Traumatic Brain Injury

McPhail 1 Julie McPhail Jill Boeck Nature and Needs of the Exceptional Learner (EDU 211) 23 April, 2009 Traumatic Brain Injury The accepted official definition for traumatic brain injury as used by the federal government is as follows: IDEA [Individuals with Disabilities Education Act] defines traumatic brain injury (TBI) as an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects [an individual’s] educational performance (Turnbull, Turnbull, and Wehmeyer 314). Traumatic brain injury (TBI, also called intracranial injury) occurs when an outside force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury) or other features (e.g. occurring in a specific location or over a widespread area). “Head injury” usually refers to TBI, but is a broader category because it can involve damage to structures other than the brain, such as the scalp and skull (Wikipedia Traumatic Brain 1).

McPhail 2 However, the terms traumatic brain injury and head injury are often used interchangeably in the medical literature (Wikipedia Head Injury 1). In addition to the classically accepted definition of the causes of traumatic brain injury, there may be some confusion because there is a condition that is not often thought of as being a part of the universally accepted standards. This is because in certain circumstances where traumatic brain injury is acquired, the condition is caused by a vector infecting humans. There is a patient who will be known as “Jane” for the purposes of this paper. Jane’s traumatic brain injury was caused by an insect bite which resulted in a systemic infection that damaged several key areas in her brain. According to the criteria of the agencies that now provide services to her, she has been classified as having a traumatic brain injury due to the areas of damage to her brain, although it was not acquired in the ways which will be examined in this work. She is unable to speak and must use a talking board or computer to communicate, cannot walk, and has had major mood swings which are characteristics of a depressive state. Jane has exhibited episodes where she is devious, ill tempered and combative. She will be pleasant to people if she deems it is in her best self interest. For example, her caregivers frequently find going to the grocery store shopping with her to be a long and tedious ordeal. While she is sitting in a wheelchair endlessly reading the labels line by line, it is not unusual for her aides to have to remain standing on their feet for hours at a time nearby her. If, however, Jane and the workers go to eat afterwards, and she discovers that she is out of money, Jane is now suddenly concerned about the aide’s comfort and physical wellbeing and suggests they sit while eating. It is then, after her

McPhail 3 seeming sudden concern for the welfare of those accompanying her, that Jane asks if the aide could please buy her lunch. This request is rarely refused her because the aides often can't help but feel that they need to accommodate her to continue her good behavior while out in public. Jane is well-educated. She graduated from high school with honors prior to her accident, and afterwards went on to attend college at the University of Buffalo where she struggled to receive a four year degree in chemistry. The term [traumatic brain injury] applies to open or closed head injuries resulting in impairment in one or more areas, such as cognition; language; memory; [ability to pay] attention; reasoning; abstract thinking; judgment; problem solving; psychosocial behavior; physical functions; information processing; and speech (Turnbull, Turnbull, and Wehmeyer 314). It is essential to keep in mind that traumatic brain injuries as defined do not apply to injuries that are congenital or degenerative in origin. Traumatic brain injuries are certainly not due to birth traumas as some used to believe. Traumatic brain injury must be an acquired injury, which means acquisition after an individual is born, but not as a result of birth delivery. ...the term TBI applies to both open and closed head injuries: An open head injury penetrates the bones of the skull, allowing bacteria to have direct contact with the brain and potentially impairing specific functions, usually only those controlled by the injured part of the brain (Turnbull, Turnbull and Wehmeyer 314).

McPhail 4 A handsome young man who attended school locally at the same time as the author of this paper was considered to be very popular with the girls and the guys. It was believed by those around him that he would do well for himself in life, having a decent job and living in a well-to-do area in the city. Some 20 years later, while shopping at a local convenience store, this young man was noticed by chance while patronizing the store. He appeared to be in line for the purpose of cashing a Social Security disability check. He bore a puckered scar which he didn't have during his time in school. It started at his right temple and ended at his jaw. More than likely, this unfortunate individual had been the victim of a shooting which left him forever scarred and impaired, as evidenced by the slurring of his speech and noticeable limp. A closed head injury does not involve penetration or a fracture of the bones of the skull. It results from an external blow or from the brain being whipped back and forth rapidly, causing it to rub against and bounce off the rough, jagged interior of the skull (Turnbull, Turnbull, and Wehmeyer 314). A local health care agency was asked to provide assistance for a male patient known as "Keith", for the purposes of this paper. Keith resides in the Riverside area. His medical chart clearly detailed and listed his condition. He had been injured in a horrific car accident. Keith had been a relatively young man when he decided to go for a ride with a so-called friend. For some reason, the driver in the accident, Keith's "friend", decided to show off and started speeding. Realizing that he was losing control of the vehicle and to minimize the damage he would sustain to himself, the driver

McPhail 5 deliberately crashed the vehicle so that the passenger side would take the brunt of the impact. The car hit the guardrail, causing Keith to fly out the window and land on his head, causing a closed TBI. Today Keith is able to speak, but is constantly repeating the phrase, "Do you know my brothers, Brent and Brian?" When the nurse arrived at his apartment one particular day as his aide was providing care, the worker inquired of her if Brent and Brian ever came to visit Keith as she had never seen or met either individual. The aide was stunned to learn from the nurse that Keith has no brothers/ Recovery from a TBI depends on a multiple of factors related to the extent of the injury. Examples include associated medical complications, and the patient’s premorbid [prior to the onset of] status (Carlson and Umphred 158). The number and magnitude of each person’s functional changes, post-TBI, will vary according to the site and extent of the injury, the length of time the person was in a coma (an unconscious state), and person’s maturational stage at the time of injury. The extent of functional changes and the course of recovery after the injury depend largely on whether it was mild, moderate, or severe (Turnbull, Turnbull, and Wehmeyer 315). Mild traumatic brain injury example: a young man who played defense on a local high school football team sustained a mild traumatic brain injury when he collided with another player. He experienced a brief loss of consciousness and was disoriented when the paramedics removed him from the field. Later in the week, while in class, he complained of lightheadedness, and seemed at times to be utterly confused. These

McPhail 6 symptoms resolved themselves after a little less than a week, and he seemed to be completely normal following that time. Severe Traumatic Brain Injury is associated with loss of consciousness for over 30 minutes, or amnesia. Symptoms of Severe TBI include all of those of MTBI, as well as headaches that gets worse or do not go away, repeated vomiting or nausea, convulsions or seizures, inability to waken from sleep, dilation of one or both pupils of the eyes (also known as aniscoria), slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation [sic] (Military Benefits 1). Aides from a local healthcare agency are presently rehabilitating an 88-year-old male patient, “John”, who sustained his traumatic brain injury from a stroke. Two years prior to his stroke, he fractured his hip after a fall in the bathroom, and earlier in his life, at the age of 42, he had been diagnosed with diabetes. Rehabilitation is challenging for the patient because he is not only dealing with his sensory-motor deficits, but also with emotional, behavioural and cognitive deficits as well. He is depressed and unmotivated, believing he will never be able to function like he did previously. The psychological considerations have an effect on the patient, his family and the attending therapists. In John’s case, his deepening depression has adverse affects on his mood, emotional outlook, and motivation. He often exhibits ill temper towards both therapists and support, acting as though it is somehow their fault that he cannot meet the extremely high expectations he has set for himself concerning his ability to assume

McPhail 7 a more independent lifestyle, like the one he had prior to the onset of his disability. In the case of his family, a number of whom who have gone out of their way to try and accommodate his new needs and do anything they can to help him, there is a sense of frustration because they do not understand John’s current psychological state and how it affects his daily ability to cope. They are experiencing a high degree of frustration at John’s lack of progress in the physical area, as well as expressing a deepening sense of dissatisfaction with John’s apparent feeling that whatever they are doing to help is somehow “not quite good enough” despite the sacrifices they have made, often at a considerable personal cost, to try and help him in his current situation. John’s depression is also affecting his relationship with the therapists who work with him due to an increasing lack of motivation. This is sometimes the genesis of feelings of anger and hostility directed towards his friends, family and therapists if they try to encourage him to participate in the activities designed to move his treatment along. Healthcare professionals who treat patients that sustained a TBI should have an overall understanding of the effects of the psychological, pathophysiological (changes of normal mechanical, physical, and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome) and social factors affecting patients with craniocerebral injury. If the patient is in a depressed state, the plan of treatment will be affected by such factors as how the patient receives the therapist during times the treatment must be carried out, the lack of motivation the patient may experience when it comes time to carry out treatment alone or with aides and/or family members, and the displaced feelings of anger and frustration the patient exhibits that ultimately will be

McPhail 8 directed at the help and support network. Patients in this state can also experience lower pain thresholds and increased fatigue which work to limit the physical gains that can be made. Careful consideration must be taken to adjust the treatment plan accordingly as to what the therapist can do to overcome the obstacles there may be to completing the elements of treatment successfully, like lessening or alleviating the lack of motivation by dealing with the patient’s depression, alleviating pain and fatigue levels and positively redirecting any hostility the patient exhibits to better the relationships the patient has with family, friends and other treatment professionals whose duty it is to aid the patient in the areas where he cannot function without help. Naturally, these steps must take into account how to better ally the family and other healthcare professionals who are components of the overall treatment team to better understand how these emotional/psychological symptoms can affect outcomes. In this way, the individual TBI patient can be best allowed to progress in the overall plan of rehabilitation as set down by his physicians, etc. The etiology [referring to the causes of diseases or pathologies] of injuries resulting from craniocerebral injury trauma is quite extensive, but it can be classified as: 1.

penetrating or open (e.g., gunshot wounds)

2.

nonpenetrating or closed (e.g., impact injury from an automobile accident)

(Vargas 201). Following an impact injury, laceration and contusions of the underlying brain tissue can develop as a direct result of the impact

McPhail 9 and may be accompanied by skull fractures. These occur secondary to the rupture of arteries and veins that supply the underlying skull, meningeal and brain tissue (Vargas 201). Subdural and epidural hematoma, which is caused by intracranial (inside the skull) hemorrhage which is a result of the rupturing of arteries and veins can lead to added damage and problems for the TBI patient. Brain damage can be classified as primary or secondary. Primary brain damage follows focal brain lesions, while secondary brain damage as a result of systemically originated insults to the brain (e.g. hypoxia or hypoglycemia). Common clinical manifestations include spasticity, decerebrate rigidity [the head is arched back, the arms are extended by the sides, and the legs are extended], decorticate rigidity [with elbows, wrists and fingers flexed, and legs extended and rotated inward], hypotonicity [flaccid paralysis], areflexia [below normal or absent reflexes] or dysreflexia [a massive sympathetic discharge], and hemiparesis or quadriparesis (Vargas 201). The patient Jane experiences decerbrative rigidity which is severe extensor spasticity in both upper and lower extremities. Whenever she becomes very upset or agitated, she screams and locks her jaws, clamping her teeth shut with an undue amount of force. In order to alleviate this condition and allow Jane’s muscular state to return to normal, her aides and workers have to basically accommodate Jane in whatever it is she currently desires.

McPhail 10 Spasticity is a term used to define any abnormal increase in tone. The term “rigidity” designates a degree of advanced or severe spasticity that may proceed the onset of contractures (Vargas 202). REHABILITATION Jane benefits weekly from selected aquatic rehabilitation intervention utilizing methods and exercises specifically designed to take advantage of the reduced gravity and extra support that in-water work provides helping to prevent contractures. Watsu ® is an applied intervention used in aquatic therapy which incorporates static passive stretches and a structured sequence of passive limb, head, and neck movements or patterns performed at water surface level (Vargus 87). Transitional flow is a procedure in which Jane’s physical therapist rotates her right and left legs passively. This motion enables the therapist to move her hands toward Jane’s ankle on each leg and then proceeds to flex her hip and knee above the water until the leg passes over the therapist’s head which rests on the back of Jane’s neck. The Halliwick method offers selected techniques that can assist in balance coordination, proprioception, and gait. It offers disabled people like Jane and Keith confidence and improved control of their bodies in the water. They will progress to the next level of swimming once the strokes have been mastered. They also provide aquatic therapy along with walking and physical therapy on land.

McPhail 11 Patients with TBI are often apraxic (apraxia is a neurological disorder characterized by the loss of the ability to execute or carry out purposeful, learned movements, despite having the desire and the physical ability to perform the movements. It is a disorder of motor planning which may be acquired, but may not be caused by incoordination, sensory loss, or failure to comprehend simple commands) and have problems with getting their limbs to move voluntarily as planned, making an interdisciplinary approach to treatment involving all members of the rehabilitation team necessary on land and in water. This coordinated team approach is required for a successful rehabilitation outcome for the patient. If they notice there is evidence of contractures, the team will make use of fabricated splints especially designed to be employed in the pool. Depending on the degree of and severity of the traumatic brain injury, once initial goals are attained, other dynamic aquatic therapy activities may be integrated into the aquatic rehabilitation plan of care which includes improvements in the areas of gait, posture, coordination, and muscle strength. MOOD DISORDERS FOLLOWING TRAUMATIC BRAIN INJURY Mood disorders are those conditions in which a disturbance of moods is the predominant clinical feature. The understanding of the mood disorder must take place at 3 levels of severity. These include: 1. The experience of the mood disorder, which refers to the conscious feeling of

depression or sadness, falling at one end of the spectrum, or of euphoria and elation on the other. Example: On one Sunday morning while getting Jane ready for church, her aides found her very pleasant and accommodating. She became emotional in church, crying from the sermon she heard. Her reaction was so

McPhail 12 overwhelming that her aide began to cry, as well. Later that same evening, Jane became so upset that her worker would not let her take food by mouth, Jane decided to ram her wheelchair into the aide at full speed, pinning her into the corner. 2. The ways the TBI sufferer feels about the situation. This expression of the

disorder can affect the level of activity and nervous system functioning, which includes changes in appetite, sleep, decreased energy and feelings of worthlessness. Example: A patient who will be referred to as “John”, is allowed care only on Fridays, Saturdays and Sundays each week. He went from walking 25 steps with his worker to barely accomplishing 10 steps due to suffering a bout of the flu which set back his mobility. John is now beginning to feel a huge sense of hopelessness about his condition and is expressing to his workers that he does not see the point of why he should even be bothering to continue with the few steps he can achieve. 3. How the TBI sufferer reacts to the new disability. The cognitive components of the disorder is characterized by the unduly negative or positive appraisal of internal or external events. Example: John’s growing depression over his inability to perform physically coupled with his unrealistically high expectations of what he should be able to achieve. Depression can be expressed differently with age. For example, infants exhibit aggression, acting out or with an increase in activity. In older adults, ease of distraction and memory problems have been noted. Depression in children is of great concern due to a noticeably higher rate of suicide among this younger population.

McPhail 13 The severity of depression ranges from mild to severe. Mild depression features symptoms such as requiring an extra conscious effort to accomplish the things that need to be done for daily living and minor impairments of social or occupational functioning. Moderate depression involves the impairments of social or occupational functioning and levels of effort midway between mild and severe, including symptoms that prevent the individual from accomplishing those things that need to be done to succeed in daily living. Severe depressions feature the marked impairment of social and occupational functioning and levels of effort needed to complete daily tasks and may also include psychotic symptoms (i.e., disturbances in eating, sleeping, sexual functioning and motivational states). The list below describes the function of each specialist and how their areas of expertise relate to head injury patients: 1. Dietician -- Keith and Jane both currently receive services relating to nutrition

following their head injuries. Both of them gained weight from their underlying depression and the new lack of activity brought on by the limitations caused by the traumatic brain injury. 2. Ear, nose and throat physician -- Keith had to have a specialist come in following

his accident. He took a blow to the front of his head, causing trauma to his nose, although not apparent to observers. The result of this injury caused him to snore and experience a number of sinus infections. 3. Neurologist – This doctor, who deals with cerebral and neurological issues, is

more of a consultative specialist than a primary care physician. The neurologist is responsible for administering an EEG (electroencephalogram) which is used to

McPhail 14 measure brain function, and to determine what kind, if any, impairments there may be in normal brain function. Other tests which may be requested include the electromyograph or electromylogram (EMG), a test where small needles are

inserted into muscles and a mild current is run along nerve pathways to see how neuroimpulses from the brain are being received and utilized by the muscles (it detects the electrical potential generated by muscle cells when these cells are mechanically active, and also when the cells are at rest). An EMG can be used to sense isometric muscular activity where no movement is produced. 4. Nurses -- this professional carries out the medical orders of the physicians and

applies any prescribed medical treatment. The nurse is responsible for getting the patient up, giving medication and charting how the TBI patient is progressing. 5. Occupational/Physical therapist – these professionals work on a rehabilitation

plan suggested by the nurse and neurologist. While the two specialists work in close conjunction with each other, in general, the physical therapist may be considered as being the one who provides rehabilitation in issues relating to the lower half of the body (i.e., walking and mobility) while the occupational therapist deals with the conditions that affect the upper extremities (sensation of touch in the fingers, the use of fine and gross motor skills to accomplish tasks like dressing, hygiene, cooking or eating, grooming, etc.). 6. Case manager -- this professional comes to the patient's home, acquires a

lengthy history from the TBI patient, and helps to decide in conjunction with the physician the type and number of healthcare workers and other professionals who need to work with the patient (i.e. physical therapist, speech pathologist,

McPhail 15 home health aides, etc.) as well as finding an Independent Living Skills Trainer (ILST) to assist the patient with functioning as normally as possible in society in light of the patient's new limitations. The case manager, in conjunction with the ILST, will work with any social service agencies to gain the maximum help the TBI patient is entitled to. 7. Insurance adjuster -- this individual is an agent of the insurance company having

the responsibility of figuring out what medical bills, etc., the insurance company is liable for. This person also functions as an advisor to the insurance company, and it is the insurance adjuster who will ultimately authorize or deny treatment. 8. Psychologist/psychiatrist -- both Jane and Keith are under the care of a

counsellor who will help them adjust their behavior and coping abilities following the new disability. The psychologist is usually called upon to help the TBI patients cope with their new emotions resulting from dealing with rehabilitation or to help the patient's family deal with different aspects of the recovery process. The psychiatrist is also an MD, which allows certain medications, necessary for emotional wellbeing to be prescribed in conjunction with those deemed necessary by the neurologist for neurological recovery. 9. Speech/Language pathologist -- this professional helps deal with such areas as

speech, language and cognitive problems. Other areas include organization, memory, planning, attention span, writing skills and reading skills. 10. Vocational rehabilitation counsellor -- this professional has been active in

assisting Jane and Keith with a successful return to work and school by setting up job and school strategies. It is the vocational rehabilitation counsellor who is

McPhail 16 responsible for locating jobs, schools or volunteer sites that best match their patients' individual needs. 11. Home healthcare workers (PCA, HHA, HCSS) – these workers come into the

home to help the TBI patient with such things as cooking, light housekeeping duties (like cleaning, doing dishes, laundry, etc.), grocery shopping, etc. That the TBI sufferer cannot accomplish alone. Certain aides receive training that also allow them to do hands-on care such as helping with bathing, eating, dressing, passive range of motion and other tasks that the patient cannot accomplish unaided. These workers can also accompany the patient for such outside activities as doctor appointments, social functions like going to church, etc. CONCLUSION Traumatic Brain Injury is caused by an external or internal physical force to the head. External agents include injuries such as a gunshot, car accident, falls and/or a sports injury which is accompanied by open trauma allowing the brain tissue to come in contact with external bacteria and/or fractures of the bones of the skull. A countercoup injury is a closed injury involving no penetration to the skull, and where the brain can be whipped back and forth inside the skull, either from blunt force trauma or extreme movement, causing it to collide with the rigid surface of the bone, bruising the delicate tissue or doing other damage like causing tearing of blood vessels, which leads to internal bleeding or swelling. Internal forces suffered by the patient can be the result of such organic causes as a stroke, heart attack, diabetes or anything which causes an obstruction of blood flow or oxygen to the brain.

McPhail 17 Whatever the cause, traumatic brain injury is devastating for the patient mentally and physically. The sufferer is no longer able to be as cogent as prior to the injury, and depending on the extent of the injury, exhibit normal rational thinking. Other limitations usually include attention deficits and mood swings. Physical effects include loss of mobility and other motor skills necessary to walk, or perform simple tasks like dressing, bathing or even eating without assistance. This new loss of independence can leave the individual feeling vulnerable, which circles back to other psychological impairments. Rehabilitation is a very important step for the TBI patient because it keeps the new physical impairments from becoming permanent and problematic for the individual. Lack of movement can result in skin break down and bed sores, muscle weakness and neurological impairments can lead to muscle atrophy and contractures, which further lead to a decrease in motor function and mobility. By working with these limitations early on, the physical and occupational therapist can enable the patient to eventually provide care for themselves. By rehabilitation, the TBI patient can rebuild self esteem as they are able to regain control of aspects of their life even with the new limitations. Other specialists on the rehabilitative team can aid in regaining control of areas of life through improvement in daily living skills like paying bills and household management, improved coping skills, improving speaking and cognitive skills, and finding appropriate adaptations to succeed by accepting help to have success where necessary in daily living and vocational goals. Although difficult to do so, it has been proven that with the appropriate motivation and team support, the TBI patient can overcome the new limitations and disabilities to live as nearly a normal life as their non-impaired counterparts.

McPhail 18 Works Cited

Carlson, Connie and Darcy Umphred. Neurorehabilitation for the Physical Therapist Assisstant. 1st print. Thorofare: Slack, Inc. 2006. Crowe, Simon F. The Behavioural and Emotional Complications of Traumatic Brain Injury. 1st print. New York: Taylor & Francis, 2008. Military Benefits. Traumatic Brain Injury Overview: Range of Symptoms. 8 January 2009. Military.com 8 January 2009. . Turnbull, Ann, Rud Turnbull, and Michael L. Wehmeyer. Exceptional Lives: Specioal Education in Today’s Schools: Fifth edition. 3rd print. Upper Saddle River: Pearson Prentice Hall. 2007. Vargas, Luis G. Aquatic Therapy: Interventions and Applications. 1st ed. Ravensdale: Idyll Arbor,Inc. 2004. Wikipedia. Head Injury. 8 April 2009 Wikipedia.org 21 April 2009. . - Traumatic Brain Injury. 17 April 2009 21 April 2009. .