Traumatic Brain Injury

What is a Traumatic Brain Injury (TBI)?

A TBI is caused by a bump, jolt, or blow to the head that causes a disruption in the normal function of the brain.

Traumatic Brain Injuries are an acquired injury. They are not genetic and they could happen to any person of any race or of any age.

Different Kinds of TBIs:

Penetrating Injury: a foreign object, like a bullet, enters the brain and causes damage to specific brain parts – symptoms vary based on what parts of the brain were damaged

Closed Head Injuries: results from a blow to the head such as a person’s head hitting the windshield in a car accident

All TBIs are different. There is a wide variety of both primary and secondary issues that come about as a result of the TBI and both kinds of injuries can cause any of the primary or secondary issues.

Recovery from a TBI ranges from physical therapy, psychotherapy, recreation therapy, occupational therapy, and speech pathology therapy.

Statistics on TBIs:

·      1.5 – 2 million people suffer TBIs each year

·      Approximately 270,000 experience a moderate or severe TBI

·      Approximately 50,000 – 70,000 die from their injury

·      About 1/3 of all injury related deaths in the United States has TBI as a contributing factor

·      75% of TBIs that occur each year are concussions

·      Between 2.5 and 6.5 million Americans alive today have had a TBI

·      Approximately 5.3 million Americans are living with some sort of cognitive disability secondary to a TBI

·      Approximately 1/3 of adults hospitalized with TBI still need help with daily activities one year after discharge

At Risk Groups/Causes:

·      TBI is a major health problem among children between the ages 0 to 4, male adolescents and young adults ages 15 to 19, and elderly people of both sexes ages 65 and up

·      1/2 of all TBIs are due to transportation accidents – major cause of TBI in people under the age of 75

·      For children 0 to 4 and elderly people 75 and up, falls are the most common cause of TBI

·      Males are twice as likely as females to experience a TBI

·      Domestic violence is a contributor to TBI – approximately 20% of TBIs are due to violence

·      Anoxia

Most Common Causes of TBI:

·      Car Accidents

·      Falls

·      Violence – firearms

·      Sports Injuries

Car Accidents:

Can cause TBI when a person’s head hits the windshield, steering wheel, dashboard, or any other object when a car accident occurs; this is called, blunt trauma. Something important to note is that there may or may not be an open wound on the person’s head after sustaining an injury. Sometimes, the force of the accident can cause a person’s brain to move around in their skull causing a TBI. In these cases, the person’s head stops moving but inertia in the brain keeps it going, thus causing the brain to smack into the walls of the skull. The injuries in this case can range from a bruised brain to a hemorrhaging brain.

Falls:

Falls are the most common cause of TBI in young children and elderly people. In the event of a fall, a person can hit their head either on the floor or on an object they fall on. Concussions, or mild TBI can result from these falls, or a more severe TBI can be the result. It is important, especially for elderly people to make sure that their walkways are clear, that there is adequate lighting throughout their home, and that any sort of obstruction in the walkway such as a rug is moved out of the way.

Violence – Firearms:

Often times, many soldiers who get shot in the head, or surrounding areas suffer TBI. Sometimes it is not even the bullet itself that causes TBI. The sheer pressure and resulting waves from the blast can cause brain damage resulting in a TBI as well.

         Sports Injuries:

Concussions are considered to be mild TBI. Many concussions sustained over time can cause permanent brain much like that of a TBI. Any contact sport can potentially cause a concussion.

Primary Brain Damage Caused by TBI:

·      Skull Fracture: breaking of the skull

·      Contusions/Bruises: oftentimes occur under the location of impact or at points where the force of the blow has driven the brain against the bony ridges of the skull

·      Hematomas/Blood Clots: occur between the skull and the brain or inside the brain itself

·      Lacerations: tearing of the frontal lobe and temporal lobes or blood vessels in the brain – the force of the blow causes the brain to move against the hard ridges of the skull causing tears

·      Nerve Damage: can happen from a cutting, or shearing, force from the blow that damages nerve cells in the brain’s nerve fibers

Secondary Brain Damage Caused by TBI:

·      Brain Swelling/Edema

·      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 During/After a TBI?

The degree of damaged caused by a TBI varies depending on what kind of injury caused the TBI and what parts of the brain were affected. Nerve damage will be the result of a severe TBI while dizziness and a headache are the results of a mild TBI. It is important to note that there aren’t two TBI that are the same. Each injury is different and therefore different kinds of brain damages occur in each case.

Mild TBI:

A TBI is classified as mild if loss of consciousness and/or confusion and disorientation lasts less than 30 minutes. In these cases, CAT scans and MRIs are often normal but the individual suffers cognitive problems, for example: headaches, difficulty thinking, memory problems, attention deficits, mood swings, and frustration.

·      Most prevalent TBI

·      Often overlooked at time of initial injury

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

·      Defined as the result of a forceful motion of the head or impact causing a brief change in mental status (confusion, disorientation, or memory loss)

·      Post injury symptoms are often referred to as Post Concussive Syndrome

         Other Names for Mild TBI:

1.    Concussion

2.    Minor Head Trauma

3.    Minor TBI

4.    Minor Brain Injury

5.    Minor Head Injury

Symptoms of Mild TBI:

·      Fatigue

·      Headaches

·      Visual disturbances

·      Memory loss

·      Poor Attention/Concentration

·      Sleep disturbances

·      Dizziness/Loss of balance

·      Irritability – emotional disturbances

·      Feelings of depression

·      Seizures

Other Symptoms Associated with Mild TBI:

1.    Nausea

2.    Loss of smell

3.    Sensitivity to light and sounds

4.    Mood changes

5.    Getting lost or confused

6.    Slowness in thinking

One important thing about Mild TBI is that not all of these symptoms may be present or noticed at the time of injury; many of these symptoms will be delayed days or weeks before they appear. In these cases, the person appears normal and often moves normally even though they don’t necessarily feel or think normal.

Moderate to Severe TBI:

Moderate Brain Injury is defined as a brain injury resulting in 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 loss of consciousness greater than 6 hours and a Glasgow Coma Scale of 3 to 8

Source: www.worksupport.com

The Glasgow Coma Scale: Used to determine the conscious state of an individual – used as both an initial assessment and a subsequent assessment. Lowest score is 3 meaning deep unconsciousness and the highest score is 15 meaning “normal.”

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

1.    Severity of initial injury

2.    Rate/completeness of physiological recovery

3.    Functions affected

4.    Meaning of dysfunction to individual

5.    Resources available to aid recovery

6.    Areas of function not affected by TBI

Cognitive Deficits Caused by Moderate/Severe TBI:

·      Attention    

·      Concentration

·      Distractibility

·      Memory

·      Speed of processing

·      Confusion

·      Perseveration

·      Impulsiveness

·      Language processing

·      “Executive functions” (working memory of reasoning, task flexibility, solving, planning, and execution)

Speech and Language:

·      Not understanding the spoken word

·      Difficulty speaking and being understood

·      Slurred speech

·      Speaking very fast or very slow

·      Problems reading

·      Problems writing

Sensory:

·      Hard time with interpretation of touch, temperature, movement, limb position, and fine discrimination

Perceptual:

·      Patterning of sensory impressions into psychologically meaningful data

Vision:

·      Partial or total loss of vision

·      Weakness of eye muscles and double vision

·      Blurred vision

·      Problems judging distance

·      Involuntary eye movements

·      Intolerance of light

Hearing:

·      Decrease or loss of hearing

·      Ringing in the ears

·      Increased sensitivity to sounds

Smell:

·      Lost or diminished sense of smell

Taste:

·      Lost or diminished sense of taste

Seizures:

·      Convulsions associated with epilepsy – disruption in consciousness, sensory perception, or motor movements

Physical Changes:

·      Physical paralysis

·      Chronic pain

·      Control of bowel and bladder

·      Sleep disorders

·      Loss of stamina

·      Appetite changes

·      Regulation of body temperature

·      Menstrual difficulties

Social-Emotional:

·      Dependent behaviors

·      Emotional ability

·      Lack of motivation

·      Irritability

·      Aggression

·      Depression

·      Disinhibition

·      Denial/lack of awareness

Aphasia: A disorder that is caused by damage to the parts of the brain used in communication such as, speaking, listening, reading, and writing. Many people who suffer moderate to severe TBI also develop Aphasia.

Speech Pathologists’ Treatment for Aphasia:

Early Stages of Recovery

·      Get general responses to sensory stimulation

·      Teaching family members and loved ones how to interact with the injured individual

Individual Becomes More Aware:

·      Maintaining attention for basic activities

·      Reducing confusion

·      Orientating the person to date, where he/she is, and what happened

Later in Recovery:

·      Finding ways to improve memory

·      Learning strategies to help problem solving, reasoning, and organizational skills

·      Working on social skills in small groups

·      Improving self-monitoring in the hospital, home, and community

Eventual Treatment:

·      Community outings to help the person plan, organize, and execute trips using memory logs, organizers, checklists, etc.

·      Working with vocational rehabilitation specialist to help the person get back to their work or find work or go back to school

Perhaps some of the greatest struggles people who have suffered a moderate to severe TBI will have, have to do with social skills. In many, if not, most cases, people who suffer moderate to severe TBI lose their sense of social norms. They no longer understand social cues and have a hard time being in situations with lots of people, especially people they don’t know or don’t remember from before their accident.

How is a TBI Diagnosed?

In the case of a moderate/severe TBI, it may be very apparent at the time of injury that the individual has suffered a TBI. If there are any questions about whether or not an individual has suffered a TBI, it is imperative that they are taken to the hospital to go through medical and psychological tests to determine if they have in fact sustained a brain injury

CT Scan:

A CT is a medical imaging process that takes pictures of “slices” of the specific body part in question. This way, the scan sees everything. For example, in the case of TBI a CT scan is used to find any sort of contusions or hemorrhaging in the brain. By seeing different “slices” or going frame by frame through the images, doctors can readily determine first, if the individual has suffered a TBI, and second, where the injury is located, allowing them to find the best treatment solution.

MRI:

An MRI is more sensitive to smaller things like, tumors, than a CT scan is. If a doctor doesn’t see any sort of brain damage show up in a CT scan, but the patient is still exhibiting symptoms of a TBI, then most likely the doctor will order an MRI as well. An MRI uses magnetic fields and radio waves to create images of the body, whereas a CT scan uses some form of radioactivity. Usually, an MRI is preferable above a CT scan for diagnostic purposes.

Using the Glasgow Coma Scale:

When an individual is suspected of having a TBI, medical professionals use the Glasgow Coma Scale as shown previously. Using this scale allows the medical professionals to determine the brain activity of an individual, starting at a mild TBI all the way to brain death when there is no more activity in the brain. On this scale a Mild TBI is 13-15, Moderate Disability is 9-12, Severe Disability is 3-8, Vegetative State is less than 3, and Brain Death is no function whatsoever.

Intracranial Pressure Monitor:

This is a monitor that is placed directly within the head of the injured individual. It is placed into a ventricle of the brain filled with cerebral spinal fluid and monitors how much pressure the fluid is placing on the brain and helps to drain this fluid as necessary. This catheter is the most effective way to monitor intracranial pressure.

In addition to these tests, doctors, nurses, therapists, and speech pathologists will use diagnostic tests to help them determine if the injured individual does in face have a TBI. Their symptoms will be closely monitored, especially if there is any sort of loss with any of their cognitive skills/abilities.

Long-Term Effects of TBI:

For each patient, the effects of their TBI will be different. For some, they will be able to overcome their injury and sustain a normal life, for others, they will never be “normal” again.

Arousal:

·      Disorders of consciousness: coma, vegetative state, minimally conscious state

·      Lethargy, daytime sleepiness

·      Insomnia

Cognitive:

·      Decreased memory and new learning

·      Decreased attention and speed of processing

·      Decreased judgment, insight, and planning

Communication:

·      Decreased language abilities (understanding another’s speech or finding words)

·      Decreased speech ability to articulate words so that others understand

Behavioral:

·      Depression and anxiety

·      Irritability and explosive anger

·      Impulsivity

Sensory:

·      Visual disturbance

·      Decreased balance and vertigo

·      Decreased hearing

Pain:

·      Chronic headache

·      Muscle and joint pain from trauma at the time of injury

·      Burning/electric type pain from nerve dysfunction

Motor:

·      Weakness

·      Decreased coordination

·      Spasticity: an abnormally increased reflex after acquired brain injury that causes loss of range of motion and contracture over time

Bowel/Bladder:

·      Incontinence from decreased awareness of when to toilet or decreased mobility to reach the toilet in time

As stated previously, each individual and their TBI will be different from someone else’s experience. Some sufferers of TBI lose feeling in certain limbs or a certain part of their body. Some sufferers are able to recover almost completely from all symptoms related to TBI. It is absolutely vital that a treatment plan is individualized for each patient. This treatment plan needs to be the works of all people involved with helping the patient recover, whether that is their doctor, their occupational therapist, or their recreation therapist. Also, for some patients, the effects of TBI listed above may only last for a little while. TBI can cause a number of other disorders as well, some sufferers end up getting epilepsy and suffer from seizures for the rest of their lives and some suffer from aphasia for a period of time.

The acute effects of TBI include many of the symptoms previously listed. They range from general dizziness to lethargy to seizures. It is important that members of the treatment team as well as the individual’s family members and loved ones understand that after suffering a TBI, a person’s personality can change completely. To understand them, we must show extreme patience, love, and concern for their well-being so they know that they are not in it alone.

Prevention of TBI:

·      In cars, make sure that seatbelts are always properly worn – it doesn’t matter how long the drive is

o   Also, make sure children are secured in proper car seats.

·      Do not ever drive under the influence of any sort of drug or alcohol

·      Always wear a helmet when riding a bike, rock climbing, etc.

·      Make sure that there are no obstructions in a walkway that could cause a small child or elderly individual to fall and get hurt

·      Keep children away from window sills or things that could tip over and make them fall to the ground

The best prevention of a TBI is to use your common sense. If you get in a car accident and are properly wearing your seatbelt, it is way less likely that you will sustain any life threatening injuries including TBI than if you weren’t properly wearing your seatbelt.

Treatment:

         Mild TBI:

         The best treatment for a person, who has suffered a Mild TBI or concussion, is rest and relaxation. They may also want to use over the counter medicines to help counteract some of the symptoms associated with a Mild TBI such as a headache and nausea. However, just because a person has not suffered a severe TBI does not mean that they should not be monitored closely. It is important to closely monitor a person who has suffered a Mild TBI because in some cases, symptoms of a more serious injury do not manifest themselves until a few hours or even days after the initial injury has occurred.

         Moderate/Severe TBI:

         In the case of either a moderate or severe TBI, immediate medical attention is necessary. The longer the brain is under pressure or bleeds, the less likely survival becomes. After the individual is stabilized, treatments will be given to help with secondary damage caused inflammation, bleeding, or reduced oxygen supply. Medications to help with secondary symptoms include diuretics, anti-seizure medication, and coma-inducing drugs (comatose brains need less oxygen to function).

         In some cases, emergency surgery is needed. In cases where the brain has bled and the blood has clotted, surgery is performed to remove that clotted blood or hematoma. In other cases surgery is needed to repair a fractured skull or to create a hole in the skull so the brain can have room to expand, thus reducing the intracranial pressure.

The Importance of Rehabilitation:

In many cases of TBI, especially moderate or severe TBI, the patient will have to re-learn how to do everything, how to walk, how to talk, even how to tie their shoes. Rehabilitation allows sufferers of TBI to have a quality of life like they did before they were injured. Therapy usually begins in the hospital and then after a while the patient will move to an in-patient rehabilitation facility where they will re-learn the vast majority of skills they need to. Again, it is important to note that each individual’s case will be different; the kind of therapy and how much a certain individual needs is determined by their treatment team.

         Treatment Team:

         Psychiatrist: oversees entire rehabilitation process

         Occupational Therapist: helps the person learn or re-learn activities of daily living

         Physical Therapist: helps with mobility and re-learning movement patterns, balance, and walking

         Speech and Language Pathologist: helps person improve communication skills

         Neuropsychologist: helps the person learn coping strategies and provides talk therapy for emotional and psychological well-being

         Social Worker/Case Manager: facilitates access to service agencies, assists with care decisions and planning, and facilitates communication between care professionals and family members

         Vocational Counselor: assesses the individual’s ability to return to work and helps find appropriate vocational opportunities

TR and TBI:

Therapeutic Recreation is essential in the healing process for patients suffering from a TBI for three reasons:

1.    It’s a method of treatment that’s used to improve many aspects of a patient’s overall well-being whether it be physically, psychologically, socially, or emotionally

2.    It’s also a method of education to increase a patient’s knowledge of and successfully provide for the patient’s leisure activities – integral parts of rehabilitation and social reintegration

3.    Participation in recreational activities is essential to “normal” living. It’s a way to express oneself, feel a sense of release, and socialize – things that are very important to the rehabilitation of a person with TBI.

Steps in the TR Process for Patients with TBI:

         Recreation Assessment:

         An individual assessment of a person’s…

1.    Strengths, interests, & values

2.    Previous leisure activities and expectations

3.    Available resources in your home and community

4.    Social needs and relationships

5.    Economic and other potential problems that surface that may hinder their ability to participate in recreational and leisure activities

6.    Life-style adjustments necessary for leisure functioning

After completing this assessment, a CTRS will interpret the information and come up with a recreation program that will allow the patient to not only meet his/her goals, but to overcome challenges. This plan will also sort out problem areas and then develop ways of coping with those issues.

Individual Treatment:

The recreation plan is completely personalized and is unique to the patient to whom it belongs. As recreation therapy begins, modifications will be made to the treatment plan based on struggles or triumphs, leading the individual to create higher and higher goals for him or herself.

Group Programs in the Hospital and Community:

Skills will be learned and then used in real-life situations to overcome very real challenges. Group programs allow for additional support so the individual does not feel alone or discouraged about their progression.

Interdisciplinary Programs:

The entire treatment team comes together to help create a recreation plan that will not only meet the recreation/leisure goals of the individual, but will also help them meet their goals in other areas with their other therapists.

Wheelchair Sports:

Many sufferers of TBI are in wheelchairs. It is important for them to know that they can still actively participate in sports such as, basketball, bowling, swimming, archery, table tennis, softball, and many more.

Outpatient Therapeutic Recreation Services:

These are ongoing programs that will allow individuals to overcome whatever barriers they need to in order to reintegrate themselves into their communities, all the while helping them to continue to strengthen their relationships and become more self-confident in who they are now, instead of focusing on who they were before their accident.

Discharge Planning:

CTRS will give references of programs and services in the individual’s community where they can find recreational and leisure activities that best suit them. These may include; special recreation associations, wheelchair sports organizations, accessible outdoor programs and facilities, continuing education programs, national support organizations, independent living centers, volunteer opportunities, etc.

It’s Not Just About Recreation

As Certified Therapeutic Recreation Specialists, we know and understand that we do more than teach people recreation skills. The skills that we teach are not only vital to helping an individual reach their recreation/leisure goals, but they help them learn the skills they need to in order to keep going in life.

For a person who has suffered a TBI, re-integrating into their community and dealing with any new limitations will be a hard and oftentimes painful process. If we are there for them and help them learn recreation skills, we can apply those principles to other parts of their lives. By teaching a person who suffered a TBI to play basketball, we are also teaching them teamwork, trust, and hard work; three very important things when it comes to daily living.

Getting in an accident that changes your life as you know it is probably one of the hardest things TBI patients will ever have to go through. It is important that we help them understand that just because they have a TBI does not mean that they cannot have a quality of life. Helping people maintain a quality of life is what we do. So if your patient struggles, fights with you, or doesn’t want to try, remember, it’s not all about the activity, it’s about them finding out that they are still them even after a terrible accident and helping them know that just because their “normal” is now different doesn’t mean that they can’t live a happy, full life.

Resources for More Information about TBI:

Brain Injury Association of America: www.biausa.org

National Resource Center for Traumatic Brain Injury: www.tbinrc.com

Centers for Disease Control and Prevention: http://www.cdc.gov/TraumaticBrainInjury/index.html

www.traumaticbraininjury.com