Traumatic Brain Injury (TBI)

What is BRAIN Injury ?

Is a general term referring to any injury that causes damage to the brain tissue. Damage may be due to increased pressure within the skull, inflammation, bruising and bleeding or necrosis (death) of an area of the brain tissue.

Acquired Brain Injury (ABI)

  • Trauma (Motor vehicle accident or a fall from height)
  • Strokes and hemorrhage
  • Infections, such as meningitis
  • Hypoxia (Lack of oxygen supply to brain tissue)
  • Brain tumors
  • Neurotoxic materials : drugs, alcohol, toxic gases and solvents

Traumatic Brain Injury (TBI)

TBI is an acquired brain injury resulting from an external trauma to the head or body, which causes the brain to shake inside the skull.

There are two types of TBI

Closed TBI:

As a result of mild impact to the brain but the skull is not penetrated
or fractured.

Open TBI:

As a result of massive impact to the brain and the skull has beenpenetrated or fractured.
– The major causes of TBI are car accidents, sports injuries and falls.
– The highest risk groups for sustaining TBI are children under 5 years of age, men aged 30 – 15 years, and the elderly.

What happens to the brain in TBI?

  • The brain is like an egg (Yolk inside an egg shell)
  • The egg shell is the skull.
  • The egg yolk is the brain itself
  • The egg white is the fluid that surrounds the brain
  • This fluid is called cerebrospinal fluid which surrounds and protects entire brain and spinal cord from impact by shock absorption. In an accident, the brain is injured by the pulling or tearing of delicate brain tissue. If the skull is broken, pieces of bone may penetrate the brain causing bleeding and bruising. Usually the damage is caused by a sudden acceleration and deceleration of the brain (for example in a car crash).

Severity classification of TBI:

Traumatic brain injury can be classified according to severity of brain tissue damage and functional loss into 3 types:

Mild TBI:

  • Loss of consciousness, if any, lasting for less than 30 minutes
  • Memory loss after the traumatic event, called post-traumatic amnesia or PTA, that lasts for less than 24 hours
  • A Glasgow Coma Score of 15 – 13

Moderate TBI:

  • A loss of consciousness that lasts for more than 30 minutes but less than 24 hours
  • Memory loss after the traumatic event, called post-traumatic amnesia or PTA, lasting for 24 hours to seven days
  • A Glasgow Coma Score of 12 – 9

Severe TBI:

  • A loss of consciousness that lasts for more than 24 hours
  • PTA lasting for seven days or longer
  • A Glasgow Coma Score of 8 or less, which indicates that the patient is in a coma

TBI Prognosis

Brain recovery is dependent on injured brain part, severity of the injury and the management procedures for each patient. Generally potential improvement happens in the first two years but a patient can still improve for years after. In most mild TBI cases, the patient will recover completely. In a small number of cases, the symptoms can last a long time and cause permanent changes to the patient’s life, for example in areas, such as personality and memory.

Patients with moderate TBI usually make a good recovery with treatment or learn to manage any problems that result from the injury Severe TBI is often caused by crushing blows or penetrating wounds to the head. These injuries can severely damage the brain. In many cases, it’s not possible to recover completely from a severe TBI.

Consequences of TBI

Following TBI, patients may experience a variety of physical, sensory, cognitive or mood related changes according to degree of severity:

Physical changes:

  • Mobility problems: Movement can become very slow, balance and coordination can be affected. Some people may need a wheelchair or other mobility aids even the can stand or walk for short distances
  • Spasticity: Limbs may be stiff or weak, and the range of movement limited. Often one side of the body is affected more than the other, depending on the area of the brain that is injured. Spasticity may cause pain or discomfort.
  • Hemiplegia, paraplegia or even quadriplegia: Weakness or paralysis affects one side of the body, lower half or all limbs respectively.
  • Seizures: Brain injury can make some people prone to epileptic seizures or ‘fits’. Many people who have had a seizure after a brain injury are given a drug for a number of years to reduce the chance of it recurring. Your physicians will monitor closely the brain activity and the effects of the medication as some drowsiness may occur.


Incontinence:

Patient may suffer lack of control of bowel or bladder either due to sensory changes in detecting the need to empty or perceptual/cognitive issues in completing the task.

  • Headaches
  • Sleep disturbances
  • Pain
  • Changes in sexual function

Sensory changes:

  • Sensitivity to noise and light: Patient can be more sensitive to visual and auditory stimulation. In such cases, the team in charge of the patients care will ensure the environment is kept calm and quiet. We may ask families not
  • to visit in large numbers, reduce the amount of light in the room and avoid sudden loud noises such as mobile phone ringtones.
  • Changes in taste, smell or touch: changes in patient perception to these sensation can vary from partial loss, total loss, hypersensitive to false sensation. This may affect ability to eat and enjoy food.
  • Hearing loss
  • Visual problems: Blurred vision, double vision and loss of part of the visual field may affect a person post brain injury

Cognitive Changes:

The cognitive effects of a brain injury affect the way a person thinks, learns and remembers. Different mental abilities are located in different parts of the brain, so a brain injury can damage some, but not necessarily all, skills as following:

Memory loss
— Problems with memory, particularly short-term and ‘working memory’, are common after brain injury. Some people may be unable to remember faces or names, or what they have read or what has been said to them. New learning may be affected, while previously learned skills may still be intact.

Language loss (aphasia)
— This may be ‘receptive’ (difficulty making sense of what is said or read) or ‘expressive’ (difficulty finding the right words to say or write), or both. This can be very frustrating for the person and for others, and patience
is needed on both sides.

Reduced concentration span
— This is very common, and can also be affected by memory problems. Completing tasks can be a problem, and the task may be abandoned before reaching the end. The person may initially appear eager to start a task but then lose interest very quickly.

Reduced information processing ability
— It may be difficult for the person to organize facts in their mind, particularly if there are also memory problems. ‘Information overload’ can be quickly reached, and can cause frustration and anger.

Repetition or ‘perseveration’
— The person may be unable to move on to another topic in the same conversation, or they may return to the same topic over and over again. They may also repeat the same action, appearing unable to break the cycle.


Impaired reasoning
— Impaired reasoning may affect a person’s ability to think logically, to understand rules, or follow discussions. The person may easily become argumentative due to lack of understanding.


Impaired insight
— Insight, also referred to as self-awareness, is the ability of a person to observe and reflect on their own thoughts and actions. Brain injuries, especially injuries to the frontal lobes, often cause this ability to be
significantly affected.

Behavioral, mood or personality changes:

Behavioral changes after brain injury are many and varied. Some appear to be an exaggeration of previous personality characteristics, while others may seem completely out of character for that person and may have one or more of following changes. Depending on which area of the brain has been affected, you may notice (or others around you may notice) that your behavior is not the same as before. You may get angry easily, laugh at things inappropriately, become angry at minor things or even physically aggressive when frustrated. These can be very challenging for you and your family as well as care givers to deal with. Your rehabilitation team may talk to you all about avoiding triggers (things which promote undesired behavior) and how to manage inappropriate behavior. The may be temporary or may change over time. The following are common behavior changes:


Dis-inhibition
— A common change early in recovery is dis-inhibition, that is, loss of control over behavior, resulting in socially inappropriate behavior.

Impulsiveness
— A person with a brain injury may tend to speak or act without thinking about the possible consequences of their behavior

Obsessive behavior
— A person may become obsessive or fixated on certain thoughts or behaviors after a brain injury.


Irritability and aggression
— Perhaps the most common behavioral change after brain injury is that of increased irritability. People with a brain injury are often impatient, intolerant of others’ mistakes, and easily irritated by interruptions, such as noise

Apathy and loss of initiative
— Some people may become passive, unresponsive and lacking in initiative after brain injury. They may appear unconcerned and even unaware of their difficulties, especially in the early stages of recovery. Others may appear
interested and have good intentions to carry out activities, but are unable to organize themselves and initiate action.

The Rehabilitation Team

You are the Patient. Your rehabilitation program is built around your goals. As a team, we are here to support you physically and emotionally in achieving your goals. A Physiatrist, a Specialized Physician in Rehabilitation Medicine who assesses and treats patients with functional impairments. The Physiatrist is responsible for medical evaluation of the patient to determine their ability to undergo therapy programs and to advise appropriate treatment programs like medication interventions, soft tissue infiltration, nerve blocks.

Based on the patients goals and wishes and the physical abilities, the Physiatrist along with a team of Physiotherapists, Occupational therapists and Speech Language therapists, Rehabilitation Nurses, Dietician and Respiratory therapists, devise a plan of care to achieve those goals. Rehabilitation also includes managing neurogenic bowel bladder, spasticity and taking care of any other medical conditions you may have such as Diabetes, hypertension or high cholesterol, to ensure you can participate fully in your rehabilitation program.

The occupational therapist’s (OT) role focuses on a person’s ability to participate in activities of daily living. These activities vary from person to person according to abilities and age. The OT looks at the person’s cognitive abilities, movement, and the ability to complete functional tasks. Your day to day rehabilitation with your OT may focus on day to day tasks such as washing and dressing, eating and drinking, writing or building the strength in your limbs to be able to complete tasks that are important to you in the future. We may focus on improving concentration, memory or problem solving if these have been affected. An occupational therapist will help you identify roles that you wish to return to participating in.

This may be caring for your children, driving, returning to work or anything that is identified by the patient that is achievable and realistic. The occupational therapist may wish to visit your home or work environment (with your consent) to establish any obstacles or barriers that may make returning there difficult. It is the occupational therapists job to try to find solutions to any issues that may arise. This may be recommending equipment, adaptations and changes to the environment.

The physiotherapist aims to re-educate movement, sensation and balance to enable you to reach their potential for functional mobility. They will complete comprehensive assessments of your physical abilities. Your day to day rehabilitation program with a physiotherapist will focus on increasing strength, balance and regain functional use. They will focus on the goals established with you. They may use a variety of techniques such as body weight activities, weights and exercise machines such as a stationary bike or treadmill to promote strength and control.


They may provide you with an exercise program to complete independently. The speech and language therapist can help if you have communication problems or swallowing problems after a TBI. If problems are identified in these areas, they may establish a treatment plan to work on goals you have identified. Your therapist’s aim will be to work with you as well as your family and careers to help you communicate your needs effectively. Rehabilitation aides assist the occupational therapists, physiotherapists and speech and language therapists. They work hard to help the therapists complete the best treatments possible in a timely and efficient manner. Sometimes 2 pairs of hands are better than one. Our Rehab Aides also help patient practice transfers, walk with aids and attending sessions on time.

Our Dietitians are trained healthcare professionals who assess a patient’s energy and nutrient requirements and develop effective treatment plans for feeding. They calculate and prescribe the appropriate quantities of calories and nutrients in artificial feeding, modified consistency diets/fluids and normal oral diets. Our Dietitian ensures that your nutritional needs are being met and can support you to make positive changes to your diet. The body needs good quality nutrition to repair after injury and it is vital that you understand how to fuel your body to help your performance throughout the day. The dietitian’s role is to help you start healthy habits for the future, maintain or achieve a healthy weight and make sure you are receiving a balanced and healthy diet during your stay in CMRC.

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