Traumatic Brain Injury (TBI) Flashcards
Traumatic brain injury (diagram on slide 3)
- brain dysfunction caused by an outside force, usually a blow to the head
- characterized by the severity of the initial blow = mild TBI, moderate TBI, or severe TBI
- external injury caused by a force towards the head
Non-traumatic brain injury (nTBI)
- brain dysfunction caused by an internal event
- includes things like stroke, anoxia, tumor, infection, aneurysm, metabolic disorders, or toxic exposure
Other commonly used brain injury terms
- acquired brain injury (ABI) = refers to any brain injury (BI) that was acquired after birth (not congenital)
- concussion = mostly used to describe mild TBI (not used consistently and often misunderstood)
Causes of brain injury (diagram on slide 4)
- stroke
- anoxic/hypoxic
- poison
- virus
- tumor
- fall
- motor vehicle accident
- stroke by an object
- sports
- IED (bomb or destructive device)
Traumatic brain injury (TBI)
- a nondegenerative, noncongenital alteration in brain function caused by an external force
Brain trauma that includes at least one of the following: - loss of consciousness
- posttraumatic amnesia (don’t know where you are)
- disorientation and confusion
Severe cases: - positive neuroimaging
- seizures
- visual deficits
- sensory loss
- hemiparesis
(Would not be able to see anything in mild cases in MRIs or CAT scans)
Classifications (levels) of TBI
- mild
- moderate
- severe
- based on loss of consciousness or coma, posttraumatic amnesia, and disorientation and confusion at the initial assessment
Glasgow Coma Scale (diagram on slide 7)
Eye opening:
- spontaneous = 4
- to sound = 3
- to pressure = 2
- none = 1
Verbal response:
- orientated = 5
- confused = 4
- words = 3
- sounds = 2
- none = 1
Motor response:
- obey commands = 6
- localizing = 5
- normal flexion = 4
- abnormal flexion = 3
- extension = 2
- none = 1
Scores:
- mild = 13-15
- moderate = 9-12
- severe = 3-8
Diagram on slide 9
PTA (post-traumatic amnesia) = how long did it take them to come out of LOC (loss of consciousness)
- mild = less than 30 min (duration of LOC) and 1 day (duration of PTA)
- moderate = 30min-24 hrs (duration of LOC) and 1-7 days (duration of PTA)
- severe = more than 24 hrs (duration of LOC) and more than 7 days (duration of PTA)
Concussions
- a type of mild TBI (induced by outside force)
- a traumatic brain injury induced by biomechanics forces
- typically results in short term neurological impairments that may or may not be detected by neuroimaging
- symptoms can show within 24-48 hours after injury (can also happen immediately)
Post-concussion syndrome
- symptoms began or have gotten worse since concussion onset and may persist for 3 or more months
Cognitive-related symptoms of post-concussion syndrome (diagram on slide 11)
- difficulty concentrating
- difficulty finding things
- difficulty reading
- easily distracted
- brain fog
- memory problems
Sensory-related symptoms of post-concussion syndrome (diagram on slide 11)
- blurry vision
- car sickness or nausea with motion
- change in (or loss of) taste or smell
- ringing ears
Mood-related symptoms of post-concussion syndrome (diagram on slide 11)
- anxiety
- depression
- feeling overwhelmed
- irritability
- low energy or motivation
- various other mood/personality changes
Blood dysregulation symptoms (diagram on slide 11)
- headache
- fatigue
- nausea
- dizziness
- sensitivity to light and noise
- sleep disturbances
- pressure in the head
- persistent neck pain
- tired eyes
Second impact syndrome (SIS)
- a condition that occurs when an concussed individual sustains a second impact upon their head before fully recovering from the first blow
- once you have had a concussion, you are more susceptible to having a second concussion
- after a concussion, your brain still is damaged (shaking in the jello mold demo)
- best way to prevent SIS is to ensure proper rest and recovery following an initial concussion
Symptoms of secondary impact syndrome
- loss of consciousness
- headache
- vomiting
- dilated pupils or vision loss
- seizure
Populations at highest risk for secondary impact syndrome
- young people ages 13-24
- males
- athletes in high contact sports, such as American football, hockey, and boxing
Common misdiagnoses of secondary impact syndrome
- cardiovascular emergency
- stroke
- seizure
Types of brain injury
- closed brain injury
- penetrating brain injury
- blast brain injury
Closed brain injury
- damage to the brain caused by blunt force
- head being struck by an object or hitting the dashboard in a MVA
Penetrating brain injury
- damage to the brain caused by a foreign object, such as a bullet
- perforates the skull and passes into the brain tissue
Blast brain injury
- damage to the brain caused by energy waves from an explosion such as a bomb
- creates bulk acceleration of the head, vascular surge in the brain, and dynamic deformation of the skull
- seen in veterans and workers who use a jackhammer
Types of brain damage
- focal
- diffuse
- primary
- secondary
Focal damage
- limited to one area of the brain
Diffuse damage
- occurs throughout multiple areas of the brain
- has more complications
Primary damage
- occurs at the time of injury and created by the direct impact or intrusion into the brain
Secondary damage
- occurs within hours to days of impact as a result of the physiological response to the injury
Coup and contrecoup injury
- coup = initial impact of the cerebral cortex against the skull
- contrecoup = rebounding of the brain to the opposite of the skull
- continues until the force of the impact has been absorbed
- cerebrum may also rotate on the brainstem
- seen in a MVA
Primary brain damage
- cellular level damage
- shearing of white matter tracts of the cerebral cortex
- stretching and shearing of brain cell axons resulting in diffuse lesions
- the structure of the brain is damaged
- working in blood tests to find markers in having a TBI
Secondary brain damage
- occurs within hours to days after impact
- neuroinflammation
- immune reaction in attempt to foster healing
- causes increased brain mass and increased intracranial pressure
- may require craniectomy (35%) = decreases the symptoms and implications of head injury
- raised intracranial pressure
- decreased cerebral blood flow
- ischemia - damaged cerebral vessels can no longer provide sufficient oxygenated blood to the brain
- damage to the brain causes swelling that is blocked by the skull, creating pressure
Incidence and prevalence of TBI in the United States
- 50,000 deaths
- 235,000 hospitalizations
- 1,111,000 emergency department visits
- ??? receiving other medical care or no care
- at least 1.4 million TBIs occur in the United States each year
TBIs in the United States by Causes (diagram on slide 20)
- motor vehicle accident (traffic)
- falls (obvious in young children and older adults)
- assault
TBIs in the United States by Sex (diagram 22)
- male are generally more of risk takers and thus occurs more to males
TBIs in the United States by Age Group (diagram 22)
- deaths
- hospitalizations
- ED visits
TBIs in the United States Among Children (0-14 years) by Causes (diagram 23)
- motor vehicle (traffic) = 11%
- falls = 39%
- assault = 4%
Top 20 concussion rates in high school sports (diagram on slide 24)
- football
- girls soccer
- boys ice hockey
- boys lacrosse
- girls basketball
- wrestling
- girls lacrosse
- boys soccer
- cheerleading
- girls volleyball
- girls field hockey
- girls softball
- boys basketball
- boys baseball
- girls swimming
- boys swimming
- girl as tack and field
- boys track and field
- girls cross country
- boys cross country
Signs and symptoms
- signs and symptoms vary greatly depending on location of the brain damage and severity of the injury
- more diffuse brain damage results in an increased in symptoms
- the more severe injury has a higher intensity and diversity of the symptoms
- severe TBI results in more residual motor symptoms but all levels report residual cognitive and psychosocial symptoms
- symptoms last for a few weeks or may persist for 3 months to a lifetime
Cumulative trauma disorder TBI
- seen with veterans with blast injuries and construction workers with jack hammering and dynamic working
- the more times a person sustains a mild TBI, the more severe the symptoms
- a person with a history of mild TBI who sustains another incident of mild TBI can potentially result in severe symptoms
- cumulative trauma disorder is the result of repeated blows to the head and is common in sports-related and domestic violence injuries
Medical complications of TBI
- coma
- seizures
- hydrocephalus
- dysautonomia
- deep vein thrombosis
- persistent vegetative state
Coma
- a state of deep unconsciousness characterized by decreased arousal and awareness of all stimuli that lasts for a prolonged or indefinite period
- coma causes the body to focus on healing the brain
- medically induced coma
Seizures
- a sudden, uncontrolled electrical disturbance in the brain the results in convulsions of the body
Hydrocephalus
- an accumulation of cerebrospinal fluid in the brain (ventricles) that causes increased pressure in the skull
- enlarged ventricles
Dysautonomia
- a failure of the sympathetic or parasympathetic components of the autonomic nervous system that results in hypertension, tachycardia, increased body temperature and blood pressure, profuse sweating, and decerebrate or decorticate posturing
Deep vein thrombosis
- a blood clot that forms in a vein deep in the body often resulting from prolonged immobilization
- common in the leg due to immobility
Persistent vegetative state
- diffuse cortical damage with minimal brainstem damage that results in automated eye and limb reactions, but a lack of voluntary and conscious functions
Sensorimotor deficits of TBI
- decerebrate rigidity
- decorticate rigidity
- spasticity
- flaccidity
- posture = damage to the brain
- reflexes
- ataxia
- tremor
- impaired motor planning
- impaired coordination
- heterotopic ossification
- edema
- contractures
- quadriparesis (tetraparesis)
- hemiplegia
- monoplegia
- sensation
Decerebrate rigidity
- extensor posture of all extremities and/or trunk due to damage to the brainstem between the vestibular nuclei and the red nucleus
- stiff and straight out, extension of everything
Decorticate rigidity
- flexion of the upper extremities and extension of the lower extremities due to severe cortical damage with the brainstem intact
- a trick to remember: it is like being cold
Spasticity
- increased involuntary, abnormal muscle tone that causes resistance to movement while at rest or resulting from the hyperexcitability of the stretch reflex
Flaccidity
- reduced, abnormal muscle toner that impacts the person’s ability to voluntarily contract the muscle
- in the upper extremity, it may lead to shoulder subluxation
- no muscle tone
Reflexes
- involuntary action produced as a response to a stimulus
- reflexes can be hypo- or hyper responsive
Ataxia
- abnormal, uncoordinated movements typically caused by damage to the cerebellum
- seen with moderate TBIs
- able to walk, but really imbalanced
Tremor
- involuntary, somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching movements
- resting tremors occur during relaxation of the muscle
- intention tremors occur during voluntary movement
Impaired motor planning
- reduced ability to form and execute a skilled, non automatic, physical movement in the correct sequence from beginning to end
- cannot get the body to figure out how to get from point A to point B
Impaired coordination
- reduced ability to use the different parts of the body together smoothly and efficiently
- coordination may be gross motor, involving large muscle groups, or fine motor, involving small muscle groups
- poor finger opposition
Heterotopic ossification
- bone formation at abnormal soft tissue sites in the synovial joints due to immobility
Edema
- excess fluid trapped in body tissues
- causes swelling
Contractures
- permanent shortening of a muscle or stiffness of the joint resulting in reduced range of motion
- it may be in response to prolonged hypertonic spasticity or edema
- difference between a contracture and spasticity is contractures have bone changes where you cannot stretch it out anymore
Quadriparesis (tetraparesis)
- impaired voluntary movement in all 4 extremities
Hemiplegia
- paralysis of one side of the body
- ex: the right leg and the right arm
Monoplegia
- paralysis of one extremity
Sensation
- the ability to detect and process sensory information including tactile, proprioceptive, kinesthetic, temperature, two-point discrimination, and localization of stimuli
Visual deficits of TBI
- convergence
- diploid
- homonymous, hemianopia
- homonymous quadranopia
- fixation
- oculomotor skills
- saccades
- nystagmus
- ptosis
- scanning
- tracking/pursuits
- visual acuity
- visual fields
- visual range of motion
Convergence
- the ability to move two eyes nasally simultaneously (the opposite is divergence)
Diplopia
- double vision
Homonymous hemianopia
- loss of visual fields in corresponding halves
- ex: left eye nasal and right eye temporal
Homonymous quadranopia
- loss of one quarter of the visual fields in corresponding quarters
- ex: lefty eye nasal superior and right eye temporal superior
Fixation
- the ability to maintain focus on an object in central vision
Oculomotor skills
- the ability to purposefully contractures the muscles of the eyes to produce coordinated movement
- to go left and right in the same direction
Saccades
- the ability to perform quick movements of the eyes from one target to another and focus the target in clear, central vision
Nystagmus
- involuntary, rapid, and repetitive movement of the eyes
Ptosis
- drooping of the eyelid
Scanning
- the ability of visually searching the environment
Strabismus
- misalignment of the eyes
Tracking/pursuits
- the ability to smoothly follow a slow-moving target and keep it in the central vision
Visual acuity
The level of clear central vision
Visual fields
- the span of vision that one sees while looking straight ahead
- while the eyes are fixated straight ahead, the visual field is 90 degrees from center to the right and to the left sides, 70 degrees inferiority and 60 degrees superiorly
Visual range of motion
- the amount of movement of the eyes in all planes of movement vertically, horizontally, and diagonally
Visual perceptual deficits of TBI
- pattern recognition
- form constancy
- figured ground perception
- visual closure
- visual organization
- spatial orientation
- topographical orientation
- unilateral inattention
- depth perception
- visual memory
- visual discrimination
- visual agnostic
- visual cognition
Pattern recognition
- a perceptual process of matching incoming visual stimuli with stored visual memories
Form constancy
- the visual perceptual ability to identify objects despite their variation of size, color, shape, position, or texture
Visual closure
- the ability to accurately identify objects that are paternally covered or missing
Visual organization
- the ability to group objects based on their identifying properties
Spatial orientation
- the visual ability to recognize the position of one’s self or objects in relation to opposing positions, directions, movement, and environmental locations
Topographical orientation
- the ability to orient oneself within the environment and to navigate through it to specific destinations
- they get lost
Unilateral inattention
- a phenomenon that causes one to experience an inability to orient and respond to one side of the environmental information
Depth perception
- the visual ability to perceive relative distance of objects
Visual memory
- the ability to take in a visual stimulus, retain its details, and store it for later retrieval
Visual discrimination
- the ability to identify unique characteristics of objects, shapes, colors, and people for comparison
Visual agnostic
- a condition in which a person cannot interpret incoming visual information
Visual cognition
- the ability to use visual information to solve problems, make decisions, and complete planning and organizational tasks through mental manipulation
Cognitive deficits of TBI
- orientation
- attention
- processing
- memory
- immediate recall/sensory register
- anterograde amnesia
- retrograde amnesia
- working memory
- long-term memory
- executive functions
- self-awareness
- always there’s cognitive deficits with a TBI
Orientation
- understanding oneself and one’s surroundings and circumstances
- ex: understanding person, place, time, and date
Attention
- the ability to direct mental processes toward information
- subtypes from lowest to highest functioning include focused attention, selective attention, sustained attention, alternating attention, and divided attention
Processing
- the ability to quickly and accurately decode elements of information into meaningful terms
Memory
- the mental storage of information and the processes involved in the acquisition, retentions, and retrieval of that information
- subtypes of memory include immediate recall/sensory register, working memory, long-term memory, episodic memory, procedural memory, semantic/declarative memory, prospective memory, and topographical memory
Immediate recall/sensory register
- the ability to recall information without any lapse in time from processing
Anterograde amnesia
- the ability to learn new long-term declarative information
Retrograde amnesia
- memory loss for information from prior to the accident
Working memory
- the ability to use information that is currently held “in mind”
Long-term memory
- the ability to recall information that is stored relatively permanently
Executive functions
- the cognitive skills required for high-level thinking
- ex: planning, problem solving, organization, judgment, self-regulation, flexibility, categorization, sequencing, abstract reasoning, divergent thinking, and conceptualization
Self-awareness
- knowledge of one’s own capacities, skills, limitations, and level of function
- they have insight to their medical conditions
Psychosocial impairments of TBI
- impulsivity
- preservation
- compulsivity
- irritability/agitation
- aggression
- disinhibition
- apathy
- depression
- reduced self-esteem
- suicide risk
- post traumatic stress disorder
- substance abuse
- personality disorders
Impulsivity
- a tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences
- they don’t ever think about safe ways or problem solving
Preservation
- the repetition of a particular response (such as a word, phrase, or gesture) regardless of the absence or cessation of a stimulus
Compulsivity
- the performance of an act persistently and respectively without it necessarily leading to an actual reward or pleasure
Irritability/agitation
- an abnormal or excessive sensitivity to stimuli
Aggression
- a hostile or violent behavior or attitude toward others with a readiness to attack or confront them without reasonable provocation
Disinhibition
- a lack of restraint with disregard for social norms, reduced awareness of environmental milieus, and poor risk assessment
Apathy
- lack of interest, enthusiasm, or concern for self or others
Depression
- a persistently low mood or loss of interest in activities
Suicide risk
- increased likelihood of dying by self-inflicted means
Posttraumatic stress disorder
- flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event
Substance abuse
- use of a drug in amounts or by methods that are harmful to the individual
Personality disorders
- a rigid and unhealthy pattern of thinking functioning and behaving with difficulty perceiving and relating to situations and people
- ex: borderline, avoidant, paranoid, obsessive-compulsive, and narcissistic personality disorders
Olfactory (I)
- type = sensory
- function = sense of smell
- associated dysfunction = unilateral or bilateral loss of sense of smell and loss of taste
Optic (II)
- type = sensory
- function = vision
- associated dysfunction = loss of vision
Oculomotor (III)
- type = motor and parasympathetic
- function = movement of the eyeball and upper eyelid and pupil constriction
- associated dysfunction = eye-movement problems
Trochlear (IV)
- type = motor
- function = movement of the eyeball
- associated dysfunction = eye-movement problems
Trigeminal (V)
- type = sensory and motor
- function = generation sensation in the face, scalp, corneas, and nasal and organ cavities and chewing
- associated dysfunction = loss of facial sensation
Abducens (VI)
- type = motor
- function = movement of the eyeball
- associated dysfunction = eye-movement problems
Facial (VII)
- type = sensory, motor, and parasympathetic
- function = taste and facial expression and secretion of tears and saliva
- associated dysfunction = loss of taste and inability to close eye
Vestibulocochlear (VIII)
- type = sensory
- function = hearing and balance
- associated dysfunction = loss of hearing and balance
Glossopharyngeal (IX)
- type = sensory, motor, and parasympathetic
- function = taste and sensation from back of tongue and swallowing and speech and secretion of saliva
- associated dysfunction = inability to swallow and hoarse voice
Vagus (X)
- type = sensory, motor, and parasympathetic
- function = taste and sensation from epiglottis and pharynx and swelling and speech and muscle contraction of thoracic and abdominal organs and secretion of digestive fluids
- associated dysfunction = inability to swallow, hoarse voice, and delayed gastric emptying
Accessory (XI)
- type = motor
- function = head and shoulder movement
- associated dysfunction = inability to move head and raise shoulder
Hypoglossal (XII)
- type = motor
- function = movement of the tongue muscles
- associated dysfunction = inability to move tongue
Brain oxygen deprivation (diagram on slide 42)
- not all brain injuries involve a blow to the head or lesion
- anoxic
- hypoxic
- How long can a person survive oxygen deprivation:
0 min = loss of oxygen
1-2 min = brain damage may begin
5 min = death of brain cells and severe brain damage
10 min or more = death is likely - overall health and specialized training may impact the timeline
Anoxic brain injury
- occurs when the brain is totally deprived of oxygen due to sudden cardiac arrest, choking, strangulation, and other sudden injuries
- ex: drowning
Hypoxic brain injury
- occurs when the brain receives less oxygen than it needs, but is not completely deprived of oxygen (only gets a fraction)
Brain tumor
- noncancerous or cancerous growth in the brain
- may damage or put pressure on surrounding brain tissue, block circulation of cerebrospinal fluid resulting in an increased intracranial pressure or cause a hemorrhage
- primary brain tumor
- secondary brain tumor
- nonmalignant
- malignant
Primary brain tumor
- a tumor that originally developed in the brain
Secondary brain tumor
- always cancerous
- a tumor that originated elsewhere in the body and has spread or metastasized to the brain
- brain metastases are estimated to be 10 times more common than primary brain tumors
- breast cancer, lung cancer, and melanoma are the most common forms of cancer to metastasize to the brain
Nonmalignant brain tumor
- benign tumor
- not cancerous
- does not spread to other body tissues
- may become life threatening due to their potential for cell growth that may press upon adjacent structures and result in tissue damage
Malignant brain tumor
- composed of abnormal cancerous cells that multiply and spread to other tissues
- primary brain tumors are both nonmalignant and malignant
- secondary brain tumors result from systemic malignancy
Diagnosis of TBI
- typically made in the ER
- use EEG, CT scans, MRI to identity the location and severity of the injury
- neurocognitive testing and symptoms inventories are used to help make the diagnosis and identify the impact and severity of the TBI
- mild TBI is at times harder to diagnose because individuals might not present to the ER immediately and CT scans may not show abnormalities
Course and prognosis of TBI
- response and recovery from TBI is highly individualized
- factors which may influence prognosis:
- severity of memory loss
- age
- intoxication at the time of injury (some studies say it is present in 1/3 to 1/2 of injuries)
- in general, individuals with TBI may experience a reduced life expectancy by 9 years
- the older you get, your brain loses neuroplasticity, which results in poorer prognosis
Occupational implications of TBI
- Disability Rating Scale (DRS)
- quantitative assessment of the disability of patients with severe brain injury
- 8 categories:
- cognitive components of self-care activities
- the general level of functioning/depoendence on others
- psychosocial skill/employability
Level I - No Response
Patient does not respond to external stimuli and appears asleep
Level II - Generalized Response
Patient reacts to external stimuli in nonspecific, inconsistent, and no purposeful manner with stereotypic and limited responses
Level III - Localized Response
Patient responds specifically and inconsistently with delays to stimuli may follow simple commands for motor action
Level IV - Confused, Agitated Response
Patient exhibits bizarre, no purposeful, incoherent or inappropriate behaviors, has no short-term recall, attention is short and nonselective
Level V - Confused, Inappropriate, Nonagitated Response
Patient gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli. Simple commands are followed consistently, memory and selective attention are impaired and new information is not retained.
Level VI - Confused, Appropriate Response
Patient gives context appropriate, goal-directed responses, dependent upon external input for direction. There is carry-over for relearned, but not for new tasks, and recent memory problems persist.
Level VII - Automatic, Appropriate Response
Patient behaves appropriately in familiar settings, performs daily routines automatically, and shows carry-over for new learning at lower than normal rates. Patient initiates social interactions, but judgment remains impaired.
Level VIII - Purposeful, Appropriate Response
Patient oriented and responses to the environment but abstract reasoning abilities are decreased relative to premorbid levels
Sequelae (a condition which is the consequence of previous injury) of Brain Injury
Physical and Medical:
- balance
- fine and gross motor skills
- range of motion/flexibilityu
- coordination
- spasticity (stiffness) and ataxia (shakiness)
- pain, particularly headache
- changes in or loss of sense
- seizures disorder
- quality of speech and swallowing issues
- endurance
- sleep disturbances
Cognitive:
- information processing
- orientation to person, place, and time
- sequencing
- problem-solving and judgment
- memory
- planning and organizing
- attention/concentration
- communication problems (word-finding, understanding others, staying on topic)
- flexible thinking
- being able to initiate or start things
Emotional/Behavioral:
- depression
- anxiety
- aggression
- flat or restricted affect
- mood swings
- emotional lability
- social skills
- disinhibition
- apathy
- exaggerated personality
- changes in drives (hunger, sex, and temper)
- impulsivity
Impact on occupational performance (TBI)
- ADL
- IADL home activities
- work/school
- leisure and recreation
- social participation
- driving
- community participation
- health management
- rest and sleep
