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Sleeping Patterns

Sleeping Patterns

Julie
Sam deals with migraines right now on a daily basis, and I think that stress is a big part of it. He can’t deal with too much at any one time. He gets overwhelmed. It really helps when we can persuade him to take a nap.

Carl
Julie’s right. I think his stress level is the key. And it really seems to help if he gets a good night’s sleep. 

Tracy
So how is Sam sleeping?

Julie
Well at first he hardly slept at all, and when he did it was during the day, when we were trying to meet with the doctors and communicate with family. Then, he’d stay awake all night. And we felt that we should be awake, too, so Carl and I weren’t getting any sleep either.

Tracy
Altered sleep patterns are... they’re very common after TBI. It can be hard to fall asleep, or to stay asleep. And some people sleep much more than usual, and then others sleep very little. So the first several weeks to months even after the injury are usually the worst. Initially the sleep patterns can be totally off, but try to stay hopeful. Most people with TBI usually resume a more normal sleep routine, similar to the one that they had before the injury. Now I know you are probably really tired of hearing this, but it just takes some time.

Carl
You’re right Tracy. Sam’s sleeping definitely improved, but it took awhile. Those first couple of months were rough, for all of us…

Tracy
It does get better over time. I know everyone is at a different phase in their recovery, so some of the strategies may not apply.  Now if your loved one is in the hospital or in a rehab facility, work with the health care team to establish healthy sleeping patterns. And once you transition home you’ll have to determine what works best for your daily schedule considering appointments, therapy, that sort of thing.

Napping may be an issue, so if it seems like your loved one is napping on and off all day they may suggest that you limit daytime naps.  That will promote better sleeping at night. If your loved one becomes agitated or frustrated, it may be that a nap is needed during the daily routine. Other recommendations for better sleep are to avoid caffeine, energy drinks of course, exercise, video games, fluids too close to bedtime.

And establishing a consistent routine also helps. So have your loved one wake up and go to bed at the same time every day. Time, patience, creative problem solving… that’s all going to really help.

Carl
One of the therapists suggested making some changes in Sam’s room, like turning the clock away from the bed, using room-darkening shades, keeping the bedroom cool. So far these have helped, but sometimes Sam just can’t sleep no matter what.

Tracy
Well, if Sam simply can’t fall asleep or stay asleep, maybe you could have him get out of bed, watch TV, read, if he’s able to, you know until he feels really tired and can just sleep naturally.

You can also talk with a member of the team about temporarily using a sleep medication or some kind of alternative therapy to establish that sleep schedule.

Carl
We’ve tried most of those things at one time or another. Some things work better than others. It just seems to depend on the day, and how Sam’s feeling. Like I said before, it does get better, so don’t get discouraged.

Balance Problems

The brain controls our physical movement and our balance. A TBI can affect balance.

Balance problems are often an early effect after TBI. They go away over time and with physical therapy.

What you might see:

  • Unsteadiness when walking 
  • Inability to walk or sit without assistance 
  • Falls 
  • Holding onto furniture, walls, other objects when walking

How you can help:

  • Encourage proper use of aids such as walkers or canes, if prescribed, in all settings (community and home).
  • Remove throw rugs from your home. 
  • Work with the physical therapist to learn how to assist your service member/veteran while he or she is sitting or walking.
  • Falls are the leading cause of non-combat TBI. Provide or arrange for supervision once you are home to prevent falls and another TBI.

Sensory Changes

The brain is the center for all five of our senses: sight, hearing, taste, smell, and touch.

When the brain is injured, each of the senses is at risk for change. There is often not much to be done about these changes in the first year after injury.

Doctors often use a “wait and see” approach with the hope that sensory changes will go away on their own.

For some sensory changes that don’t go away over time, surgery may help. For others, therapy and learning to live with the effect will be in order.

What you might see:

  • Vision changes, such as blurry vision, double vision, or sensitivity to light 
  • Hearing changes, including muffled hearing or ringing in the ears (tinnitus) in one or both ears
  • Changes in taste and smell. This could be a complete lack of taste and smell or an altered taste, such as a metallic flavor in the mouth

How you can help:

  • A neuro-ophthalmologist can evaluate visual changes. A neurologist can evaluate other sensory changes.
  • Reinforce wearing of an eye patch or special glasses if ordered for double vision.
  • Ask your service member/veteran to avoid alcohol. It may increase sensitivity to light and noise.
  • Seek professional advice about whether or not it is safe for your family member to drive if he or she is having a change in vision.
  • Have his or her hearing checked. Use hearing aids, if needed. 
  • Ask a dietitian about tips for eating if taste and smell are lost or altered.
  • Make sure you have a working smoke alarm in the house if his or her sense of smell has been lost.
  • Try to be patient. Sensory changes can improve over the first several months or years after TBI. Work with the health care team to track how the senses are working. Seek further evaluation and treatment options as needed.

Spasticity

An injury to the brain can cause an abnormal increase in muscle tone called spasticity. A spastic muscle does not easily relax the way a normal muscle does.

This effect is most common with a severe and/or penetrating brain injury.

Regular stretching, splints to keep limbs in proper position, and medications are common treatments.

Severe spasticity can be painful so pain management may be in order.

What you might see:

  • Involuntary muscle tightness and stiffness 
  • Muscle contractions 
  • Decreased range of movement and abnormal posture

How you can help:

  • The physical therapist will develop a stretching program for your family member. Ask the physical therapist to teach you this program.
  • Post diagrams of the stretches. Help your family member do the recommended stretches.
  • If splints are used, learn how to apply them. Find out how long they are to be worn each day.
  • Monitor your family member’s skin for pressure points from the splints. Alert nurses to areas of redness and breakdown.
  • Tell the health care team if the spasticity gets worse. This could be a sign of an underlying problem.
  • If spasticity is so severe that it interferes with comfort, positioning, and general functioning, ask the doctor about treatment options. These include implanting a muscle relaxant pump.

Hemiparesis, Hemiplegia

Muscle movement originates in the brain. A TBI can affect movement.

Movement of the right side of the body is controlled by the left side of the brain, and movement of the left side of the body is controlled by the right side of the brain.

What you might see:

  • Muscle weakness on only one side of the body (hemiparesis).
  • Total paralysis of the arm, leg, and trunk on one side of the body (hemiplegia).

How you can help:

  • Your service member/veteran’s physical therapist and occupational therapist will develop leg and arm exercises. Ask to learn these exercises.
  • Realize that your family member may take longer to move around. Allow extra time to get places.
  • Encourage use of prescribed assistive devices, such as a walker or cane. They help your family member stay safe and independent.
  • You may notice decreased sensation in affected limbs. Monitor skin for pressure points from the splints. 
  • Alert the team to areas of redness and breakdown.
  • Therapists may recommend certain sleeping positions that are best for the affected limb(s). Follow their suggestions.

Bladder/Bowel Changes

Even bowel and bladder functions are controlled by the brain. For many people with TBI, bowel and bladder functions are impaired in the early days to weeks following injury. Health care providers expect this and are prepared to help. Urinary catheters and use of diapers or pads may be needed. Bowel and bladder retraining are part of the rehabilitation process. Fortunately, with time and practice, most people with TBI regain control of these body functions.

What you might see:

  • Loss of bladder or bowel control 
  • Increased urgency to urinate 
  • Incomplete bladder or bowel emptying 
  • Increased bladder infections 
  • Constipation
  • Memory and cognitive problems such that the person does not recognize the need to urinate/defecate or recall when he or she last did so
  • Skin problems due to incontinence

How you can help:

  • Indwelling urinary catheters followed by the use of pads or diapers are common early on. Reassure your service member/veteran that these are nearly always temporary.
  • The rehabilitation nurse will teach bladder “training” which often includes a specific fluid schedule, limiting fluids in the evening, and timed attempts to empty the bladder. Help your service member/veteran adhere to the recommended schedule and interventions.
  • Bowel “training” often includes scheduled attempts, a high fiber diet, adequate fluids, physical activity, eating meals at regular times, and possible use of medications, including suppositories. Help your service member/veteran to adhere to the recommended schedule and interventions.
  • Monitor for skin breakdown and report it to health care providers.

Swallowing/Appetite & Weight

Many people with traumatic injuries do not drink or eat for a period of time. As a result, they lose weight.

Once the person is fully awake and able to follow directions, swallowing can be evaluated. It is important to fully evaluate swallowing before the injured person drinks or eats.

The purpose of evaluating the person’s ability to swallow is to make sure that what he or she eats goes into the stomach, not into the lungs. When food or fluid slips into the lungs, it often results in pneumonia.

A speech or occupational therapist evaluates swallowing. This may be done in the person’s hospital room.

If not, the therapist may escort your family member to the x-ray department for a video fluoroscopy. Your family member will consume a barium-laced liquid or food that will light up on an x-ray. The x-ray helps the therapist to see precisely where it is going.

Once your service member/veteran is cleared to drink or eat, he or she may only be able to consume certain types of liquids and foods. Most people do best with medium consistencies, rather than thin fluid or very chewy, tough foods.

With practice, most people will return to a normal diet.

Appetite can be affected. Some people with TBI complain of a reduced appetite. Others gain weight due to boredom, memory problems, and an increased appetite.

Work with the health care team to learn how to help your service member/veteran have a healthy diet and a healthy weight.

What you might see:

  • Choking or coughing during meals
  • Pocketing of food inside the mouth and/or drooling
  • Decreased interest in eating
  • Weight loss, without trying to lose weight (possibly due to loss of taste and smell)
  • Overeating, resulting in weight gain
  • Memory problems: failure to remember when to eat or when last ate

How you can help:

  • Do not offer fluids or food until your service member/veteran has been cleared to drink and eat.
  • If on a special diet with restricted fluids and foods, work with the therapists and dietitians to learn what foods are allowed. Learn how to assist your family member to drink and eat if special strategies are needed (i.e., eat slowly, chin tuck during swallow, double swallow, follow every bite of food with fluid).
  • Short-term changes in appetite are common. Don’t worry about early weight loss. Most often, the weight is regained once the person is home.
  • Monitor your service member/veteran’s body weight and learn what his or her ideal weight range is from the dietitian.
  • Report appetite changes to the health care team. These may be a sign of depression, general emotional distress, medication problems, or other medical conditions.
  • Ask for a dietitian to review dietary intake and to learn more about meal preparation and a balanced diet.
  • It is common to have reduced taste and smell following TBI. Talk with the dietitian about how to use spices and flavorings to perk up the taste of food.
  • Weight gain following TBI is common. It is usually due to lack of physical activity. But sometimes it is due to boredom. Work with your service member/veteran to remain physically active and engaged in outside activities. Establish set meal times. Discourage overeating or too many snacks.
  • Encourage your service member/veteran to be involved, as able, in grocery shopping and meal planning/preparation.
  • Write meal times in the planner/memory book. Check off meals when finished.

Visual Spatial Problems

Visual spatial abilities begin in the brain. They include blind spots and/or changes in the brain’s ability to understand what the eyes see.

The ability to perceive where you are in space and in relation to other items in the environment may also be affected by TBI. This is called spatial awareness.

Injury to the right side of the brain in particular can lead to difficulties in these areas.

What you might see:

  • Tendency to ignore things on one side of the body
  • Bumping into things on the affected side
  • Difficulty finding his or her way around, especially in new places
  • Difficulty recognizing shapes and telling the difference between shapes
  • Turning head towards the unaffected side
  • When reading, cutting words in half or beginning to read in the middle of the sentence or page
  • Mistaking the location of a chair when sitting down 
  • Misjudging distance; for example, missing the cup when pouring 
  • Standing too close or too far from others in social situations 
  • Confusion between right and left 
  • Reports of impaired vision

How you can help:

  • Ask for a neuro-ophthalmologist to identify your service member/veteran’s specific visual and/or visual spatial problems.
  • Stand on and place objects on the affected side. Encourage your service member/veteran to look to that side (this is called visual cueing).
  • Remind your service member/veteran to frequently look around the environment, especially toward the affected side (this is called visual scanning).
  • Use visual cues (e.g., a dark line) on one side of a page to encourage visual scanning of the entire page.
  • Arrange your house to make tasks easier. For example, have items to accomplish a task organized in one place.
  • Show your service member/veteran around new places several times. Avoid sending him or her to new places alone.
  • Limit clutter in the house. Try not to move items around.
  • Remind your service member/veteran to use handrails when available.
  • Provide gentle reminders that he or she is standing too close or far away during social encounters.
  • Seek professional advice about whether or not it is safe for your service member/veteran to drive.

Apraxia

A person with apraxia can often understand what to do and has the physical ability to do the task. However, his or her body simply has trouble cooperating with his or her best intentions.

This is a direct result of injury to the brain, often to the parietal lobe.

People with apraxia may have trouble using items correctly.

What you may see:

  • Trying to use a toothbrush to comb hair or a fork to eat soup 
  • Unable to follow spoken directions accurately. For example, he or she may not give “thumbs up” when asked. 
  • Putting clothes on backwards, upside down, inside out

How you can help:

  • Guide the person to complete the task the right way. For example: Place your hand over your family member’s hand and move it through the correct motions to perform a specific task.
  • Redirect your service member/veteran to perform other common tasks in the correct order, one step at a time.
  • Write down instructions for your service member/veteran.
  • Post a daily routine or schedule for hygiene and other daily tasks (e.g., dressing) and write the routine down in your service member/veteran’s calendar/memory notebook.

Seizures

Seizures happen when the electrical system in the brain misfires.

Seizures can be frightening to watch.

Two kinds of seizures may occur following a severe TBI:

  • Early seizures—also called “generalized seizures” or “Grand Mal seizures”—typically happen during the first week after an injury.
  • Later seizures usually occur after the first week of injury in individuals who have never had a seizure before. People who have late-onset seizures are more likely to have a penetrating injury or one that causes a large amount of bleeding in the brain.

Seizures can be temporary or chronic. Late-onset seizures carry a greater risk of future seizures than do early seizures.

A neurologist is the member of the health care team who usually diagnoses seizures. He or she will treat seizures with medications.

What you may see:

  • Generalized shaking or jerking of the arms and legs 
  • Loss of consciousness 
  • Altered attention, emotion, sensation, or movement 
  • Complaints of strange odors or sensations

Late-onset seizures can also cause changes in smell, behavior, or personality. Sometimes, people mistake a seizure as a psychiatric disorder.

Ask your doctor early on about how to recognize a seizure and what to do if one occurs.

How you can help:

  • For a first seizure, call your doctor as soon as possible.
  • If not a first seizure, alert the doctor. Make an appointment to have anti-seizure medication and blood levels checked.
  • Talk to the doctor before adding or stopping medications or herbal treatments. These can change the blood level of the anti-seizure medication and make it ineffective.
  • During a seizure:
    •  Keep calm.
    •  Don’t hold your family member down or try to stop his or her movements.
    •  Loosen ties or anything around the neck that makes breathing hard to do.
    •  Clear anything hard or sharp from the surrounding area.
    •  Put something flat and soft under the head.
    •  Turn the person gently onto one side. This helps keep the airway clear.
    •  Do not try to force the mouth open. 
    •  Stay with the person until the seizure ends.
CALL 911 if your service member/veteran experiences:
  • Difficulty breathing during or after a seizure 
  • Seizure lasting more than five minutes
  • Second seizure that happens immediately after the first seizure
  • Difficulty waking up from the seizure or a second seizure without waking up in between

Some things are triggers for seizures. These include: 

  • Stress 
  • Overuse of alcohol and/or other drugs 
  • Being overworked and/or tired

Help your service member/veteran to avoid these triggers.

Driving laws for people with seizures vary from state to state. Check with your Department of Motor Vehicles to find out what the rules are for your family member if he or she has a seizure disorder.

Heterotrophic Ossification

Heterotrophic ossification (HO) happens when bone forms in an unnatural location, such as in soft tissue or muscle.

What you may see:

  • Swelling, warmth, limited range of motion, pain in soft tissue areas or a muscle

How you can help:

  • Rest the arm or leg where the pain is. Ask for physical therapy to maintain range of motion.
Related Information:
Sleep Changes
Other Physical Effects
Glossary
Frequently Asked Questions
"He had visual field deficits right after the injury. They’ve since gotten a little bit better, but he still has visual field deficits. He lost hearing in his right ear, so he can’t hear sometimes when I’m trying to talk to him." -  Aimee W.

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