Traumatic Brain Injury (TBI)
What is a TBI?
According to TBI Recovery Center (2006), “TBI is any injury to the brain caused by trauma to the head. If there is trauma to the brain, but the skull is not broken, the TBI is known as a closed head injury. This could occur, for example, if a person in an automobile accident hits his head on the steering wheel, but does not have a skull fracture. If an object such as a bullet penetrates the skull and injures the brain, the TBI is known as a penetrating head injury.” There are several different types of TBI (TBI Recovery Center, 2006):
Concussion: A concussion is the most minor and common type of TBI. A concussion is caused when the brain receives a somewhat minor trauma from an impact, such as a hit to the head by an object or person or from a sudden change in momentum, such as a fall. It may or may not result in a short loss of consciousness (not exceeding 20 minutes) and can be diagnosed by observing common symptoms such as headache, confusion, and vomiting. Difficulty with thinking skills (e.g., difficulty “thinking straight,” memory problems, poor judgment, poor attention span, a slowed thought processing speed) (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
Skull Fracture: A skull fracture occurs when the skull cracks or breaks. A depressed skull fracture occurs when pieces of broken skull press into the tissue of the brain. A penetrating skull fracture occurs when something pierces the skull and injures the brain (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
Contusion: A contusion is bruising or bleeding of the brain (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
Hematoma: A hematoma is a collection of blood inside the body (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
Another type of brain injury is called Acquired brain Injury. This describes damage to the brain not associated with trauma to the head or skull and typically involves the entire brain. Common causes of acquired brain injury are loss of oxygen to the brain due to drowning, toxic exposure to carbon monoxide, as well as heart attack and stroke (Brain Injury Association of America, 2006b).
How prevalent is TBI?
The Brain Injury Association of America (2006) estimates that every year 1.4 million Americans experience a traumatic brain injury. 1 TBI is an umbrella term that spans a wide continuum of symptoms and severity. Studies estimating the prevalence of TBI among returning veterans have been difficult, with prevalence rates ranging from 5% to 23% in larger studies using non-clinical samples. The large majority (80%) of combat head injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom are mild concussions, as opposed to severe, debilitating TBI. 2
What are symptoms of TBI?
There are various levels of TBI, including mild and moderate or severe TBI (TBI Recovery Center, 2006).
Mild TBI: Symptoms of mild TBI include headache; confusion; lightheadedness; dizziness; blurred vision or tired eyes; ringing in the ears; bad taste in the mouth; fatigue; a change in sleep patterns; mood changes; and trouble with memory, concentration, attention, or thinking. The injury may or may not result in a brief period of unconsciousness.
Moderate or Severe TBI: Symptoms of moderate to severe TBI may be similar to symptoms of mild TBI, but they may also include a headache that gets worse or does not go away, repeated vomiting or nausea, convulsions or seizures, inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the arms or legs, loss of coordination, increased confusion, restlessness, or agitation.
Most workplace difficulties are the result of cognitive functional limitations such as remembering, organizing, learning, and planning skills. (Hirsh et al., 1996).
What accommodations are suggested to support individuals who are diagnosed with TBI?
The Job Accommodation Network (JAN) has listed several accommodations for TBI. These include activities or actions around various topics such as:
- Install ramps, handrails, and provide handicap parking spaces
- Install lever style door handles
- Clear pathways of travel of any unnecessary equipment and furniture
- Provide written information in large print
- Change fluorescent lights to high intensity, white lights
- Increase natural lighting
- Provide a glare guard for computer monitors
- Consult a vision specialist particularly with someone who has lost part of or all of their vision
Maintaining stamina during the workday
- Permit flexible scheduling, allow longer or more frequent work breaks
- Provide additional time to learn new responsibilities
- Provide self-paced workload
- Provide backup coverage for when the employee needs to take breaks
- Allow for time off for counseling
- Allow for use of supportive employment and job coaches
- Allow employee to work from home during part of the day
- Provide for job sharing opportunities
- Allow part-time work schedules
- Reduce distractions in the work area
- Provide space enclosures or a private office
- Allow for use of white noise or environmental sound machines
- Allow the employee to play soothing music using a music player and headset
- Increase natural lighting or provide full spectrum lighting
- Reduce clutter in the employee’s work environment
- Plan for uninterrupted work time
- Divide large assignments into smaller tasks and steps
- Restructure job to include only essential functions
Difficulty staying organized and meeting deadlines
- Make daily TO-DO lists and check items off as they are completed
- Use several calendars to mark meetings and deadlines
- Remind employee of important deadlines via memos or e-mail or weekly supervision
- Use a watch or pager with timer capability
- Use electronic organizers
- Divide large assignments into smaller tasks and steps
- Assign a mentor to assist employee in determining goals and provide daily guidance
- Schedule weekly meetings with supervisor, manager, or mentor to determine if goals are being met
- Allow the employee to tape record meetings
- Provide type written minutes of each meeting
- Use notebooks, calendars, or sticky notes to record information for easy retrieval
- Provide written as well as verbal instructions
- Allow additional training time
- Provide written checklists and use color-coding to help identify items
- Post instructions close to frequently used equipment
- Provide picture diagrams of problem solving techniques, e.g., flow charts
- Restructure the job to include only essential functions
- Assign a supervisor, manager, or mentor when the employee has questions
Working effectively with supervisors
- Provide positive praise and reinforcement
- Provide written job instructions
- Write clear expectations of responsibilities and the consequences of not meeting them
- Allow for open communication with managers and supervisors
- Establish written long term and short term goals
- Develop strategies to deal with problems before they arise
- Provide written work agreements
- Develop a procedure to evaluate the effectiveness of the accommodation
Difficulty handling stress and emotions
- Provide praise and positive reinforcement
- Refer to counseling and employee assistance programs
- Allow telephone calls during work hours to doctors and others for needed support
- Provide sensitivity training to coworkers
- Allow the employee to take a break as a part of a stress management plan
- Provide flexible leave for health problems
- Provide a self-paced work load and flexible hours
- Allow employee to work from home
- Provide part-time work schedule
Issues of change
- Recognize that a change in the office environment or of supervisors may be difficult for a person with a brain injury
- Maintain open channels of communication between the employee and the new and old supervisor in order to ensure an effective transition
- Provide weekly or monthly meetings with the employee to discuss workplace issues and productions levels
For more information about TBI and accommodations, please visit
1 Brain Injury Association of America. (2006). What is brain injury? Brain Injury Association of America.
2 American Heroes at Work. (2012). Frequently Asked Questions About Traumatic Brain Injury (TBI) & Employment. Retrieved from http://www.americasheroesatwork.gov/forEmployers/factsheets/FAQTBI/.