Traumatic Brain Injury (TBI)
Overview
Traumatic brain injury (TBI) is damage to the brain caused by a blow to the head. The severity of the injury may range from minor, with few or no lasting consequences, to major, resulting in profound disability or death.
Although any injury to the brain is serious, and severe damage can be fatal, medical and surgical advances have improved the odds for surviving a TBI. Nevertheless, coping with the life-changing consequences of traumatic brain injury presents a great challenge for patients, families, physicians, therapists, and society.
Anatomy
The brain is the hub of the central nervous system and controls all bodily functions and processes. It weighs about three pounds and is surrounded by protective bone called the skull or cranium. The brain has the texture of gelatin and is held together by three layers of membranes called the dura, pia, and arachnoid. Between the pia and arachnoid membranes is the subarachnoid space, through which a network of arteries and veins carries blood to and from the heart. Injury to these blood vessels can lead to blood clots, which can exert damaging pressure against the brain's delicate tissue. The brain is surrounded by a cushioning reservoir of cerebrospinal fluid (CSF).
The lower part of the brain (called the brain stem) passes through a hole at the base of the skull and merges with the spinal cord and the rest of the nervous system. The brain stem can be compared to a telephone cable with thousands of individual wires (nerve fibers) that carry signals to and from all parts of the body. The brain stem also regulates such body functions as consciousness, fatigue, heart rate, and blood pressure. Damage to the stem can cause loss of consciousness, or concussion of the brain.
Behind the brain stem is the cerebellum, a curved mass of nerve tissues that regulates balance and coordinates fine motor skills. It enables us to move quickly and smoothly, thread a needle, or throw a dart with accuracy.
The cerebral cortex is the largest part of the brain and is shaped like a large, wrinkled, walnut divided in half (the right and left cerebral hemispheres) and joined at the center. The right hemisphere controls the left side of the body; the left hemisphere controls the right side. In most people, the left hemisphere regulates language and speech and the right hemisphere controls nonverbal, spatial skills such as the ability to draw or play music. If the right side of the brain is damaged, movement in the left arm and leg, vision to the left, or hearing in the left ear, may be affected. An injury to the left side of the brain affects speech and movement on the right side of the body.
The cerebral cortex is further divided into several areas called lobes. Of these:
- The left and right frontal lobes, located behind the forehead, control intellectual activities, such as the ability to organize, and figure prominently in personality, behavior, and emotional control.
- The temporal lobes, situated immediately behind and below the frontal lobes and just behind the ears, control memory, speech and comprehension.
- The parietal lobes located at the back of the head and above the ears, control the ability to read, write, and understand spatial relationships.
- The areas between the frontal and parietal lobes regulate movement and sensation.
- The occipital lobes, situated at the back of the head, control sight.
In the middle of the cerebral cortex are several small white nuclei, or nerve centers, called the diencephalon. Among these is the pea-sized hypothalamus, which regulates appetite, thirst, temperature, and some aspects of memory and controls sexual arousal. Another is the limbic system, which is associated with the control of emotions and moods.
Damage to these areas can result in impairment to the functions they regulate.
Incidence and Prevalence
The Centers for Disease Control and Prevention (CDC) estimate that 100 out of 100,000 people in the United States suffer TBI each year, of which approximately 52,000 die. Estimates of the number of people who have survived a TBI range from 2.5 million to 6.5 million. The range is broad because mild TBI often goes unreported.
The cost of traumatic brain injuries in the United States is estimated at $48.3 billion annually: $31.7 billion in hospitalization costs and another $16.6 billion in costs associated with fatalities.
The CDC estimates the total cost of acute care and rehabilitation for TBI victims in the United States is $9 billion to $10 billion per year, not including indirect costs to families and society (e.g., lost earnings, work time, and productivity for family members, caregivers, and employers, or the costs associated with providing social services).
It is estimated that over a lifetime, it can cost between $600,000 and $1,875,000 to care for a survivor of severe TBI.
Signs and Symptoms
Signs and symptoms of neurological impairment caused by TBI depend on which structures in the brain are damaged.
Common symptoms include:
- Anxiety, nervousness
- Behavioral changes:
- difficulty controlling urges (disinhibition)
- impulsiveness
- inappropriate laughter
- irritability
- Blurry or double vision (diplopia)
- Depression
- Difficulty concentrating or thinking
- Difficulty finding words or understanding the speech of others (aphasia)
- Difficulty swallowing (dysphagia)
- Dizziness
- Headache
- Incoordination of movements
- Lightheadedness
- Loss of balance; difficulty walking or sitting
- Loss of memory
- Muscle stiffness and/or spasms
- Seizures
- Sleep difficulties (more or less sleep than pre-injury)
- Slurred and/or slowed speech
- Tingling, numbness, pain, or other sensations
- Sense of spinning (vertigo )
- Weakness in one or more limbs, facial muscles, or on an entire side of the body
Symptoms typically progress through three successive stages:
- Coma
- Post-traumatic Amnesia
- Recovery
Coma
Severe TBI usually results in coma, a loss of consciousness. When in a coma, the patient's eyes are closed and he or she shows no reaction when spoken to, touched, or pinched. Some patients demonstrate a reflexive movement, such as a handgrip, when an arm or leg is touched or squeezed. A coma can be brief or can persist for hours, days, weeks, months, or even years. The longer a person is unconscious, the more severe the injury, and the greater the chance for permanent neurological damage. (more about coma)
A concussion is a brief (seconds to minutes) loss of consciousness caused by a blow to the head. The prognosis for recovery usually is good.
Post-traumatic Amnesia
Once a patient responds with purposeful movement or attempts to communicate, he or she has progressed to post-traumatic amnesia (PTA). Purposeful movements include obeying a command to close the eyes or lift a limb and attempts to communicate by speaking, mouthing words, and/or gesturing.
PTA is a state of acute confusion. The hallmark of this stage is cognitive impairment (i.e., problems with perception, thinking, remembering, and concentration). During this stage, patients often cannot concentrate long enough to capture anything in their memory. The most common symptoms of PTA associated with TBI include the following:
- Answering the same question, asked repeatedly, with different responses
- Difficulty performing simple tasks, such as counting to 10 and reciting days of the week or months of the year
- Distractibility, attention jumps from one subject to another
- Inability to remember what happened in the preceding minutes, hours, or days
- Losing train of thought while responding to a question
- Responding inconsistently, vaguely, or tangentially
- Staring blankly at an observer
Behavioral changes often occur during PTA and the patient may be uncharacteristically quiet and passive, or aggressive and agitated. A patient may manifest disinhibition-saying or doing things that come to mind which typically are not acted upon-such as making inappropriate comments about someone's physical appearance (e.g., "You look really sexy"). Impulsivity is also common. For example, a patient may abruptly try to get out of bed, even with both legs in casts.
Patients usually have little or no awareness of these cognitive and behavioral impairments and typically remember nothing of their actions or what happened to them during PTA, even though they were fully conscious.
Recovery
When patients begin retaining information-such as the current month and year, where they are or why they are in the hospital-they have emerged from PTA and entered into the recovery phase. This can last weeks, months, or years, depending on which areas of the brain are damaged, and the severity of that damage. Recovery is characterized by progressive improvement in cognitive and behavioral functions. Sometimes behavior becomes more difficult when the patient becomes aware of his or her new limitations, resulting in frustration and depression that can be difficult to treat because of cognitive impairments.
Gains typically occur fairly rapidly at first, but the speed of improvement slows over months and years until a recovery plateau is reached. The more severe the injury, the longer it takes to plateau. Even when the patient's rate of improvement seems to stabilize, subtle, recognizable improvements may continue. These late changes develop very slowly and are so subtle that, unless specifically watched for, they may go unrecognized. They usually do not significantly impact the patient's functional status or the amount of supervision or support needed.
Risk Factors
TBI occurs twice as often in men as in women. Populations at a higher risk include:
- Individuals between the ages of 15 and 24 years
- Individuals age 75 and older
Half of all traumatic brain injuries involve alcohol use, either by the victim or the person causing the injury.
Children age five and younger are also at a higher-than-average risk. According to the National Pediatric Trauma Registry, more than 30,000 children are permanently disabled each year as a result of brain injuries. The greatest risk occurs from midafternoon to early evening, and during weekends and the summer months. Children are especially at risk after school. Nearly half (42.6%) of all children's injuries occur in roads, 34.3% occur at home and 6.6% occur in recreation areas.
Causes
The three most common causes of TBI are the following:
- Motor vehicle, bicycle, or vehicle-pedestrian mishaps (more than 50%)
- Falls (approximately 25%)
- Violence (nearly 20%)
Vehicle-related injuries involve people of all ages. Falls are most common among the elderly and the very young. Alcohol and medication use are common contributing factors in falls. Gunshot wounds account for a small proportion of TBIs (10%), but a high percentage of related fatalities (44%). Nine out of ten people who incur TBI from a firearm die.
Domestic abuse (including shaken baby syndrome) and sports injuries are common causes of TBI. Approximately 3% of all hospitalizations for TBI are incurred while playing sports. Most sports-related TBI are relatively minor and therefore go unreported.
Diagnosis
Patients suffering TBI are typically brought to a hospital emergency room for initial diagnosis and treatment. Once vital signs are assessed and stabilized, and other life-threatening injuries are identified and treated, the process of diagnosing the extent of brain injury begins.
A complete neurological evaluation is performed to rule out conditions requiring neurosurgical attention, such as hematomas, depressed skull fractures, and elevated intracrantial pressure (ICP). X-rays, CT scans, and/or MRI scans may be performed to determine if the bones of the skull are fractured and if bone fragments have penetrated the brain tissues.
The patient may be presented with a series of questions (What is your name? Where are you? What day is it?) and given simple commands (Wiggle your toes. Hold up two fingers.) to determine if he or she can open their eyes, move, speak, and understand what is happening around them. If possible, a detailed medical history is performed to identify any previous injuries, existing seizure disorders, learning disabilities, prior psychiatric or psychological treatment, and/or substance abuse.
The patient's degree of consciousness is assessed to determine the severity of brain injury and predict his or her chances for recovery. To do this, physicians typically use the Glasgow Coma Scale (GCS), which measures the patient's ability to open their eyes, move, and speak. The more severe the injury, the lower the total score suggesting little chance for complete recovery.
Glasgow Coma Scale
Eye Opening
4 = Responds spontaneously
3 = Responds to voice
2 = Responds to pain
1 = No response
Best Motor Response
6 = Follows commands
5 = Localizes to pain
4 = Withdraws to pain
3 = Decorticate (produces an exaggerated posture of upper extremity flexion and lower extremity extension in response to pain)
2 = Decerebrate (produces an exaggerated posture of extension in response to pain)
1 = No Response
Best Verbal Response
5 = Oriented and converses
4 = Disoriented and converses
3 = Inappropriate words
2 = Incomprehensible sounds
1 = No response
Total scores of 8 or below indicate a true coma and severe brain injury. Scores of 9 to 12 suggest moderate brain injury; scores of 13 and above indicate mild brain injury. However, the severity of the brain injury is not determined by GCS alone, as treatable conditions such as infection and dehydration may lower the GCS score.
When the patient is unconscious, the duration or length of coma (LOC) may be used to assess the severity of TBI and predict outcome. The longer the length of coma, the more severe the injury is. An LOC of less than about 20 minutes reflects a mild brain injury; longer than about 6 hours after admission reflects severe injury; between 20 minutes and 6 hours suggests moderate injury.
The neurological examination may show signs indicating the severity of injury such as increased reflexes and muscle tone (spasticity), abnormal movements (tremors), difficulty swallowing, or slurring of speech, all of which may indicate a moderate to severe head injury.
Imaging
Neuroradiological tests using computer-assisted brain scans help visualize damage to the brain. The most common of these is computerized axial tomography (CAT or CT scan), an x-ray technique that produces a cross-sectional image of the brain. CT scans can detect physical changes in the brain such as hematomas and swelling, which may require immediate treatment. The procedure is painless and takes 15 to 45 minutes, during which the patient must lie completely still.
Another useful diagnostic test is magnetic resonance imaging (MRI scan), which uses a large magnet and radio waves to generate computerized images of the brain without exposing the patient to x-ray radiation. MRIs produce high resolution images of brain structures and are painless, but noisy. The patient must lie on a flat table in the machine, typically shaped like a long tube. An MRI can take up to 60 minutes.
Depending on individual circumstances, a variety of other diagnostic tools and techniques may be employed. These include the following:
- Angiogram-A test to examine blood vessels in the brain. It involves injecting dye into an artery supplying blood to the brain, usually by means of a catheter inserted in the groin. The test takes 1 to 3 hours.
- ICP Monitor-A device used to measure intracranial pressure (pressure within the brain). It consists of a small tube, placed into or on top of the brain through a small hole in the skull, connected to a transducer that registers the pressure.
- EEG (electroencephalograph)-A test to measure electrical activity in the brain. It uses electrodes, in the form of patches, applied to the head. This painless procedure can be done at bedside or in a hospital's EEG department. The duration of the test varies.
X-rays, MRIs, and CT scans can detect fractures, hemorrhages, swelling, and certain kinds of tissue damage, but they do not always detect traumatic brain injury. This is because TBI, especially in its milder forms, often involves subtle traumas scattered among neurons and supportive tissues, stretched or damaged axon membranes (diffuse axonal injury), chemical injury caused by the biochemical cascade of toxic substances in the brain tissues, and cellular dysfunction. These changes often cannot be found with standard imaging procedures. More sophisticated imaging techniques that measure brain cell metabolism, such as single-photon emission computed tomography (SPECT) or positron emission tomography (PET), can help diagnose such injuries.
Types
Early brain injury
Early brain injury, or early complications of a head injury, can be diffuse or focal.
Diffuse injuries are characterized by microscopic damage throughout many areas of the brain. Forces exerted on the brain tissues cause damage to the axons-the "wires" that enable nerve cells to communicate with each other.
A focal brain injury is confined to a specific area of the brain and causes localized damage that can often be detected with a CT scan or x-ray.
Diffuse axonal injury
A diffuse axonal injury (DAI) causes shearing of large nerve fibers and stretching of blood vessels in many areas of the brain. In addition to bleeding (hemorrhage), this type of injury can trigger a biochemical cascade of toxic substances in the brain during the days following the initial injury.
DAI occurs throughout the brain, and the frontal and temporal lobes are particularly susceptible. The most prominent manifestation of DAI is impaired cognitive function, resulting in
- disorganization,
- impaired memory, and
- varying degrees of inattentiveness.
DAI also can occur in relatively small, but important, nerve centers (or white matter tracts) causing visual field loss or weakness on one side of the body.
Hypoxic-ischemic injury
Hypoxic-ischemic injury (HII) causes swelling in the brain that restricts the flow of blood-borne oxygen, glucose, and other nutrients. These injuries can be exacerbated by other injuries to the body that further reduce the amount of oxygen entering the bloodstream through the lungs.
Patients with HII and DAI face a poor prognosis and typically experience memory impairment and reduced cognitive function.
Focal Brain Injuries
Contusions
Focal contusions are bruises that cause swelling, bleeding, and destruction of brain tissue. They typically occur in the frontal and temporal lobes, where memory and behavior centers are located. Less often, they occur in the parietal and occipital lobes. Tiny contusions in the brainstem can interfere with the muscles that control eye movement, resulting in double vision (diplopia).
Symptoms of brain contusion include the following:
- Abnormal sensations
- Behavior impairment
- Loss of some or all vision
- Loss of coordination, weakness (less common)
- Memory impairment
Contusions shrink as swelling diminishes but can leave scars in brain tissue that cause permanent neurological impairment.
Hemorrhage
A cerebral or intracranial (inside the skull) hemorrhage occurs when blood leaks from a damaged vessel into brain tissue. The size of a hemorrhage can range from tiny to large and symptoms depend on the size and location of the damage. Bleeding usually develops within minutes of a TBI but it can develop hours to days after the initial injury.
Infarction
Infarction is the medical term for stroke. Infarctions associated with TBI occur when an artery to the brain is compressed by the swelling of surrounding tissues, preventing the flow of blood-borne oxygen and nutrients to brain cells. Most TBI-induced strokes involve the posterior cerebral artery and affect the occipital and temporal lobes causing loss of peripheral vision and speech or language problems.
Hematoma
A subdural hematoma (SDH) is slow bleeding outside the brain, usually over the surface of the frontal or parietal lobe. Typically, it is caused by damage to a vessel carrying venous blood (i.e., blood that has passed through capillaries and distributed oxygen to the tissues). An acute hematoma may develop slowly, taking minutes to days to manifest. If large enough, it can exert a dangerous amount of pressure on the brain, necessitating surgery to drain the accumulated blood and relieve pressure.
An epidural hematoma (EDH) occurs outside the brain and is usually caused by a damaged artery. Arteries carry blood under high pressure; therefore, a large EDH can cause pressure to build up within minutes, even seconds. This condition requires immediate surgery to relieve pressure and prevent severe permanent damage or death.
Subarachnoid hemorrhage (SAH) refers to a small amount of bleeding that spreads thinly over the surface of the brain. This usually is an incidental finding detected on a CT scan and has little significance. SAH is more significant when caused by the bursting of an aneurysm (weakened blood vessel) in the brain, such as during a stroke.
Late secondary complications
Complications can develop in the brain weeks or even months after the initial injury. The most common late secondary complications are hydrocephalus and chronic subdural hematoma.
There are several pockets in the brain called ventricles. Cerebrospinal fluid (CSF) produced in these ventricles surrounds and coats the surface of the brain and spinal cord. CSF is constantly produced and reabsorbed into the bloodstream. TBI can disrupt this process. If too much fluid builds up in the ventricles and enlarges them, a condition called hydrocephalus results, creating pressure on brain tissues and preventing nerve cells from functioning properly.
A chronic subdural hematoma (SDH), or hygroma, is a focal brain injury characterized by an accumulation of blood or spinal fluid on the surface of the brain that exerts pressure on brain tissues. Increased pressure inside the skull (intracranial pressure or ICP) can produce several complications, including weakness on the opposite side of the body, speech difficulties, and confusion. Although chronic SDH often resolves on its own, persistent symptoms may require surgery to relieve pressure.
Intracranial pressure (ICP)
In the days and weeks after a traumatic brain injury, patients are monitored closely for any sign of increased intracranial pressure (ICP), a dangerous complication in which the brain's soft tissues become squeezed against the skull. This occurs when trauma to the head causes damaged blood vessels to leak or form clots (hematomas) or produces an imbalance in the amount of cerebrospinal fluid (CSF) in the ventricles. Because the skull is rigid and the space between it and the brain is small, there is no room for expansion. Extra fluid or clots in the brain (intercerebral clots) or the space between it and the skull (subdural or extradural clots) produce increased pressure, which can damage the brain in two ways: (1) by squeezing it against the skull or (2) by compressing its blood vessels to the point where circulation is impeded. Either complication can be fatal.
Treatment
There are three stages of treatment for TBI:
- 1. Acute-to stabilize the patient immediately after the injury;
- 2. Subacute-to rehabilitate and return the patient to the community; and
- 3. Chronic-to continue rehabilitation and treat the long-term impairments.
Acute Treatment
Initial acute treatment focuses on saving the victim's life. Rescue or emergency personnel unblock airways, assist breathing, and keep blood circulating. Cardiopulmonary resuscitation may be as necessary. Treatment then focuses on stabilizing the patient. Hospital personnel then take over, working to maintain the body fluid levels and prevent or treat infections and other complications.
Several types of TBI require surgery. Surgery may be performed within hours or days of the injury, if a blood clot causes increased intracranial pressure (ICP). Some clots must be removed; others must not be removed because of the danger of disturbing them. Subdural hematomas and intracerebral hemorrhages may also increase ICP, sometimes necessitating surgery.
During acute treatment, swelling in the brain (edema) is monitored and treated. Brain edema can have dire consequences, causing increased pressure inside the head (intracranial pressure or ICP). Because the skull is hard, ICP can compress or squeeze the soft brain tissue against it, preventing blood from circulating adequately in the brain tissue and causing damage to brain cells. Most edema subsides within a few days or weeks, but a few minutes or hours of excessive ICP can cause permanent damage.
To manage this condition, a device called an ICP monitor can be inserted through the skull to provide physicians with a constant pressure reading. If the ICP rises too high, medications are administered to draw fluid out of the brain and into blood vessels, decrease the brain's metabolic requirements, and increase blood flow to the injured tissues. The patient also can be placed on a ventilator to ensure an adequate supply of oxygen (hyperventilation), which is necessary to promote healing. When brain swelling is particularly severe, elevated pressure can only be relieved temporarily by surgically removing a portion of the skull. This allows swollen tissues to bulge out reducing the risk for pressure-induced damage.
A buildup of fluid inside the brain is also a concern in acute treatment. If the fluid-containing spaces in the brain (ventricles) experience blockage, a neurosurgeon must insert a tube called a shunt to drain the fluid build up (hydrocephalus). This allows the ventricles to shrink and restores normal function to brain cells. Elevated ICP due to swelling, hydrocephalus, or blood clots significantly impacts recovery from TBI.
Seizures may occur seconds, weeks, or years after TBI. A seizure can be a minor twitching of one finger or limb, or a complete loss of consciousness accompanied by involuntary movements of the entire body. Seizures can be particularly dangerous during this time, so most patients with moderate to severe TBI receive antiseizure medication for at least the first few weeks.
Another important aspect of acute care is the prevention of other medical problems. One concern is the development of abnormally high or low levels of sodium, calcium, sugar, or other substances in the blood that can worsen confusion and precipitate seizures. TBI patients also are at high risk for infections, including pneumonia, urinary tract infections, and sinusitis, which must be treated promptly and aggressively.
Subacute Treatment
Subacute treatment is provided after stabilization, which ranges from medical stability to a patient's return to the community or admission to a chronic care facility. The patient is usually admitted to an acute rehabilitation hospital equipped to manage TBI and its complications. At admission, most patients still are in post-traumatic amnesia (PTA).
The main goals of subacute treatment are
- early detection of complications,
- facilitation of neurological and functional recovery, and
- prevention of additional injury.
Early detection of complications
In subacute treatment, facility staff watches for and treat bedsores, muscle contractions, infections, and other complications, such as fluid accumulation in the brain (e.g., hydrocephalus, subdural hygromas), that may require surgical treatment. A neurologist investigates for complications if the patient fails to progress as expected.
Facilitation of neurological and functional recovery Neurological function often improves incompletely, so rehabilitation professionals-physical, occupational and speech therapists, nurses, neuropsychologists, neurologists, and others specializing in traumatic brain injury-help patients and their families understand neurological impairments. They encourage patients and their families to take advantage of improvements as they occur. Sometimes a patient must learn new ways to do simple routine tasks-such as how to button a shirt or tie a shoe with one hand, or how to compensate for memory loss by using a logbook or calendar.
Prevention of injury
During PTA, many patients experience poor balance, incoordination, weakness, or cognitive impairments that place them at risk for injury. They may be impulsive and unaware of their physical limitations and may try to climb out of bed or walk by themselves when it is unsafe to do so. Agitation and restlessness may also lead to injury. A well-designed rehabilitation unit and well-trained staff can keep them safe, using little or no medication.
In most cases, patients are discharged from the hospital once they emerge from PTA and can demonstrate, along with family and caregivers, that they will be safe in the home.
Disabilities and handicaps
Disability refers to loss of physical and mental function caused by neurological impairment. Examples include the following:
- Decreased ability to interact with others in socially acceptable ways
- Decreased ability or inability to walk
- Inability to carry or manipulate objects
- Inability to feel characteristics of objects
- Inability to process and retain information
- Inability to see clearly
- Poor coordination of fingers or limbs
Handicap refers to the overall disadvantage a person with one or more disabilities may experience. Some examples are:
- Difficulty forming and maintaining personal and professional relationships
- Difficulty participating in civic and social activities
- Difficulty participating in physical recreational activities
- Decreased ability or inability to work for pay and benefits
Chronic Treatment
Disabilities from TBI may last a lifetime, and different interventions may be appropriate even many years later. This is particularly true for survivors of moderate to severe TBI. It is essential for survivors, their families, and caregivers to be involved in designing and implementing the rehabilitation plan.
There are two categories of chronic treatment:
- Community-based rehabilitation and return to work or school, and
- Treatment of long-term consequences of the injury.
Community-based rehabilitation
Ultimately, rehabilitation must take place in the community rather than the controlled environment of a rehabilitation facility. Some patients do best with individual therapy (speech, occupational, physical) at an outpatient facility or at home. For others, a multidisciplinary, case-managed program works best. Most urban regions in the United States have these programs. This approach utilizes a team of professionals that is usually composed of one or more therapists and social workers, a case manager, and vocational specialist. Case-managed programs are very effective, especially for patients with complex medical and social problems.
Treatment of consequences of TBI
Patients may have residual symptoms that require skilled management by qualified neurologists, physiatrists, and neuropsychologists. Common symptoms and their related treatments include:
- Abnormal muscle tone (e.g., spasticity, dystonia) may be treated with physical therapy, oral medication, and minor surgery.
- Chronic pain sometimes requires medication, physical therapy, and psychological techniques.
- Depression, anxiety, and behavioral problems usually are treated with medication and psychotherapy.
- Seizures and headaches may require medication.
The Glasgow Coma Scale is useful for predicting early outcome from a head injury but it is less useful for estimating how a patient eventually will function in daily, independent living.
Many rehabilitation centers use the Ranchos Los Amigos Scale of Cognitive Functioning to follow the recovery of the head injury survivor and to determine when he/she is ready to begin a structured rehabilitation program. The scale is divided into eight stages, from coma to appropriate behavior and cognitive functioning.
Rancho Los Amigos Levels of Cognitive Functioning
I. No response to stimulation
II. Generalized response to stimulation
III. Localized response to stimulation
IV. Confused, agitated behavior
V. Confused, inappropriate, nonagitated behavior
VI. Confused, appropriate behavior
VII. Automatic, appropriate behavior
VIII. Purposeful, appropriate behavior
This scale does not take into account many changes in the patient's cognitive, memory, and motor functions that suggest whether he or she will be able to return to work or school. Assessments by neuropsychologists, speech pathologists, and therapists are needed.
The amount of social support a person receives gradually becomes the most important factor in ensuring the fullest possible recovery. Once the patient plateaus, family, friends, and an experienced treatment team of physicians, therapists, social workers and psychologists must work together to provide critical emotional, physical, medical, and psychological support.
Subacute Treatment
Subacute treatment is provided after stabilization, which ranges from medical stability to a patient's return to the community or admission to a chronic care facility. The patient is usually admitted to an acute rehabilitation hospital equipped to manage TBI and its complications. At admission, most patients still are in post-traumatic amnesia (PTA).
The main goals of subacute treatment are
- early detection of complications,
- facilitation of neurological and functional recovery, and
- prevention of additional injury.
Early Detection of Complications
In subacute treatment, facility staff watches for and treat bedsores, muscle contractions, infections, and other complications, such as fluid accumulation in the brain (e.g., hydrocephalus, subdural hygromas), that may require surgical treatment. A neurologist investigates for complications if the patient fails to progress as expected.
Facilitation of Neurological and Functional Recovery
Neurological function often improves incompletely, so rehabilitation professionals-physical, occupational and speech therapists, nurses, neuropsychologists, neurologists, and others specializing in traumatic brain injury-help patients and their families understand neurological impairments. They encourage patients and their families to take advantage of improvements as they occur. Sometimes a patient must learn new ways to do simple routine tasks-such as how to button a shirt or tie a shoe with one hand, or how to compensate for memory loss by using a logbook or calendar.
Prevention of Injury
During PTA, many patients experience poor balance, incoordination, weakness, or cognitive impairments that place them at risk for injury. They may be impulsive and unaware of their physical limitations and may try to climb out of bed or walk by themselves when it is unsafe to do so. Agitation and restlessness may also lead to injury. A well-designed rehabilitation unit and well-trained staff can keep them safe, using little or no medication.
In most cases, patients are discharged from the hospital once they emerge from PTA and can demonstrate, along with family and caregivers, that they will be safe in the home.
Disabilities and Handicaps
Disability refers to loss of physical and mental function caused by neurological impairment.
Examples include the following:
- Decreased ability to interact with others in socially acceptable ways
- Decreased ability or inability to walk
- Inability to carry or manipulate objects
- Inability to feel characteristics of objects
- Inability to process and retain information
- Inability to see clearly
- Poor coordination of fingers or limbs
Handicap refers to the overall disadvantage a person with one or more disabilities may experience. Some examples are:
- Difficulty forming and maintaining personal and professional relationships
- Difficulty participating in civic and social activities
- Difficulty participating in physical recreational activities
- Decreased ability or inability to work for pay and benefits
Chronic Treatment
Disabilities from TBI may last a lifetime, and different interventions may be appropriate even many years later. This is particularly true for survivors of moderate to severe TBI. It is essential for survivors, their families, and caregivers to be involved in designing and implementing the rehabilitation plan.
There are two categories of chronic treatment:
- Community-based rehabilitation and return to work or school, and
- Treatment of long-term consequences of the injury.
Community-based Rehabilitation
Ultimately, rehabilitation must take place in the community rather than the controlled environment of a rehabilitation facility. Some patients do best with individual therapy (speech, occupational, physical) at an outpatient facility or at home. For others, a multidisciplinary, case-managed program works best. Most urban regions in the United States have these programs. This approach utilizes a team of professionals that is usually composed of one or more therapists and social workers, a case manager, and vocational specialist. Case-managed programs are very effective, especially for patients with complex medical and social problems.
Treatment of Consequences of TBI
Patients may have residual symptoms that require skilled management by qualified neurologists, physiatrists, and neuropsychologists.
Common symptoms and their related treatments include:
- Abnormal muscle tone (e.g., spasticity, dystonia) may be treated with physical therapy, oral medication, and minor surgery.
- Chronic pain sometimes requires medication, physical therapy, and psychological techniques.
- Depression, anxiety, and behavioral problems usually are treated with medication and psychotherapy.
- Seizures and headaches may require medication.
The Glasgow Coma Scale is useful for predicting early outcome from a head injury but it is less useful for estimating how a patient eventually will function in daily, independent living.
Many rehabilitation centers use the Ranchos Los Amigos Scale of Cognitive Functioning to follow the recovery of the head injury survivor and to determine when he/she is ready to begin a structured rehabilitation program. The scale is divided into eight stages, from coma to appropriate behavior and cognitive functioning.
Rancho Los Amigos Levels of Cognitive Functioning
I. No response to stimulation
II. Generalized response to stimulation
III. Localized response to stimulation
IV. Confused, agitated behavior
V. Confused, inappropriate, nonagitated behavior
VI. Confused, appropriate behavior
VII. Automatic, appropriate behavior
VIII. Purposeful, appropriate behavior
This scale does not take into account many changes in the patient's cognitive, memory, and motor functions that suggest whether he or she will be able to return to work or school. Assessments by neuropsychologists, speech pathologists, and therapists are needed.
The amount of social support a person receives gradually becomes the most important factor in ensuring the fullest possible recovery. Once the patient plateaus, family, friends, and an experienced treatment team of physicians, therapists, social workers and psychologists must work together to provide critical emotional, physical, medical, and psychological support.
Prevention
Because most traumatic brain injuries are caused by motor vehicle and bicycle accidents, primary TBI prevention for these risk factors focuses on taking advantage of the many innovations that have been designed to make driving and riding safer.
Automobile air bags, seatbelts, and infant or child safety seats greatly reduce the risk for serious injury or death in an accident. Despite overwhelming evidence that seatbelts and safety seats save lives, an estimated 26% of the population neglects or resists using them and others use or install them incorrectly.
To prevent or reduce the severity of TBI and other crash-induced trauma, drivers and passengers should always:
- Wear lap belts and shoulder harnesses.
- Use properly installed infant and child safety seats. A representative of your local police department or highway patrol can show you the proper method of installation.
- Avoiding drinking and driving, or driving under the influence of drugs or medications.
Air bags have proven effective in reducing crash-related head injuries. However, air bags deploy with considerable force and should never be used with a rear-facing child safety seat. Children under the age of 12 should always ride in the back seat.
Speed limits and improved road design have reduced traffic-related TBI.
The use of helmets for motorcycle and bicycle riding and other recreational sports can prevent or minimize TBI.
Recent improvements in the design of strollers and shopping carts have helped to reduce the incidence of TBI associated with falls by children.
Research
Researchers are looking for ways to reduce the amount of damage caused by TBI. Administering certain medications within minutes or hours of the injury is a promising possibility. Another approach is to enhance the brain's natural recovery mechanisms. In the future, we may be able to make intact brain areas take over for injured areas more quickly and completely. Rehabilitation professionals are researching new ways to help TBI survivors return to the highest possible level of function. The technological and biomedical developments that will enhance the lives of brain injury survivors depend on continued success in pharmacology, biomedical engineering, and computer science research.
Prognosis
Physicians look at several indicators to predict the level of a patient's recovery during the first few weeks and months after injury:
- Duration of coma
- Severity of coma in the first few hours after the injury (as measured by the Glasgow Coma Score)
- Duration of post-traumatic amnesia (PTA)
- Location and size of contusions and hemorrhages in the brain
- Severity of injuries to other body systems sustained at the time of the TBI
Precise predictions are difficult with TBI, but some generalizations can be made:
- The more severe the injury, the longer the recovery period, and the more impairment a survivor will have once recovery has plateaued.
- Recovery from diffuse axonal injury takes longer than recovery from focal contusions.
- Recovery from TBI with hypoxic injury is less complete than without significant hypoxic injury.
- The need for surgery does not necessarily indicate a worse outcome. For example, a patient requiring the removal of a blood clot may recover as completely as one who never needs surgery.
Cognitive and behavioral processes are controlled by specific areas of the brain, so the location of the injury determines the type of impairment. For example, patients who suffer a diffuse axonal injury and/or a diffuse hypoxic injury often have difficulty with concentration and long-term memory. They may have trouble dealing with more than one thing at a time, difficulty keeping track of appointments, and keeping organized. Those who suffer focal contusions or hemorrhages have problems associated with the particular brain areas affected. For example, a hemorrhage deep in the left side of the brain may cause weakness of the right side of the body. A patient with contusions of the frontal lobes may have trouble being organized or may have behavioral problems such as abnormal passivity, impulsiveness, or aggressiveness.
The length of time a patient spends in a coma correlates to both post-traumatic amnesia (PTA) and recovery times:
- Coma lasting seconds to minutes results in PTA that lasts hours to days; recovery plateau occurs over days to weeks.
- Coma that lasts hours to days results in PTA lasting days to weeks; recovery plateau occurs over months.
- Coma lasting weeks results in PTA that lasts months; recovery plateau occurs over months to years.
Physicians trained in the care of brain-injured patients can best determine how these generalizations apply to a particular TBI survivor.
There are several mechanisms of recovery after brain injury. Initial improvement may be due to the reduction of swelling (edema) of brain tissue occurring over days, weeks or months, depending on the severity of the injury. Next, damaged brain cells begin functioning again, usually over a period weeks to months. Finally, undamaged areas of the brain may, to a certain extent, take over the functions of areas that suffer permanent damage.