An acquired brain injury (ABI) occurs after birth when the brain is injured, often resulting in changes in how a person thinks, acts, and feels. If the result of external forces, a bump, jolt, or blow to the head directly or indirectly, a Traumatic Brain Injury, or TBI, can occur – leading to potentially chronic challenges affecting not only the person, but the family, community, and services.1 One of the more challenging aspects of brain injury can be the invisible nature of it. Many effects of a brain injury cannot be seen by the outside eye – making stigma, awareness, and understanding from the general public a challenging aspect of brain injury for survivor, family members, and professionals.

The invisibility and wide range of brain injury effects can make identification a challenge. Brain injury ranges in severity, effects, and changes depending on the classification, area of the brain, rehabilitation, support and many other factors. There are different classifications when observing TBI – mild, moderate, and severe. Mild TBIs, or mTBIs, can be separated into two categories:  complicated and uncomplicated. The term uncomplicated mTBI refers to injuries with normal neuroimaging and are also known as concussions. If neuroimaging is abnormal, that is referred to as a complicated mTBI. Despite being the most prevalent classification, mTBI identification is commonly missed because symptoms present immediately or show up later in life. Moderate and severe TBI have respectively greater changes in consciousness and memory loss and are more often treated in hospitals. The classification as determined by these characteristics is indicative of the severity of the injury and is used to help determine the intensiveness of the acute management needed, such as imaging, hospitalization, sedation, and ventilation. It provides some information regarding the prognosis in the long term but is not absolute – a mild injury may not mean mild consequences. Repeated mTBIs occurring over an extended period (i.e., months, years) can result in cumulative neurological and cognitive challenges. Similarly, repeated mTBIs occurring within a short period (i.e., hours, days, or weeks) can be catastrophic or even fatal.2

Characteristics Mild/Concussion Moderate Severe
Structural imaging Normal Normal or abnormal Normal or abnormal
Loss of consciousness (LOC) 0-30 minutes Greater than 30 minutes, less than 24 hours Greater than 24 hours
Alteration of consciousness (AOC) Up to 24 hours Greater than 24 hours Greater than 24 hours
Posttraumatic amnesia (PTA) 0-1 day Greater than 1 and less than 7 days Greater than 7 days
Glascow Coma Scale score 13-15 9-12 3-8

United States:

  • The CDC estimated that in 2013 2.8 million people sustained a TBI in the US.
    • 50,000 die,
    • 282,000 are hospitalized, and
    • 5 million, nearly 90%, are treated and released from an emergency department (ED).
    • An unknown number of individuals receive other medical care or no care. There is no estimate for the number of people with non-fatal TBI seen outside of an emergency department of a hospital or who receive no care at all.3
  • Direct medical costs and indirect costs of TBI, such as lost productivity, totaled an estimated $60 billion in the United States in 2000.4
  • Estimated Average Percentage of Annual TBI by External Cause in the United States3
    • Falls  –  47%
    • Struck By/Against – 15%
    • Motor Vehicle-Traffic  –  14%
    • Assault  –  9%
    • Unknown/Other  –  15%

North Carolina:

  • During 2015, a TBI was sustained by 78,775 people in North Carolina alone or in combination with other injuries/conditions – according to ED, hospitalization, and death data.5
    • 1,825 (18.7 per 100,000) died
    • 7,062 (66.8 per 100,000), were hospitalized
    • 69,729 (701.2 per 100,000) were treated and released from EDs
    • An unknown number of individuals sustained injuries that were treated in other settings or went untreated.
  • Individuals 65 and older were the highest number of TBI-related deaths and ED visits, as well as most affected by hospitalizations.
  • Men were more likely to sustain a TBI than women, in correlation to the national population where men are 1.5 times more likely to sustain a TBI than women.

There are potentially many more individuals in North Carolina living with TBI-related long-term disability based on CDC state correlates. However, these numbers are likely an underestimate and a larger problem due to difficulty with data collection and the invisible nature of brain injury.

Over the span of six years (2007–2013), while rates of TBI-related ED visits increased by 47%, hospitalization rates decreased by 2.5% and death rates decreased by 5%.16 This can mean that more people are living with the effects of brain injury because of advances in medical care, training, and access to treatment. When a brain injury occurs, it can affect the individual, family, and entire community. Many individuals desire to engage in their community or with other in their environment to contribute or have a meaningful day. By coming together as advocates to provide an accepting and tolerant environment, the community as a whole can thrive.


TBI is the signature wound of the Iraq and Afghanistan wars with over 370,000 military service members worldwide identified with a TBI from 2000-2017. TBIs can occur in military service from a variety of sources including gunshots, blasts, motor-vehicle collisions, or training exercises. With NC having the third largest active duty population and over 770,000 veterans, many service members may need long-term care in North Carolina communities related to diagnosed or undiagnosed injuries. TBI can often be masked in military populations due to stigma or co-occurring mental health conditions.6

Sports- & Age-related

An estimated 1.6-3.8 million sports- and recreation-related concussions occur in the US each year with the most common injuries occurring from cycling, football, baseball/softball, and soccer. The actual incidence may potentially be much higher for those not treated or treated by their general doctor. The leading cause of TBI in the US is falls, with children 0-4 years of age and adults 75 years of age and older most at risk.7

Domestic Violence & Intimate Partner Assaults

TBI can be an unrecognized result of domestic violence and intimate partner assaults, commonly in women. The head and face are most commonly targets in these situations for TBI and individuals may experience an ABI if they lose oxygen to their brain caused by airway obstruction for too long of a time (caused by choking, strangulation, near drowning, or drug reaction/overdose). In one study, 67% of women at three metropolitan EDs reported problems potentially head-injury related with 30% experienced a loss of consciousness at least once. Multiple traumatic or acquired brain injuries can lead to cumulative cognitive, physical and emotional challenges over time and therefore make disengaging from the situation almost impossible due to decision-making and planning.8,9

Individuals experiencing Homelessness or Economic Instability

TBI-related cognitive and behavioral challenges (e.g., limitations in memory; planning and organization; and reasoning, comprehension and problem solving, as well as impulsive decision-making) lead to an increased risk for economic and housing instability.10 Homeless individuals also are more vulnerable to common causes of TBI: Substance abuse related accidents (including falls) and victimization from violence. Thus, TBI-related cognitive and behavioral deficits not only increase risk for homelessness, but homelessness itself contributes to increased risk for TBI. On one night in January 2017, 8,962 people experienced homelessness in NC (be sure to take this number with a grain of salt as it is only a snapshot of a much larger population).11 Meanwhile, in one study of 904 people, approximately half of those experiencing homelessness had sustained a TBI, of which 70% experienced their first brain injury before they experienced homelessness.12 We do not know the true numbers of individuals that are experiencing homelessness in NC or the true number of people with TBI experiencing homelessness, but with increased access to community resources and screening the hope is that more people can be identified and their needs addressed.

Mental Health Experiences

Studies have indicated that those with positive TBI screens were more likely to have mental health disorders. The most common mental health disorders following a brain injury are schizophrenia, depression, bipolar disorder, and organic mental disorder. The nature of and whether mental health disorders or TBI have a direct causal effect on one another is heavily debated in research. In addition, diagnosis can be difficult due to the overlapping of signs and symptoms of concussion/mTBI and mental illness. For example, an individual with a TBI may experience agitation, impulsivity, poor-judgement that may mirror differences in attention deficit/hyperactivity disorder (ADHD). Flashbacks, hypervigilance, avoidance, nightmares could be attributed to TBI or to post-traumatic stress disorder (PTSD). An individual with depression may experience lack of motivation, sadness, and fatigue – so may a person with a TBI.13,14 It is important when working with individuals with mental health conditions to consider TBI and similarly mental health to consider with TBI. Similarly, if you are living with TBI and experiencing mental health symptoms, connect with community resources including your doctor, a counselor, or neuropsychiatrist. Mental health after brain injury may be attributed to a variety of factors that either medication, alternative therapies, or community/social engagement can be helpful for

Substance Misuse

Similarly, to the overlapping symptoms between metal health and TBI, substance misuse and TBI interconnect as well.15 The relationship with substance misuse including alcohol and other drugs is a complicated and often bidirectional one. A large number of TBIs incur when individuals are intoxicated due to poor motor control, impaired decision making, vulnerability to victimization, and propensity toward belligerent/aggressive behaviors. Likewise, substance misuse following injury can increase the risk of sustaining additional TBIs, interfere with the brain’s recovery process after brain injury, have a more powerful effect after brain injury, and increase the risk of seizures after brain injury.1 If you have an individual who has an identified TBI and is using substances, these are important factors to consider. If you are having trouble with substances, it can be helpful to seek professional consult as substance misuse can frequently affect mood, employment retention, social relationships, and community involvement. This can make it important to screen for TBI and ABI to assist in accessing appropriate services if you are a professional working with individuals who are misusing substances.

Physical/sensory changes (how your muscles or bodily health is affected):

  • Seizures/History of
  • Fatigue
  • Headaches
  • Sleep disturbance
  • Weakness/paralysis
  • Movement & coordination
  • Sexual function
  • Balance
  • Sensory changes (sight, smell, touch, hearing, taste)

Thinking/cognitive changes (how you process and engage with your environment)

  • Memory/recall & mental flexibility
  • Attention/concentration & learning
  • Planning & organization
  • Initiation & motivation
  • Task-switching and sequencing
  • Safety awareness and impulsivity
  • Problem solving, decision-making, judgement, and reasoning
  • Social skills, processing, & speech (understanding or producing)
  • Fatigue

Feelings/Emotion and Behavior changes (how you feel and actions that may be different from prior to injury)

  • Difficulty with regulation (emotions, actions, etc.)
  • Self-awareness
  • Personality
  • Irritability
  • Unrelated laughter or crying
  • Lethargy
  • Restlessness
  • Co-occurring psychological conditions (depression, anxiety, bipolar disorder, etc.)

Neurons are the communicating agents within the brain. All sensations, movements, thoughts, and feelings are a result of chemical signals (or neurotransmitters) produced between these cells. Neurons cannot communicate alone, however. Glial cells are like a warm blanket for the neurons, making neurons communicate at lightning speed. Recently scientists found out that glial cells are actually more in number than neurons in the brain. Therefore, if glial cells are affected through a brain injury, one’s processing speed may be compromised and neurons may not be nourished to thrive. Neurons and glial cells can be damage at the cellular level due to a lack of oxygen, excessive bleeding, swelling/pressure within the skull, or the tearing of neurons due to their long structure. The result can be chemical changes within the brain or functional changes affecting physical, cognitive, emotional, behavioral, and social capacities.

The brain is divided up into hemispheres and then lobes. Where the injury occurs within the brain can be reflective of the challenges and changes that occur afterwards. For example, the frontal lobe is responsible for concentration, planning, regulation, and organization. People after a frontal lobe injury may appear inattentive, have difficulty with initiation, or act impulsively. That is likely due to the connections that are affected within the brain.

Left hemisphere Right Hemisphere
  • controls movement and sensation in the right side of the body
  • verbal and logical functions including language (listening, reading, speaking, and writing)
  • thought and memory involving words
  • controls movement and sensation in the left side
  • nonverbal and intuitive functions such as putting bits of information together to make up an entire picture
  • recognizing oral and visual patterns and designs (music and art)
  • expressing and understanding emotions
Part of the brain Related functions
Frontal lobe Organization & regulation (attention, processing, decision-making, initiation, etc.)
Parietal lobe Integrating sensory information
Temporal lobe memory, language, hearing
Occipital lobe Visual processing
Brain Stem Arousal, Breathing, Heart rate
Motor & sensory cortex Movement and senses
Cerebellum Coordination & balance
Limbic system Fight or Flight, Reward Pathway, and Emotions

Just because a part of the brain may be injured, there is potential for physical and cognitive rehabilitation based on neuroplasticity – the brain’s capacity to change and adapt as the result of interactions with environment. This “re-wiring” of the brain can make it possible for an undamaged area to complete functions previously managed by a damaged area. For some, compensation strategies such as assistive technology, calendars, alarms, lists, and more can be helpful in completing daily tasks and helping with routines.

Brain injury can change many aspects about a person, but they, you, are just that – a person. It is possible to live a fulfilling life and find meaning even if traditional or past hobbies may not be as attainable. It means finding new solutions, addressing challenges, and promoting advocacy. Some helpful strategies may include:

Structure & Routine

Connecting with Resources & Supports

  • Connecting with resources in your community can be challenging but very helpful in terms of finding help. Finding professionals that you can trust and feel comfortable with can mean everything when it comes to medication or symptom management, community participation, and getting you closer to your goals. If you are not finding much help in your community, check online while using safe internet practices. There may be online support groups, social media groups, blogs, or videos that can be helpful in connecting with others.
    • Check out our resource book for more information in your NC community.

Education on Brain Injury & Advocacy

  • Educating yourself on brain injury can help to advocate for yourself and others. By understanding the brain and what a brain injury is, you can better look into strategies or ways to better perform job tasks or daily activities including communicating with others, helping with memory, or managing emotions of behaviors. Unfortunately, there is much stigma out there for people with disabilities and brain injury – but with education and knowledge, showing people your strengths and what you can offer, minds can be changed and people can thrive. Here are some more resources for your review:

Creativity, Flexibility, & Patience

  • Creativity and flexibility are the cornerstone for rehabilitation and living after a brain injury. Whether it is finding new ways of doing tasks or restructuring the day, things are not always going to work out right the first, second, or maybe even third time. By having patience, creativity, and flexibility, you can keep the original goal in mind and try new ways to accomplish that goal.

Self-Care and Management

  • Whether you are a survivor, family member, or professional, it is important to take care of yourself. Even if it is one hour per week, try to find something that you enjoy and commit the time. By taking a little bit of time for yourself, you can better take on the demands of rehabilitation, promote attention and memory, and get closer to your goals. By taking care of yourself, you can better take care of others whether it’s through respite or connecting with neighbors to allow the time for you. Professionals needs self-care too, to prevent burnout and better allow you to help the people you serve. Here are some more resources for your review:

Explore Use of Adaptive Tools/Technologies or Strategies

Link with Others

  • Living with a brain injury can often feel isolating and lonely – relating to others and feeling as if you are not alone can be empowering and helpful. Support groups & daily activities with other survivors allows an accepting environment to connect and work of skills after injury. Online groups, blogs, or videos can be meaningful if community resources are sparse in your area.

Brain Injury: What is & What Now?

Parts of the Brain


Brain Injury Guide

Printable Versions:

(Coming Soon)


Falls Prevention

Heart Health

Contact the Brain Injury Association of NC for more information about brain injury and resources in your area. Online and in-person training is also available by contacting us, checking out on Education & Training section, or visiting

  1. Brain Injury Association of America (BIAA). The Essential Brain Injury Guide Edition 5.0. Vienna, VA. 2015.
  2. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
  3. Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2007 and 2013. MMWR Surveill Summ 2017;66(No. SS-9):1–16. DOI:
  4. Coronado VG, Haileyesus T, Cheng TA, Bell JM, Haarbauer-Krupa J, Lionbarger MR, Flores-Herrera J, McGuire LC, Gilchrist J. Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil 2015; 30 (3): 185–197.
  5. NC Division of Public Health. NC Special Emphasis Report: Traumatic Brain Injury 2015. Published October 2017. Accessed June 2018.
  6. Department of Defense (DoD). DoD Numbers for Traumatic Brain Injury Worldwide — Totals. Retrieved from: Published November 2016. Accessed February 15, 2017.
  7. American Association of Neurological Surgeons. Sports-related Head Injury. Published August 2014. Accessed February 15,2017.
  8. NC DHHS. Traumatic Brain Injury (TBI) and Hypoxic Brain Injury in Intimate Partner Violence (IPV)/Domestic Violence (DV). Published 2016. Accessed February 2017.
  9. Corrigan, John D., et al. “Early identification of mild traumatic brain injury in female victims of domestic violence.” American journal of obstetrics and gynecology 188.5 (2003): S71-S76.
  10. Hwang, Stephen W., et al. “The effect of traumatic brain injury on the health of homeless people.” Canadian medical association Journal 179.8 (2008): 779-784. doi: 10.1503/cmaj.080341
  11. NC Coalition to End Homelessness. (2017) NC 2017 Point-in-Time Count. Accessed June 21, 2018.
  12. Lafferty, Briana. “Traumatic brain injury: a factor in the causal pathway to homelessness?.” The Journal for Nurse Practitioners 6.5 (2010): 358-362.
  13. Orlovska, Sonja, et al. “Head injury as risk factor for psychiatric disorders: a nationwide register-based follow-up study of 113,906 persons with head injury.” American journal of psychiatry 171.4 (2014): 463-469.
  14. Schwarzbold, Marcelo, et al. “Psychiatric disorders and traumatic brain injury.” Neuropsychiatric disease and treatment(2008).
  15. McHugo, Gregory J., et al. “The prevalence of traumatic brain injury among people with co-occurring mental health and substance use disorders.” The Journal of head trauma rehabilitation3 (2017): E65-E74.
  16. Centers for Disease Control and Prevention. (April 27, 2017). TBI: Get the Facts. Accessed June 21, 2018.

Lauren Costello, MS CRC CBIS

Lauren Costello has been the Central Resource and State Training Coordinator at the Brain Injury Association of NC from 2016-2018. She received dual Bachelor’s degrees from Virginia Tech in Biological Sciences and Psychology and received her Master’s degree from the University of North Carolina at Chapel Hill in Clinical Rehabilitation and Mental Health Counseling. She has had the opportunity to work with individuals with brain injury, mental health, and developmental disability in research, hospital, home, and community settings. She is a Certified Rehabilitation Counselor and Brain Injury Specialist.