By Tania Barroso, M.D.
The rate of Traumatic Brain Injury (TBI) has increased tremendously over the past decade. This is mostly because of injuries sustained in sports and on the battlefield by our brave military personnel. It has been called “the silent epidemic,†since there has been very little knowledge and lack of screening protocols in the past, which led to frequent missed brain injuries and, hence, to lack of appropriate management. The good news is that this has directed us to an increase in awareness followed by improvements in the tracking, identification and treatment of brain injuries.
As a physiatrist working with veterans, I have been challenged by the complicated nature of these injuries in our military population. Their brain injuries are usually complex, compound and accompanied by numerous comorbidities such as PTSD and chronic pain. Fortunately, new breakthroughs and focused rehabilitation programs are now in place to meet the needs of patients with brain injury, not only for our veterans and service members, but also for the general community.
What is TBI?
TBI, also known as acquired brain injury, occurs when a sudden trauma disrupts the normal function of the brain. The effects of TBI can vary in duration and severity. Thankfully, the majority of brain injuries are of the mild range, but for many people with severe TBI, long-term rehabilitation is often necessary to maximize function and independence. Even with mild TBI, the consequences to a person’s life can be overwhelming.
TBI Symptoms and Sequelae
TBI can cause a host of physical, cognitive, social, emotional and behavioral effects, and its outcome can range from complete recovery to permanent disability or death. Symptoms vary according to the severity of the injury and the stage of recovery. Mild TBI symptoms may be difficult to identify because the patient may look normal and act coherent. Nonspecific symptoms, such as headaches and fatigue, can easily be ignored and overlooked. Typically, signs and symptoms manifest quickly after injury, but sometimes symptoms may be delayed by weeks and even months. Seizures, dizziness, vision problems, attention deficit and personality disorders can all result from mild TBI and last for many years. Severe TBIs can result in paresis, aphasias, spasticity and contractures. Emotional and behavioral symptoms may include depression, anxiety and personality changes.
Epidemiology
The Centers for Disease Control and Prevention (CDC) states that there are 1.7 million TBIs each year and that TBI is a contributing factor to a third (30.5 percent) of all injury-related deaths in the United States.(1) It is a leading cause of death and disability around the globe, and the impact on society and economy is huge.
It is important to understand that these numbers underestimate the true incidence of TBI because first, they do not include military-related TBIs, second, they do not include brain injuries diagnosed and treated in the outpatient settings, and third, they do not include mild brain injuries that were missed or where the patient did not seek medical care.
Military-related TBI
In the military, brain injury has become known as the “signature wound†and one of the invisible injuries of the wars in Iraq and Afghanistan. Since Sept. 11, 2001, more than 2.5 million service members have been deployed to Iraq and Afghanistan in Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn. More than 250,000 cases of TBI in the military have been reported between the years 2000 and 2012. The most common cause of military-related TBIs are blast explosions. Most of these injuries are classified in the mild spectrum, although the long-term consequences are anything but mild.
What is unique to military-related brain injury is the complexity of its relationship to PTSD, depression, drug abuse and suicidality. It is extremely difficult to determine whether their symptomatology is a result of PTSD or from a mild TBI because they frequently overlap. There are still knowledge gaps and uncertainty when it comes to the treatment of these co-occurring conditions.
Congress initiatives, such as the National Research Action Plan and the Defense and Veterans Brain Injury
Center, were created to develop more research in these areas and to improve access to mental healthcare for veterans, service members and their families. All service members are being evaluated for brain injury when they return from combat tours in order to diagnose TBI early and treat it more effectively.
Sports-related TBI
Sports-related TBI has also become a popular topic in the medical community and on social media over the last few years. Repetitive concussive impacts have been linked to long-term devastating consequences, such as dementia and chronic traumatic encephalopathy. An initial cognitive and physical rest period, followed by a gradual increase in physiologic and cognitive stress in asymptomatic athletes, is the hallmark of the management. Continued education to the general public is essential to properly identify concussed individuals and direct them to appropriate medical care.
Causes of TBI
In the civilian sector, the leading cause of sustaining a TBI is through falls.(1) This is followed by motor vehicle crashes, stuck by/against events and assaults. Blasts are a leading cause of TBI for active duty military personnel in war zones.(2)
Severity of TBI
The severity of a TBI injury may range from mild to severe. Although the severity level has prognostic value, it does not necessarily predict the likelihood of functional recovery. Tools to measures severity include the Glascow Coma Scale (GCS), duration of coma and the length of posttraumatic amnesia (PTA).
It is important to understand that mild TBI, unlike moderate or severe TBI, often cannot be corroborated with objective diagnostic tools, and MRI and CT scans may be completely normal. New and exciting research on the development of blood biomarkers and eye-tracking devices for diagnosing brain injury is getting closer. Hopefully, it will serve as a standard diagnostic tool in the future. Early diagnosis leads to better intervention, therefore better recovery and treatment outcomes.
Rehabilitation After TBI
There is no doubt that a brain injury can drastically change a person’s life. The majority of mild TBI patients recover within three months with minimal treatment. Serious brain injury survivors acquire a mix of lifelong impairments, but with hard work and the support of their loved ones, they can regain some abilities lost to their injuries.
Brain tissue healing begins as soon as the patient is stabilized. The brain can rewire and grow new neural pathways among its territories through plasticity, which is the process through which a healthy area of the brain assumes the functions of an injured area. However, these processes alone are not enough to enable a patient to resume his or her pre-injury potential. For the best outcome, a patient must participate in a specialized rehabilitation program.
To achieve maximum quality of life, a brain injury patient must learn ways to work around his or her new deficits. Brain rehabilitation aims to help patients relearn lost life skills and teach them compensatory strategies for long-term functional deficits. Some people may be able to return to their premorbid level of functioning, and some may need lifetime care. It is of utmost importance that the rehabilitation team incorporates efforts among family, employers and friends to improve community integration outcomes.
Rehabilitation can take place in various settings. Possible settings include inpatient rehabilitation hospitals, outpatient rehabilitation, home-based rehabilitation, comprehensive day program and independent living center. A rehabilitation program is determined based on the needs of the individual. Ideally, rehabilitation services should begin as soon as the survivor is medically stabilized, but patients benefit most from rehabilitation when they have reached a level of 3 or 4 on the Rancho Scale, which means they are starting to interact and become aware of their surroundings.
Services include physical therapy, physical medicine, occupational therapy, psychiatric care, psychological care, speech and language therapy and social support. Patients may need evaluations for bowel and bladder control, speech abilities, swallowing abilities, strength and coordination, ability to understand language, mental and behavioral state and social support needs.
As to cognitive rehabilitation, neuropsychological assessment through standardized tests that measure cognitive function are performed as early as possible and repeated throughout the rehabilitation course in order to monitor their progress. Areas assessed include attention and concentration, verbal memory, visual memory, executive function, language, motor function, neurobehavioral function and validity. These evaluations are useful in targeting areas for cognitive rehabilitation and identifying intervention strategies to optimize treatment outcomes. Cognitive skills can be relearned with a structured rehab plan of strategies and repetition.
Behavioral and emotional changes are very common in TBI. They are usually most distressing to caregivers, family and friends of the patient. Behavioral disorders can include apathy, aggression, irritability, impulsivity, poor social skills, substance abuse and several psychiatric diagnoses. Pharmacologic therapies can be extremely helpful in helping control these symptoms, but environmental controls also play an important role, especially in agitated patients.
Brain survivors may have a variety of physical problems, such as contractures, paresis and possibly other bodily injuries associated with the trauma that impairs their mobility. Physical therapists are key to help overcome these physical impairments.
Social interaction is also addressed in rehabilitation. When the patient is ready, the survivor is slowly reintroduced into the community and social skills are tested.
The Role of Pharmacology in TBI Management
There are a wide range of TBI neurologic and medical complications that are addressed by the physiatrist in the acute and post-acute stages. Particular attention must be paid to the use of medication that may adversely affect cognitive functioning.
Seizures can be seen in the first 24 hours (immediate), in the first two to seven days (early) and/or after seven days (late). The use of phenytoin has been shown to be effective during the first week after a TBI. If there is no seizure after one week, continued use is not warranted.
Balance disorders can be treated with medications, surgery, dietary modifications, vestibular balance rehabilitation therapy and visual therapies. Medications for dizziness should only be used on a short-term basis to minimize negative effects in rehabilitation therapies.
Post-traumatic headaches are seen in 30 percent to 50 percent of patients with mild TBI,(3) with tension-type headaches being more common than the migraine-type. Treatments for post-traumatic headaches are similar to that of primary headache.
Spasticity is a common problem among patients with brain injury. Spasticity is a velocity-dependent increase in tone. This means that the faster a patient attempts to move, the more resistance to that movement occurs. Physical therapy and early intervention is important to prevent development of contractures due to spasticity. Anti-spasticity medications include tizanidine, clonidine, dantrolene, diazepam and baclofen. Local injection therapy includes motor point blocks and Botox.
Arousal may fluctuate during the day in persons with TBI. Dopaminergic agents (amantadine and bromocriptine) are the most commonly used drugs to improve arousal and fatigue.
Attention issues are frequently treated with methylphenidate, which has been shown to improve attention, reaction times and processing speeds.
Agitation and aggression are problematic behaviors common in TBI and may be very stressful, especially for the caregivers. Environmental controls are essential for reducing the triggers for agitation. Benzodiazepines are avoided due to the potential negative effect on brain recovery. Anxiolytics, mood stabilizers, antipsychotics and antidepressants are preferred.
Memory is best addressed with the use of compensatory strategies and services. Cholinergic medications such as donepezil and rivastigmine improve arousal and attention, which indirectly help with memory because they improve the ability to learn.
TBI-related depression and emotional ability are treated with antidepressants. SSRIs are first-line because they are generally believed to be neutral with respect to cognitive functioning.
TBI occurs in 1.7 million Americans annually. TBI rehabilitation includes a variety of services that are individualized to the patient’s needs. Proper diagnosis and early intervention are vital to successful outcomes.
Management of TBI symptoms and complications requires an experienced professional in the appropriate setting. Environmental, psychosocial and pharmacologic interventions are useful in the rehabilitation of cognitive, emotional and behavioral issues after TBI.
References
1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
2. Department of Defense and Department of Veterans Affairs (2008). “Traumatic Brain Injury Task Forceâ€. http://www.cdc.gov/nchs/data/icd9/ Sep08TBI.pdf.
3. Post-traumatic headache: neuropsychogical and psychological effects and treatment implications J Head Trauma, Rehabil 1999
4. www.Brainlinemilitary.org
5. Up-to-Date Advances in Rehabilitation: Review Issue Traumatic Brain Injury: A Review of Practice Management and Recent Advances.
J Physical Medicine and Rehabilitation Clinics of North America, 2007; 18: 681-710
6. www.traumaticbraininjury.com
7. Braddom, Randall. Physical Medicine & Rehabilitation. Philadelphia: Saunders Elsevier, 2007
8. Frontera, Walter. Essentials of Physical Medicine and Rehabilitation. Philadelphia: Saunders Elsevier, 2008
Tania Barroso, M.D. practices physical medicine and rehabilitation at the Veteran’s Medical Center in Atlanta. A native of Puerto Rico, she obtained her B.A. and M.D. with honors from the University of Puerto Rico in 2006. She completed her physical medicine and rehabilitation residency at Emory University from 2007 to 2010. She is a diplomate of the American board of PM&R and a member of the American academy of PM&R. She is currently an associate professor for the Emory University Residency Training Program.
