Alterations in brain function after loss of docosahexaenoate due to dietary restriction of n-3 fatty acids. Journal of Molecular Neuroscience, 16(2-3), 299-307. doi:10.1385/JMN:16:2-3:299

[7] Barkhoudarian, G., et al., (2011). The Molecular Pathophysiology of Concussive Brain Injury. Clinics in Sports Medicine, 30(1), 33-48. doi:10.1016/j.csm.2010.09.001

[8] Navarro, A. et al., (2005). Vitamin E at high doses improves survival, neurological performance, and brain mitochondrial function in aging male mice. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 289(5). doi:10.1152/ajpregu.00834.2004

[9] Sreejayan, (1994). Curcuminoids as Potent Inhibitors of Lipid Peroxidation. Journal of Pharmacy and Pharmacology, 46(12), 1013-1016. doi:10.1111/j.2042-7158.1994.tb03258.x, and; Sreejayan, (1997). Nitric Oxide Scavenging by Curcuminoids. Journal of Pharmacy and Pharmacology, 49(1), 105-107. doi:10.1111/j.2042-7158.1997.tb06761.x

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Sleep

[1] Healthlink BC

[2] Duclos, Catherine et al. Parallel recovery of consciousness and sleep in acute traumatic brain injury. Neurology, December 2016 DOI: 10.1212/WNL.0000000000003508 via the article Recovery from brain injury, better sleep go hand in hand

[3] Information for this section sourced in part from msktc.org

Part of rehabilitation and recovery after brain injury is taking care of physical health and wellbeing. This includes diet, exercise, sleep, and other healthy habits. Individuals with a brain injury may struggle with these kinds of habits. If that is the case for your patients/clients, they may rely on you to provide them with assistance or refer them to specialists such as dietitians.

Topics in this section include:

• Alcohol & drug use
• Nutrition
• Sleep

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Substance use after a brain injury

About 20% of people who survive a traumatic brain injury will develop a new problem with substance use [1]. Brain injuries that have an impact on emotional regulation or risk-taking may increase the risk of substance use disorders. Boredom, pain, and stress can also cause a person to use drugs for relief. People who used drugs and alcohol before their injury may wonder if it is safe to return to use.

In general, research suggests that it is best to avoid using alcohol or other substances after brain injury to allow the brain to heal and avoid more serious problems. Understanding how drugs affect recovery after brain injury can help you and your patient/client navigate this issue.

There are several effects that substance use can have on someone after their brain injury, including:

• Impulsivity or poor judgment
• Increased risk of seizures
• Increased risk of another brain injury
• Slowing down or limiting recovery
• Problems with balance and walking
• Problems with concentration and memory
• Feeling increased effects from alcohol and drugs
• Increased feelings of depression
• Negative interactions with prescribed medications

Drinking alcohol after a brain injury

The brain may be more susceptible to the effects of alcohol, which can impact balance, coordination, mood, and cognitive processing. Alcohol is also incredibly dangerous to mix with prescription medications they may be taking after their acquired brain injury. If they drink regularly, alcohol may also be having a negative effect on recovery.

While abstaining from alcohol is the safest option, it is always best to encourage your patient/client to speak with their doctor about alcohol use and their brain injury.

Substance use rehabilitation and brain injury

One of the existing challenges with treatment for substance use and brain injury at the same time is that current facilities/programs are not equipped to handle both. The majority of brain injury rehabilitation, community, and support programs require participants to be sober. Similarly, centres and programs that specialize in addiction support are not able to handle the needs of someone with a brain injury. While there are more and more resources being developed to help service providers, there is still a need for programs and facilities to develop working knowledge of the diverse needs of individuals seeking treatment for problematic substance use.

If your patient/client is using drugs or alcohol, it is important for them to work with professionals to ensure they are not using at the time of appointments. Encourage your patient/client to develop an open and honest dialogue with their treatment team is the best way to ensure they will be able to continue their rehabilitation.

Resources and supports for people with substance use disorders

• Alcoholics Anonymous branches in Canada 
• Find a Narcotics Anonymous meeting
• The Smart Recovery Program 
• From Canada.ca: a complete list of substance use support services available by province/territory
• How to discuss substance use – a guide by Canada.ca
• The Acquired Brain Injury Partnership Project has an informative video on substance use and brain injury
• Addiction – An Information Guide provided by the Centre for Addiction and Mental Health for people with substance use problems and their families/friends.
• Canada’s Low-Risk Drinking Guidelines
• Find a branch of the Canada Mental Health Association
• HelpGuide.org’s practical tips for overcoming addiction
• You and Substance Use Workbook by HeretoHelp BC
• Opioid Overdose Prevention Toolkit. Please note this is Ontario specific, but the information is applicable Canada-wide
• Brain injury and substance use workbook
• Additional information on opioid overdose

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See sources

[1] The Mental Health Commission

[2] Basics of Compassion Fatigue, The Figley Institute

[3] Centre for Addiction and Mental Health (CAMH)

Information for this page sourced in part from compassionfatigue.org