Appendix III: recovering from mild head trauma – a guide for patients

Who is this guide for?

This guide is for people who experience persistent difficulties following a mild head trauma.

Information in this brochure includes a description of mild head trauma symptoms, why they may persist and how vicious cycles between unhelpful thought patterns and actions can develop. Furthermore, tips about overcoming some of these symptoms and additional support are provided.

People can sustain mild head traumas as a result of road traffic accidents, falls, assaults or other injuries involving a blow' to the head.

This guide aims to cover a range of difficulties that may be relevant to some people and not to others.

Mild head trauma symptoms

Mild head trauma can occur following a blow' to the head. This may cause short-term confusion, disorientation or dizziness. Loss of consciousness may happen for a few seconds or minutes. Many people who suffer such mild injuries may choose not to go to hospital or seek medical care as the injury may not affect them in a substantial way.

Sometimes, following mild head trauma, people develop a number of symptoms. These include:

• • Physical difficulties such as headaches, dizziness and fatigue
• • Emotional difficulties such as irritability, anxiety and depression
• • Cognitive difficulties such as problems with concentrating and remembering things.

The experience of a potentially highly dangerous event alerts the body’s stress or arousal system. This may lead to a range of difficulties that become associated w'ith fear of having damaged the head or brain. Permanent damage to the brain under these circumstances is very rare.

It is important to be aware that mild head trauma symptoms are relatively common. A lot of people get headaches or forget things from time to time. However, the combination of prior experiences of headaches or forgetfulness with the stress of having had a sudden unexpected life event, like an accident, may aggravate the situation, resulting in mild head trauma symptoms.

Following a sudden, unexpected life event, the body tends to absorb information from the environment so as to make sure that any signs of danger are not missed again. This can activate our fight/flight or threat system, placing our brain on “high alert.”

This is an understandable and normal reaction and will usually go away with time. It is important that you remind yourself of this fact.

What if some symptoms persist?

Some people experience symptoms for longer. This can be because these symptoms interact with each other, which can make them more troublesome. For example, after just a few days, if someone experiences a headache that won’t go away (physical), they may feel more irritable (emotioned), have less patience and begin to worry that something might be seriously wrong with their brain (cognitivelthinking skills). Eventually, they may have problems concentrating on anything else, find it hard to pay attention and to remember information (cognitivelthinking skills). Thus, a vicious cycle may develop where physical symptoms (e.g., head pain or dizziness) trigger intense fears (that there might be something seriously wrong with the head/ brain) leading to constant worries (which distract the attention and ability to focus, leading to the impression of forgetfulness).

A vicious cycle of mild brain trauma symptoms:

Another example is that worries about changes to your lifestyle may substantially exacerbate the situation. For instance, if someone is unable to return to work straight away because of an injury (physical), they may begin to worry (emotional) about financial issues, job security or meeting their social and family responsibilities. The intensity of such unhelpful thoughts (cog- nitivelthinking skills) may lead to increased muscle tension, which is often experienced in the neck, shoulder and back area, resulting in tension-type headaches (physical). Additionally, sleep problems (physical) are a common consequence of distress and worry, which then further increase difficulties with concentration and thought processing (cognitive/thinking skills).

Many of the described symptoms and difficulties are common in everyday life for everybody (we all get tired, stressed and forget things from time to time). However, people may notice these difficulties and worry about them more when they are feeling stressed. After mild head trauma, it can be easy to forget that memory and concentration lapses, feelings of fatigue or even exhaustion used to happen even before the accident.

As mentioned earlier, different head trauma symptoms interact and complex patterns or vicious cycles may develop, which may be harder to resolve. In such cases, it is vital to find proactive coping strategies to disrupt these unhelpful patterns and to improve well-being.

Emotional difficulties

It is common to experience a variety of emotional difficulties following mild head trauma. Apart from simply not feeling well physically and being in pain, you may often experience additional worries such as the following:

• • feeling unsafe or vulnerable in the world
• • believing the world is unpredictable
• • fear of unexpected harm
• • anxiety and/or nervousness
• • fear of severe health problems
• • frustration and irritability
• • guilt
• • low mood
• • uncertainty about the future, e.g., work, family
• • loss of control

These symptoms are a natural response to the sudden, unexpected traumatic event, and can fade completely with time. They are also the common consequence of many different types of stressful experiences or critical life events.

WHAT CAN I DO?

Talk about and reflect on your thoughts and feelings with someone. This is the best way to overcome low mood.

The following questions may shift the perspective you hold:

• • How do these thoughts make me feel?
• • What are the advantages and disadvantages of thinking this way?
• • Am I thinking in a particularly negative way, such as jumping to conclusions or seeing things just in black-and-white?
• • What is the evidence for thinking or believing this?
• • What possible alternative views are there? Is there evidence to support these alternative views instead?
• • Can I test any of these thoughts in real-life?
• • What would I say to a friend who was in a similar situation?

Worrying about your health and your ongoing symptoms can be very stressful. Persisting symptoms after an accident can raise more questions about underlying missed injuries or whether you can even get better.

It is important to become aware of how you can manage stress and tension by maintaining a positive outlook about the recovery. Feelings of vulnerability and loss of personal safety can be extremely disturbing and can lead to the vicious cycles outlined above.

Fears and anxiety

The emotional impact of mild head trauma may be experienced as fear or increased anxiety about certain situations, e.g., being around people or returning to driving, particularly if these are related to the accident. When people feel more stressed, worried or anxious, they often become “better” at noticing the things that might go wrong (this is called hypervigilance).

Avoidance of anxiety triggers

Avoiding situations that make you feel anxious can in fact keep your symptoms or anxiety going. A good example of this is travel anxiety, where people avoid using the kind of transport associated with their accident. The stress and anxiety, which might be triggered by travelling, results in a “prediction” that this type of transport will cause another accident.

People may also avoid reminders of events around their injury, or avoid talking about it with friends or relatives. While this is an effective way of reducing anxiety and distress in the short term, it can cause substantial disruption over the medium and long term. For example, if a person no longer drives as a result of an accident, they may find their life becoming increasingly restricted and less pleasant.

WHAT CAN I DO?

Tackling avoidance is an important component in overcoming your symptoms. One helpful strategy is called exposure. Exposure means 'facing your fears' and is the opposite of avoidance. When we avoid something we fear, the fear gets stronger. If we acknowledge our fears and learn we can cope then we can manage similar situations in the future. Exposure can be done in real situations or in imaginary ones. The key to success is starting with something not too scary and gradually strengthening your coping skills.

Generate some positive statements. Practise them when you're feeling okay. Have them 'ready at hand’ in situations which may make you feel anxious. For example:

• • "I may feel anxious now, but it will become easier and easier over time".
• • "Anxiety is not dangerous - it's just uncomfortable".
• • "I am going to take some nice, slow breaths and keep going".
• • "Gradually, I am getting better".

Remain focused on your activity.

Practise relaxation. Slow down the breathing rate during the exposure. This will reduce the arousal.

Depression and low mood

People sometimes become depressed when unpleasant things happen to them. Traumatic accidents or prolonged periods of negative health symptoms are associated with the release of stress hormones, which cause depressive symptoms (amongst other disturbances). These symptoms and difficulties can create concern, upset and worry. Individuals may wonder if they will ever improve. In addition, there may be a number of ways in which a person’s life has changed (e.g., people may go from working to not working, from financial security to financial uncertainty). Often, the effects of these changes can result in losing or restricting opportunities to do enjoyable, rewarding things. This can contribute to someone becoming, and staying, depressed.

When people are low in mood, they tend to have negative thoughts about themselves. These thoughts may not be helpful or an accurate picture of the situation. They maintain the negative feelings about oneself or feelings about being stuck. Sitting around doing very little can maintain low moods and provide extra opportunity to worry and ruminate about problems and concerns.

WHAT CAN I DO?

• • Focus on manageable, meaningful activity on a regular basis.
• • Have specific plans about what and when things can be done.
• • Adapt activities on a 'bad day'. Stick to the main task.
• • Shift unhelpful thoughts:

Become aware of what you are thinking and how it is making you feel.

Balance your thinking. Explore alternatives.

Look at situations from different points of view.

You might say to yourself:

'What other ways are there to view the situation?'

'What would I say to a friend if they were thinking that?'

• Balanced thoughts can enhance your mood.

Irritability

Irritability is another sign of heightened arousal originating from a traumatic incident. Following an incident, the body becomes more receptive to surrounding signals in order to check for unexpected danger. This leads to an information overload, resulting in a range of posttraumatic symptoms, including irritability.

This is not just an unpleasant experience; it also interferes with one’s ability to get along with others. Many people who are affected in this way comment that they used to be very laid-back and feel as if their personality has changed. This sometimes triggers the fear that other people might reject them or that they might be aggressive with others without meaning to be.

WHAT CAN I DO?

The helpful hints and tips also apply to overcoming irritability.

It is important to adopt a healthy lifestyle:

Sleep

Involvement in purposeful activities Exercise

Daily relaxation practice

This can reduce over-arousal and reduce the stress experience.

• • Be open and communicate to others if you are feeling on edge.
• • Become aware of the situation and make adaptations:

Wear ear plugs Talk calmly

Expose yourself for a limited time only

• • Plan ahead. Think about solutions.
• • Avoid negative thinking traps e.g. taking comments too personally, jumping to conclusions or overreacting.

Physical symptoms

Headaches

Headaches that develop some time after the accident and persist are most commonly tension-type headaches or posttraumatic migraines.

WHAT CAN I DO?

It is important to adopt a helpful routine including rests and relaxation.

When headaches are occurring:

• • Reduce or change your activity.
• • Try a short relaxation or mindfulness exercise.
• • Go for a walk.
• • Promote relaxation in your neck and shoulder muscles
• • Use warmth like a wheat pack or hot water bottle.
• • Mobilise your head and neck or roll your shoulders to relieve tension.
• • Prevent stiffness and tightness.
• • Avoid pain killers as a preventative measure.

Sensitivity to noise and light

Increased sensitivity to bright lights or loud noises can be a sign of an over- active nervous system. Following an accident, the nervous system is likely to absorb more sensory stimuli to make sure that potentially dangerous signals are not missed again. This means that the sensory systems are highly sensitised, which can also increase tension or the likelihood of headaches.

WHAT CAN I DO?

• • Think ahead about the places you intend to visit: can you prepare yourself or can you make reasonable adjustments?
• • Reduce the time you spend in places with bright lights or loud noises.
• • Use tinted glasses or ear plugs.
• • Plan only one challenging activity per day.
• • Use relaxation and slow breathing techniques before, during and after exposure to over-stimulating situations.
• • Divert your attention to alternative and purposeful activities.
• • Perform tasks that require mindful awareness as these help to take your mind away from uncomfortable sensations.

Dizziness and vertigo

Dizziness and vertigo are also very common head trauma symptoms. They are associated with micro-changes to our vestibular system. This system is responsible for helping us balance; information is sent to the brain from our visual processes, our inner ear and proprioceptors in our joints. Our brain then has to make sense of all this information and make adjustments to keep us balanced. If any part of this system is disturbed, we sometimes experience feelings of dizziness, loss of balance or vertigo.

You may be referred to a specialist in Vestibular Rehabilitation, who can carry out an assessment of your dizziness and balance. They will select relevant exercises to help you manage your symptoms. You will probably be advised to do these exercises several times a day. You are likely to experience some dizziness as you perform these exercises. Remember that you are in control of your symptoms - if the dizziness becomes too much, then stop and allow it to settle. You may need to do the exercises a little more slowly at first but do not skip them - regular practice will optimise the recovery of your balance system. Think of a ballet dancer - most people feel dizzy when they spin around; however, with practise, a ballet dancer can perform multiple spins at speed without becoming dizzy, as their brains have learnt to adapt. This is similar to the training you are doing to your vestibular system whilst performing these exercises.

Before you start any exercises prescribed by your therapist, set aside a few minutes to practise relaxation. Start by making sure you are breathing slowly. Keep your shoulders down and your chest still, and breathe by just letting your stomach go in and out. After you have been breathing slowly for a few minutes, follow each of your exercises and, once you can do this, practise staying relaxed while carrying out the vestibular exercises.

WHAT CAN I DO?

Dizziness and vertigo after head trauma are often experienced as having ‘sea legs'. Such sensations resolve eventually if you carry on with your normal activities and move around naturally. Specific vestibular exercises can improve your recovery.

• • Ask your head trauma specialist or physiotherapist for guidance regarding such exercises.
• • Combine vestibular exercises with relaxation practice to optimise the desensitisation and reduce potential distress.

Sleep problems

Difficulty falling asleep and/or disrupted sleep throughout the night can have a profound effect on our ability to function during the day. People with sleep disturbances often report problems with memory and concentration. They might feel irritable and stressed and may have low energy levels. Some people might experience nightmares or disturbing dreams about feeling out of control, being chased or being in danger. Sleep problems are most likely to be related to worry, stress, anxiety and low moods. Discomfort or pain may aggravate the situation.

Here is an example of a vicious cycle of sleep difficulties:

WHAT CAN I DO?

It is important to create the right conditions for effective sleep. This is called 'Sleep Hygiene'.

• Review your sleep environment:

Dark bedroom

Comfortable mattress and pillows Right temperature Remove screens

• • Have a regular sleep routine. Go to bed and get up at the same time every day.
• • Have a laid-back approach. Do not try to will yourself to sleep.
• • Have a relaxing bedtime routine:

Use relaxation exercises

Take a bath

Read

• Avoid:

Heavy meals Alcohol

Excessive exercise

Over-stimulating material before bedtime e.g. TV, computer games and mobile phones

• • Discuss sleep medication with your GP if necessary.
• • Find a way to problem-solve your worries and concerns during the day:

Talk them over with someone Write them down

Fatigue and reduced energy levels during the day: “The Boom and Bust Trap”

Some people who experience frequent mild head trauma symptoms can be disappointed or feel guilty that they cannot perform their daily activities or fulfil their responsibilities to the standard they were once used to. Instead of slowing down or letting go of those expectations, they try to squeeze as many tasks into symptom-free periods as they can, or try to catch up with unfinished activities. Later, they find that their fatigue has become so severe that they have to rest for longer periods.

This is called the “Boom and Bust Cycle.” This can interfere with people making changes in their life.

A vicious cycle of over-activity and prolonged rest:

WHAT CAN I DO?

The body needs to balance its resources to stay healthy. Persisting mild trauma problems indicate that the body is short on resources. It is vital to increase resources and energy before one can gradually engage in more demanding activities.

Some people set themselves high standards or expect a much quicker recovery. Replace unhelpful thoughts like:

'I used to do so much more'

'I should be doing more'

'If I push myself harder, I will recover quicker' with kind and balanced thoughts like:

'I can take a step at a time'

'If I look after myself well, I can recover'.

• • Monitor energy levels and keep a steady pace regarding daily activities.
• • Keep activities at a sustainable level of energy. This may mean:

Saying 'no' to extra jobs or responsibilities Turning over some responsibilities to other people Getting enough rest Limiting the number of working hours.

• • Schedule rest periods before getting tired in order to recharge your batteries. Rest requires being mentally and physically still and quiet i.e. not watching television.
• • Allow yourself to slow down, rather than being 'on the go' all the time.
• • Stick to the plans and resist the temptation of pushing harder on the 'good' days, or not doing anything at all on the 'bad' days. Remember, the goal is to build up a sustainable level of energy.
• • Set realistic standards. This is how balanced thoughts can be formed which can enhance one's mood.

Cognitive difficulties

Cognitive, or thinking, difficulties include problems with short-term memory, attention and concentration, reduced thinking speed or diminished ability to problem solve.

There are a number of reasons why you may experience cognitive difficulties after a mild head injury. It is important to remember that your cognitive, emotional and physical systems are all linked. The stress of the accident, the resulting symptoms and life changes often cause people to forget that lapses of memory and attention are very common for everyone.

Short-term memory problems are usually related to problems with attention; if you find it difficult to attend to information, it will be difficult for you to remember it later. After a sudden, unexpected injury, the brain can go into a “high alert” or “danger” mode, which means the attention systems are set to focus on and look out for danger. This can then interfere with your brain’s ability to attend to usual, everyday information and, in turn, may lead to forgetfulness.

In other words, when your brain is trying to take in all the information in your environment to check for potential danger, it can struggle to focus on the information you would like it to. For example, you might find yourself becoming distracted easily, it might be difficult to focus in busy environments and you may not be able to recall information that you would usually remember.

Other mild head trauma symptoms can also interfere with thinking. For example, pain, anxiety and fatigue can all impact your ability to process information. The brain only has the capacity to focus on so much at one time. Therefore, if it is telling you that you are in pain or if you are focusing on worries (e.g., about the symptoms you are experiencing) then it will not be working as effectively on processing other information or problem solving.

You may have extra responsibilities following a head trauma in addition to your usual activities, for example, visiting health clinics, having meetings with employers or seeking help from solicitors. These sorts of additional responsibilities can also add to the load on your cognitive systems and lead to you feeling overwhelmed.

WHAT CAN I DO?

• • Simplify your life and your environment in order to reduce distractions.
• • Ask yourself 'Where is my focus?'
• • Practise relaxation.
• • Allow time to process information.
• • Use breaks and rests efficiently.
• • Repeat and rehearse important information and tasks.
• • Have a structured schedule for appointments and commitments. Use a compensatory aid e.g. a diary or a phone.
• • Remember memory lapses are common.

Try not to dwell on them when they happen.

• Remind yourself that gradually you will be getting better.

Be mindful of your improvements and of situations in which you can be attentive and remember well.

Appendix IV