TRAUMATIC BRAIN INJURY
blood vessels from shear-strain of angular
GENERAL MEDICAL BACKGROUND
I. DEFINITION
 An insult to the brain, caused by an external
physical force (contact or rotational forces)
that may produce a diminished or altered state of
consciousness, which results in an impairment of
cognitive abilities or physical functioning. It can al-
so result in the disturbance of behavioral or emo-
tional functioning.
 Also known as intracranial injury, occurs when an
external force traumatically injures the brain.
 Describes sudden physical damage and trauma to
the brain.
 Acquired, non-progressive injury to the brain.
II. EPIDEMIOLOGY
 2x in M than in F.
 Most common in young children (0 - 4 years
old).
 Peak incidence of 15 - 24 years old.
 Hospitalization and death as a result of TBI is
most common in older adults (65 years old and
over).
 Usually occur as a consequence of:
o Falls (32%)
o MVA (19%)
o Struck by or against events (18%)
o Assault (10%)
 Leading cause of injury related death and disa-
bility in the US, an average of 1.4 million TBI
occur each year, including 1.1 million emergen-
cy department visits, 235,000 hospitalizations,
and 50,000 deaths.
III. ETIOLOGY
 A blow or jolt to the head
 An injury that penetrates the head and enters
brain tissue
 Injuries occurring at Work, at Home, Sports
 Single, Largest Indirect Cause: Alcohol Abuse
 Others: Drug Abuse
 Major Direct Causes:
o MVA
o Falls (children & elderly)
o Violent acts
o Sports injuries
IV. PATHOPHYSIOLOGY
 MOI: Contact, acceleration, deceleration and ro-
tational forces of the brain relative to the bony
skull causes compression, strain, shearing and
displacement in the brain tissue.
V. CLASSIFICATION
A. Primary Brain Injury
I. Diffuse Axonal Injury (DAI)
 Disruption and tearing of axons and small
acceleration; results in neuronal death and
petechial hemorrhages.
 Acceleration/decceleration and rotational
forces that commonly results in MVA.
 Responsible for initial LOC.
 Affectation of the ff results to initial LOC:
o Corpus Callosum
o Pons
o Midbrain
o W. Matter of the Cerebrum
II. Focal Injury
 Contusion/Polar Brain Damage
 MC: Inferior Frontal & Anterior Temporal
lobes
 Neurobehavioral syndrome:
o Agitation
o Physically & Verbally Aggressive
o Sensory & Motor changes
 Cranial Nerve Damage
III. Coup - Contrecoup Injury
 Injury at point of impact and opposite
point of impact
IV. Closed or Open Injury
 Closed (Non-missile) Head Injury
o Dura mater remains intact
o The skull can be fractured, but not
necessarily
 Open (Penetrating) Head Injury
o Occurs when an object pierces the
skull and breaches the dura mater.
B. Secondary Brain Injury
I. Hypoxic Ischemic Injury
 Results from systemic problems that
compromise cerebral circulation.
 Can be caused by systemic hypotension,
anoxia, and damage to specific territories
of the brain
 Can lead to global damage and associ-
ated to poor cognitive function and lower
expected outcomes
II. Intracranial hematoma
 Often associated with patients who ‗talk
and die‘, that is those who are lucid for a
period of time after initial injury but who
later lapse into coma and die.
 Usually classified according to the site
(epidural, subdural, or intracerebral) and
by the time after injury in which they de-
velop.
III. Raised intracranial pressure
 Results from swelling or abnormality of
brain fluid dynamics or hematoma.
 Normal ICP – increased ICP correlates
with poorer expected outcomes.
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  Ssx:  Anesthesia of a portion of the nose, eye-
 Headache brow and forehead.
 Vomiting without nausea o CN VII
 Ocular Palsies  CN VII Palsy
 Altered Level of Consciousness o CN VIII
 Back Pain  Petrous/mastoid fracture
 Papilledema  Escape of CSF from the auditory canal:
 Pupillary Dilatation Otorrhea
 Abducens Palsy  (+) Battle sign: Hematoma at the mastoid
 Cushing‘s Triad process
o CN IX - XII
VI. CLINICAL MANIFESTATIONS  Cardiac Irregularities
 Excessive salivation
▪ Disorders of Consciousness  Loss of sensation and gag reflex of the
palate
▪ Cognitive and Behavioral Impairments
 Loss of taste on the posterior third of the
o Loss of executive functions that regulate, tongue
control, and coordinate cognitive process-  Hoarse voice
es  Dysphagia
o Behavior maybe excessive or disinhibited.  Deviation of the tongue to the side of the
o Inappropriate social and interpersonal be- lesion
haviors
o Mood disturbances may include depres-
▪ Motor Deficits
sion and anxiety
o Ataxia
o Pseudobulbar affectations o Flaccidity
o Motor, sensory and verbal perseveration
o Decorticate posturing
o Imitation of gestures
o Decerebrate posturing
o Restlessness
o Refusal to cooperate ▪ Heterotopic Ossification
o Impulsivity o Onset is 4 - 12 weeks after injury
o Hyperactivity ▪ Medical Complications
o Memory impairment o Neurogenic hypertension
o Psychosis o Cardiac dysrhythmias
▪ Pain o Neurogenic pulmonary edema
o Head and neck pain common in whiplash o Aspiration pneumonia
o Neuropathic pain o Pulmonary emboli
o Myofascial pain o Disseminated intravascular coagulation
o Fibromyalgia o Hyponatremia
o Chronic pain o Iatrogenic infections are common
▪ Cranial Nerve Damage VII. COMPLICATIONS
o MC affected: CN VII
 Headache
o 2nd MC affected: CN III  Altered consciousness
o Least affected: CN 4, 9, 10, 11
o Commonly occurs with acceleration and
o CN I
decceleration type of injuries and may occur
 Due to cribriform plate fracture with some focal injuries.
 S/s: Hyposmia or Anosmia
 Escape of CSF from the nasal cavity: Rhi- LEVELS OF CONSCIOUSNESS
norrhea O Alert
 Racoon‘s eye / Panda Bear Sign -Awake and easily arousable - oriented x 3
 Otorrhea O Lethargic (Somnolent)
o CN II -Difficult to arouse, drowsy, thinking slow but
 Monocular blindness appropriate
 Dilated pupil with an absent direct pupillary O Obtunded
response -Sleeps most of the time, confused when
 Brisk consensual response to light arouse, speech mumbled
o CN III & VI O Stupor (Semi-comatose)
 Doll‘s Eyes (Oculocephalic Response) -Responds only to vigorous shake or pain,
o CN IV non verbal
 Vertical diplopia mimicking a CN III palsy O Unresponsive (Coma)
o CN V -Completely unconscious, no response to
pain
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 o Vegetative State full spectrum of cognitive, affective, and emo-
-No capacity to interact with the environ- tional function of the individual.
ment, decreased level of awareness with
eye opening & sleep/wake cycle but cannot Glasgow Coma Scale (GCS)
follow commands/speak. - Most common scoring system used to describe the
o PVS level of consciousness in a person following trau-
- Vegetative state present for 1 month or matic brain injury.
more; no meaningful motor and cognitive - Used to help gauge the severity of an acute brain
function and a complete absence of aware- injury.
ness of surroundings and self. - The test is simple, reliable & correlates well with
o Locked-in Syndrome outcome following severe brain injury.
 Seizures - Factors like drug use, alcohol intoxication, shock
 Fluid buildup or low blood oxygen can alter a patient‘s level of
- CSF may build up in the spaces in the brain consciousness.
(cerebral ventricles) ➛ swelling and in-
creased pressure in the brain.
 Infections
- Skull fractures or penetrating wounds can
tear the layers of protective tissues (menin-
ges) that surround the brain ➛ meningitis.
 Blood vessel damage
 Hydrocephalus
 Hydrothalamic and Endocrine Dysfunction
 Psychiatric Problems
 Nerve damage
 Cognitive Problems
o PT is often disoriented to PPT.
o Anterograde memory deficit (inability to
learn new things).
o Retrograde memory deficit (inability to re-
member previously learned materials).
o Post traumatic amnesia (time between the
injury and when the Pt is again able to re-
member ongoing events).
 Communication Problems
 Behavioral Changes
 Emotional Changes
 Sensory Problems
 Degenerative Brain Diseases
 Alzheimer‘s Dse
 Parkinson‘s Dse
 Dementia Pugilistica
- Chronic traumatic encephalopathy with charac-
teristics of dementia. May affect amateur box-
ers, wrestler as well as athletes in other sports Ranchos Los Amigos Level of Cognitive Function-
that suffers repeated concussions. ing (LOCF)
- Describes a predictable sequence of neurobehav-
VII. DIAGNOSIS ioral recovery of TBI
 Diagnostic Tools - Provides rationale for cognitive rehabilitation pro-
o MRI gram.
o CT-Scan
o Cerebral Blood Flow Mapping
o Intracranial Pressure Monitor
o EEG & Evoked Potentials

 Assessment Tools:
o Glasgow Coma Scale

 Neuropsychological Testing
- Battery of tests, performed by a neuropsy-
chologist, is the best means of determining the

44
 Rappaport’s Disability Rating Scale (DRS)
- Covers a wide range of functional area & used to
classify levels of disability ranging from death to no
disability.
- Used serially to document pt. progress over time.

Feeding,
Eye Open- Motor Re-
Communication Toileting,
ing sponse
Grooming
0- 0 - Oriented 0 - Obeying 0.0 - Com-
Sponta- 1 - Confused 1 - Localizing plete
neous 2 - Inappropriate 2 - Withdraw- 1.0 - Partial
1 - To 3 - Incompre- ing 2.0 - Mini-
speech hensible 3 - Flexing mal
2 - To pain 4 - None 4 - Extending 3.0 - None
3 - None 5 - None
―Employability‖ (as full-
Level of Functioning (Physi-
time worker, homemak-
cal & Cognitive Disability)
ers, or student)
0.0 - Completely Independ- 0.0 - Not restricted
ent 1.0 - Selected jobs, com-
1.0 -Dependent in Special petitive
Environment 2.0 - Sheltered workshop;
2.0 - Mildly dependent - noncompetitive
limited assistance (nonresi- 3.0 - Not employable
dent helper)
3.0 - Moderately dependent
- moderate assistance (per-
son in home)
4.0 - Markedly dependent -
assist all major activities, all
times
5.0 - Totally dependent - 24
hr nursing care
Glasgow Outcome Scale (GOS)
- Used to correlate severity measures & outcome
- Does not really indicate functional abilities
- Used primarily for research purposes

45
Galveston Orientation & Amnesia Test (GOAT)  Affective disorder
- GOLD standard in PTA  Depression
- Most common & widely used assessment tool in  Whiplash-associated disorder
POST TRAUMATIC AMNESIA

LENGTH OF AMNE- SEVERITY OF INJU- GENERAL HEALTHCARE MANAGEMENT

SIA RY
I. MEDICAL INTERVENTION
< 5 minutes Very mild
 Early rescuscitation to stabilize cardiovascular
5-60 minutes Mild and respiratory system

1-24 hours Moderate  Systolic Blood Pressure should be kept less

than 90mmhg and oxygen saturation above
1-7 days Severe 90%

 Patients with severe injury and some with

1-4 weeks Very severe
moderate injury will need to be intubated
>4 weeks Extremely severe
 Patient‘s neck should be stabilized with a col-
o
lar and head elevated to 30 to protect the
spine avoid increase ICP

Functional Independence Measurement (FIM)  Use GCS

- instrument is a basic indicator of patient disability
- is used to track the changes in the functional abil-  Neurological Examination is done to deter-
ity of a patient during an episode of hospital reha- mine if neurosurgery is warranted
bilitation care.
II. PHARMACOLOGIC INTERVENTION

FIM GRADING  Anti-anxiety

7 Complete Independence (Timely & safely)  Anticoagulants

 Anticonvulsants
6 Modified Independence (Device)
 Diuretics

 Muscle relaxants
5 Supervision (Subject= 100%)
 Stimulants

III. SURGICAL INTERVENTION

4 Minimal Assistance (Subject= 75% or more)
 Surgical Decompression
3 Moderate Assistance (Subject= 50-74 or o Craniectomy
more)
o Craniotomy
2 Maximal Assistance(Subject= 25%-49% or
more)  External Ventricular Drain

IV. OTHER HEALTHCARE MANAGEMENT

1 Total Assistance (Subject= <25)
 Physician

 Speech-Language Pathologist
VIII. DIFFERENTIAL DIAGNOSIS
 Occupational Therapist
 CVA
 Anoxic brain injury  Rehabilitation Nurse
 Metabolic encephalopathy
 Case Manager/Team Coordinator
46
  Social Worker PLAN OF CARE & INTERVENTION
 Neuropsychologist
PROBLEM PLAN OF INTERVENTION
 Respiratory care practitioner LIST CARE

 Recreational Therapist Impaired Normalize Use simple and

arousal, atten- arousal, atten- breakdown any
tion, and cogni- tion & cognition complex com-
tion mands.
PT EXAMINATION, EVALUATION AND DIAGNO-
Always orient the
SIS
patient as to per-
son place and
I. POINTS OF EMPHASIS
time.
 HPI
 Systems review Agitation ↓ the level of Reduce level of
 General signs of increase ICP agitation stimulation in the
 Cranial nerve function environment
 Speech & communication
 Sensory Allow patient to
thrash about in
 Changes in behaviour floor bed
 Vital signs Allow patient to
 Respiratory function pace around the
 Muscle tone/ DTRs unit with 1:1 su-
 ROM/MMT pervision
 Functional Assessment Allow confused
patient to be ver-
bally inappropriate
II. PROBLEM LIST
1. Impaired arousal, attention, and cognition Promote relaxation
2. Agitation techniques
3. Abnormal posturing & (+) primitive reflexes
4. Sensory impairments
5. Spasticity Abnormal Pos- ↓ abnormal Techniques to
6. LOM turing & (+) posturing & decrease abnor-
7. Muscle weakness Primitive Re- primitive re- mal posturing &
8. Impaired balance flexes flexes primitive reflex
9. Fatigue & deconditioning such as proper
positioning and
handling of body
III. PT DIAGNOSIS parts
Pattern D: Impaired Motor Function and Sensory
Spasticity ↓ Spasticity Rood‘s inhibition
Integrity Associated With Nonprogressive Disor-
techniques
ders of the Central Nervous System—Acquired in
Adolescence or Adulthood

Sensory Im- Improve sensa- Roods technique

pairments tion and stimulation
exercises.

47
Limitation of ↑ Range of  PROM, AA-
Motion motion ROM exercis-
es (15 reps x
3 sets)
 Stretching of
tight muscles
(15 seconds
hold x 10 rep-
etitions)
 Serial Casting
is often used
for PF or bi-
ceps contrac-
ture.
Ex. with a PF con-
tracture, the ankle
is stretched into as
much DF as pos-
sible and then
short leg cast is
applied. After 1
week, the cast is
removed. The
muscle is
stretched again
and another cast is
applied. This pro-
cedure is repeated
until satisfactory
gains in ROM are
achieved.
 US

Muscle Weak- ↑ muscle Progressive resis-

ness strength tive exercises us-
ing thera bands,
ankle weights and
dumbbells
(10 reps x 3 sets)

Impaired bal- Normalize bal- High-level, task-

ance & toler- ance oriented balance
ance. and gait training
inside the parallel
bars, Weight shift-
ing exercises and
balance activities
using the wobble
board as progres-
sion.

Fatigue & De- Lessen the Breathing exercis-

conditioning occurrences of es for x4 reps.
fatigue and
focusing on Brisk walking on a
Reconditioning treadmill for 15-30
minutes and pro-
gress to
Light jogging for
15- 30 minutes.

48