Dysphasia is term for speech problems as a result of damage to the brain. The process of speaking is a complex one which involves the larynx, pharynx, lungs and multiple parts of the brain. Damage to these structures or anywhere along the pathways between them can result in varying forms of speech problems. Similarly, other factors such as fatigue, pain, medications, hearing or general confusion may affect the quality of communication.

At its most basic, the process of communication can be considered to be comprised of two major elements: a sensory element that understands what others are saying and a motor element that converts the thoughts that the individual wants to express into the co-ordinated physical movements to produce articulated speech. Both of these elements are controlled by the so-called ‘dominant’ part of the brain. This is the left hemisphere of the brain in right-handed people and right hemisphere in many people who are left-handed.

The motor element involved in speech production is called Broca’s area. The sensory element is called Wernicke’s area. Different forms of brain injuries can dramatically affect speech if either part of the brain is damaged. Damage to parts of the cerebellum and brain stem can also affect the ability to speak. The most common cause of damage to either area is through strokes, bleeds or aneurysms.

Damage to Broca’s area is more often observed – especially after a stroke – and produces a problem with speech called an expressive dysphasia, also called motor dysphasia or telegraphic speech. An individual with an expressive dysphasia will understand fully what others are saying and know what they want to say but the correct words will not come out. As a result, the speech can be broken or disjointed. The individual affected will be fully aware that the words coming out are not what they want to say and as a result can be very frustrated, upset and tearful. The risk of development of depression is particularly high in people affected with this type of speech problem. Fortunately, a mixture of time and speech therapy can help greatly; however, many may be left with residual ongoing speech and word-finding problems. Use of picture charts can help some to communicate better. Family members can quickly become used to some of the speech patterns and understand what the individual means to say despite the fact that the speech is disjointed. Encouraging the individual to speak slower and more clearly can also help since word finding problems are far worse if the individual speaks too fast.

Damage to Wernicke’s area produces a sensory dysphasia or receptive dysphasia. Fortunately, this happens less often than a motor dysphasia. In a sensory dysphasia the individual misinterprets what others are saying to them. Their speech will appear fluent but will be nonsensical. They will be unaware of the fact that others don’t understand them. On hospital wards in the acute setting they can appear very confused or agitated but this is usually due to the fact that they have no understanding of what is going on around them. As a family member, it can be difficult to cope with this form of dysphasia and it is advisable to offer the individual gentle reassurance and try and use simple language with lots of non-verbal body language to communicate.

If an individual has damage to the back part of the brain, they can develop a speech problem similar to that seen in someone who is drunk. The individual will be able to talk but the words come out poorly articulated and sound slurred, nasal and monotonous. It can be difficult at first to follow what is being said, especially if there is associated word-finding difficulties. This form of speech problem can be seen in a wide variety of other neurological disorders including Huntington’s disease, multiple sclerosis and motor neuron disease. One of the problems associated with it is that the general public can judge individuals with this speech pattern and think that they are intoxicated. I have encountered horror stories of people with brain injuries being refused to board a bus due their slurring speech. This can lead to the individual being very self-conscious and avoiding going out socially.

Swallowing difficulties, called dysphagia, can commonly occur after a brain injury for a number of reasons. The whole process of swallowing requires the co-ordinated efforts of a number of parts of the brain and muscles within the mouth, throat, and gullet (oesophagus). Damage to the frontal lobes or parts of the brainstem can damage that ability to co-ordinate things or can affect the individual’s ability to concentrate appropriately to complete the complex task. Lying down all the time or being in the wrong position can also make it harder and sometimes after being unconscious for a while, the muscles themselves can lose their tone and be less efficient in their task.

Swallowing problems are serious and not just an inconvenience. At its most severe, food can go into the lungs instead of the stomach and cause the individual to choke or become very unwell with an aspiration pneumonia. At a minimum, swallowing problems are associated with coughing, spluttering, wheezing and spitting-out food/drink when trying to swallow. It’s unpleasant and upsetting for the patient, however those with very severe brain injuries who lack insight may not understand the connection between swallowing food and choking and can potentially endanger their lives if they get access to food.

A swallowing assessment by a speech therapist is a potentially lifesaving test given the hazards of food going down the wrong way. The assessment needs to be performed before an individual is declared safe to eat or drink. In most hospitals, a sign above the bed will say whether food or fluids can be consumed orally by the patient. If oral intake is not allowed, then it is really important not to give the individual anything by mouth even if they are demanding food or drink. Wet swabs can be used to moisten the lips but breaking the rules and giving food potentially endangers the health of the individual and can lead to safeguarding concerns being made.

An individual with severe swallowing problems who is unable to eat or drink can obtain their nutritional requirements in other ways. Nasogastric feeding involves inserting a small feeding tube into the nose and down the oesophagus (or gullet) and into the stomach. The position of the tube is checked by X-ray and a bag of a liquid feed is attached and slowly administered overnight or over a period of hours. Nasogastric feeding is a short-term solution. For those with longer-term feeding problems a tube is inserted into the stomach under general anaesthetic. This form of feeding is called percutaneous endoscopic gastrostomy (PEG) or enteral feeding.

When there is some ability to swallow, the safety of swallowing can be improved by thickening the consistency of foods and fluids. However, some individuals may require the addition of food thickeners to water and other liquid foods. These thickeners turn the food into a jelly-like or wallpaper paste-like semi-solid texture. Theoretically they are tasteless, however, most people don’t enjoy having to use thickeners especially for liquids like tea or coffee.

Balance is the ability to be upright without toppling and falling over. Dizziness is the name given to the sensation that the individual or the world is swaying or spinning – it can in itself cause balance difficulties or result from balance problems. Balance is quite an underrated and surprisingly complicated mechanism involving coordination between a number of different parts of the body and different parts of the brain. Problems with steadiness lead to difficulty with sitting up, standing up and walking and results in falls. Individuals with the most severe forms of balance problems are incapable of safely mobilising on their own and will frequently require wheelchairs.

Due to the fact that a number of different parts of the brain are involved in stability, damage to any one of these areas can result in balance problems.

When an individual is bed bound for a prolonged period of time they become weak due to muscle bulk loss. The body’s blood pressure mechanism also is affected as the body starts to get used to being flat. The mechanisms that automatically take place every morning when we get up from a lying down position fail and as a result the blood pressure drops and the individual feels weak and they get a sensation of dizziness when they try to raise their head above the pillow. Physiotherapists and nurses can treat this by gently raising the angle of the head on a progressive basis over a period of days to weeks and bit by bit getting them to sit up and eventually stand up. Exercises and stretches are used to progressively improve muscle strength and stamina so that the individual can stand.

Individuals who aren’t bed bound can suffer from a sensation of dizziness and develop balance problems due to damage or irritation to balance sense organs that exist within the ear. This balance sense, or vestibular system organ, consists of three tiny semi-circular canals that are orientated at 90 degrees to each other. In normal circumstances the stimulation of one set of canals at a particular angle relative to the other allows the brain to work out the position of the head . After a head injury, this very delicate organ can be damaged by small pieces of debris in the canals which gives the individual the sensation that their head is in a different position to where the eyes and other ear is saying it is. This disconnect in information creates a sensation of dizziness and causes balance issues. Physiotherapists are able to move that small piece of grit out of the canals and reduce the imbalance through getting the individual to reposition their head in certain ways.

The brain centrally processes the information it receives from those semi-circular canals and other position sensors that are located in muscles throughout the body. The cerebellum, located at the back of the brain, processes this information and uses it to adapt fine movement so that it is more co-ordinated. The cerebellum can be damaged directly due to trauma or as a result of medication or drugs. The unsteadiness seen in individuals who are drunk is, in part, due to the effect of alcohol on this part of the brain.

Balance problems may also result from neglect of one side of the body. Damage to the frontal lobes means that the individual’s ability to plan movement is impaired so that they move impulsively and unwisely. Attention problems may mean that they aren’t able to respond to sudden changes in movement required.

Tinnitus is a distressing sense of hearing a buzzing, ringing, hissing or other sound in the ears in the absence of an external cause. One or both ears may be affected. Traumatic brain injury is just one of many causes – others include ear damage, wax build-up, sinusitis or tumours. Like dizziness, it is seen in all levels of traumatic brain injury and is frequently seen in post-concussion syndrome. It may have many causes but is usually due to some degree of damage or irritation of the sensitive hearing structures of the ears from a trauma. Many individuals find it very distressing and it can affect sleep and be a cause of anxiety and depression.

Treatment of tinnitus is generally dependent on the cause but it responds poorly to medications, though sedatives and antidepressants are regularly used and can help greatly with associated anxiety or sleep problems. Cognitive behavioural therapy (CBT) and relaxation therapy are also used in its management with various degrees of success. Regular meditation and having background noise are also excellent ways of improving quality of life associated with the symptoms. In most cases, it improves with time. Individuals with tinnitus in particular should be wary of reading online forums related to the condition. These forums often present worse case scenarios and can be more of a source of stress than the tinnitus itself.

The ability to walk after a brain injury can be affected due to a long list of causes. Direct damage to the brain, the balance centres or damage to the limbs themselves can all severely affect mobility.

Fractures, dislocations or sprains to limbs as a result of the trauma that led to the brain injury can obviously affect whether an individual can walk and the quality of their mobilisation. Prolonged immobility due to being bed bound causes weakening of muscles remarkably quickly. Dizziness and balance problems can also adversely affect the individual’s confidence to get out and walk.

Mobilisation within the brain is initiated, controlled and modified by a number of structures. Movements are initiated by the motor cortex in the frontal lobes, with the left motor cortex controlling movement on the right side of the body and vice versa. Damage to the motor cortex will produce paralysis or weakness on the opposite side. This part of the brain can be damaged in strokes, bl...