TRAUMATIC BRAIN INJURY(TBI) KRISNADAS PAL

What is Traumatic Brain injury?

Traumatic brain injury is defined as damage to the brain resulting from external mechanical
force, such as rapid acceleration or deceleration impact, blast waves, or penetration by a
projectile, leading to temporary or permanent impairment of brain function.
Traumatic brain injury (TBI) has a dramatic impact on the health of the nation: it accounts for
15–20% of deaths in people aged 5–35 yr old, and is responsible for 1% of all adult deaths.
TBI is a major cause of death and disability worldwide, especially in children and young
adults. Males sustain traumatic brain injuries more frequently than do females.
Approximately 1.4 million people in the UK suffer a head injury every year, resulting in
nearly 150 000 hospital admissions per year. Of these, approximately 3500 patients require
admission to ICU. The overall mortality in severe TBI, defined as a post-resuscitation
Glasgow Coma Score (GCS) ≤8, is 23%. In addition to the high mortality, approximately
60% of survivors have significant ongoing deficits including cognitive competency, major
activity, and leisure and recreation. This has a severe financial, emotional, and social impact
on survivors left with lifelong disability and on their families.
It is well established that the major determinant of outcome from TBI is the severity of the
primary injury, which is irreversible. However, secondary injury, primarily cerebral
ischaemia, occurring in the post-injury phase, may be due to intracranial hypertension,
systemic hypotension, hypoxia, hyperpyrexia, hypocapnia and hypoglycaemia, all of which
have been shown to independently worsen survival after TBI.

Mechanism of injury:
The type, direction, intensity, and duration of forces all contribute to the characteristics and
severity TBI. Forces that may contribute to TBI include angular, rotational, shear,
and translational forces.
Even in the absence of an impact, significant acceleration or deceleration of the head can
cause TBI; however in most cases a combination of impact and acceleration is probably to
blame. Forces involving the head striking or being struck by something,
termed contact or impact loading, are the cause of most focal injuries, and movement of the
brain within the skull, termed noncontact or inertial loading, usually causes diffuse
injuries. The violent shaking of an infant that causes shaken baby syndrome commonly
manifests as diffuse injury. In impact loading, the force sends shock waves through the skull
and brain, resulting in tissue damage. Shock waves caused by penetrating injuries can also
destroy tissue along the path of a projectile, compounding the damage caused by the missile
itself.
Damage may occur directly under the site of impact, or it may occur on the side opposite the
impact (coup and contrecoup injury, respectively).When a moving object impacts the
stationary head, coup injuries are typical, while contrecoup injuries are usually produced
when the moving head strikes a stationary object.

Pathophysiology:
One type of focal injury, cerebral laceration, occurs when the tissue is cut or torn. Such
tearing is common in orbito frontal cortex in particular, because of bony protrusions on the
interior skull ridge above the eyes. In a similar injury, cerebral contusion (bruising of brain
tissue), blood is mixed among tissue. In contrast, intracranial hemorrhage involves bleeding
that is not mixed with tissue.
Hematomas, also focal lesions, are collections of blood in or around the brain that can result
from hemorrhage. Intra cerebral hemorrhage, with bleeding in the brain tissue itself, is an
intra-axial lesion. Extra-axial lesions include epidural hematoma, subdural
hematoma, subarachnoid hemorrhage, and intra -ventricular hemorrhage. Epidural hematoma
involves bleeding into the area between the skull and the dura mater, the outermost of the
three membranes surrounding the brain. In subdural hematoma, bleeding occurs between the
dura and the arachnoid mater. Subarachnoid hemorrhage involves bleeding into the space 298
between the arachnoid membrane and the pia mater. Intraventricular hemorrhage occurs
when there is bleeding in the ventricles.

Signs and Symptoms(Clinical features):

Symptoms are dependent on the type of TBI (diffuse or focal) and the part of the brain that is
affected. Unconsciousness tends to last longer for people with injuries on the left side of the
brain than for those with injuries on the right. Symptoms are also dependent on the injury's
severity. With mild TBI, the patient may remain conscious or may lose consciousness for a
few seconds or minutes. Other symptoms of mild TBI include headache, vomiting, nausea,
lack of motor coordination, dizziness, difficulty balancing, lightheadedness, blurred vision or
tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, and changes in sleep
patterns. Cognitive and emotional symptoms include behavioral or mood changes, confusion,
and trouble with memory, concentration, attention, or thinking. Mild TBI symptoms may also
be present in moderate and severe injuries.
A person with a moderate or severe TBI may have a headache that does not go away,
repeated vomiting or nausea, convulsions, an inability to awaken, dilation of one or both
pupils, slurred speech, aphasia (word-finding difficulties), dysarthria (muscle weakness that
causes disordered speech), weakness or numbness in the limbs, loss of coordination,
confusion, restlessness, or agitation. Common long-term symptoms of moderate to severe
TBI are changes in appropriate social behavior, deficits in social judgment, and cognitive
changes, especially problems with sustained attention, processing speed, and executive
functioning. Alexithymia, a deficiency in identifying, understanding, processing, and
describing emotions occurs in 60.9% of individuals with TBI. Cognitive and social deficits
have long-term consequences for the daily lives of people with moderate to severe TBI, but
can be improved with appropriate rehabilitation.
When the pressure within the skull (intracranial pressure, abbreviated ICP) rises too high, it
can be deadly. Signs of increased ICP include decreasing level of consciousness, paralysis or
weakness on one side of the body, and a blown pupil, one that fails to constrict in response to
light or is slow to do so. Cushing's triad, a slow heart rate with high blood pressure and
respiratory depression is a classic manifestation of significantly raised ICP. Anisocoria,
unequal pupil size, is another sign of serious TBI. Abnormal posturing, a characteristic
positioning of the limbs caused by severe diffuse injury or high ICP, is an ominous sign.
Unequal pupil size: A sign of serious Brain injury.
Small children with moderate to severe TBI may have some of these symptoms but have
difficulty communicating them. Other signs seen in young children include persistent crying,
inability to be consoled, listlessness, refusal to nurse or eat, and irritability.

Classification of TBI:
TBI is usually classified based on severity, anatomical features of the injury, and the
mechanism (the causative forces).
Severity of TBI by using Glasgow coma scale, PTA and LOC:
Classification systems for determining the severity of TBI may use duration of PTA
alone or with other factors such as Glasgow Coma Scale (GCS) score and duration
of loss of consciousness (LOC) to divide TBI into categories of mild, moderate, and
severe(Table-1).
Table:1
Severity level GCS PTA LOC
Mild 13–15 <1 days 0–30 minutes
Moderate 9–12 >1 to <7days >30 min to<24 hours
Severe 3–8 >7 days >24 hours
Glasgow Coma Scale(Table-2):
Brain injuries can be classified into mild, moderate, and severe categories. The Glasgow
Coma Scale (GCS), the most commonly used system for classifying TBI severity, grades a
person's level of consciousness on a scale of 3–15 based on verbal, motor, and eye-opening
reactions to stimuli. It is generally agreed that a TBI with a GCS of 13 or above is mild, 9–12
is moderate, and 8 or below is severe.301
Table-2.
EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
1-None 1-None 1-None
2-To pain 2-Incomprehensible sounds 2-Abnormal extension
3-To voice 3-Inappropriate words 3-Abnormal flexion.
4-Spontaneously 4-Confused 4-Withdraws from pain.
5-Oriented 5-Localises to pain
6-Obeys commands
Post-traumatic amnesia (PTA):
It is a state of confusion that occurs immediately following a traumatic brain injury (TBI) in which the
injured person is disoriented and unable to remember events that occur after the injury. The term
"posttraumatic amnesia" was first used in 1928 in a paper by Symonds to refer to the period between
the injury and the return of full, continuous memory, including any time during which the patient was
unconscious.The person may be unable to state his or her name, where he or she is, and what time it
is. When continuous memory returns, PTA is considered to have resolved. While PTA lasts,
new events cannot be stored in the memory. About a third of patients with mild head
injury are reported to have "islands of memory", in which the patient can recall only some
events. During PTA, the patient's consciousness is "clouded". Because PTA involves
confusion in addition to the memory loss typical of amnesia, the term "posttraumatic
confusional state" has been proposed as an alternative.
There are two types of amnesia: retrograde amnesia (loss of memories that were formed
shortly before the injury) and anterograde amnesia (problems with creating new memories
after the injury has taken place). Both retrograde and anterograde forms may be referred to as
PTA, or the term may be used to refer only to anterograde amnesia.
PTA has been proposed to be the best measure of head trauma severity, but it may not be a
reliable indicator of outcome. However, PTA duration may be linked to the likelihood that
psychiatric and behavioral problems will occur as consequences of TBI.

PTA is considered a hallmark of concussion, and is used as a measure of predicting its

severity. It may be more reliable for determining severity of concussion than GCS because
the latter may not be sensitive enough; concussion sufferers often quickly regain a GCS score
of 15.
Longer periods of amnesia or loss of consciousness immediately after the injury may indicate
longer recovery times from residual symptoms from concussion. Increased duration of PTA
is associated with a heightened risk for TBI complications such as post-traumatic epilepsy.
The severity of TBI using PTA alone is shown in table-3.
Table-3
SEVERITY PTA
VERY MILD < 5 MINUTES
MILD 5-60 MINUTES
MODERATE 1-24 HOURS
SEVERE 1-7 DAYS
VERY SEVERE 1-4 WEEKS
EXTREMELY SEVERE >4WEEKS

Mechanism-related classification divides TBI into:

i. Closed injury: A closed (also called non penetrating, or blunt) injury occurs when the
brain is not exposed.303
ii. Penetrating head injury: . A penetrating, or open, head injury occurs when an object
pierces the skull and breaches the dura mater, the outermost membrane surrounding the
brain..
Classification of TBI by its pathological(Anatomical) features:
Lesions can be extra-axial, (occurring within the skull but outside of the brain) or intra-axial
(occurring within the brain tissue). Damage from TBI can be focal or diffuse, confined to
specific areas or distributed in a more general manner, respectively. However, it is common
for both types of injury to exist in a given case.

Diagnostic tools:
Some of the current imaging techniques used for diagnosis and treatment include CT
scans and MRIs . Besides the diagnostic tools clinical examination and use of Glasgow
coma scale help to dignose and grade the severity of the injury. The preferred radiologic test
in the emergency setting is computed tomography (CT): it is quick, accurate, and widely
available.Followup CT scans may be performed later to determine whether the injury has
progressed.
Magnetic resonance imaging (MRI) can show more detail than CT, and can add information
about expected outcome in the long term. It is more useful than CT for detecting injury
characteristics such as diffuse axonal injury in the longer term.However, MRI is not used in
the emergency setting for reasons including its relative inefficacy in detecting bleeds and
fractures, its lengthy acquisition of images, the inaccessibility of the patient in the machine,
and its incompatibility with metal items used in emergency care.A variant of MRI since 2012
is High definition fiber tracking (HDFT).
Other techniques may be used to confirm a particular diagnosis. X-rays are still used for head
trauma, but evidence suggests they are not useful; head injuries are either so mild that they do
not need imaging or severe enough to merit the more accurate CT.Angiography may be used
to detect blood vessel pathology when risk factors such as penetrating head trauma are
involved..
Functional imaging can measure cerebral blood flow or metabolism, inferring
neuronal activity in specific regions and potentially helping to predict
outcome. Electroencephalography and transcranial doppler may also be used. The most 304
sensitive physical measure to date is the quantitative EEG which has documented an 80% to
100% ability in discriminating between normals and traumatic brain injured subjects.
Treatment of Traumatic Brain Injury:
Depending on the injury, treatment required may be minimal or may include interventions
such as medications, emergency surgery or surgery years later. Physical therapy, speech
therapy, recreation therapy, occupational therapy and vision therapy are to be employed for
facilitation of recovery and rehabilitation.
It is important to begin emergency treatment within the so-called "golden hour" following the
injury. People with moderate to severe injuries are likely to receive treatment in an intensive
care unit followed by a neurosurgical ward. Treatment depends on the recovery stage of the
patient. In the acute stage the primary aim of the medical personnel is to stabilize the patient
and focus on preventing further injury because little can be done to reverse the initial damage
caused by trauma. Rehabilitation is the main treatment for the sub acute and chronic stages of
recovery.309
Treatment Acute Stage:
Certain facilities are equipped to handle TBI better than others; initial measures include
transporting patients to an appropriate treatment center. Both during transport and in hospital
the primary concerns are ensuring proper oxygen supply, maintaining adequate cerebral
blood flow, and controlling raised intracranial pressure (ICP), since high ICP deprives the
brain of badly needed blood flow and can cause deadly brain herniation. Other methods to
prevent damage include management of other injuries and prevention of seizures.
Neuroimaging is helpful but not flawless in detecting raised ICP. A more accurate way to
measure ICP is to place a catheter into a ventricle of the brain, which has the added benefit of
allowing cerebrospinal fluid to drain, releasing pressure in the skull.Treatment of raised ICP
may be as simple as tilting the patient's bed and straightening the head to promote blood flow
through the veins of the neck. Sedatives, analgesics and paralytic agents are often
used. Hypertonic saline can improve ICP by reducing the amount of cerebral water
(swelling), though it is used with caution to avoid electrolyte imbalances or heart
failure. Mannitol, an osmotic diuretic, was also studied for this purpose, but such studies have
been heavily questioned..Diuretics, drugs that increase urine output to reduce excessive fluid
in the system, may be used to treat high intracranial pressures, but may
cause hypovolemia (insufficient blood volume). Hyperventilation (larger and/or faster
breaths) reduces carbon dioxide levels and causes blood vessels to constrict; this decreases
blood flow to the brain and reduces ICP, but it potentially causes ischemia and is, therefore,
used only in the short term. Administration of corticosteroids is associated with an increased
risk of death, and so it is recommended that they not be given routinely.
Endotracheal intubation and mechanical ventilation may be used to ensure proper oxygen
supply and provide a secure airway. Hypotension (low blood pressure), which has a
devastating outcome in TBI, can be prevented by giving intravenous fluids to maintain a
normal blood pressure. Failing to maintain blood pressure can result in inadequate blood flow
to the brain. Blood pressure may be kept at an artificially high level under controlled
conditions by infusion of norepinephrine or similar drugs; this helps maintain
cerebral perfusion. Body temperature is carefully regulated because increased temperature
raises the brain's metabolic needs, potentially depriving it of nutrients. Seizures are common.
While they can be treated with benzodiazepines, these drugs are used carefully because they
can depress breathing and lower blood pressure. TBI patients are more susceptible to side
effects and may react adversely or be inordinately sensitive to 310
some pharmacological agents. During treatment monitoring continues for signs of
deterioration such as a decreasing level of consciousness.
Traumatic brain injury may cause a range of serious coincidental complications which
include cardiac arrhythmias and neurogenic pulmonary edema. These conditions must be
adequately treated and stabilised as part of the core care for these patients.
Surgery can be performed on mass lesions or to eliminate objects that have penetrated the
brain. Mass lesions such as contusions or hematomas causing a significant mass effect (shift
of intracranial structures) are considered emergencies and are removed surgically. For
intracranial hematomas, the collected blood may be removed using suction or forceps or it
may be floated off with water. Surgeons look for hemorrhaging blood vessels and seek to
control bleeding. In penetrating brain injury, damaged tissue is surgically debrided,
and craniotomy may be needed. Craniotomy, in which part of the skull is removed, may be
needed to remove pieces of fractured skull or objects embedded in the brain. Decompressive
craniectomy (DC) is performed routinely in the very short period following TBI during
operations to treat hematomas; part of the skull is removed temporarily (primary DC). DC
performed hours or days after TBI in order to control high intracranial pressures (secondary
DC) has not been shown to improve outcome in some trials and may be associated with
severe side effects.
Intensive care management of TBI:
Management of TBI in intensive care is targeted at optimizing cerebral perfusion,
oxygenation and avoiding secondary insults. There is good evidence that protocolized
management leads to improved outcome after TBI and may be further improved by treatment
within a specialist neuroscience critical care unit.Most clinically adopted protocols for
management of TBI are based around providing good basic intensive care and interventions
to target cerebral perfusion pressure (CPP) and intracranial pressure (ICP). The following
figure(Figure-6) shows an intensive care unit, where Physicians, Surgeons, Physiotherapists
and Nurses work in a team approach.311
Treatment Chronic Stage::
Once medically stable, patients may be transferred to a sub acute rehabilitation unit of the
medical center or to an independent rehabilitation hospital. Rehabilitation aims to improve
independent function at home and in society and to help adapt to disabilities and has
demonstrated its general effectiveness, when conducted by a team of health professionals
who specialise in head trauma. As for any patient with neurologic deficits, an
interdisciplinary approach is key to optimising outcome. The interdisciplinary team include
the Physiatrists or neurologists , Physiotherapy, Speech and language therapy, cognitive
rehabilitation therapy, and occupational therapy etc. The aim of the team will be to assess
function and design the rehabilitation activities for each patient. Treatment
Neuropsychiatric symptoms such as emotional distress and clinical depression may
involve mental health professionals such as therapists, psychologists, and psychiatrists,
while neuropsychologists can help to evaluate and manage cognitive deficits.

Physiotherapy for Traumatic Brain Injury :

Physiotherapy to TBI patients is employed both in the Acute and Chronic stages of the
condition. The aim of Physiotherapy in different stages of the condition are as follows:

1. Acute stage: The physiotherapist works along with the medical and nursing team in
and out of ICU in the acute stage, with the following aims:
i. Positioning and turning of the patient(if allowed) to maintain soft tissue length, and prevent pressure
ulcer formation.
ii. Regular passive movements to maintain joint range of motion.
iii. Breathing techniques and postural drainage without head tilt, without or with suction to remove
secretions(if not ventilated).
iv. To note the vital signs and asses the conscious level periodically, to assist the Physician/Surgeon to
judge prognosis and plan further management.
2. Chronic stage:
The aim of Physiotherapy in the chronic stage include:312
i. To normalize muscle tone.
ii. To improve strength, endurance.
iii. To improve posture and balance.
iv. Restore function.
v. Assist in the Rehabilitation .
The aim of rehabilitation is to improve /restore mobility with or without Orthotics and
walking aids and enable to achieve ADL/IADL with or without adaptive technology. After
discharge from the inpatient rehabilitation treatment unit, care may be given on
an outpatient basis. Community-based rehabilitation will be required for a high proportion of
patients, including vocational rehabilitation; this supportive employment matches job
demands to the worker's abilities. People with TBI who cannot live independently or with
family may require care in supported living facilities such as group homes. Respite care,
including day centers and leisure facilities for the disabled, offers time off for caregivers, and
activities for people with TBI.
Pharmacological treatment can help to manage psychiatric or behavioral
problems. Medication is also used to control post-traumatic epilepsy; however the preventive
use of anti-epileptics is not recommended. In those cases where the person is bedridden due
to a reduction of consciousness, has to remain in a wheelchair because of mobility problems,
or has any other problem heavily impacting self-caring capacities, caregiving and nursing are
critical. The most effective research documented intervention approach is the activation
database guided EEG biofeedback approach which has shown significant improvements in
memory abilities of the TBI subject which are far superior than traditional approaches
(strategies, computers, medication intervention).

Outcome of TBI :
It can cause a host of physical, cognitive, social, emotional, and behavioral effects, and
outcome can range from complete recovery to permanent disability or death.

Prevention measures:
Prevention measures include use of technology to protect those suffering from automobile
accidents, such as seat belts and sports or motorcycle helmets, as well as efforts to reduce the
number of automobile accidents, such as safety education programs and enforcement of
traffic laws.
Role of Occupational therapy in management of Cognitive and perceptual dysfunction of
head injured patients
Cognitive and perceptual problems are two most puzzling and disabling
difficulties that a person can experience .Thinking, remembering ,reasoning and making
sense of the world around us are fundamental to carrying out everyday living activities.
Problem with these may create devastating effect on individual’s life and the lives of his or
her family.
What is it?
Cognition is the process of knowing including awareness, reasoning, judgment,
intuition and memory.
Perception is the integration of sensory impression into information i.e. psychologically meaningful.
Clinical indicators
It causes diminished level of functioning in all patients experienced brain damage.
Patients may show the following characteristics,
.

lsively.

object to another.

n recalling old or remembering recent memories.

How an occupational therapist can help
Occupational therapist is the member of rehabilitation team who are specially trained
to examine and treat cognitive and perceptual deficits in relation to functional adaptation.
There are step by step approaches to make the patient maximally independent in his or her
life.
An occupational therapist leads a person to be not only physically fit but also
emotionally and socially well adjustable to re integrate him or her in the society.
The different steps of occupational therapy intervention includes,
he functions needed to enhance performance.
eat an adaptive motor response
and thus facilitate the improvement of cognitive and perceptual dysfunction.

to illness to recover functional abilities.

ensatory techniques and fabricate splints and assistive devices to make the person
maximally independent where any deficit persists.
e illness and necessary safety procedures.
to reintegrate these persons into the society.

Thus an occupational therapist can help a person with cognitive and perceptual
impairment along with physical dysfunction, starting from acute care up to the re-integration
or re-establishment of that person in the society.