Head injuries are damage to the scalp,
skull, or brain caused by trauma. When it
affects the brain, they’re called a traumatic brain injury, or TBI.
To most people, head injuries are considered an acceptable
risk when engaging in sports and other types of recreational activities. But
they’re dangerous. They can lead to permanent disability, mental impairment,
and even death. There are steps you can take to lower the risk and protect
yourself and your children.
Types of
Head Injuries
There are many different
types of head injuries.
- Concussion. This is the most common type of head injury. A concussion is
a type of traumatic brain injury (TBI) that happens when the brain is jarred or shaken hard enough to bounce against the skull.
It can range from mild to severe. You don't have to be hit in the head to
get a concussion. An impact elsewhere on the body can create enough force
to jar the brain.
- Contusion. A bruise on the actual brain itself is called
a contusion. It can cause bleeding and swelling.
- Intracranial hematoma (ICH). This is
bleeding under the skull in the brain that forms a clot. Brain hematomas
range from mild to severe and are grouped according to where they form.
- Skull fracture. Sometimes, a
broken skull bone can affect the brain. The broken pieces of bone can cut
into the brain and cause bleeding and other types of injury.
Head
Injury Causes
The most common causes
of head injuries are:
- Car or motorcycle accidents
- Falls
- Child abuse
- Acts of violence
A concussion or other
head injury can also happen when two athletes collide or a player is hit in the
head with a piece of sporting equipment. In soccer, even "heading"
the ball can cause a concussion.
Among the sports-related
activities that cause the highest number of head injuries for all ages:
- Cycling
- Football
- Basketball
- Baseball and softball
- Riding powered recreational vehicles such as dune
buggies, go-karts, and mini bikes
According to the Brain
Injury Association of America, the five leading activities that cause
concussions in children and adolescents aged 5-18 years of age are:
- Cycling
- Football
- Basketball
- Playground activities
- Soccer
Sports activities and
trauma aren’t always the cause of head injuries. Contusions or brain
hemorrhages can have other causes, such as:
- Long-term high blood pressure (in adults)
- Bleeding disorders
- Use of blood thinners or certain recreational
drugs
Head
Injury Signs and Symptoms
Signs and symptoms of a
concussion may show up immediately, or they can take hours or even days to show
up. You don’t always lose consciousness with a concussion. A concussion causes
changes in a person's mental status and can disrupt the normal functioning of
the brain. Multiple concussions can have a long-lasting,
life-changing effect.
Signs of a TBI,
like a concussion, include:
Signs or symptoms that a
head injury may be more than a concussion and requires emergency treatment
include:
- Changes in size of pupils
- Clear or bloody fluid draining from the nose, mouth, or ears
- Convulsions
- Distorted facial features
- Facial bruising
- Fracture in the skull or face
- Impaired hearing, smell, taste, or vision
- Inability to move one or more limbs
- Irritability
- Lightheadedness
- Loss of consciousness
- Low breathing rate
- Restlessness, clumsiness, or lack of coordination
- Severe headache
- Slurred speech or blurred vision
- Stiff neck or vomiting
- Sudden worsening of symptoms after initial
improvement
- Swelling at the site of the injury
- Persistent vomiting
Head
Injury Treatment
If you think you may
have a concussion or suspect that someone else has one, the most important step
to take is to prevent further injury. Stop whatever activity you are involved
in and tell someone you think you may have been injured. Then get medical
attention. If you're playing as part of a team, ask to be taken out of the game
and tell the coach what happened. If a fellow player has signs of being
confused or a sudden loss of coordination, be sure to report this to a coach.
If you are coaching a team and you notice a potential injury, take the person
out of the game, and see that the person gets medical care.
Receiving medical
attention as soon as possible is important for any type of potentially moderate
to severe TBI. Undiagnosed injuries that don't receive proper care can cause
long-term disability and impairment. Keep in mind that although death from
a sports injury is rare, brain injuries are
the leading cause of sports-related deaths.
Symptoms should be closely
monitored often with a moderate to severe injury. It may require an overnight
stay in the hospital. A doctor may take X-rays to check for potential skull
fracture and stability of the spine. In some cases the doctor may ask for
a CT scan or an MRI to check on the extent of the
damage that occurred. More severe injuries may need surgery to relieve pressure
from swelling.
If a child sustains a
head injury, don’t automatically have them X-rayed. Monitor them carefully for
age appropriate symptoms of a TBI such as confusion or behavioral change. Don’t
give them medications, including aspirin, without advice from your doctors.
If the doctor sends you
home with an injured person, they’ll instruct you to watch that person closely.
That may involve waking the person every few hours to ask questions such as
"What's your name?" or "Where are you?" to be sure the
person is OK. Be sure you've asked the doctor and understand what symptoms to
watch for and which ones require immediate attention.
Guidelines urge doctors
not allow someone who has been injured to return to activity that involves risk
of further injury until completely free of symptoms. That usually takes a few
weeks. But symptoms of severe injury could persist for months or even years. A
person with a moderate to serious injury will likely require rehabilitation
that may include physical and occupational therapy, speech and language therapy, medication, psychological counseling, and social support.
REHABILITATION FOR HEAD INURY
Traumatic brain injury (TBI) is damage to the brain as a result of an external
force to the brain and it is associated with changes in consciousness that can
cause cognitive, physical and psychosocial functional disorders. This is a
typical example of multiple disability in the adult and poses a challenge to
the rehabilitation team because of the myriad problems the patient presents
with. This chapter gives a brief overview about the condition without delving
into much detail.
The temporary or permanent damage to the internal structures of the brain
presents as:
• Motor disturbances
• Sensory disturbances and
• Cranial nerve involvement
TBI may be classified as mild moderate or severe
Mild head injury is manifested by any one or more of the following:
Any focal neurologic deficits, which may or may not be persistent.
Any period of loss of consciousness
Any alteration in mental state immediately after the accident
Any loss of memory for events immediately before or after the accident
Glasgow Coma Scale (GCS) score greater than 12
Admission in a hospital for less than 48 hours
Moderate traumatic brain injury:
GCS score of 9-12 or higher
Intracranial lesion that needs surgery
CT abnormality
Admission and stay for more than 2 days in the hospital
Severe Trauma is suspected when GCS score below 9 within 48 hours of
the injury.
Motor Disturbances
The usual abnormalities include monoplegia, hemiplegia, and quadriplegia.
Great variations exist initially and presentation of the patient can fluctuate
from flaccidity to spasticity with abnormal reflexes. In some cases decorticate
or decerebrate rigidity is found. Examples of typical motor disturbances are:
• Abnormal flexor responses in upper limb and abnormal extensor responses
in lower limb
• Abnormal extensor responses in upper and lower extremities
• Absence of motor responses (flaccid)
Sensory Disturbances
• Hemisensory loss involving ipsilateral face
• Hemisensory loss on the contralateral side
CLINICAL PRESENTATION
Primary Disability
Frontal lobe
• Expressive dysphasia (dominant hemisphere)
• Personality change-antisocial behavior
• Loss of inhibitions
• Loss of initiative
• Intellectual impairment
• Profound dementia (especially if corpus callosum is involved)
Multiple deformities in an adult with brain injury
Temporal lobe
Receptive dysphasia (dominant hemisphere)
Visual field defect
Upper homonymous quadrantanopia
Parietal Lobe
Loss of sensation
Sensory inattention
Loss of localization of touch
Visual field defect
Loss of two point discrimination
Lower homonymous quadrantanopia
Astereognosis
Occipital lobe
Visual field defect-homonymous hemianopia
Hypothalamus/Pituitary Damage
Endocrine Dysfunction
Supratentorial injuries may directly damage the I and II cranial nerves.
Cavernous sinus compression or invasion may involve the III and IV cranial
nerves.
Infratentorial:
Deterioration of consciousness level
Pupillary abnormalities
Tremor (red nucleus)
Vomiting, hiccough (medulla)
Impaired eye movements
Cerebellum:
Ataxic gait
Dysarthria
Intention tremor
Nystagmus
Dysmetria
Movement Disorders:
Tremors
Ballismus
Myoclonic jerks
Focal and general dystonia
Chorea athetosis
Tics
Eye:
Paralysis
Orbital fractures
Infection
Field deficits
Diplopia
Blindness
Nose:
Traumatic anosmia
Mouth and Throat:
Dental and gingival problems
Dental injuries
Jaw fractures
Dysphagia
Larynx:
Vocal cord trauma, paralysis
Cranial Neuropathies
Paralysis of cranial nerves 1-12 resulting in varying symptoms like diplopia,
vertigo, dysarthria or dysphagia.
Secondary Disability (other organ failure due to prolonged immobilization)
The person with traumatic brain injury could have suffered from multiple
injuries as in a road traffic accident, and a complete assessment of all
organs is needed. Multiple system failure may be primary in this case,
but also may be secondary due to the patient being confined to bed for a
long time, in an unconscious or semi-conscious state. The other organs
affected are:
Skin:
Decubitus ulcers
Infections
Sweat disorders
Oedema
Ear:
Hearing deficits, deafness
Infection
Trauma
Lungs:
Emboli
Pulmonary oedema
Recurrent pneumothorax
Restrictive defects
Pneumonia
Broncho-pleural cutaneous fistula
Atelectasis
Adult respiratory distress syndrome
Gastrointestinal Tract:
Gastroparesis-sluggish gut
Esophagitis-acid reflux
Peptic ulcer
Hepatitis:
Elevated liver function tests
Heart:
Direct Trauma
Pericardial effusion
Heart failure
Arrhythmia
Peripheral vascular system:
Thrombophlebitis
Hypotension
Hypertension
Genitourinary System:
Infection calculi formation
Incontinence
Trauma of bladder or kidney
Sexual dysfunction
Metabolic and endocrine system:
Hypothalamic-pituitary failure
Electrolyte and fluid disorders
Syndrome of inappropriate
Malignant hyperthermia
antidiuretic hormone (SIADH)
Salt wasting syndrome
Uraemia
Musculoskeletal system:
Fractures
Spasticity
Osteoporosis
Occult spinal cord injury
Contractures
Radiculopathy - Pain syndromes
Heterotopic ossification
Cutaneous neuroma
Peripheral nervous system:
Neuropathies
Nerve compression syndrome
Drug reactions
Reflex sympathetic dystrophy
Local Injury (peroneal, sciatic and ulnar nerves)
REHABILITATION ASSESSMENT
Assessment in the Acute Phase
Once a patient with TBI has regained consciousness, it is essential to decipher
what structures have suffered damage, in order to determine the need of post
acute rehabilitation services. The patient may have:
• Impairment of higher functions: memory, concentration and orientation.
• Cognitive communication disorder: Language problems, particularly
aphasia.
• Emotional, psychological and behavioral problems
• Motor impairments such as weakness, altered tone and lack of co-ordination
in the limbs
• Oromotor problems with speech and swallowing difficulty.
• Sensory impairments like visual problems, hearing loss.
• Bowel and bladder incontinence
Assessment in Later Phases
In addition to the above the following will be assessed for rehabilitation:
Self care (Functional assessment): for washing, feeding and other ADL’s
Movement:
• In bed
• Sitting to standing
• Bed to chair
Ambulation on flat surfaces, uneven ground, stairs and in crowded environments
Social aspects like
• family
• housing
• occupation
• hobbies
• lifestyle
ASSESSMENT SCALES
Assessment is generally done clinically at the bedside on the guidelines given
above but when these parameters have to be quantified, for example, the level
of coma, the independence level or the disability levels, it is advisable to use
standardized scales.
Rancho Los Amigos Scale
The patient may be in coma and he is assessed according to the Rancho Los
Amigos Scale (given below concisely). This universally recognized scale was
developed for use in the planning of treatment, monitoring the recovery, and
classifying outcome levels in brain injury. It is an easy and simple test to perform
for evaluating cognition of the patients and is a validated test. Not only does
it give a status on the patient but it can also follow-up and compare between
patients. There are 8 classification levels, ranging from no response (level I) to
“confused and agitated” (level IV) to purposeful and appropriate (level VIII)
I. No Response: The patient does not respond to environmental stimuli such
as sounds, sights, touch or movement.
II. Generalized Response: There will be a delayed response to environment,
which may be non specific, like chewing, sucking, breathing faster,
moaning or moving some part of the body. Sweating or increased blood
pressure may occur as part of an overall systemic response.
III. Localized Response: The patient is awake on and off during the day,
moves body more and recognizes people around him. He may follow
simple instructions like ‘open your mouth’ but responds inconsistently
or incoherently to simple questions.
IV. Confused-Agitated: The patient becomes very confused or agitated,
reacting to what he sees hears or feels by lashing out, shouting, using
abusive language, or tossing about. He cannot follow directions,
cooperate with the care giver, or concentrate even for a few seconds.
V. Confused-Inappropriate, Non-Agitated: This confused patient is less
agitated than stage 4, and is not oriented to time or place. His memory
and concentration are poor. He follows commands slowly and is still
fully dependent for his ADLs. He may get obsessed on an idea or activity
(perseveration) and needs help to switch to the next part of the activity.
Past memory may be better than recent memory.
VI. Confused-Appropriate: This patient is still confused in memory and
thought processes but can remember some snatches from a conversation.
He can be persuaded to follow a certain routine, but will get confused
and upset if it is changed. He is more oriented to time and place but
cannot do multitasking, that is many tasks at a time.
VII. Automatic-Appropriate: This person can follow his routine, take care of
himself and is independent in most self care activities. However he is
still confined to a routine and any change might irritate him. Long range
planning or strategies still elude him, and he gets flustered in crowded
surroundings. He is incapable of handling an emergency.
VIII. Purposeful-Appropriate: In this stage the person is more adaptable, and
is more aware of his loss of memory. He starts to compensate for his
deficits and does not flounder in stressful situations. However when a
new challenge presents itself he may show poor judgement.
OTHER SCALES
AGITATED BEHAVIOR SCALE FUNCTIONAL INDEPENDENCE MEASURE
Disability rating scale DRS: This scale though developed for brain injury, is
used for other assessment programs. There are 8 items in 4 categories; arousal
and awareness; cognitive ability to handle self-care functions; physical
dependence and psychosocial adaptability. DRS scores range from 0 to 30;
a lower score indicates a lower level of disability, and a higher score obviously
means more independence.
Neuro-behavioral scale: The neuro-behavioral rating scale has 27 variables.
DISABILITY SCALE (DRS)
Category Item Instructions Score
Arousability, Awareness Eye Opening
0 = spontaneous and Responsivity
1 = to speech
2 = to pain
3 = none
Communication
0 = oriented Ability
1 = confused
2 = inappropriate
3 = incomprehensible
4 = none
Motor Response
0 = obeying
1 = localizing
2 = withdrawing
3 = flexing
4 = extending
5 = none
Cognitive Ability for Feeding
0 = complete Self Care Activities
1 = partial
2 = minimal
3 = none
Toileting
0 = complete
1 = partial
2 = minimal
3 = none
Grooming
0 = complete
1 = partial
2 = minimal
3 = none
Dependence on Others Level of Functioning
0 = completely independent
1 = independent in special environment
2 = mildly dependent
3 = moderately dependent
4 = markedly dependent
5 = totally dependent
Psychosocial Adaptability Employability
0 = not restricted
1 = selected jobs
2 = sheltered workshop(non-competitive)
3 = not employable
Treatment
The treatment has been dealt with as:
• Medical treatment
• Surgical treatment
• Rehabilitation.
Medical treatment: The ABC -airway, breathing and circulation and vital signs
need to be monitored during the acute phase.
Surgical treatment: The neurosurgeon may be called on to perform the
following on brain injured patients:
• Burr-holes
• Craniotomy
• Craniectomy
• Ventriculo-peritoneal shunt (Hydrocephalus).
REHABILITATION—PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
Acute Stage
Aims
• To clear the chest and to enhance breathing
– Postural drainage within any limitations imposed by raised intracranial
pressure and additional trauma.
– Vibration/Percussion (if there is injury to chest—contraindicated).
– Mechanical suction
To prevent joint stiffness and deformity from muscle contracture. Maintain
joint length and muscle length by passive movement
• To enhance functional activities confined to the bed
• To prevent pressure sores
• Bladder-care if necessary.
• Inhibit development of reflexes and abnormal muscle tone by proper
positioning.
Principles of Physiotherapy for the Conscious Patient
The aim of physical therapy once the patient regains consciousness is to aid
the recovery of normal functioning, to provide compensatory strategies for the
symptoms that persist, and to increase independence through facilitation of
motor control and skills. The therapist does the following:
• Encourage active coughing and huffing
• Assisted active exercise to facilitate voluntary movement
• Establish communication both verbally and non-verbally
• Increase sensory awareness by the use of touch and pressure
• Re-education of righting and equilibrium reactions
• Re-educate functional activities by choosing the right activities and adaptive
aids for them.
Physiotherapy in Later Stage
1. Supportive seating and standing: If a patient lies down continuously he
is prone to secondary problems like osteopenia and reduction in muscle
bulk. He is mobilized to sitting [even with support] which promotes
normal proprioception, postural tone and joint alignment. Appropriate
wheel chairs and supportive systems help to maintain the head and
trunk in good position and free the upper limbs for functional use in the early stages. People with complex postural needs should be referred
to a movement disorder clinic.
An adult with brain injury being made to stand in a tilt-standing frame
2. Aids and Orthoses: Orthoses like AFO help to maintain stability during
walking and prevent deformity. Care must be taken while fitting the
orthosis to avoid pressure areas, especially where deformity exists and
sensation is impaired. Hand splints are given to prevent deformity.
3. Rehabilitation of motor control: The patient is suspended from a harness
and made to walk with its support on a treadmill. Strength training, gait
re-education, and aerobic exercises are given to improve cardiorespiratory
function and promote activities.
4. Continence: Bladder and bowel incontinence is a major hassle not only
for the patient but also for the care giver. Toilet programs are based on
bladder retraining and reinforcement for cognitive impairments,
intermittent catheterization where there is post-micturition residual
volume of >150 ml, and supra-pubic catheters in place of long term
catheters. In case of constipation- a diet with roughage and sufficient
fluid intake, bulk laxatives will help evacuate bowels easily. Mobilizing
the patient to standing also helps the constipated patient.
5. Visual and hearing impairments: Use of hearing aids, prosthesis and
planning of adaptive strategies or augmentative communication (Ref
Chap 5)
6. Pain: Pain is sometimes under-diagnosed in traumatic brain injury
because of poor communication and cognitive deficits in patients who
are unable to describe their sensory experiences. The causes of pain may
be diverse: heterotopic ossification, shoulder pains due to subluxation,
spasticity, or malalignment, and secondary damage to soft-tissues like
the impingement of the rotator-cuff. Neuropathic pain may be due to local
hypersensitivity to touch.
7. Cognition: Cognitive rehabilitation has proven to be effective but the
effectiveness of specific intervention is not known. Rehabilitation starts
with using one of the assessment tools. The patient is kept in his home
amongst relatives without distractions and unpleasant associations. A
goal oriented program that needs some planning sequencing and problem
solving is given.
8. Aids to improve memory
• External
– Reminders by others
– Tape recorders
– Written notes
– Personal organizer, diary
– Time reminders-Alarm clocks/phone calls
– Orientation board with lists written out
• Internal
– Mental retracing of events; rehearsal
– Visual imaging
– Alphabet searching; mnemonics
– Association with items already recalled
9. Management of Agitation: Reduce the level of stimulation in the
environment by placing patient in a quiet private place
Remove painful stimuli if possible, e.g. tubes, catheters, restraints, traction
Limit number and length of therapy sessions if patient is highly resistant
Provide therapy in the patient’s room and not make him or her undergo
unnecessary transportation
Protect patient from harming self or others
Communicate to patient briefly and simply: Let one person speak to the
patient at a time
Reorient patient to place and time repeatedly
10. Sexuality: Advice about sexuality should cover both the physical aspects
(positioning, erectile dysfunction, and sensory deficits) and psychological
aspects (communication, fears, poor self image and lack of interest by
the patient or partner). If sexually inappropriate behavior like
exhibitionism or masturbation is severe or inappropriate then it should
be referred to the psychiatrist or psychologist.
11. Electro-encephalographic biofeedback/ neuro-feedback (Ref Chap 13)
12. Training balance: The patient often exhibits difficulty in maintaining his
center of gravity within his base of support due to visual, vestibular and
sensorimotor disturbances. Individuals may not perform body
movements that challenge their balance.
Actions may need to be modified initially so that the postural
adjustments are initially small, which are:
• Looking up at the ceiling (the proprioception of the feet is activated to
ensure that the centre of body mass does not move back)
• Changing the shape of the base of support
• Reaching the arm forward towards an object and increasing its distance
from the body
• Varying the object size and weight to make use of both the hands
• Turning to look behind without moving the feet
• Reaching sideways, backwards and towards the floor
Speech Therapy
Speech is often affected by symptoms like jaw thrust, clenching, and retraction,
which can affect jaw closure and repetitive mandibular movement needed for
chewing. This has a snowballing effect as lack of proper chewing can lead
to poor digestion, and thereby to poor nutrition. The food given to such patients
should be initially liquid, then semi liquid introduced through naso-gastric
or gastrostomy tubes. The speech therapist gives exercises to control tongue
thrust and to develop tongue coordination and strength. The face, neck and
lip muscles are also strengthened.
Role of the Physiatrist
The Physiatrist is called in as a consultant even when the patient is still in
the intensive care unit.
The post acute rehabilitation phase depends on the expressed and perceived
needs of the patient and the family. If comprehensive rehabilitation is required,
even at a slow rate of progression, the patient may be referred to an inpatient
facility. Where the patient can be managed at home, a ‘day treatment program’
can be given which provides
• Extensive cognitive rehabilitation
• Behavior management
• Daily life skills training
• Community activities and
• Pre-vocational activities
When a brain-injured person has regained the ability to learn and interact
appropriately with others, community based treatment alternative may be
considered. In the inpatient or step down care models, the brain-injured person
lives in a supervised group home setting and is given progressively increasing
responsibility in the skills needed to live independently.
Vocational Rehabilitation
A final step in social reintegration is return to work. This is done through
the vocational evaluator and the placement officer
• Vocational assessment and training
• Placement into a job in the community or sheltered work setting after job
trial.
During the long recovery process, the social worker can coordinate and
provide social support. The case manager acts as a liaison between the patient,
family and service providers, maintains medical records, and arranges for
medical visits, screen programs and facilities. This person also facilitates
financial and insurance matters, which are of critical importance in sustaining
the patient.
CONCLUSION
The rehabilitation of a brain injured patient is extremely challenging and
demands the involvement of almost all members of the rehabilitation team.
It is a tedious and time consuming process which can frustrate the patient,
his relatives and even the staff. This is because, unlike cerebral palsy, the patient
and those around him remember how he was prior to the accident, and find
it difficult to reconcile themselves to the present condition. With advanced
technology and surgical procedures it is possible to envisage a near normal
lifestyle in the future even for the severely brain injured.
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