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Additional Information
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What is a Traumatic Brain
Injury?
TBI, also called acquired brain injury or simply head
injury, occurs when a sudden trauma causes damage to the
brain. The damage can be focal - confined to one area of
the brain - or diffuse - involving more than one area of
the brain. TBI can result from a closed head injury or
a penetratinghead injury. A closed injury occurs
when the head suddenly and violently hits an object but
the object does not break through the skull. A penetrating
injury occurs when an object pierces the skull and enters
brain tissue.
What Are the Signs and Symptoms
of TBI?
Symptoms of a TBI can be mild, moderate, or severe, depending
on the extent of the damage to the brain. Some symptoms
are evident immediately, while others do not surface until
several days or weeks after the injury. A person with a
mild TBI may remain conscious or may experience a loss
of consciousness for a few seconds or minutes. The person
may also feel dazed or not like himself for several days
or weeks after the initial injury. Other symptoms of mild
TBI include headache, confusion, lightheadedness, dizziness,
blurred vision or tired eyes, ringing in the ears, bad
taste in the mouth, fatigue or lethargy, a change in sleep
patterns, behavioral or mood changes, and trouble with
memory, concentration, attention, or thinking.
A person with a moderate or severe TBI may show these
same symptoms, but may also have a headache that gets worse
or does not go away, repeated vomiting or nausea, convulsions
or seizures, inability to awaken from sleep, dilation
of one or both pupils of the eyes, slurred speech, weakness
or numbness in the extremities, loss of coordination, and/or
increased confusion, restlessness, or agitation. Small
children with moderate to severe TBI may show some of these
signs as well as signs specific to young children, such
as persistent crying, inability to be consoled, and/or
refusal to nurse or eat. Anyone with signs of moderate
or severe TBI should receive medical attention as soon
as possible.
What Are the Causes of and
Risk Factors for TBI
Half of all TBIs are due to transportation accidents involving
automobiles, motorcycles, bicycles, and pedestrians. These
accidents are the major cause of TBI in people under age
75. For those 75 and older, falls cause the majority of
TBIs. Approximately 20 percent of TBIs are due to violence,
such as firearm assaults and child abuse, and about 3 percent
are due to sports injuries. Fully half of TBI incidents
involve alcohol use.
The cause of the TBI plays a role in determining the patient's
outcome. For example, approximately 91 percent of firearm
TBIs (two-thirds of which may be suicidal in intent) result
in death, while only 11 percent of TBIs from falls result
in death.
What Are the Different Types
of TBI?
Concussion is the most minor and the most common
type of TBI. Technically, a concussion is a short loss
of consciousness in response to a head injury, but in common
language the term has come to mean any minor injury to
the head or brain.
Other injuries are more severe. As the first line of defense,
the skull is particularly vulnerable to injury. Skull fractures
occur when the bone of the skull cracks or breaks. A depressed
skull fracture occurs when pieces of the broken skull
press into the tissue of the brain. A penetrating skull
fracture occurs when something pierces the skull,
such as a bullet, leaving a distinct and localized injury
to brain tissue.
Skull fractures can cause bruising of brain tissue called
a contusion. A contusion is a distinct area of
swollen brain tissue mixed with blood released from broken
blood vessels. A contusion can also occur in response to
shaking of the brain back and forth within the confines
of the skull, an injury called . contrecoup ..
This injury often occurs in car accidents after high-speed
stops and in shaken baby syndrome, a severe form
of head injury that occurs when a baby is shaken forcibly
enough to cause the brain to bounce against the skull.
In addition, contrecoup can cause diffuse axonal injury ,
also called shearing , which involves damage to
individual nerve cells ( neurons ) and loss of
connections among neurons. This can lead to a breakdown
of overall communication among neurons in the brain.
Damage to a major blood vessel in the head can cause a hematoma ,
or heavy bleeding into or around the brain. Three types
of hematomas can cause brain damage. An epidural hematoma involves
bleeding into the area between the skull and the dura.
With a subdural hematoma , bleeding is confined
to the area between the dura and the arachnoid membrane .
Bleeding within the brain itself is called intracerebral
hematoma .
Another insult to the brain that can cause injury is anoxia .
Anoxia is a condition in which there is an absence of oxygen
supply to an organ's tissues, even if there is adequate
blood flow to the tissue. Hypoxia refers to a
decrease in oxygen supply rather than a complete absence
of oxygen. Without oxygen, the cells of the brain die within
several minutes. This type of injury is often seen in neardrowning
victims, in heart attack patients, or in people who suffer
significant blood loss from other injuries that decrease
blood flow to the brain.
What Medical Care Should
a TBI Patient Receive?
Medical care usually begins when paramedics or emergency
medical technicians arrive on the scene of an accident
or when a TBI patient arrives at the emergency department
of a hospital. Because little can be done to reverse the
initial brain damage caused by trauma, medical personnel
try to stabilize the patient and focus on preventing further
injury. Primary concerns include insuring proper oxygen
supply to the brain and the rest of the body, maintaining
adequate blood flow, and controlling blood pressure. Emergency
medical personnel may have to open the patient's airway
or perform other procedures to make sure the patient is
breathing. They may also perform CPR to help the heart
pump blood to the body, and they may treat other injuries
to control or stop bleeding. Because many head-injured
patients may also have spinal cord injuries, medical professionals
take great care in moving and transporting the patient.
Ideally, the patient is placed on a back-board and in a
neck restraint. These devices immobilize the patient and
prevent further injury to the head and spinal cord.
As soon as medical personnel have stabilized
the headinjured patient, they assess the patient's condition
by measuring vital signs and reflexes and by performing
a neurological examination. They check the patient's temperature,
blood pressure, pulse, breathing rate, and pupil size in
response to light. They assess the patient's level of consciousness
and neurological functioning using the Glasgow Coma
Scale, a standardized, 15-point test that uses three
measures - eye opening, best verbal response, and best
motor response - to determine the severity of the patient's
brain injury.
The results of the three tests are added up to determine
the patient's overall condition. A total score of 3 to
8 indicates a severe head injury, 9 to 12 indicates a moderate
head injury, and 13 to 15 indicates a mild head injury.
Imaging tests help in determining the diagnosis and prognosis
of a TBI patient. Patients with mild to moderate injuries
may receive skull and neck X-rays to check for bone fractures
or spinal instability. The patient should remain immobilized
in a neck and back restraint until medical personnel are
certain that there is no risk of spinal cord injury. For
moderate to severe cases, the gold standard imaging test
is a computed tomography (CT) scan. The CT scan
creates a series of crosssectional X-ray images of the
head and brain and can show bone fractures as well as the
presence of hemorrhage, hematomas, contusions, brain tissue
swelling, and tumors. Magnetic resonance imaging (MRI) may
be used after the initial assessment and treatment of the
TBI patient. MRI uses magnetic fields to detect subtle
changes in brain tissue content and can show more detail
than X-rays or CT. Unfortunately, MRI is not ideal for
routine emergency imaging of TBI patients because it is
time-consuming and is not available in all hospitals.
Approximately half of severely head-injured patients will
need surgery to remove or repair hematomas or contusions.
Patients may also need surgery to treat injuries in other
parts of the body. These patients usually go to the intensive
care unit after surgery.
Sometimes when the brain is injured swelling occurs and
fluids accumulate within the brain space. It is normal
for bodily injuries to cause swelling and disruptions in
fluid balance. But when an injury occurs inside the skull-encased
brain, there is no place for swollen tissues to expand
and no adjoining tissues to absorb excess fluid. This increased
pressure is called intracranialpressure (ICP) .
Medical personnel measure patients. ICP using a probe
or catheter. The instrument is inserted through the skull
to the subarachnoid level and is connected to a monitor
that registers the patient's ICP. If a patient has high
ICP, he or she may undergo a ventriculostomy ,
a procedure that drains cerebrospinal fluid (CSF) from
the brain to bring the pressure down. Drugs that can be
used to decrease ICP include mannitol or barbiturates,
although the safety and effectiveness of the latter are
unknown.
How Does a TBI Affect Consciousness?
A TBI can cause problems with arousal, consciousness,
awareness, alertness, and responsiveness. Generally,
there are five abnormal states of consciousness that
can result from a TBI: stupor, coma, persistent vegetative
state, locked-in syndrome, and brain death.
Stupor is a state in which the patient is unresponsive
but can be aroused briefly by a strong stimulus, such
as sharp pain. Coma is a state in which the
patient is totally unconscious, unresponsive, unaware,
and unarousable. Patients in a coma do not respond to
external stimuli, such as pain or light, and do not have
sleep-wake cycles. Coma results from widespread and diffuse
trauma to the brain, including the cerebral hemispheres
of the upper brain and the lower brain or brainstem.
Coma generally is of short duration, lasting a few days
to a few weeks. After this time, some patients gradually
come out of the coma, some progress to a vegetative state,
and others die.
Patients in a vegetative state are unconscious
and unaware of their surroundings, but they continue
to have a sleep-wake cycle and can have periods of alertness.
Unlike coma, where the patients eyes are closed, patients
in a vegetative state often open their eyes and may move,
groan, or show reflex responses. A vegetative state can
result from diffuse injury to the cerebral hemispheres
of the brain without damage to the lower brain and brainstem.
Anoxia, or lack of oxygen to the brain, which is a common
complication of cardiac arrest, can also bring about
a vegetative state.
Many patients emerge from a vegetative state within
a few weeks, but those who do not recover within 30 days
are said to be in a persistent vegetative state (PVS) .
The chances of recovery depend on the extent of injury
to the brain and the patient's age, with younger patients
having a better chance of recovery than older patients.
Generally adults have a 50 percent chance and children
a 60 percent chance of recovering consciousness from
a PVS within the first 6 months. After a year, the chances
that a PVS patient will regain consciousness are very
low and most patients who do recover consciousness experience
significant disability. The longer a patient is in a
PVS, the more severe the resulting disabilities will
be. Rehabilitation can contribute to recovery, but many
patients never progress to the point of being able to
take care of themselves.
Locked-in syndrome is a condition in which
a patient is aware and awake, but cannot move or communicate
due to complete paralysis of the body.
Unlike PVS, in which the upper portions of the brain
are damaged and the lower portions are spared, locked-in
syndrome is caused by damage to specific portions of
the lower brain and brainstem with no damage to the upper
brain. Most locked-in syndrome patients can communicate
through movements and blinking of their eyes, which are
not affected by the paralysis. Some patients may have
the ability to move certain facial muscles as well. The
majority of locked-in syndrome patients do not regain
motor control, but several devices are available to help
patients communicate.
With the development over the last half-century of assistive
devices that can artificially maintain blood flow and
breathing, the term brain death has come into
use. Brain death is the lack of measurable brain function
due to diffuse damage to the cerebral hemispheres and
the brainstem, with loss of any integrated activity among
distinct areas of the brain. Brain death is irreversible.
Removal of assistive devices will result in immediate
cardiac arrest and cessation of breathing.
Advances in imaging and other technologies have led
to devices that help differentiate among the variety
of unconscious states. For example, an imaging test that
shows activity in the brainstem but little or no activity
in the upper brain would lead a physician to a diagnosis
of vegetative state and exclude diagnoses of brain death
and locked-in syndrome. On the other hand, an imaging
test that shows activity in the upper brain with little
activity in the brainstem would confirm a diagnosis of
locked-in syndrome, while invalidating a diagnosis of
brain death or vegetative state. The use of CT and MRI
is standard in TBI treatment, but other imaging and diagnostic
techniques that may be used to confirm a particular diagnosis
include cerebral angiography, electroencephalography
(EEG), transcranial Doppler ultrasound, and single photon
emission computed tomography (SPECT).
What Immediate Post-Injury
Complications Can Occur From a TBI?
Sometimes, health complications occur in the period
immediately following a TBI. These complications are
not types of TBI, but are distinct medical problems
that arise as a result of the injury. Although complications
are rare, the risk increases with the severity of the
trauma. Complications of TBI include immediate seizures,
hydrocephalus or post-traumatic ventricular enlargement,
CSF leaks, infections, vascular injuries, cranial nerve
injuries, pain, bed sores, multiple organ system failure
in unconscious patients, and polytrauma (trauma to
other parts of the body in addition to the brain).
About 25 percent of patients with brain
contusions or hematomas and about 50 percent of patients
with penetrating head injuries will develop immediate
seizures , seizures that occur within the first
24 hours of the injury. These immediate seizures increase
the risk of early seizures - defined as seizures
occurring within 1 week after injury - but do not seem
to be linked to the development of /I>post-traumatic
epilepsy (recurrent seizures occurring more than 1
week after the initial trauma). Generally, medical
professionals use anticonvulsant medications to treat
seizures in TBI patients only if the seizures persist.
Hydrocephalus or post-traumatic ventricular enlargement
occurs when CSF accumulates in the brain resulting
in dilation of the cerebral ventricles (cavities in
the brain filled with CSF) and an increase in ICP.
This condition can develop during the acute stage of
TBI or may not appear until later. Generally it occurs
within the first year of the injury and is characterized
by worsening neurological outcome, impaired consciousness,
behavioral changes, ataxia (lack of coordination or
balance), incontinence, or signs of elevated ICP. The
condition may develop as a result of meningitis ,
subarachnoid hemorrhage, intracranial hematoma, or
other injuries. Treatment includes shunting and draining
of CSF as well as any other appropriate treatment for
the root cause of the condition.
Skull fractures can tear the membranes that cover
the brain, leading to CSF leaks. A tear between the
dura and the arachnoid membranes, called a CSF
fistula , can cause CSF to leak out of the subarachnoid
space into the subdural space; this is called a subdural
hygroma . CSF can also leak from the nose and
the ear. These tears that let CSF out of the brain
cavity can also allow air and bacteria into the cavity,
possibly causing infections such as meningitis. Pneumocephalus occurs
when air enters the intracranial cavity and becomes
trapped in the subarachnoid space.
Infections within the intracranial cavity are a dangerous
complication of TBI. They may occur outside of the
dura, below the dura, below the arachnoid (meningitis),
or within the space of the brain itself (abscess).
Most of these injuries develop within a few weeks of
the initial trauma and result from skull fractures
or penetrating injuries. Standard treatment involves
antibiotics and sometimes surgery to remove the infected
tissue. Meningitis may be especially dangerous, with
the potential to spread to the rest of the brain and
nervous system.
Any damage to the head or brain usually results in
some damage to the vascular system, which provides
blood to the cells of the brain. The body's immune
system can repair damage to small blood vessels, but
damage to larger vessels can result in serious complications.
Damage to one of the major arteries leading to the
brain can cause a stroke, either through bleeding from
the artery ( hemorrhagic stroke ) or through
the formation of a clot at the site of injury, called
a thrombus or thrombosis , blocking
blood flow to the brain ( ischemic stroke ).
Blood clots also can develop in other parts of the
head. Symptoms such as headache, vomiting, seizures,
paralysis on one side of the body, and semiconsciousness
developing within several days of a head injury may
be caused by a blood clot that forms in the tissue
of one of the sinuses, or cavities, adjacent to the
brain. Thrombotic-ischemic strokes are treated with
anticoagulants, while surgery is the preferred treatment
for hemorrhagic stroke. Other types of vascular injuries
include vasospasm and the formation of aneurysms .
Skull fractures, especially at the base of the skull,
can cause cranial nerve injuries that result in compressive
cranial neuropathies . All but three of the 12
cranial nerves project out from the brainstem to the
head and face. The seventh cranial nerve, called the
facial nerve, is the most commonly injured cranial
nerve in TBI and damage to it can result in paralysis
of facial muscles.
Pain is a common symptom of TBI and can be a significant
complication for conscious patients in the period immediately
following a TBI. Headache is the most common form of
pain experienced by TBI patients, but other forms of
pain can also be problematic. Serious complications
for patients who are unconscious, in a coma, or in
a vegetative state include bed or pressure sores of
the skin, recurrent bladder infections, pneumonia or
other life-threatening infections, and progressive
multiple organ failure.
General Trauma
Most TBI patients have injuries to other parts of
the body in addition to the head and brain. Physicians
call this polytrauma. These injuries require immediate
and specialized care and can complicate treatment of
and recovery from the TBI. Other medical complications
that may accompany a TBI include pulmonary (lung) dysfunction;
cardiovascular (heart) dysfunction from blunt chest
trauma; gastrointestinal dysfunction; fluid and hormonal
imbalances; and other isolated complications, such
as fractures, nerve injuries, deep vein thrombosis ,
excessive blood clotting, and infections.
Trauma victims often develop hypermetabolism or
an increased metabolic rate, which leads to an increase
in the amount of heat the body produces. The body
redirects into heat the energy needed to keep organ
systems functioning, causing muscle wasting and the
starvation of other tissues. Complications related
to pulmonary dysfunction can include neurogenic pulmonary
edema (excess fluid in lung tissue), aspiration pneumonia
(pneumonia caused by foreign matter in the lungs),
and fat and blood clots in the blood vessels of the
lungs.
Fluid and hormonal imbalances can complicate the
treatment of hypermetabolism and high ICP. Hormonal
problems can result from dysfunction of the pituitary,
the thyroid, and other glands throughout the body.
Two common hormonal complications of TBI are syndrome
of inappropriate secretion of antidiuretic hormone
(SIADH) and hypothyroidism.
Blunt trauma to the chest can also cause cardiovascular
problems, including damage to blood vessels and internal
bleeding, and problems with heart rate and blood
flow. Blunt trauma to the abdomen can cause damage
to or dysfunction of the stomach, large or small
intestines, and pancreas. A serious and common complication
of TBI is erosive gastritis , or inflammation
and degeneration of stomach tissue. This syndrome
can cause bacterial growth in the stomach, increasing
the risk of aspiration pneumonia. Standard care of
TBI patients includes administration of prophylactic
gastric acid inhibitors to prevent the buildup of
stomach acids and bacteria.
What Disabilities
Can Result From a TBI?
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 patient.
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).
Within days to weeks of the head injury approximately
40 percent of TBI patients develop a host of troubling
symptoms collectively called postconcussion
syndrome (PCS). A patient need not have suffered
a concussion or loss of consciousness to develop
the syndrome and many patients with mild TBI suffer
from PCS. Symptoms include headache, dizziness,
vertigo (a sensation of spinning around or of objects
spinning around the patient), memory problems,
trouble concentrating, sleeping problems, restlessness,
irritability, apathy, depression, and anxiety.
These symptoms may last for a few weeks after the
head injury. The syndrome is more prevalent in
patients who had psychiatric symptoms, such as
depression or anxiety, before the injury. Treatment
for PCS may include medicines for pain and psychiatric
conditions, and psychotherapy and occupational
therapy todevelop coping skills.
Cognition is a term used to describe the processes
of thinking, reasoning, problem solving, information
processing, and memory. Most patients with severe
TBI, if they recover consciousness, suffer from
cognitive disabilities, including the loss of many
higher level mental skills. The most common cognitive
impairment among severely head-injured patients
is memory loss, characterized by some loss of specific
memories and the partial inability to form or store
new ones. Some of these patients may experience post-traumatic
amnesia (PTA) , either anterograde or retrograde.
Anterograde PTA is impaired memory of events that
happened after the TBI, while retrograde PTA is
impaired memory of events that happened before
the TBI.
Many patients with mild to moderate head injuries
who experience cognitive deficits become easily
confused or distracted and have problems with concentration
and attention. They also have problems with higher
level, so-called executive functions, such as planning,
organizing, abstract reasoning, problem solving,
and making judgments, which may make it difficult
to resume pre-injury work-related activities. Recovery
from cognitive deficits is greatest within the
first 6 months after the injury and more gradual
after that.
Patients with moderate to severe TBI have more
problems with cognitive deficits than patients
with mild TBI, but a history of several mild TBIs
may have an additive effect, causing cognitive
deficits equal to a moderate or severe injury.
Many TBI patients have sensory problems, especially
problems with vision. Patients may not be able
to register what they are seeing or may be slow
to recognize objects. Also, TBI patients often
have difficulty with hand-eye coordination. Because
of this, TBI patients may be prone to bumping into
or dropping objects, or may seem generally unsteady.
TBI patients may have difficulty driving a car,
working complex machinery, or playing sports. Other
sensory deficits may include problems with hearing,
smell, taste, or touch. Some TBI patients develop
tinnitus, a ringing or roaring in the ears. A person
with damage to the part of the brain that processes
taste or smell may develop a persistent bitter
taste in the mouth or perceive a persistent noxious
smell. Damage to the part of the brain that controls
the sense of touch may cause a TBI patient to develop
persistent skin tingling, itching, or pain. Although
rare, these conditions are hard to treat.
Language and communication problems are common
disabilities in TBI patients. Some may experience aphasia ,
defined as difficulty with understanding and producing
spoken and written language; others may have difficulty
with the more subtle aspects of communication,
such as body language and emotional, non-verbal
signals.
In non-fluent aphasia , also called Broca's
aphasia or motor aphasia, TBI patients often have
trouble recalling words and speaking in complete
sentences. They may speak in broken phrases and
pause frequently. Most patients are aware of these
deficits and may become extremely frustrated. Patients
with fluent aphasia , also called Wernicke's
aphasia or sensory aphasia, display little meaning
in their speech, even though they speak in complete
sentences and use correct grammar. Instead, they
speak in flowing gibberish, drawing out their sentences
with non-essential and invented words. Many patients
with fluent aphasia are unaware that they make
little sense and become angry with others for not
understanding them. Patients with global aphasia have
extensive damage to the portions of the brain responsible
for language and often suffer severe communication
disabilities.
TBI patients may have problems with spoken language
if the part of the brain that controls speech muscles
is damaged. In this disorder, called dysarthria ,
the patient can think of the appropriate language,
but cannot easily speak the words because they
are unable to use the muscles needed to form the
words and produce the sounds. Speech is often slow,
slurred, and garbled. Some may have problems with
intonation or inflection, called prosodic dysfunction .
An important aspect of speech, inflection conveys
emotional meaning and is necessary for certain
aspects of language, such as irony.
These language deficits can lead
to miscommunication, confusion, and frustration
for the patient as well as those interacting
with him or her.
Most TBI patients have emotional or behavioral
problems that fit under the broad category of
psychiatric health. Family members of TBI patients
often find that personality changes and behavioral
problems are the most difficult disabilities
to handle. Psychiatric problems that may surface
include depression, apathy, anxiety, irritability,
anger, paranoia, confusion, frustration, agitation,
insomnia or other sleep problems, and mood swings.
Problem behaviors may include aggression and
violence, impulsivity, disinhibition, acting
out, noncompliance, social inappropriateness,
emotional outbursts, childish behavior, impaired
self-control, impaired selfawareness, inability
to take responsibility or accept criticism, egocentrism,
inappropriate sexual activity, and alcohol or
drug abuse/addiction. Some patients' personality
problems may be so severe that they are diagnosed
with borderline personality disorder, a psychiatric
condition characterized by many of the problems
mentioned above. Sometimes TBI patients suffer
from developmental stagnation, meaning that they
fail to mature emotionally, socially, or psychologically
after the trauma. This is a serious problem for
children and young adults who suffer from a TBI.
Attitudes and behaviors that are appropriate
for a child or teenager become inappropriate
in adulthood. Many TBI patients who show psychiatric
or behavioral problems can be helped with medication
and psychotherapy.
Are There Other
Long-Term Problems Associated With a TBI?
In addition to the immediate post-injury complications
discussed, other long-term problems
can develop after a TBI. These include Parkinson's
disease and other motor problems, Alzheimer's
disease, dementia pugilistica , and
post-traumatic dementia.
Alzheimer's disease (AD) - AD is a
progressive, neurodegenerative disease characterized
by dementia, memory loss, and deteriorating cognitive
abilities. Recent research suggests an association
between head injury in early adulthood and the
development of AD later in life; the more severe
the head injury, the greater the risk of developing
AD. Some evidence indicates that a head injury
may interact with other factors to trigger the
disease and may hasten the onset of the disease
in individuals already at risk. For example,
people who have a particular form of the protein
apolipoprotein E (apoE4) and suffer a head injury
fall into this increased risk category. (ApoE4
is a naturally occurring protein that helps transport
cholesterol through the bloodstream.)
Parkinson's disease and other motor problems -
Movement disorders as a result of TBI are rare
but can occur. Parkinson's disease may develop
years after TBI as a result of damage to the
basal ganglia. Symptoms of Parkinson's disease
include tremor or trembling, rigidity or stiffness,
slow movement (bradykinesia), inability to move
(akinesia), shuffling walk, and stooped posture.
Despite many scientific advances in recent years,
Parkinson's disease remains a chronic and progressive
disorder, meaning that it is incurable and will
progress in severity until the end of life. Other
movement disorders that may develop after TBI
include tremor, ataxia (uncoordinated muscle
movements), and myoclonus (shock-like contractions
of muscles).
Dementia pugilistica - Also called
chronic traumatic encephalopathy, dementia pugilistica
primarily affects career boxers. The most common
symptoms of the condition are dementia and parkinsonism
caused by repetitive blows to the head over a
long period of time. Symptoms begin anywhere
between 6 and 40 years after the start of a boxing
career, with an average onset of about 16 years.
Post-traumatic dementia - The symptoms
of post-traumatic dementia are very similar to
those of dementia pugilistica, except that post-traumatic
dementia is also characterized by long-term memory
problems and is caused by a single, severe TBI
that results in a coma.
What Kinds of
Rehabilitation Should a TBI Patient Receive?
Rehabilitation is an important
part of the recovery process for a TBI patient.
During the acute stage, moderately to severely
injured patients may receive treatment and
care in an intensive care unit of a hospital.
Once stable, the patient may be transferred
to a subacute unit of the medical center or
to an independent rehabilitation hospital.
At this point, patients follow many diverse
paths toward recovery because there are a wide
variety of options for rehabilitation.
In 1998, the NIH held a Consensus Development
Conference on Rehabilitation of Persons with
Traumatic Brain Injury. The Consensus
Development Panel recommended that TBI patients
receive an individualized rehabilitation
program based upon the patient's strengths
and capacities and that rehabilitation services
should be modified over time to adapt to
the patient's changing needs. The panel
also recommended that moderately to severely
injured patients receive rehabilitation treatment
that draws on the skills of many specialists.
This involves individually tailored treatment
programs in the areas of physical therapy,
occupational therapy, speech/language therapy,
physiatry (physical medicine), psychology/psychiatry,
and social support. Medical personnel who
provide this care include rehabilitation
specialists, such as rehabilitation nurses,
psychologists, speech/language pathologists,
physical and occupational therapists, physiatrists
(physical medicine specialists), social workers,
and a team coordinator or administrator.
The overall goal of rehabilitation
after a TBI is to improve the patient's ability
to function at home and in society. Therapists
help the patient adapt to disabilities or
change the patient's living space, called
environmental modification, to make everyday
activities easier.
Some patients may need medication for psychiatric
and physical problems resulting from the
TBI. Great care must be taken in prescribing
medications because TBI patients are more
susceptible to side effects and may react
adversely to some pharmacological agents.
It is important for the family to provide
social support for the patient by being involved
in the rehabilitation program. Family members
may also benefit from psychotherapy.
It is important for TBI patients and their
families to select the most appropriate setting
for rehabilitation. There are several options,
including home-based rehabilitation, hospital
outpatient rehabilitation, inpatient rehabilitation
centers, comprehensive day programs at rehabilitation
centers, supportive living programs, independent
living centers, club-house programs, schoolbased
programs for children, and others. The TBI
patient, the family, and the rehabilitation
team members should work together to find
the best place for the patient to recover.
How Can TBI
be Prevented?
Unlike most neurological disorders, head
injuries can be prevented. The Centers for
Disease Control and Prevention (CDC) have
issued the following safety tips for reducing
the risk of suffering a TBI.
- Wear a seatbelt every time you drive
or ride in a car.
- Buckle your child into a child safety
seat, booster seat, or seatbelt (depending
on the child's age) every time the child
rides in a car.
- Wear a helmet and make sure your children
wear helmets when
- riding a bike or motorcycle;
- playing a contact sport such
as football or ice hockey;
- using in-line skates or riding
a skateboard;
- batting and running bases in
baseball or softball;
- riding a horse;
- skiing or snowboarding.
- Keep firearms and bullets stored in
a locked cabinet when not in use.
- Avoid falls by
- using a step-stool with a grab
bar to reach objects on high shelves;
- installing handrails on stairways;
- installing window guards to keep
young children from falling out
of open windows;
- using safety gates at the top
and bottom of stairs when young
children are around.
- Make sure the surface on your child's
playground is made of shock-absorbing
material (e.g., hardwood mulch, sand).
To read the rest of this excellent article from the National
Institute of Neurological Disorders and Stroke, please click
here: http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm
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