Part of rehabilitation and recovery after brain injury is taking care of physical health and wellbeing. 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.
Topics in this section include:
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 or alcohol before their injury may return to use.
Research suggests that it is best to avoid using alcohol and other substances after brain injury to avoid negative impacts. 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, including the risk of oxygen restriction
- 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. It can also have a negative effect on recovery and poor interaction with prescribed medication.
Substance use rehabilitation and brain injury
A challenge with accessing ongoing treatment for substance use disorders and brain injury is that facilities/programs are rarely equipped to handle the concurrent complexities. The majority of brain injury rehabilitation, community, and support programs require participants to be sober. Similarly, centres and programs that specialize in problematic substance use 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
Nutrition
Patients/clients in recovery often neglect their nutrition for a variety of reasons—but it can be an important part of recovery. The food we eat supplies us with energy and nutrients that our brain and body use to complete physical, cognitive, and mental activities.
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. Keep in mind that healthy is a subjective term, and is different for everyone depending on their body, lifestyle, and nutrient needs. This should be determined by a health care expert that specializes in nutrition.
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 at its best [1]. In addition to getting enough calories, it is important they also get specific nutrients, such as amino acids, protein, omega 3 fats, vitamins and minerals.
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.
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.
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.
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.
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 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 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.
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 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 be helpful. Studies have also shown a link between Vitamin E and neurological performance [8]. Vitamin E is found in certain oils, nuts, and spinach and functions as an antioxidant. Curcumin is a yellow curry spice that has also been suggested to help preserve cognitive abilities [9]. Although they would need a lot to have the results shown in the studies, even small amounts may help.
Factors that can impact nutrition after brain injury
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.
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
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.
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.
Sleep
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.
The importance of sleep in brain injury recovery
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
- Impediments to completing rehabilitation exercises
Common sleep problems after brain injury
Sleeping problems can become cycles that are difficult to break. The key is finding ways to understand the relationship with sleep and developing methods to support healthy sleeping patterns.
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.
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.
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.
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.
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.
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.
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]
A great way to monitor sleep and understand how it is affecting the individual is to ask them to keep a sleep journal.
The individual can also keep track of sleep through technology specifically designed to help monitor sleep. For example, some fitness trackers have sleep functions.
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
Nutrition
[1] Keatley and Whittamore, Understanding Mild Traumatic Brain Injury
[3] The OCF-18 Adjusters Guide
[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
Sleep
[1] Healthlink BC
[3] Information for this section sourced in part from msktc.org
