Traumatic Brain Injury (TBI)

OT Dude Academy’s Free NBCOT® Exam Prep Course Neurology Traumatic Brain Injury (TBI)

Involves an external force that is either closed (non-penetrating) or open (penetrating, skull is fractured).

Epidemiology

Males are about 2x as likely to suffer a TBI than females.1 

Causes of TBI

  • Falls
  • Assault
  • Motor vehicle accidents (MVAs)
  • Sports or recreational injuries
  • Shaken Baby Syndrome and child abuse
  • Gunshow wounds (GSWs)
  • Workplace injuries
  • Domestic violence
  • Military actions2 

Impact

TBI, even mild TBI, can result in long-term physical, cognitive, behavioral, and psychosocial consequences. TBI can affect the client’s ability to perform daily activities and return to work.3 4 5 6  TBI can also lead to other health conditions, including increased risk of alcohol abuse, developing epilepsy, depression, and Alzheimer’s disease.7 8 9 

Severity

Severity is important to consider as there is a relationship to cute and post-acute medical care and outcomes.10 11  In research and practice, common indicators of severity have been based on the Glasgow Coma Scale (GCS), duration of post-traumatic amnesia (PTA), and duration of the loss of consciousness (LOC).12  A general classification system for TBI is mild, moderate, and severe.

Signs and Symptoms

TBI may be associated with executive functioning deficits, memory and attention deficits, and slowed cognitive processing. Emotional dysfunction includes social communication, social cognition, emotional regulation, empathy, self-regulation, self-control, and self-awareness.13 14 15 16 17 18 19 

Headaches are the most common symptom of after a mild head injury.20 

Mild TBI Symptoms

  • Headache
  • Nausea
  • Vomiting
  • Blurred or double-vision (diplopia)
  • Seeing stars or lights
  • Balance problems
  • Dizziness
  • Light or noise sensitivity
  • Tinnitus
  • Drowsiness
  • Fatigue
  • Irritability
  • Depression
  • Anxiety
  • Sleeping more than usual
  • Difficulty falling asleep
  • Feeling “slowed down”
  • Feeling “in a fog” or “dazed”
  • Difficulty concentrating
  • Difficulty remembering21 

Moderate/Severe TBI Symptoms

  • Seizures22 
  • Rigidity and posturing (decorticate, decerebrate) 23 24 
  • Dystonia, hypertonicity, hypotonicity
  • Motor decline (gross and fine)
  • Bradykinesia
  • Praxis
  • Decreased muscle strength
  • Impaired balance25 
  • Coordination
  • Gait impairment26 
  • Inattention
  • Decreased concentration
  • Distractibility
  • Visual-spatial conceptualization
  • Information processing
  • Poor judgment
  • Poor executive function27 
  • Disorientation
  • Anxiety
  • Expression
  • Emotional withdrawal
  • Conceptual disorganizaiton
  • Disinhibition
  • Guilt
  • Memory deficit
  • Agitation
  • Poor insight and self-appraisal
  • Depression
  • Hostility
  • Decreased motivation
  • Suspiciousness
  • Fatigue
  • Hallucination
  • Blunted affect
  • Poor planning
  • Liability
  • Comprehension deficit28 
  • Sleep disturbances – anxiety, fatigue, daytime sleepiness29 
  • Impulsivity30 
  • Severe disability
  • Vegetative State
  • Death31 

Outcome Measures

  • Glasgow Outcome Scale Extended (GOSE) 32 
  • Disability Rating Scale
  • Functional Independence Measure (FIM)
  • CARE Tool
  • Rancho Los Amigos Scale33 
  • Candian Occupational Performance Measure (COPM) 34 
  • Goal Attainment Scaling (GAS) 35 
  • Community Integration Questionnaire (CIQ) 36 
  • Craig Handicap Assessment and Reporting Technique (CHART) 37 

Rehabilitation

  • Family education
  • PROM
  • Contracture prophylaxis
  • Serial casting
  • Strengthening and endurance training
  • Stretching
  • Mobilization
  • Symptom management – pain38 
  • Environmental modifications – reducing sensory stimulation: noise, alarms, lighting, televisions; orienting to the time of day39 
  • Aromatherapy and alternative modalities40 
  • Reduction of peripheral and lines41 
  • Avoid the use of restraints if possible42 
  • Self-care ADLs43 
  • Scheduled/Timed-toileting program44 
  • Cognition and problem-solving (CO-OP Approach) 45 
  • Rest and sleep – scheduled; address breathing and sleep disturbances, e.g., OSA; reducing naps and caffeine intake46 47 
  • Home integration
  • Community integration
  • Social integration
  • Return to work37 
  1. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.[↩]
  2. Brain Injury Association of America. (n.d.). Brain Injury Overview. Retrieved from https://www.biausa.org/brain-injury/about-brain-injury/basics/overview[↩]
  3. US Dept of Health and Human Services. National Institutes of Health. Office of the Director. Rehabilitation of Persons with Traumatic Brain Injury: NIH Consensus Statement. October 26–28 1998. Bethesda, Md: National Institutes of Health; 16(1):1–41.[↩]
  4. McAllister TW, Sparling MB, Flashman LA, Guerin SJ, Mamourian AC, Saykin AJ. Differential working memory load effects after mild traumatic brain injury. Neuroimage. 2001;14(5):1004–1012.[↩]
  5. Alves W, Macciocchi SN, Barth JT. Postconcussive symptoms after uncomplicated mild head injury. J Head Trauma Rehabil. 1993;8(3):48–59.[↩]
  6. Englander J, Hall K, Stimpson T, Chaffin S. Mild traumatic brain injury in an insured population: subjective complaints and return to employment. Brain Inj. 1992;6(2):161–166.[↩]
  7. Horner MD, Ferguson PL, Selassie AW, Labbate LA, Kniele K, Corrigan JD. Patterns of alcohol use 1 year after traumatic brain injury: a population-based, epidemiological study. J Int Neuropsychol Soc. 2005;11(3):322–330.[↩]
  8. Holsinger T, Steffens DC, Phillips C, et al. Head injury in early adulthood and the lifetime risk of depression. Arch Gen Psychiatry. 2002;59(1):17–22.[↩]
  9. Plassman BL, Havlik RJ, Steffens DC, et al. Documented head injury in early adulthood and risk of Alzheimer’s disease and other dementias. Neurology. 2000;55(8):1158–1166.[↩]
  10. CIFU, D.X., KEYSER-MARCUS, L., LOPEZ, E., et al. (1997). Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis. Arch. Phys. Med. Rehabil. 78, 125–131.[↩]
  11. CREPEAU, F., & SCHERZER, P. (1993). Predictors and indicators of work status after traumatic brain injury: a metaanalysis. Neuropsych. Rehabil. 3, 5–35[↩]
  12. Malec, J. F., Brown, A. W., Leibson, C. L., Flaada, J. T., Mandrekar, J. N., Diehl, N. N., & Perkins, P. K. (2007). The mayo classification system for traumatic brain injury severity. Journal of neurotrauma, 24(9), 1417-1424.[↩]
  13. Farrer TJ, Hedges DW. Prevalence of traumatic brain injury in incarcerated groups compared to the general population: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. (2011) 35:390–4. doi: 10.1016/j.pnpbp.2011.01.007[↩]
  14. Azouvi P, Arnould A, Dromer E, Vallat-Azouvi C. Neuropsychology of traumatic brain injury: an expert overview. Rev Neurol. (2017) 173:461–72. doi: 10.1016/j.neurol.2017.07.006[↩]
  15. Pitman I, Haddlesey C, Ramos SD, Oddy M, Fortescue D. The association between neuropsychological performance and self-reported traumatic brain injury in a sample of adult male prisoners in the UK. Neuropsychol Rehabil. (2015) 25:763–79. doi: 10.1080/09602011.2014.973887[↩]
  16. Rabinowitz AR, Levin HS. Cognitive sequelae of traumatic brain injury. Psychiatr Clin North Am. (2014) 37:1–11. doi: 10.1016/j.psc.2013.11.004[↩]
  17. Ryan NP, Anderson V, Godfrey C, Eren S, Rosema S, Taylor K, et al. Social communication mediates the relationship between emotion perception and externalizing behaviors in young adult survivors of pediatric traumatic brain injury (TBI). Int J Dev Neurosci. (2013) 31:811–9. doi: 10.1016/j.ijdevneu.2013.10.002[↩]
  18. Osborne-Crowley K, McDonald S. A review of social disinhibition after traumatic brain injury. J Neuropsychol. (2018) 12:176–99. doi: 10.1111/jnp.12113[↩]
  19. Robertson K, Schmitter-Edgecombe M. Self-awareness and traumatic brain injury outcome. Brain Inj. (2015) 29:848–58. doi: 10.3109/02699052.2015.1005135[↩]
  20. Uomoto, J. M., & Esselman, P. C. (1993). Traumatic brain injury and chronic pain: differential types and rates by head injury severity. Archives of physical medicine and rehabilitation, 74(1), 61-64.[↩]
  21. Marshall, S., Bayley, M., McCullagh, S., Velikonja, D., & Berrigan, L. (2012). Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Canadian Family Physician, 58(3), 257-267.[↩]
  22. Carney, N., Totten, A. M., O’Reilly, C., Ullman, J. S., Hawryluk, G. W., Bell, M. J., … & Ghajar, J. (2017). Guidelines for the management of severe traumatic brain injury. Neurosurgery, 80(1), 6-15.[↩]
  23. Munakomi S, M Das J. Decorticate Posturing. [Updated 2021 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555949/[↩]
  24. Tamashiro, M., Cozzo, D., Mattei, M., Salierno, F., Rivas, M. E., Alzúa, O., … & Leiguarda, R. (2012). Early motor predictors of recovery in patients with severe traumatic brain injury. Brain injury, 26(7-8), 921-926.[↩]
  25. Keren, O., Reznik, J., & Groswasser, Z. (2001). Combined motor disturbances following severe traumatic brain injury: an integrative long-term treatment approach. Brain injury, 15(7), 633-638.[↩]
  26. Walker, W. C., & Pickett, T. C. (2007). Motor impairment after severe traumatic brain injury: a longitudinal multicenter study. Journal of rehabilitation research and development, 44(7), 975.[↩]
  27. Barman, A., Chatterjee, A., & Bhide, R. (2016). Cognitive impairment and rehabilitation strategies after traumatic brain injury. Indian journal of psychological medicine, 38(3), 172-181.[↩]
  28. Lippert-Grüner, M., Kuchta, J., Hellmich, M., & Klug, N. (2006). Neurobehavioural deficits after severe traumatic brain injury (TBI). Brain injury, 20(6), 569-574.[↩]
  29. Gardani, M., Morfiri, E., Thomson, A., O’Neill, B., & McMillan, T. M. (2015). Evaluation of sleep disorders in patients with severe traumatic brain injury during rehabilitation. Archives of physical medicine and rehabilitation, 96(9), 1691-1697.[↩]
  30. Rochat, L., Beni, C., Billieux, J., Azouvi, P., Annoni, J. M., & Van der Linden, M. (2010). Assessment of impulsivity after moderate to severe traumatic brain injury. Neuropsychological Rehabilitation, 20(5), 778-797.[↩]
  31. Maas, A. I., Stocchetti, N., & Bullock, R. (2008). Moderate and severe traumatic brain injury in adults. The Lancet Neurology, 7(8), 728-741.[↩]
  32. Steiner, E., Murg-Argeny, M., & Steltzer, H. (2016). The severe traumatic brain injury in Austria: early rehabilitative treatment and outcome. Journal of trauma management & outcomes, 10(1), 1-6.[↩]
  33. Cifu, D. X., Kreutzer, J. S., Marwitz, J. H., Rosenthal, M., Englander, J., & High, W. (1996). Functional outcomes of older adults with traumatic brain injury: a prospective, multicenter analysis. Archives of physical medicine and rehabilitation, 77(9), 883-888.[↩]
  34. Phipps, S., & Richardson, P. (2007). Occupational therapy outcomes for clients with traumatic brain injury and stroke using the Canadian Occupational Performance Measure. American Journal of Occupational Therapy, 61(3), 328-334.[↩]
  35. Doig, E., Fleming, J., Cornwell, P. L., & Kuipers, P. (2009). Qualitative exploration of a client-centered, goal-directed approach to community-based occupational therapy for adults with traumatic brain injury. American Journal of Occupational Therapy, 63(5), 559-568.[↩]
  36. Trombly, C. A., Radomski, M. V., Trexel, C., & Burnett-Smith, S. E. (2002). Occupational therapy and achievement of self-identified goals by adults with acquired brain injury: Phase II. American Journal of Occupational Therapy, 56(5), 489-498.[↩]
  37. Kim, H., & Colantonio, A. (2010). Effectiveness of rehabilitation in enhancing community integration after acute traumatic brain injury: A systematic review. American Journal of Occupational Therapy, 64(5), 709-719.[↩][↩]
  38. Irving MH, Irving PM: Associated injuries in head injured patients. J Trauma 1967;7:500–11[↩]
  39. Kahn DM, Cook TE, Carlisle CC, et al: Identification and modification of environmental noise in an ICU setting. Chest 1998;114:535–40[↩]
  40. Morris N: The effects of lavender (Lavendula angustifolium) baths on psychological well-being: Two exploratory randomised control trials. Complement Ther Med 2002;10:223–8[↩]
  41. Zafonte RD, Hammond FD, Rahimi R: Air embolism in the agitated traumatic brain injury patient: An unusual complication. Brain Inj 1996;10:759–61[↩]
  42. Food and Drug Administration announcement. March 25, 2005[↩]
  43. Hellweg, S. (2012). Effectiveness of physiotherapy and occupational therapy after traumatic brain injury in the intensive care unit. Critical care research and practice, 2012.[↩]
  44. Engst C, Chhokar R, Robinson D, et al: Implementation of a scheduled toileting program in a long term care facility: Evaluating the impact on injury risk to caregiving staff. AAOHN J 2004;52:427–35[↩]
  45. Dawson, D. R., Gaya, A., Hunt, A., Levine, B., Lemsky, C., & Polatajko, H. J. (2009). Using the cognitive orientation to occupational performance (CO-OP) with adults with executive dysfunction following traumatic brain injury. Canadian journal of occupational therapy, 76(2), 115-127.[↩]
  46. Castriotta RJ, Lai JM: Sleep disorders associated with traumatic brain injury. Arch Phys Med Rehabil 2001;82:1403–6[↩]
  47. Webster JB, Bell KR, Hussey JD, et al: Sleep apnea in adults with traumatic brain injury: A preliminary investigation. Arch Phys Med Rehabil 2001;82:316–21[↩]
Previous Lesson
Back to Topic
Next Lesson