Traumatic brain injury (TBI) is the most common type of brain injury appropriate for brain injury specialist rehabilitation and it has a set of unique characteristics, effects and impacts, which require the unique elements in brain injury specialist rehabilitation.
To understand the essentials of brain injury specialist rehabilitation, it is helpful to understand TBI and severe TBI in particular.
The key takeaway messages from understanding severe TBI are useful for understanding the requirements of brain injury specialist rehabilitation.
Part of Paul's story
Getting immediate help
Emergency
Mountain retrieval, ambulance, local hospital treatment, helicopter transfer to metro hospital
Surviving
Acute
Neurosurgery, intensive care, inpatient therapy
TBI occurs as the result of some external force being applied to the brain in an accident or trauma.
The mechanism of the injury itself is a key factor in what makes rehabilitation different for people with TBI from other neurological brain injuries.
In TBI there is an external force from an accident or trauma that may result in the brain being penetrated by objects, cut by internal bony skull ridges, torn, stretched, bruised or become swollen from the twisting and shearing forces as the brain moves around inside the skull, or is squashed when the skull is compressed or split open. Oxygen may not be able to get through to brain cells and there may be bleeding. Some brain cells will die while others recover partially or completely. The pattern of intact cells will be quite scattered.
Depending on the type and velocity of the forces affecting the brain, different areas throughout the whole brain are affected. This is different from stroke where a clot prevents oxygen travelling to the cells supported by that blood vessel, or where a blood vessel might burst and affect the immediate area and possibly the area distal to the bleed if the blood supply is cut off. The damage is limited to the area of the brain supplied by that vessel, e.g. middle cerebral artery, and other areas remain intact.
Common mechanisms of TBI
Closed
- Crush injuries with compression of the skull caught between two hard surfaces.
- Acceleration and deceleration injuries: injuries in which the head is in motion and then abruptly comes to a halt. For example, if a car hits a tree, the car suddenly stops, and the driver's head hits the steering wheel. The brain within the skull still has forward momentum and can hit the inner surface of the skull (which has bony edges) with some force, causing internal bruising, lacerations and bleeding.
- Diffuse axonal injury: the twisting motions or sudden changes in brain momentum that accompany some accidents may cause the bundles of nerve fibres (brain white matter) to be stretched or shear. The term closed head injury is often used to describe this type of TBI because the damage to the brain occurs as the result of these internal mechanisms but usually with the skull remaining intact.
Open
- Penetrating injuries: this describes cases where some external object, e.g. knife or arrow, pierces the skull and there is direct contact with underlying brain tissue.
Adults
In Australia, the annual incidence of TBI resulting in hospitalisations is estimated to be 150 per 100,000 and cost the Australian economy $8.6 billion per year in 2008.1
Khan et al (2003) analysed Australian data while determining the severity of TBI to provide an epidemiological profile of the incidence of adults admitted to hospital for TBI.22 It is about 150 per 100,000 population per year.
- In the under 65-year-old group the incidence of TBI peaks in the age group 15-35 years.
- The ratio of patients aged under 65 years is 3.4 males to 1 female, a differential largely thought to be related to risk-taking behaviour among young males.
- Motor vehicle-related trauma accounts for about two-thirds of moderate and severe TBI, with falls and assaults being the next most common causes.
- Alcohol is associated with up to half of all cases of people admitted with TBI.
- Prevalence of mild TBI is likely to be an underestimate due to classification and diagnostic errors and because a large proportion of people with mild TBI do not present to hospital.
| Category | Rate per 100,000 |
|---|---|
Mild | 64 to 131 |
Moderate and severe | 12 to 14 |
All | 150 |
Children
In NSW a retrospective study determined the demographics, causes, treatment and outcome of TBI in patients admitted to The Children’s Hospital at Westmead emergency from 2006 to 2011.3
Over the six-year period, there were 1489 presentations at The Children’s Hospital at Westmead. The demographics and statistics outlined:
- gender: 65% were male and 35% were female
- age: the mean age was seven years
- severity: 93% mild, 1.5% as moderate and 5.5% as severe
- sports and recreational injuries accounted for 26% of all TBI presentations
- motor vehicle accidents accounted for 77% of all TBI deaths.
In NSW there are two common ways of prospectively measuring the severity of TBI.
- The level of responsiveness and duration of unconsciousness (coma) as measured by the Glasgow Coma Scale.16
- Duration of post-traumatic amnesia (PTA), evidenced by a period during which the person is disorientated, unable to learn and the inability to know time, place or person (self).
The impact of the injury on the brain determines severity and ranges from concussion to persistent vegetative states and is typically classified from mild to very severe.
The Glasgow Coma Scale is a most useful tool for guiding medical and surgical interventions in the acute phase following injury. The duration of PTA is a most useful tool for determining the outcome following TBI for the individual. People with severe and very severe TBI usually require specialist brain injury rehabilitation.
Mild TBI
A mild TBI is also called a concussion. Most people with mild TBI make a good physical recovery within days, weeks or months. Some experience ongoing problems with living and learning (mild-complicated TBI).
Moderate TBI
About one third of people with a moderate brain injury experience some lifelong problems in functioning.
Severe TBI
Ninety percent of people with a severe brain injury experience lifelong problems in functioning.
Very severe TBI
100% of people with a severe brain injury experience lifelong problems in functioning.
The Care and Needs Scale and Paediatric Care and Needs Scale provides validated tools to measure the level of impact on different domains of functioning after TBI and the hours of support required to maximise participation and minimise disability.56,57
In 2014, Jagnoor and Cameron identified that the mechanisms of recovery are poorly understood and there is considerable variability in patterns of recovery.21
People with very mild and mild TBIs can be expected to recover quickly. However, some will have psychological consequences of the injury that will require assessment and management. Most people experiencing mild TBI recover fully within days to months but a small percentage (1-20%) of individuals continue to experience symptoms three months after injury.
Recovery from moderate or severe TBI tends to follow a negatively accelerating curve, which is most rapid in the first three to six months but may continue for several years.
They considered that much of the early spontaneous recovery after TBI is explained by the resolution of temporary physiological changes. In addition there are regenerative neuronal changes that have been associated with behavioural improvement. However, the potential for regenerative growth is limited, particularly in the case of severe injuries. It is thought that most recovery beyond this occurs through the substitution or reorganisation of neural structures and functions. There is a growing body of evidence to suggest that environmental stimulation and specifically behavioural therapies can alter brain function and organisation after injury.
Because the recovery and rehabilitation from severe brain injury is typically most rapid in the first three to six months (but may continue for several years), the rehabilitation pathway typically goes from the point of injury to the person being back in the community.21
Part of Paul's story
Back at work
Paul and his friend get jobs in the snowfields, where they will share accommodation. Paul keeps in email contact with his case manager, provides updates and shares concerns. Other friends have started working in the area and Paul is happy.
Paul is discharged from the community team 20 months post injury.
TBI impacts multiple domains.
The International Classification of Functioning, Disability and Health (ICF) provides clinicians and researchers, policymakers and others with a comprehensive framework for relevant domains of human experience that are affected by health conditions such as TBI (in the context of environmental and personal factors).59
The ICF Core Sets for TBI are intended as an international standard of what to measure. They are not health status measures but instead are a comprehensive list of relevant domains of functioning for TBI. They provide a practical checklist for working with people with TBI in the context of specialised brain injury rehabilitation programs in NSW.
| A. Body structures | B. Body functions | C. Activities and participation | D. Environmental factors |
|---|---|---|---|
| Injury | Impairments | Impacts | Supports and barriers, impacts |
| Structure of brain | Consciousness functions Energy and drive functions Attention functions Memory functions Emotional functions Higher-level cognitive functions Sensation of pain Control of voluntary movement functions | Carrying out daily routine Conversation Walking Self-care Complex interpersonal interactions Family relationships Acquiring, keeping and terminating a job Recreation and leisure | Products and technology for personal use in daily living Products and technology for personal indoor and outdoor mobility and transportation Immediate family Friends Social security services, systems and policies Health services, systems and policies* |
| A. Body structures | B. Body functions | C. Activities and participation | D. Environmental factors |
|---|---|---|---|
| Injury | Impairments | Impacts | Supports and barriers, impacts |
| Structure of brain | Temperament and personality Sexual functions Sleep functions | Handling stress and other psychological demands Intimate relationships Making decisions | Extended family Acquaintances, peers, colleagues, neighbours and community members |
* These 23 categories in the Core Set are a starting point for what’s typical, not an exhaustive list of all possible impairments and impacts.
Part of Paul's story
Re-learning skills
Inpatient specialised brain injury rehabilitation, case management, TLP with shared accommodation
Back into the community
At home
Rehabilitation training with father and community therapists, case management, GP care
The specific impairments are particular to each person. These impairments can be profound and long-term with personality and behaviour change leading to significant lifestyle effects.
In addition psychological distress post TBI is highly prevalent after a TBI and can present with mixed mental health issues with features of depression, anxiety, anger and stress.
Examples of common impairments
Neurological impairment (motor, sensory and autonomic)
- Sleep disturbance – insomnia, fatigue
- Medical complications – spasticity, post-traumatic epilepsy, hydrocephalus
- Heterotopic ossification
- Sexual dysfunction
Cognitive impairment
- Memory impairment, difficulty with new learning, attention and concentration, reduced speed and flexibility of thought processing, impaired problem-solving skills
- Problems in planning, organising and making decisions
- Language problems – dysphasia, problems finding words and impaired reading and writing skills
- Impaired judgment and safety awareness
- Cognitive fatigue
Personality and behavioural changes
- Impaired social and coping skills, reduced self-esteem
- Altered emotional control, poor frustration tolerance and anger management, denial and self-centredness
- Inappropriate social behaviour including increased anger or aggression
- Reduced insight, disinhibition, impulsivity
- Psychiatric disorders – anxiety, depression, post-traumatic stress disorder, psychosis
- Apathy, amotivational states
Part of Paul's story
Continuing to re-learn
Living skills
ADL support and rehabilitation training provided by father, case management, return to work program, social work
Living in the community
Services and activities
ADL support provided by father, community team monitoring, case management
The impairments caused by the TBI have significant impacts on the person, their life, family and friends and their ability to live and work in the community.
Families also face many challenges themselves as they adjust to the impact of the changes to the person with TBI, as well as their own circumstances, for example giving up work to be the caregiver, changes in sibling and parent relationships. Families remain the constant presence amid a continually changing spectrum of providers and professionals as treatment and recovery progress.
Part of Paul's story
Back into the community
At home
Rehabilitation training with father and community therapists, case management, GP care
Families share unique roles as:
- observers throughout all stages of their loved one’s care
- experts with a dual perspective of pre- and post-knowledge of abilities and difficulties
- communicators and liaisons with professional caregivers
- advocates for their loved one.
Examples of impacts and social consequences
Life impacts for person with TBI
- Unemployment and financial hardship
- Inadequate academic achievement
- Lack of transportation alternatives
- Inadequate recreational opportunities
- Loss of pre-injury roles, loss of independence
- Increased service utilisation
Increased risks for person with TBI
- Substance abuse
- Mental health problems
- Homelessness
- Social isolation
- Suicide
Person with TBI: challenging behaviours
- Inappropriate social behaviour
- Verbal aggression
- Adynamia (lack of strength or vigour)
Person with TBI’s relationships
- Difficulties in maintaining interpersonal relationships
- Marital breakdown
- Not forming relationships and remaining single
Life transition impacts
- Hospital to community
- Return to work and study if possible, or alternatives if not possible
Sources for stress for family members
- Family members having to give up work and being impacted financially
- Increased level of conflict due to temper control problems
- Family members (especially partners) having to take on new roles if partner with TBI is no longer able to play these roles
- Family members who play a caring or support role losing touch with their own social networks and becoming more socially isolated
- Family members experiencing grief or depression and mourning for the person they knew before the TBI
- Family members experiencing post-traumatic stress if they witnessed or were involved in the accident that caused the injury