Traumatic Brain Injury

Traumatic Brain Injury

By: Emily Welch and Leticia Morales

Winter 2013

Rec 470

Definition of Traumatic Brain Injury (TBI)

Traumatic brain injury occurs when an external mechanical force causes brain dysfunction.

Traumatic brain injury usually results from a violent blow or jolt to the head or body. An object penetrating the skull, such as a bullet or shattered piece of skull, also can cause traumatic brain injury.

Mild traumatic brain injury may cause temporary dysfunction of brain cells. More serious traumatic brain injury can result in bruising, torn tissues, bleeding and other physical damage to the brain that can result in long-term complications or death.

Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue.  Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain.

No two TBIs are alike. There is a wide range of symptoms and effects because of this. In addition, the brain doesn’t heal like other parts of the body do which can cause long lasting effects.

Recovery from TBI is functional recovery, or trying to regain function in affected parts of the body and mind.

An additional risk of TBI is that often a person that sustains it is also susceptible to spinal cord injuries.

Statistics

·      1.5 million TBIs a year

·      Boys ages 0-4 and 65+ people are most commonly seen TBIs in the emergency room

·      50,000 deaths occur every year resulting from a TBI

·      85,000-125,000 people suffer long term disabilities per year

·      5.3 million in the U.S. live with long term disabilities from TBI

·      In every age group, TBI’s are more common in males than females.

·      Young adults and the elderly are the most at risk.

Causes of TBI

A TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. 

It is acquired, NOT GENETIC.

The causes of TBI are diverse.  The top three causes are: car accident, firearms and falls.  Firearm injuries are often fatal: 9 out of 10 people die from their injuries.  Young adults and the elderly are the age groups at highest risk for TBI. 

·       Falls. Falling out of bed, slipping in the bath, falling down steps, falling from ladders and related falls are the most common cause of traumatic brain injury overall, particularly in older adults and young children.

·       Vehicle-related collisions. Collisions involving cars, motorcycles or bicycles — and pedestrians involved in such accidents — are a common cause of traumatic brain injury.

·       Violence. About 10 percent of traumatic brain injuries are caused by violence, such as gunshot wounds, domestic violence or child abuse. Shaken baby syndrome is traumatic brain injury caused by the violent shaking of an infant that damages brain cells.

·       Sports injuries. Traumatic brain injuries may be caused by injuries from a number of sports, including soccer, boxing, football, baseball, lacrosse, skateboarding, hockey, and other high-impact or extreme sports.

·       Explosive blasts and other combat injuries. Explosive blasts are a common cause of traumatic brain injury in active-duty military personnel. Although the mechanism of damage isn't well understood, many researchers believe that the pressure wave passing through the brain significantly disrupts brain function. Traumatic brain injury also results from penetrating wounds, severe blows to the head with shrapnel or debris, and falls or bodily collisions with objects following a blast.

TBIs from Car Accidents

Almost half of all reported traumatic brain injuries are the result of an automobile accident. A traumatic brain injury can occur as a result of any force that penetrates or fractures the skull; areas which are susceptible during an auto accident.

Trauma to the brain can occur during an automobile accident when the skull strikes, for example, an object like a steering wheel or windshield.  There may or may not be an open wound to the skull due to the accident, however in automobile accidents, the skull may not necessarily need to have been penetrated or fractured for a traumatic brain injury to occur.  In the case of an automobile accident the sheer force of the accident can cause the brain to collide against the internal hard bone of the skull. The reason why this can occur is that when a moving head comes to a quick stop, the brain continues in its movement, striking the interior of the skull. This can cause bruising of the brain (referred to as a contusion) and bleeding (brain hemorrhage) which may not be visible at the time of injury.

Blunt trauma is a more serious type of head injury that can occur in an automobile accident when a moving head strikes a stationary object like the windshield, where the head is impacted causing an open wound which can be sustained from a variety of sources such as roof crush or occupant ejection in a car accident.  At impact the brain opposite the site of impact is pulled away from the skull, injuring the brain there.

Different Types of TBIs

Penetrating Injuries: In these injuries, a foreign object (e.g., a bullet) enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged.

Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage:

Primary brain damage, which is damage that is complete at the time of impact, may include:

§  skull fracture: breaking of the bony skull

§  contusions/bruises: often occur right under the location of impact or at points where the force of the blow has driven the brain against the bony ridges inside the skull

§  hematomas/blood clots: occur between the skull and the brain or inside the brain itself

§  lacerations: tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the brain (the force of the blow causes the brain to rotate across the hard ridges of the skull, causing the tears)

§  nerve damage (diffuse axonal injury): arises from a cutting, or shearing, force from the blow that damages nerve cells in the brain's connecting nerve fibers

Secondary brain damage, which is damage that evolves over time after the trauma, may include:

§  brain swelling (edema)

§  increased pressure inside of the skull (intracranial pressure)

§  epilepsy

§  intracranial infection

§  fever

§  hematoma

§  low or high blood pressure

§  low sodium

§  anemia

§  too much or too little carbon dioxide

§  abnormal blood coagulation

§  cardiac changes

§  lung changes

§  nutritional changes

What happens in the Brain:

 The degree of damage can depend on several factors, including the nature of the event and the force of impact. Injury may include one or more of the following factors:

·      Damage to brain cells may be limited to the area directly below the point of impact on the skull.

·      A severe blow or jolt can cause multiple points of damage because the brain may move back and forth in the skull.

·      A severe rotational or spinning jolt can cause the tearing of cellular structures.

·      A blast, as from an explosive device, can cause widespread damage.

·      An object penetrating the skull can cause severe, irreparable damage to brain cells, blood vessels and protective tissues around the brain.

·      Bleeding in or around the brain, swelling, and blood clots can disrupt the oxygen supply to the brain and cause wider damage.

One big risk of TBI is that often the individual doesn’t know that he/she has brain damage. The symptoms of the above effects in the brain may not manifest themselves for hours to days to weeks.

Mild TBI

A brain injury can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration. These injuries are commonly overlooked.

Other Names For Mild TBI

·      Concussion

·      Minor head trauma

·      Minor TBI

·      Minor brain injury

·      Minor head injury

Mild Traumatic Brain Injury is:

·      Most prevalent TBI

·      Often missed at time of initial injury

·      15% of people with mild TBI have symptoms that last one year or more.

·      Defined as the result of the forceful motion of the head or impact causing a brief change in mental status (confusion, disorientation or loss of memory) or loss of consciousness for less than 30 minutes.

·      Post injury symptoms are often referred to as post concussive syndrome.

Symptoms of Mild TBI

·      Loss of Consciousness for a few seconds to a few minutes

·      No loss of consciousness, but a state of being dazed, confused, or disoriented

·      Fatigue

·      Headaches

·      Visual disturbances

·      Memory loss

·      Poor attention/concentration

·      Sleep disturbances (difficulty sleeping or sleeping more than usual)

·      Dizziness/loss of balance

·      Sensory problems (blurred vision, ringing in the ears, bad taste in the mouth)

·      Irritability-emotional disturbances

·      Feelings of depression

·      Seizures

·      Nausea

·      Loss of smell

·      Sensitivity to light and sounds

·      Mood changes

·      Getting lost or confused

·      Slowness in thinking

These symptoms may not be present or noticed at the time of injury.  They may be delayed days or weeks before they appear.  The symptoms are often subtle and are often missed by the injured person, family and doctors.

The person looks normal and often moves normal in spite of not feeling or thinking normal.  This makes the diagnosis easy to miss.  Family and friends often notice changes in behavior before the injured person realizes there is a problem.  Frustration at work or when performing household tasks may bring the person to seek medical care.

Moderate to Severe TBI

Severe brain injury is associated with loss of consciousness for more than 30 minutes and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits range from impairment of higher level cognitive functions to comatose states. Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability or emotional problems. The range of injuries and degree of recovery is very variable and varies on an individual basis. They result in permanent neurobiological damage that can produce lifelong deficits to varying degrees.

§  Moderate brain injury is defined as a brain injury resulting in a loss of consciousness from 20 minutes to 6 hours and a Glasgow Coma Scale of 9 to 12.

§  Severe brain injury is defined as a brain injury resulting in a loss of consciousness of greater than 6 hours and a Glasgow Coma Scale of 3 to 8.

The impact of a moderate to severe brain injury depends on the following:

·      Severity of initial injury

·      Rate/completeness of physiological recovery

·      Functions affected

·      Meaning of dysfunction to the individual

·      Resources available to aid recovery

·      Areas of function not affected by TBI

Symptoms of Mild to Moderate TBI

§  Attention/Concentration difficulties

§  Distractibility

§  Memory difficulties

§  Speed of Processing

§  Confusion

§  Perseveration/Impulsiveness

§  Language Processing Difficulties

§  not understanding the spoken word (receptive aphasia)

§  difficulty speaking and being understood (expressive aphasia)

§  slurred speech

§  speaking very fast or very slow

§  problems reading and/or writing

§  difficulties with interpretation of touch, temperature, movement, limb position and fine discrimination

§  the integration or patterning of sensory impressions into psychologically meaningful data

§  partial or total loss of vision

§  weakness of eye muscles and double vision, blurred vision

§  problems judging distance

§  involuntary eye movements

§  intolerance of light

§  decrease or loss of hearing

§  increased sensitivity to sounds, ringing in the ears

§  loss or diminished sense of smell

§  loss or diminished sense of taste

§  the convulsions can involve disruption in  consciousness, sensory perception, or motor movements

§  Physical paralysis/spasticity

§  Chronic pain

§  Control of bowel and bladder

§  Sleep disorders

§  Loss of stamina/Lack of Motivation

§  Appetite changes

§  Menstrual difficulties

§  Dependent behaviors

§  Emotional ability

§  Irritability/Aggression

§  Depression

§  Denial/lack of awareness

Aphasia

A severe TBI can cause Aphasia. Aphasia is an acquired communication disorder that impairs a person's ability to process language, but does not affect intelligence. Aphasia impairs the ability to speak and understand others, and most people with aphasia experience difficulty reading and writing. Like TBIs, aphasia can range from mild to severe.

Like a TBI, aphasia is acquired and can occur in people of all age groups and races in both genders.

Aphasia affects about 1 million Americans, or 1 in every 250 people. More than 100,000 Americans acquire it each year.

Because aphasia affects speech and language skills, many people that acquire it find it hard to return to work and perform other normal life activities.

If symptoms of aphasia last longer than two or three months, a complete recovery is unlikely, but many people can and do improve over long periods of time.

Diagnosing a TBI

Information about the injury and symptoms:
If you observed someone being injured or arrived immediately after an injury, you may be able to provide medical personnel with information that's useful in assessing the injured person's condition. Answers to the following questions may be beneficial in judging the severity of injury:

·       How did the injury occur?

·       Did the person lose consciousness?

·       How long was the person unconscious?

·       Did you observe any other changes in alertness, speaking, coordination or other signs of injury?

·       Where was the head or other parts of the body struck?

·       Can you provide any information about the force of the injury? For example, what hit the person's head, how far did he or she fall, or was the person thrown from a vehicle?

·       Was the person's body whipped around or severely jarred?

Glasgow Coma Scale
This 15-point test helps a doctor or other emergency medical personnel assess the initial severity of a brain injury by checking a person's ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues. Abilities are scored numerically. Higher scores mean milder injuries.

I. Motor Response
6 – Obeys commands fully
5 – Localizes to noxious stimuli
4 – Withdraws from noxious stimuli
3 – Abnormal flexion, i.e. decorticate posturing
2 – Extensor response, i.e. decerebrate posturing
1 – No response

II. Verbal Response
5 – Alert and Oriented
4 – Confused, yet coherent, speech
3 – Inappropriate words and jumbled phrases consisting of words
2 – Incomprehensible sounds
1 – No sounds

III. Eye Opening
4 – Spontaneous eye opening
3 – Eyes open to speech
2 – Eyes open to pain
1 – No eye opening

The final score is determined by adding the values of I+II+III.

Mild TBI scores a 13-15.

Moderate Disability (9-12):

§  Loss of consciousness greater than 30 minutes

§  Physical or cognitive impairments which may or may resolve

§  Benefit from Rehabilitation

Severe Disability (3-8):

§  Coma: unconscious state.  No meaningful response, no voluntary activities

Vegetative State (Less Than 3):

§  Sleep wake cycles

§  Aruosal, but no interaction with environment

§  No localized response to pain

Persistent Vegetative State:

§  Vegetative state lasting longer than one month

Brain Death:

§  No brain function

§  Specific criteria needed for making this diagnosis

Imaging tests:

·       Computerized tomography (CT). A CT scan uses a series of X-rays to create a detailed view of the brain. A CT scan can quickly visualize fractures and uncover evidence of bleeding in the brain (hemorrhage), blood clots (hematomas), bruised brain tissue (contusions) and brain tissue swelling.

·       Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of the brain. Doctors don't often use MRIs during emergency assessments of traumatic brain injuries because the procedure takes too long. This test may be used after the person's condition has been stabilized.

Intracranial pressure monitor
Tissue swelling from a traumatic brain injury can increase pressure inside the skull and cause additional damage to the brain. Doctors may insert a probe through the skull to monitor this pressure.

The person must also be monitored for additional or worsening symptoms. The severity and types of symptoms can help doctors diagnose the severity of the injury and the area of the brain affected.

Long Term Effects of TBI

The effects of TBI can be profound. Individuals with severe injuries can be left in long-term unresponsive states. For many people with severe TBI, long-term rehabilitation is often necessary to maximize function and independence.  Even with mild TBI, the consequences to a person’s life can be dramatic. Change in brain function can have a dramatic impact on family, job, social and community interaction.

Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability or emotional problems. Changes in personality are also very common in people who received a severe TBI. The range of injuries and degree of recovery is very variable and varies on an individual basis because no TBIs are alike and affect people in the same ways.

TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.

·       Thinking: Memory and reasoning 

·       Sensation: touch, taste, and smell 

·       Language: communication, expression, and emotion: depression, anxiety, personality changes, aggression, acting out, and social inappropriateness

Many of the long term effects are symptoms that remain and continue to cause difficulties for the individual.

TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.

About 75% of TBIs that occur each year are concussions or other forms mild TBI.

Repeated mild TBIs occurring over an extended period of time (months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (hours, days, or weeks) can be catastrophic or fatal.

Approximately half of severely head-injured patients will need surgery to remove or repair hematomas (ruptured blood vessels) or contusions (bruised brain tissue).

Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the individual. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).

More serious head injuries may result in stupor, an unresponsive state, but one in which an individual can be aroused briefly by a strong stimulus, such as sharp pain; coma, a state in which an individual is totally unconscious, unresponsive, unaware, and unarousable; vegetative state, in which an individual is unconscious and unaware of his or her surroundings, but continues to have a sleep-wake cycle and periods of alertness; and a persistent vegetative state, in which an individual stays in a vegetative state for more than a month.

Immediate Treatment

Mild forms of TBI are given pain medications and are monitored for worsening or additional symptoms. The person may have to wait an a certain amount of time allotted by a doctor before returning to work, school, or recreational activities. It is best to return to normal routines gradually.

More severe forms of TBI may result in the need for surgery. About half of the patients admitted for severe TBI receive surgery to remove or repair ruptured blood vessels and contusions or to repair skull fractures.

Most people who have received a severe TBI will require rehabilitation. Recovery is functional recovery. They may need to relearn basic skills, such as walking or talking. The goal is to improve their abilities to perform daily activities. This therapy begins in the hospital following surgery or other treatment.

The Goals of Rehab

The treatment team has many members because of the life altering situation and medical risks and complications involved in a TBI. The team may consist of a Physiatrist, an Occupational Therapist, a Physical Therapist, a Speech and Language Pathologist, a Neuropsychologist or Psychiatrist, a Social Worker, a Rehab Nurse, a TBI Nurse Specialist, a Vocational Counselor, and a Recreational Therapist.

The goals of the treatment team and the patient are to:

·       Stabilize the medical and rehabilitation issues related to brain injury and the other injuries.

·       Prevent secondary complications. Complications could include pressure sores, pneumonia and contractures.

·       Restore lost functional abilities. Functional changes could include limited ability to move, use the bathroom, talk, eat and think.

·       The staff will also provide adaptive devices or strategies to enhance functional independence.

·       The staff will begin to analyze with the family and the patient what changes might be required when the person goes home.

TR with TBI Patients

 Therapeutic recreation services are essential to the patient with TBI for three important reasons:

• A method of treatment to improve your physical, psychological, social, and emotional well-being, such as conducting a volleyball activity to improve balance
• A method of education to increase your knowledge of and successfully provide for your leisure activities, which are an integral part of your rehabilitation and social reintegration
• Recreational participation, which is necessary for a normalized, balanced lifestyle for all people, and essential as a means of self-expression, release, and socialization for the people with TBI.

Like all other rehabilitation therapies, therapeutic recreation helps you achieve your highest possible level of independence and quality of life.

Recreation Assessment

     The recreational therapy process begins with an individual assessment of your:

• Strengths, interests, and values
• Previous leisure activities and expectations
• Available resources in your home and community
• Social needs and relationships
• Economic and other potential problem areas in your participating in recreational and leisure activities, and
• Life-style adjustments necessary for healthy leisure functioning.

     Based on the assessment, you and the recreational therapist plan a program that builds on your abilities and either corrects problem areas or develops ways of coping with them. Therapeutic recreation involves several components in a continuum of developmental services.

Individual Treatment

     Activities of interest to you are analyzed and broken down into components. The components are examined to determine how the activity would contribute to your treatment goals. And modifications in the activity are made to better support your physical, cognitive, and social goals.

Group Programs in the Hospital and Community

     Skills, such as dealing effectively in variable real-life situations, are learned and applied through enjoyable activities in a supportive, realistic environment - such as arts and crafts, games, shopping, movies, and sightseeing tours

Interdisciplinary Programs

     Recreation, occupational, and physical therapists, together with nurses, staff interdisciplinary groups where goals for your successful reintegration into the community are planned by you, participated in, and processed to identify problem areas and successes - such as planning for, going to, and evaluating a trip to a museum.

Wheelchair Sports

     Wheelchair sports, such as basketball, bowling, swimming, archery, table tennis, softball, etc. are taught and promoted.

Outpatient Therapeutic Recreation Services

     Ongoing therapeutic recreation services to eliminate barriers to your participating in community recreation activities and self-satisfying leisure activities which enable you to develop social skills within a group structure, form new relationships with peers, and continue to improve your self-confidence and rehabilitation skills.

Discharge Planning

     Agencies and services in the community are identified that can support your ongoing needs for recreational and leisure activities - such as special recreation associations, wheelchair sports organizations, accessible outdoor programs and facilities, continuing education programs, national support organizations, independent living centers, volunteer opportunities, etc.

In addition to functional defects, often people with a TBI experience isolation and a sense of loss. A TR Specialist often treats secondary diagnoses and problems such as depression and anxiety.

TR folks help people with a TBI reach a healthy leisure lifestyle despite their TBI. A TR person is on the treatment team with PT and OT people, so often Leisure Education is the TRS’s most important duty, but they can also be involved in improving functional abilities.

Leisure Education aids in helping people develop balanced lifestyles as well as having a release and a form of self expression. A TRS helps the patient develop new skills, so they can continue to participate in recreation despite their disability. The TRS also helps the person overcome barriers they see to their recreation and helps them develop the skills and knowledge to participate in meaningful recreation by themselves. The patient is able to access resources to aid in their recreation. In addition, the patient learns the importance of keeping up an active, healthy leisure lifestyle. They learn the fulfillment that can come from it and the necessity of it.

TR people can also help improve the client’s functional abilities through activities such as horseback riding, aquatic therapy, and group activities. Group activities are valuable in that they provide support and socialization for people with a TBI. Because so many people that sustain a TBI experience life altering changes as a result, they often get depressed or feel a great sense of loss because they know what life was like without a disability. Group therapy programs and activities are useful in aiding people to make friends and to relate to each other because of their injuries. Groups provide support and a social setting in which clients can develop important skills.

Aquatic Therapy

Aquatic Recreation Therapy allows an individual with a TBI to attempt patterns of movement in the water. Completing movement in the water leads to strengthened muscles and increased stability and improved balance.

Movement exploration in the water also helps individuals understand their bodies, which is especially applicable to people who lack feeling and knowledge of what their body is now capable of. Aquatic therapy also relaxes muscles and relieves pain and muscle spasms. It can maintain and increase range of motion in joints and improve muscular strength and endurance. This can lead to an increase in their enjoyment of life and an increase in self-esteem and self-awareness as individuals are able to complete tasks on their own.

Preventing TBIs

• Seat belts and airbags. Always wear a seat belt in a motor vehicle. Small children should always sit in the back seat of a car and be secured in child safety seats or booster seats that are appropriate for their size and weight.
• Alcohol and drug use. Don't drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive.
• Helmets. Wear a helmet while riding a bicycle, skateboard, motorcycle, snowmobile or all-terrain vehicle. Also wear appropriate head protection when playing baseball or contact sports, skiing, skating, snowboarding or riding a horse.

Preventing falls
For the elderly:

• Install handrails in bathrooms
• Put a nonslip mat in the bathtub or shower
• Remove area rugs
• Install handrails on both sides of staircases
• Improve lighting in the home
• Keep stairs and floors clear of clutter
• Get regular vision checkups
• Get regular exercise

Preventing head injuries in children:

• Install safety gates at the top of stairs
• Keep stairs clear of clutter
• Install window guards to prevent falls
• Put a nonslip mat in the bathtub or shower
• Use playgrounds that have shock-absorbing materials on the ground
• Make sure area rugs are secure
• Don't let children play on fire escapes or balconies

Video Links for TBI Info and Stories:

Soldier with TBI:

http://www.youtube.com/watch?v=YCfnIUsmLkg

Josh’s Story:

http://www.youtube.com/watch?v=YCfnIUsmLkg

Amy’s Story:

http://www.youtube.com/watch?v=4zYpwG6Aetc

Other Stories:

http://www.youtube.com/watch?v=dyqGys9Htbo

About TBI:

http://www.youtube.com/user/TBIVoices?v=kv3Egbc82ZI

More Information on TBI:

http://www.ninds.nih.gov/disorders/tbi/tbi.htm

http://www.cdc.gov/traumaticbraininjury/

http://www.mayoclinic.com/health/traumatic-brain-injury/DS00552

http://www.traumaticbraininjury.com/