Traumatic Brain Injury (TBI)

• Loss of consciousness
• Headache
• Confusion
• Dizziness
• Blurred vision
• Lightheadedness
• Ringing in the ears
• Fatigue or lethargy
• Bad taste in the mouth
• Change in sleeping patterns
• Problems with memory, concentration, and/or attention
• Behavioral mood changes
• Depression

Traumatic brain injuries can be classified as mild, moderate, or severe. This classification is based on the symptoms of the patients and a neurologic exam. The injury itself is classified as a primary or secondary injury.

Primary injury. Caused by a mechanical force that happens at the moment of the injury. Two main mechanisms of injury include contact and acceleration-deceleration. A contact injury is usually caused by an object striking the head or the head striking an object and the brain hitting the inside of the skull. Acceleration-deceleration injuries are most often caused in a motor vehicle accident, or whiplash injury. Primary injuries can be penetrating (open-head) or nonpenetration (closed-head).

Secondary injury. This type of TBI is not caused by a mechanical insult but may be delayed after the initial impact occurs. A secondary injury will layer on top of the initial head trauma and usually take time to develop. Common secondary injuries include swelling of the brain and increased pressure within the skull.

A TBI is caused by an excessive force, blow, or penetrating injury to the head. Falls are the leading cause of traumatic brain injuries, accounting for nearly half of all TBI-related emergency room visits. The second leading cause is being hit by or struck against an object. The third leading cause of a TBI is motor vehicle crashes.

Age. People over the age of 75 are at the highest risk for TBI. The leading cause of death for a TBI is from a fall in individuals 65 years of age or older.

Motor vehicle accidents. Younger individuals are at a higher risk for getting a TBI from being involved in a motor vehicle accident (MVA). MVAs are the leading cause of death for people between the ages of 15-34.

Other risk factors for TBI include:

• History of prior concussion
• Female sex
• Playing football, ice hockey, or soccer
• Riding a bicycle

Your doctor will perform a thorough physical exam and use different tests to determine the severity of the traumatic brain injury. Because the injury is to your brain, your doctor will perform “neuro-checks” to assess the neurological function of the brain. These neuro-checks consist of a series of tasks and questions in quick succession with your responses recorded to determine the level of injury. Other tests used to diagnose the level of severity of a TBI are:

Imaging tests. The most common image taken of your brain uses computerized tomography or a CT scan. The CT uses X-rays taken from various angles to create a complete picture of the brain. This scan reveals bleeding or bruising in the brain. If your healthcare provider wants a more detailed image then you will have an MRI (magnetic resonance imaging) scan. These are usually ordered in follow-up exams as they take more time.

Blood tests. Mild concussions may not show up in a CT scan but still need to be diagnoses to avoid further complications. There are two proteins released into the blood after a mild concussion occurs that can be identified using a blood test.

Glasgow coma scale (GCS).This scale (3- to 15- point) is used to determine a patient’s level of consciousness and neurologic function immediately after the injury. The scale is based on motor response, verbal response, and eye-opening (eyes open to voice command, no response to pain, etc.).

Measurements for level of injury. Your doctor will assess the level of injury by checking for memory loss and loss of consciousness duration. A mild TBI or concussion will present with no memory loss or a loss of memory for less than 24 hours. In moderate to severe TBIs, a person may suffer from memory loss that lasts from 24 hours to 7 days (moderate) or longer (severe). A mild, moderate, and severe TBI are classified as follows:

• Mild – no loss of consciousness (GCS 13 -15)
• Moderate – Unconscious for more than 30 minutes to 24 hours (GCS 9-12)
• Severe – Unconscious for more than 24 hours (GCS 8 or lower)

Other tests. The long-term effects of TBIs may require various tests that help your healthcare team design a treatment plan for recovery. These include tests for:

• Speech and language
• Swallowing ability
• Breathing ability and lung function
• Cognition tests
• Social communication skills
• Neuropsychological assessments

A mild TBI (concussion) may not require specialized medical treatment. You should follow up with your healthcare provider and follow all the instructions given to you. This usually involves a complete rest and return to normal physical activities. If you try to return to your normal daily routine too soon, you may have a longer recovery. Listen to your doctor!

Emergency care. The emergency treatment for TBI involves stabilizing the patient to keep his or her vitals, like blood pressure and breathing, within a healthy range. This includes making sure the brain is receiving enough oxygen and bleeding in the brain is under control.

Surgery. If the TBI involves bleeding or increased pressure on the skull, surgery may be part of the emergency care. A surgeon may need to remove pools of blood or blood clots (hematomas) to reduce pressure. If the skull was fractured, a surgeon will need to remove pieces of the skull or other fragments to speed up the healing process. If the pressure is causing brain damage, a hole is made in the skull or a shunt will be inserted to allow for the fluid to drain.

Medications. These are prescribed to help treat the symptoms of TBI and to reduce the risk of associated conditions that may follow after initial symptoms subside. These include:

• Anti-anxiety medications
• Anticoagulants to prevent clotting and improve blood flow
• Anticonvulsants to prevent seizures
• Antidepressants to modulate mood instability and depression
• Muscle relaxants
• Stimulants to reduce lethargy and concentration deficits
• Diuretics to remove excess fluid and reduce pressure

Rehabilitation therapy. A traumatic brain injury can result in emotional, cognitive, and physical difficulties for a few days to several months following the initial injury. In these cases, your healthcare team will develop a treatment plan that involves rehabilitation therapy. Be patient with yourself and ask for help from your friends and family to help you work through rehabilitation. Recovery is possible and you should have the help you need anytime you need. Just ask for help. Your rehabilitation will begin in the hospital and if needed will continue after you leave. Your therapy may involve the following:

• Physical therapy to increase your strength, balance abilities, and flexibility
• Cognitive therapy to improve memory, attention, and learning
• Speech therapy to assist in speaking and communication difficulties
• Psychological counseling to learn coping skills and work through instability issues
• Occupational therapy to help with daily tasks (i.e., getting dressed)
• Vocational counseling to help you return to work

Emotional. A brain injury can affect the way a person feels or expresses emotions and can lead to emotional problems such as mood swings and mood changes that come upon quickly. These symptoms improve with time. This can be frustrating and stressful for the person with a TBI and for the family who is supporting the patient. These symptoms do improve with time. If you are struggling with mood swings, talk with your healthcare provider. There are medications available for you that can stabilize your mood and counseling will help you learn coping mechanisms to help you through the hard times.

Physical. Recovery from a TBI can be difficult, especially when coping with the physical symptoms that may linger for months after your injury. You may have trouble sleeping, feel fatigued easily, have problems with balance, and visual disturbances. Headaches are also common. Practice healthy eating and sleeping behaviors, avoid nicotine, and excessive caffeine and alcohol. Relaxation techniques may also be helpful. Remember that many of the physical symptoms that follow a TBI will lessen in severity with time.

Thinking and cognition. Many people who have experienced a brain injury will have trouble concentrating, planning, remembering, and thinking in general. Thinking and cognition difficulty symptoms may show up right after the injury or may occur long after the injury. If you or a loved one suddenly has a change in cognition or processing, such as confusion, attention problems, or memory impairment, make an appointment to see a doctor right away. Your healthcare team will help develop a treatment plan, including memory and organization skills, to help in your recovery.

Consult your physician before you take a supplement or alternative therapy to make sure you are safe to practice the activity and the supplement does not interact with any medications.

DHA (docosahexaenoic acid). This omega-3 fatty acid has been shown to reduce inflammation in the brain in patients with mild to moderate traumatic brain injuries. A daily supplement of DHA is recommended by some clinicians for a year following injury.

Lipoic acid. Patients with TBI have an increased amount of oxidative stress after the injury occurs, a state in the body that leads to inflammation and neurodegenerative damage. Oxidative stressoccurs when there is an imbalance between free radicals and antioxidants in the body that causes damage to the body’s tissues and cells. The cells in the body produce free radicals during normal metabolism and these damaging molecules are neutralized by antioxidants produced by the body. Lipoic acid is a supplement that has been shown in studies to inhibit oxidative stress and protect against neuronal injury.

Mind-body practice. Anxiety and depression often occur in people who have suffered from a TBI. A recent study showed patients with a history of TBI who took part in a cloud-based mindfulness seminar had an improved attitude about life and reduced stress responses. Mindfulness-based practices focus on reducing stress through breathing and meditation exercises that encourage you to be present at the moment and set an intention for the day. Mindfulness cognitive-based therapy can help to build your self-esteem and teach you tools for achieved mental clarity.

Cerebrovascular exercise. Activities that promote cerebral and cardiovascular health can help to clear out toxic proteins and increase tolerance to pain. Swimming, biking, and running are excellent choices in exercise (with approval from your physician) that will aid in your recovery and reduce your need for pain medications to cope with symptoms.

• Wear a seat belt every time you drive
• Do not drive under the influence of alcohol or drugs
• Wear a helmet or protective headgear when playing sports
• Make your home safer
• Have your vision checked once yearly
• Practice strength and balance exercises
• Check in with your doctor about prescriptions that make you dizzy
• Childproof your home (i.e., safety gates, window guards, etc.)
• Cover your child’s outdoor play area with soft material

Chronic traumatic encephalopathy (CTE)is a neurogenerative disease caused by repeated blows to the head. If you are subjected to repeated head traumas you are susceptible to developing CTE which is a form of brain degeneration. Athletes who play contact sports (like boxing or football) or military personnel (exposed to explosive blasts) are at a higher risk of CTE. This disease cannot be diagnosed in a living person and is usually found during an autopsy of the brain. CTE has no cure.

Other complications of TBI include:

• Swelling in the brain causing pressure against the skull (hydrocephalus)
• Deep vein thrombosis (blood clot in a deep vein)
• Posttraumatic seizures
• High or low blood pressures
• Death
• Insomnia
• Cognitive decline
• Headaches and/or migraines
• Posttraumatic depression
• Gait abnormalities
• Agitation

Cassidy, D., et al. (2004, February). Incidence, risk factors, and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, 43 (43 Suppl), 28-60. Retrieved from:https://pubmed.ncbi.nlm.nih.gov/15083870/

Centers for Disease Control and Prevention. (2020, August 28). Traumatic brain injury and concussion. Retrieved from Centers for Disease Control and Prevention:https://www.cdc.gov/traumaticbraininjury/

Eske, J. (2019, April 03). How does oxidative stress affect the body? Retrieved from:https://www.medicalnewstoday.com/articles/324863#antioxidants

Lucke-Wold, B. (2019, April 30). Complementary and alternative therapies for TBI: Key points for clinicians. Retrieved from:https://www.neurologylive.com/view/complementary-and-alternative-therapies-tbi-key-points-clinicians