Brain Injury and Recovery • What is a brain injury • Types of brain injury • Levels of Brain injury • Factors that impact recovery • How are brain injuries treated • Stages of recovery and how to respond
Why is brain injury called the silent epidemic? Because of the magnitude of the problem, brain trauma has remained largely unknown by the American public. There are currently 5.3 million individuals—a little more than 2 percent of the U.S. population—living with a disability resulting from a traumatic brain injury. When considering an individual’s family and circle(s) of support, brain injury touches the lives of approximately one in every 10 persons in the United States. The annual statistics of brain injury are staggering: • 1 million people are treated and released from hospital emergency departments • 230,000 people are hospitalized and survive • 80,000 Americans experience the new onset of long-term disability following hospitalization for traumatic brain injury (TBI) • 50,000 people die
What Is a Brain Injury? • The term refers to an injury to the brain that is usually the result of an accident, or sometimes and assault. Injuries can result from blows to the head such as suffered in an automobile accident or fall, as a result of lack of oxygen or blood supply to the brain.
Traumatic Brain Injury (TBI) • A traumatic brain injury occurs when an outside force impacts the head hard enough to cause the brain to move within the skull or if the force causes the skull to break and directly hurts the brain.
Types of TBI –Closed Head Injury • Closed Head Injury: the result of a bow to the head which causes the brain to move or shake within the skull. The sharp and hard internal surfaces of the skull can cut and bruise the brain. • Movement or shaking can cause the brain to be damaged in many areas, not only at the point of the blow. For this reason, persons with closed head injuries can show a wide range of problems. • Often called diffused injuries
Types of TBI- Open Head Injury • An open head injury is the result of a sharp object entering the brain through the skull, such as a bullet. In this type of injury, damage to the brain tissue is seen mostly in one area-the area of penetration • These types of injuries are called focal injuries
Primary Injuries • Diffuse Axonal Injury- ADiffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident.Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear. • Concussion-caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged. • Coup-Contrecoup Injury-This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion • Penetration Injury-Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bone and fragments from the object into the brain. • Contusion-A contusion is a bruise (bleeding) on the brain
Secondary Injuries • When a TBI occurs, other factors can affect the brain, called secondary injuries. These can cause further problems in addition to the trauma • Bleeding (hemorrhage)- when deep blood vessels in the brain are injured an bleed causing injury from loss of blood or pressure • Blood clots (hematomas)- clots can form when there is bleeding. Clots can create pressure, which can lead to further damage • Swelling (edema)- causes pressure which can damage the brain • Lack of oxygen (anoxia)- because of bleeding in the brain or injury to other parts of the body, the flow of oxygen to the brain may be poor and cause damage.
Symptoms of a TBI • Spinal fluid (thin water-looking liquid) coming out of the ears or nose • Loss of consciousness; however, loss of consciousness may not occur in some concussion cases • Dilated (the black center of the eye is large and does not get smaller in light)or unequal size of pupils • Vision changes (blurred vision or seeing double, not able to tolerate bright light, loss of eye movement, blindness) • Dizziness, balance problems • Respiratory failure (not breathing) • Coma (not alert and unable to respond to others) or semicomatose state
Symptoms of TBI cont. • Paralysis, difficulty moving body parts, weakness, poor coordination • Slow pulse • Slow breathing rate, with an increase in blood pressure • Vomiting • Lethargy (sluggish, sleepy, gets tired easily) • Headache • Confusion • Ringing in the ears, or changes in ability to hear
Symptoms of TBI cont • Difficulty with thinking skills (difficulty “thinking straight”, memory problems, poor judgment, poor attention span, a slowed thought processing speed) • Inappropriate emotional responses (irritability, easily frustrated, inappropriate crying or laughing) • Difficulty speaking, slurred speech, difficulty swallowing • Body numbness or tingling • Loss of bowel control or bladder control
Acquired Brain Injury An acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth.
Causes of Acquired Brain Injury • Airway obstruction • Near-drowning, throat swelling, choking, strangulation, crush injuries to the chest • Electrical shock or lightening strike • Trauma to the head and/or neck • Traumatic brain injury with or without skull fracture, blood loss from open wounds, artery impingement from forceful impact, shock • Vascular Disruption
Causes Continued • Heart attack, stroke, arteriovenous malformation (AVM), aneurysm, intracranial surgery • Infectious disease, intracranial tumors, metabolic disorders • Meningitis, certain venereal diseases, AIDS, insect-carried diseases, brain tumors, hypo/hyperglycemia, hepatic encephalopathy, uremic encephalopathy, seizure disorders • Toxic exposure • Illegal drug use, alcohol abuse, lead, carbon monoxide poisoning, toxic chemicals, chemotherapy (not all the time).
Levels of Brain Injury • the severity of neurological injury to the brain by using an assessment called the Glascow Coma Scale (GCS) to. The terms Mild Brain Injury, Moderate Brain Injury, and Severe Brain Injury are used to describe the level of initial injury in relation to the neurological severity caused to the brain. There may be no correlation between the initial Glascow Coma Scale score and the initial level of brain injury and a person’s short or long term recovery, or functional abilities. • Keep in mind that there is nothing “Mild” about a brain injury—again, the term “Mild” Brain injury is used to describe a level of neurological injury. Any injury to the brain is a real and serious medical condition
Mild Traumatic Brain InjuryGlascow Coma Scale score 13-15 • Loss of consciousness is very brief, usually a few seconds or minutes • Loss of consciousness does not have to occur—the person may be dazed or confused • Testing or scans of the brain may appear normal • A mild traumatic brain injury is diagnosed only when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion
Moderate TBI Glascow Coma Scale Score 9-12 • A loss of consciousness lasts from a few minutes to a few hours • Confusion lasts from days to weeks • Physical, cognitive, and/or behavioral impairments last for months or are permanent. • Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits.
Severe Brain InjuryGlascow Coma Score 8 or less • Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks, or months. Severe brain injury is further categorized into subgroups with separate features: • Coma • Vegetative State -Arousal is present, but the ability to interact with the environment is not. Eye opening can be spontaneous or in response to stimulation.General responses to pain exist, such as increased heart rate, increased respiration, posturing, or sweatingSleep-wakes cycles, respiratory functions, and digestive functions return • Persistent Vegetative State • Minimally Responsive State-demonstrate: Primitive reflexes,Inconsistent ability to follow simple commands, and an awareness of environmental stimulation • Akinetic Mutism-a neurobehavioral condition that results when the dopaminergic pathways in the brain are damaged. • Locked-in Syndrome
A Healthy Brain Before we can understand what happens when a brain is injured, we must realize what a healthy brain is made of and what it does. The brain is enclosed inside the skull. The skull acts as a protective covering for the soft brain. The brain is made of neurons (nerve cells). The neurons form tracts that route throughout the brain. These nerve tracts carry messages to various parts of the brain. The brain uses these messages to perform functions. The functions include our thought processes, physical movements, personality changes, behavioral changes, and sensing and interpreting our environment. Each part of the brain serves a specific function and links with other parts of the brain to form more complex functions.
Functions of the Brain: Frontal, Temporal, Parietal, Occipital, Brain Stem The brain is divided into main functional sections, called lobes. These sections or brain lobes are called the Frontal Lobe, Temporal Lobe, Parietal Lobe, Occipital Lobe, The Cerebellum, and the Brain Stem. Each has a specific function, as described below.
Frontal Lobe • Initiation • Problem Solving • Judgment • Inhibition of behavior • Planning and anticipation • Self-monitoring • Motor Planning • Personality • Emotions • Awareness of abilities and limitations • Organization • Attention and concentration • Mental flexibility • Speaking (expressive language)
Temporal Lobe • Memory • Hearing • Understanding language (receptive language) • Organization • Sequencing
Parietal Lobe • Sense of touch • Differentiation (identification) of size, shapes, and colors • Spatial perception • Visual perception
Occipital Lobe • Vision
Cerebellum • Balance • Coordination • Skilled motor activity
Brain Stem • Breathing • Heart rate • Arousal and consciousness • Sleep and wake cycles • Attention and concentration
An Injured Brain When a brain injury occurs, the functions of the neurons, nerve tracts, or sections of the brain can be effected. If the neurons and nerve tracts are effected, they can be unable or have difficulty carrying the messages that tell the brain what to do. This can result in Thinking Changes, Physical Changes, and Personality and Behavioral Changes. These changes can be temporary or permanent. They may cause impairment or a complete inability to perform a function.
Thinking Changes Memory Decision makingPlanningSequencingJudgmentAttentionCommunicationReading and writing skillsThought processing speedProblem solving skillsOrganizationSelf-perceptionPerceptionThought flexibilitySafety awarenessNew learning Physical Changes Muscle movement Muscle coordinationSleepHearing VisionTasteSmellTouchFatigue WeaknessBalanceSpeechseizuresSexual Functioning
Personality and Behavioral Changes Social skills Emotional control and mood swings Appropriateness of behaviorReduced self-esteemDepressionAnxietyFrustrationStress DenialSelf-centerednessAnger managementCoping skillsSelf-monitoring remarks or actionsMotivationIrritability or agitationExcessive laughing or crying
Right or Left Brain The functional sections or lobes of the brain are also divided into right and left sides. The right side and the left side of the brain are responsible for different functions. General patterns of dysfunction can occur if an injury is on the right or left side of the brain.
Left Side of the Brain • Difficulties in understanding language (receptive language) • Difficulties in speaking or verbal output (expressive language) • Catastrophic reactions (depression, anxiety) • Verbal memory deficits • Impaired logic • Sequencing difficulties • Decreased control over right-sided body movements Injuries of the Right Side of Brain can cause: • Visual-spatial impairment • Visual memory deficits • Left neglect (inattention to the left side of the body) • Decreased awareness of deficits • Altered creativity and music perception • Loss of “the big picture” type of thinking • Decreased control over left-sided body movements
Diffuse Brain Injury (The injuries are scattered throughout both sides of the brain) • Reduced thinking speed • Confusion • Reduced attention and concentration • Fatigue • Impaired cognitive (thinking) skills in all areas
Just as no two people are alike, no two brain injuries are alike. Appropriate treatment and rehabilitation will vary from individual to individual. Programs and treatments change, as a person's needs change. It is important to recognize that "more therapy" does not make a person "better", but that "appropriate" therapy may.
Factors that Affect Recovery • Age at the time of injury • Area and amount of injury • Time since the injury happened • Skills and behavior before injury • Motivation for recovery • Substance use and/or abuse • Past brain injury or concussion
How Are Brain Injuries Treated Medically (ICU) • Treatment is aimed at stopping any bleeding, preventing an increase in pressure within the skull, controlling the amount of pressure and removing any large blood clots • Treatments may include: positioning, fluid restriction, medications, ventricular drain, ventilator, surgery (craniotomy, burr holes, bone flap removal)
The Recovery Process • Ranchos Los Amigos Scale of Cognitive Functioning As recovery progresses, the Ranchos Los Amigos Scale of Cognitive Function becomes the tool most widely utilized to assess cognitive and behavioral functioning. This describes the cognitive and behavioral status of the individual at the time, and directs the planning and evaluation of treatment plans and goals throughout the entire recovery process. It also represents a non-medical framework for family members to begin to understand brain injury in a way that helps them interact with their loved one in a more sensitive, positive manner, contributing to the rehabilitation process.
The Ranchos Los Amigos Scale consists of eight levels, and is described below. Individuals go through these levels at different rates, and improvement may vary at any level. Individuals may fluctuate between two levels at the same time. Suggestions for working with your family member at each stage of recovery is provided.
Stages of Recovery Level I - No ResponsePatient appears to be in a deep sleep and is completely unresponsive to any stimuli presented to him.
How to Respond to Level 1 It is not really known what an individual can hear and understand while in a coma or early stages of recovery. Family and staff should therefore monitor their interactions and conversations at bedside, always keeping in mind the possibility some activity may be remembered.
Stages of Recovery Level II - Generalized Response • Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. • Responses are limited in nature and are often the same regardless of stimulus presented. • Responses may be physiological changes, gross body movements, and/or vocalization. • Often, the earliest response is to deep pain. Responses are likely to be delayed.
How to Respond to Level II • During periods of wakefulness, provide simple and meaningful stimulation. • Describe activities to your loved one such as "now I am washing your right hand". • Speak in slow, calm, and normal tones, and show affection often, in whatever way you can. • When eyes are opened, try to have him/her look at you and at other visitors. • Keep periods of stimulation brief (5-15 minutes), as your family member has to rest. • Family and friends should share stimulation responsibilities as you too have to rest.
Stages of Recovery Level III - Localized Response • Patient reacts specifically, but inconsistently, to stimuli. • Responses are directly related to the type of stimulus presented as in turning head toward a sound or focusing on an object presented. • The patient may withdraw an extremity and/or vocalize when presented with a painful stimulus. • May follow simple commands in an inconsistent, delayed manner such as closing eyes, squeezing or extending an extremity.
Once external stimuli is removed, patient may lie quietly. • May also show a vague awareness of self and body by responding to discomfort by pulling at nasogastric tube or catheter or resisting restraints. • Patient may show a bias toward responding to some persons (especially family, friends) but not to others.
How to respond to Level III • Increase and direct stimulation efforts at reorienting your family member with who they are and what has happened. • At each visit, describe who you are, provide the date, where they are and why. • Bring familiar and significant objects to the individual; provide photographs of family and friends, identified by name on the back to assist staff who can also help stimulate his/her memory. • With increased periods of alertness, discuss significant past, such as school, employment, longtime relationships, hobbies.
Continue to ask for simple commands to be followed, initiate and assist with self-care tasks. • Ask simple questions that require only "yes" or " no " answers, allowing time to respond. • Remain patient and sensitive to signs of frustration.
Stages of Recovery • Level IV - Confused/Agitated • Patient is in a heightened state of activity with severely decreased ability to process information. • Is detached from the present and responds primarily to his/her own internal confusion. • Behavior is frequently bizarre and non-purposeful relative to his/her immediate environment. • May cry out or scream out of proportion to stimuli even after removal, show aggressive behavior, attempt to remove restraints or tubes, or crawl out of bed in a purposeful manner. • Patient does not, however, discriminate among persons or objects and is unable to cooperate directly with treatment efforts.
Verbalization is frequently incoherent and/or inappropriate to the environment. • Confabulation may be present; patient may be euphoric or hostile. Thus, gross attention to environment is very short and selective attention is often nonexistent. • Being unaware of present events, patient lacks short-term recall and may be reacting to past events. • Is unable to perform self-care (feeding, dressing) without maximum assistance. • If not disabled physically, he/she may perform motor activities such as sitting, reaching, and ambulating, but as part of his/her agitated state and not as a purposeful act or on request, necessarily.
Responding to Level IV • The goals of this stage are to decrease agitation and increase awareness. • Use calm, soft speech and slow careful movements to lessen the tendency for agitation. • Continue to provide opportunities for the individual to respond to stimuli and simple commands, encourage and assist with self-care tasks, continue to associate the individual with familiar things. • Remove distractions such as TV or radio, to restrict stimulation to one sense (auditory, visual or tactile) at a time. • Attempt to correct an inappropriate or inaccurate response, but do not argue the point.
Responding to Level IV cont • If confusion and agitation is ongoing, do not try to rationalize with the person, allow him/her time to relax. • Do not ignore them however, instead provide human contact and soothing reassurances. • Avoid sedatives as they can slow the thinking process, and add to the confusion. • Seeing a family member engage in unusual and aggressive behavior is very difficult to endure. • Try to remember not to take any of the comments and behaviors personally. • The Confused-Agitated stage is a sign of improvement, and a necessary step towards recovery.