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The Brain Injury Association of America defines a traumatic brain injury as an insult to the brain, not of degenerative or congenital nature, caused by an external physical force that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning.Any injury to the head may cause traumatic brain injury (TBI). There are two major types of TBI:
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Penetrating Injuries: In these injuries, a foreign object (e.g., a bullet) enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged.
Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage:
People with a brain injury often have cognitive (thinking) and communication problems that significantly impair their ability to live independently. These problems vary depending on how widespread brain damage is and the location of the injury.
Brain injury survivors may have trouble finding the words they need to express an idea or explain themselves through speaking and/or writing. It may be an effort for them to understand both written and spoken messages, as if they were trying to comprehend a foreign language. They may have difficulty with spelling, writing, and reading, as well.
The person may have trouble with social communication, including:
taking turns in conversation
maintaining a topic of conversation
using an appropriate tone of voice
interpreting the subtleties of conversation (e.g., the difference between sarcasm and a serious statement)
responding to facial expressions and body language
keeping up with others in a fast-paced conversation
Individuals may seem overemotional (overreacting) or “flat” (without emotional affect). Most frustrating to families and friends, a person may have little to no awareness of just how inappropriate he or she is acting. In general, communication can be very frustrating and unsuccessful.
In addition to all of the above, muscles of the lips and tongue may be weaker or less coordinated after TBI. The person may have trouble speaking clearly. The person may not be able to speak loudly enough to be heard in conversation. Muscles may be so weak that the person is unable to speak at all. Weak muscles may also limit the ability to chew and swallow effectively.
Treating traumatic brain injury occurs when a patient is admitted to the hospital. Doctors work diligently to stabilize his or her condition, which can include unblocking airways, maintaining blood flow to the brain and, in extreme cases, resuscitation. In addition, doctors treat open wounds and administer antibiotics to prevent infection. Once a patient has stabilized, his or her doctors may order MRI scans, CT scans, or X-rays to help assess the level of brain damage. Doctors may also prescribe anti-convulsion medication to prevent seizures.
In some instances, traumatic brain injury can lead to increased intracranial pressure. These cases often require surgery to accommodate brain swelling and excess fluid. Open head injuries may require surgery to remove broken skull fragments and insert synthetic pieces that protect delicate brain tissue.
Traumatic brain injury rehabilitation is an important part of treatment because it helps patients regain or manage impaired brain functions and minimizes long-term traumatic brain injury disabilities. Through rehabilitation, patients are sometimes able to regain important brain functions such as speech, memory and mobility. Rehabilitation can also help a victim’s family cope with the tragedy.
Traumatic brain injury has many other causes, complications and treatments. Please read other articles on this site for more information on diagnosis, treatment and prevention of traumatic brain injury.
The recovery process is different for everyone. Just as no two people are alike, no two brain injuries are alike. Recovery is typically lengthy-from months to years-because the brain takes a long time to heal. These tips, directed at the person with a brain injury, will help your loved one improve after the injury:
Get lots of rest.
Avoid doing anything that could cause another blow or jolt to the head.
Ask the doctor when it’s safe to drive a car, ride a bike, play sports or use heavy equipment, because reaction time may be slower after a brain injury.
Take prescription medication according to thedoctor’s instructions.
Do not drink alcohol or use street drugs.
Write things down to help with memory problems.
Ask the doctor to recommend rehabilitation services that might help recovery, and follow those recommendations
Mild traumatic brain injuries usually require no treatment other than rest and over-the-counter pain relievers to treat a headache. However, a person with a mild traumatic brain injury usually needs to be monitored closely at home for any persistent, worsening or new symptoms. He or she also may have follow-up doctor appointments.
The doctor will indicate when a return to work, school or recreational activities is appropriate. It’s best to avoid physical or thinking (cognitive) activities until symptoms have stopped. Most people return to normal routines gradually.
Immediate emergency care
Emergency care for moderate to severe traumatic brain injuries focuses on making sure the person has an adequate oxygen and blood supply, maintaining blood pressure, and preventing any further injury to the head or neck. People with severe injuries may also have other injuries that need to be addressed.
Additional treatments in the emergency room or intensive care unit of a hospital will focus on minimizing secondary damage due to inflammation, bleeding or reduced oxygen supply to the brain.
Medications to limit secondary damage to the brain immediately after an injury may include:
Diuretics. These drugs reduce the amount of fluid in tissues and increase urine output. Diuretics, given intravenously to people with traumatic brain injury, help reduce pressure inside the brain.
Anti-seizure drugs. People who’ve had a moderate to severe traumatic brain injury are at risk of having seizures during the first week after their injury. An anti-seizure drug may be given during the first week to avoid any additional brain damage that might be caused by a seizure. Additional anti-seizure treatments are used only if seizures occur.
Coma-inducing drugs. Doctors sometimes use drugs to put people into temporary comas because a comatose brain needs less oxygen to function. This is especially helpful if blood vessels, compressed by increased pressure in the brain, are unable to deliver the usual amount of nutrients and oxygen to brain cells.
Emergency surgery may be needed to minimize additional damage to brain tissues. Surgery may be used to address the following problems:
Removing clotted blood (hematomas). Bleeding outside or within the brain can result in a collection of clotted blood (hematoma) that puts pressure on the brain and damages brain tissue.
Repairing skull fractures. Surgery may be needed to repair severe skull fractures or to remove pieces of skull in the brain.
Opening a window in the skull. Surgery may be used to relieve pressure inside the skull by draining accumulated cerebral spinal fluid or creating a window in the skull that provides more room for swollen tissues.
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Most people who have had a significant brain injury will require rehabilitation. They may need to relearn basic skills, such as walking or talking. The goal is to improve their abilities to perform daily activities.
Therapy usually begins in the hospital and continues at an inpatient rehabilitation unit, a residential treatment facility or through outpatient services. The type and duration of rehabilitation varies by individual, depending on the severity of the brain injury and what part of the brain was injured. Rehabilitation specialists may include:
Physiatrist, a doctor trained in physical medicine and rehabilitation, who oversees the entire rehabilitation process
Occupational therapist who helps the person learn, relearn or improve skills to perform everyday activities
Physical therapist, who helps with mobility and relearning movement patterns, balance and walking
Speech and language pathologist, who helps the person improve communication skills and use assistive communication devices if necessary
Neuropsychologist or psychiatrist, who helps the person manage behaviors or learn coping strategies, provides talk therapy as needed for emotional and psychological well-being, and prescribes medication as needed
Social worker or case manager, who facilitates access to service agencies, assists with care decisions and planning, and facilitates communication among various professionals, care providers and family members
Rehabilitation nurse, who provides ongoing rehabilitation care and services and who helps with discharge planning from the hospital or rehabilitation facility
Traumatic brain injury nurse specialist, who helps coordinate care and educates the family about the injury and recovery process
Recreational therapist, who assists with leisure activities
Vocational counselor, who assesses the ability to return to work and appropriate vocational opportunities, and provides resources for addressing common challenges in the workplace
Prognosis (or Chance of Recovery)
It is difficult to predict how well someone who has had a brain injury will recover, partly because there is no test a doctor can use to predict recovery. The Glasgow Coma Scale is used to determine the initial severity of a brain injury. It is often used at the scene of the accident or in the emergency room. This scale uses eye movements and ability to speak and move other parts of the body to determine the seriousness of the injury. Ask your doctor to explain the tests used to determine your loved one’s ability to recover.
Your loved one’s prognosis will depend on many factors, including the severity of the injury, the type of injury, and what parts of the brain have been affected. Prompt diagnosis and treatment will help the recovery process.
In discussing possible effects of TBI, the immediate physiological recovery (which may continue over months and years) was discussed in a prior question. When the moderately or severely injured person has completed this initial recovery, the long-term functional deficits associated with TBI come to the fore. What areas of functioning may be affected by injury to the brain? Any or all of the functions the brain controls may be impacted. However, given that individuals differ greatly in their response to injury, any specific individual may experience only one, a few, or most of the possible effects. Further, a change in any of the possible areas of dysfunction, if it occurs at all, will vary in intensity across individuals – from very subtle to moderate to life threatening.
It is important to be aware also that not all functions of the individual are impacted by TBI. For example, feelings toward family, long-term memories, the ability to ski or cook, one’s knowledge of the world, and so forth – all may be intact, along with numerous other characteristics of an individual, even one who has experienced a moderate to severe injury.
Individuals with a moderate-to-severe brain injury most typically experience problems in basic cognitive skills: sustaining attention, concentrating on tasks at hand, and remembering newly learned material. They may think slowly, speak slowly, and solve problems slowly. They may become confused easily when normal routines are changed or when the stimulation level from the environment exceeds their threshold. They may persevere at tasks too long, being unable to switch to a different tactic or a new task when encountering difficulties. Or, on the other hand, they may jump at the first “solution” they see, substituting impulsive responses for considered actions. They may be unable to go beyond a concrete appreciation of situations, to find abstract principles that are necessary to carry learning into new situations. Their speech and language may be impaired: word-finding problems, understanding the language of others, and the like.
A major class of cognitive abilities that may be affected by TBI is referred to as executive functions – the complex processing of large amounts of intricate information that we need to function creatively, competently and independently as beings in a complex world. Thus, after injury, individuals with TBI may be unable to function well in their social roles because of difficulty in planning ahead, in keeping track of time, in coordinating complex events, in making decisions based on broad input, in adapting to changes in life, and in otherwise “being the executive” in one’s own life.
With appropriate training and other supports, the person may be able to learn to compensate for some of these cognitive difficulties.
TBI may cause emotional, social, or behavioral problems and changes in personality. These may include emotional instability, depression, anxiety,hypomania, mania, apathy, irritability, problems with social judgment, and impaired conversational skills. TBI appears to predispose survivors to psychiatric disorders including obsessive compulsive disorder, substance abuse, dysthymia, clinical depression, bipolar disorder, and anxiety disorders. In patients who have depression after TBI, suicidal ideation is not uncommon; the suicide rate among these persons is increased 2- to 3-fold. Social and behavioral symptoms that can follow TBI include disinhibition, inability to control anger, impulsiveness, lack of initiative, inappropriate sexual activity, poor social judgment, and changes in personality. With TBI, the systems in the brain that control our social-emotional lives often are damaged. The consequences for the individual and for his or her significant others may be very difficult, as these changes may imply to them that “the person who once was” is “no longer there.” Thus, personality can be substantially or subtly modified following injury. The person who was once an optimist may now be depressed. The previously tactful and socially skilled negotiator may now be blurting comments that embarrass those around him/her. The person may also be characterized by a variety of other behaviors: dependent behaviors, emotional swings, lack of motivation, irritability, aggression, lethargy, being very uninhibited, and/or being unable to modify behavior to fit varying situations.
A very important change that affects many people with TBI is referred to as denial (or, lack of awareness): The person becomes unable to compare post-injury behavior and abilities with pre-injury behavior and abilities. For these individuals, the effects of TBI are, for whatever reason, simply not perceived – whether for emotional reasons, as a means of avoiding the pain of fully facing the consequences of injury, or for neurological reasons, in which brain damage itself limits the individual’s ability to step back, compare, evaluate differences, and reach a conclusion based on that process.
With appropriate training, therapy, and other supports, the person may be able to reduce the impact of some of these emotional and behavioral difficulties.
The TBI Research Center at Mount Sinai is conducting research to help people with TBI who experience depression and other mood disturbances
Useful Resources & Services for Families Affected by TBI
National Disability Rights Network Protection and Advocacy for Individuals with Disabilities
Protection and Advocacy (P&A) System and Client Assistance Program (CAP)
This nationwide network of congressionally mandated disability rights agencies provides various services to people with disabilities, including TBI. P&A agencies provide information and referral services and help people with disabilities find solutions to problems involving discrimination and employment, education, health care and transportation, personal decision-making, and Social Security disability benefits. These agencies also provide individual and family advocacy. CAP agencies help clients seeking vocational rehabilitation. For more information on P&A and CAP programs, contact the National Disability Rights Network at: www.napas.org or (202) 408-9514.
Traumatic Brain Injury Model Systems
Funded through the National Institute on Disability and Rehabilitation Research, the TBI Model Systems consist of 16 TBI treatment centers throughout the U.S. The TBI Model Systems have extensive experience treating people with TBI and are linked to well established medical centers which provide high quality trauma care from the onset of head injury through the rehabilitation process.
For more information on the TBI Model Systems, go towww.tbindsc.org/Centers/centers.asp or call the TBI Project Coordinator at (973) 414-4723 to find the center nearest you.
Brain Injury Association of America (BIAA) Chartered State Affiliates
BIAA is a national program with a network of more than 40 chartered state affiliates, as well as hundreds of local chapters providing information, education and support to individuals, families and professionals affected by brain injury.
To locate your state’s TBI programs that can be of assistance, visit the Brain Injury Association of America’s online listing of chartered state affiliates at www.biausa.org/stateoffices.htm, or call (800) 444-6443.
Social Security Disability Insurance (SSDI) & Supplemental Security Income (SSI)
It is possible that your loved one may be entitled to SSDI and/or SSI. SSDI and SSI eligibility is dependent on a number of factors including the severity of the disability and what assets and income your loved one has. You should contact the Social Security Administration to find out more about these programs and whether your loved one will qualify for these benefits. For more information on SSDI and SSI, contact the Social Security Administration at www.ssa.gov or (800) 772-1213.
Centers for Independent Living (CIL)
Some families have found that it is important to encourage their loved one with a TBI to continually learn skills that can allow them to live independently in the community.
The CILs exist nationwide to help people with disabilities live independently in the community and may have resources to help your loved one reach a goal of living alone. CIL services include advocacy, peer counseling, case management, personal assistance and counseling, information and referral, and independent living skills development. For more information on the CIL system, contact the National Council on Independent Living at www.virtualcil.net/cils or (703) 525-3406.
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