After the event

November 2014

FocusAfter the event

Traumatic brain injury – support for injured people and their carers

Volume 43, No.11, November 2014 Pages 758-763

Jagnoor Jagnoor

Ian D Cameron

Background

Traumatic brain injury (TBI) is a major cause of lifelong disability and death worldwide, but is considered a ‘silent epidemic’ as society is largely unaware of the magnitude of the problem. TBI is a complex injury with a broad spectrum of symptoms and disabilities. Pa-tients with a TBI may have a range of physical, mental, cognitive and social problems.

Objective/s

This article provides a summary of the available evidence for assessing TBI and managing the common mental health, physical and cognitive/behavioural issues associated with TBI.

Discussion

Translational and clinical research has revealed that TBI can no longer be regarded as a single clinical entity with a defined outcome. Each type of injury can lead to a distinct clinical condition that requires careful assessment and appropriate management to reduce long-term disability. In this article we discuss some of the more common health issues related to TBI.

Traumatic brain injury (TBI) is a complex injury with a broad spectrum of symptoms and disabilities. It is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force.1 Improvements in the acute management of TBI have resulted in a reduction in mortality rates for people with severe TBI. This, together with the relative youth of those who commonly sustain TBI, has led to a growth in the number of people living with disability as a result of TBI. The Australian Institute of Health and Welfare has reported a TBI rate of 107 per 100 000 population in Australia. Most studies suggest that approximately 20% of patients with TBI admitted to hospital have sustained moderate or severe head injuries, and the other 80% have mild injuries.2 TBI is a subset of the wider diagnostic group of acquired brain injury (ABI). It includes brain injury acquired as a result of other mechanisms, such as vascular, metabolic, neoplastic and infectious mechanisms.

The majority of moderate-to-severe TBIs result from motor vehicle crashes. Other causes of TBI include falls, bicycle accidents, assaults and sports injuries and the latter causes a higher proportion of mild TBIs. With the ageing of the population there are an increasing number of older people injured and killed as a result of fall-related TBIs. A study has shown that TBI due to assault was 21 times more likely in Aboriginal and Torres Strait Islander peoples, compared with non-Indigenous Australians.3 In recent years the use of explosive devices in armed conflict has added a new mechanism of injury – blast injury – the effects of which are the focus of considerable current research, particularly in the USA.

This article has been adapted and updated from earlier guidelines4,5 and provides a summary of the current evidence on the management of some of the common conditions among people who have had a TBI.

Mechanisms of TBI

Neuropathological evidence suggests that there are several mechanisms of brain injury, some operating at the moment of impact and others as a consequence of secondary complications. This results in significant heterogeneity in the subsequent effects of injury across individuals. Acceleration or deceleration forces may cause laceration of the scalp, skull fracture and/or shifting of the intracranial contents, with resultant focal and diffuse changes. Focal changes include haematoma formation resulting from tearing of blood vessels, and contusion or bruising, most commonly on the basal and polar portions of the frontal and temporal lobes. Complications, including brain swelling, infection, raised intracranial pressure and respiratory arrest, may cause secondary brain injury. Results of clinical trials examining the efficacy of drugs that block various processes contributing to secondary brain injury have unfortunately been disappointing.6–8

Limitations in the sensitivity of imaging techniques make delineating the precise nature and extent of injury in an individual difficult. The scans may show decreasing brain volume with time, which correlates with diffuse axonal injury (DAI) and may assist in identifying severe brain injury. It is nevertheless apparent from the neuropathological evidence available that DAI is common, particularly in severe TBI caused by motor vehicle crashes, and its prognosis for recovery is different from that for stroke.9 Long-term studies of recovery from TBI show ongoing improvements for at least 2–5 years after injury.10

Diagnosis and assessment of TBI

A TBI can range from a mild brain injury, to severe or profound brain damage. It is important to accurately assess the severity of the TBI as this is important for prognosis and management. The patient’s recall of events at the time of the TBI and shortly after is often inaccurate. Therefore, the initial clinical documentation from the ambulance or hospital emergency department should be obtained before making decisions about investigation and management.

Two reliable indicators of damage severity include how long the person is in a coma and the length of time in post-traumatic amnesia (PTA). In Australia, the most common means of assessing PTA is the Westmead PTA Scale.11 Clinical severity scores and neuro-imaging techniques are also used for diagnosing and determining the severity of brain injury. The commonly used clinical severity score is the Glasgow Coma Scale (GCS).12 The accepted clinical classification of TBI severity with reference to initial GCS and PTA is shown in Table 1. Older age is a strong negative predictor of outcome. For clinical assessment of suspected severe TBI, standard assessments of cognitive status (such as the Mini Mental State Examination) are not sensitive enough to detect the types of cognitive impairment that are present and so computed tomography (CT) or magnetic resonance imaging (MRI) is used to detect structural changes in moderate-to-severe TBI.13

Table 1. Determining the severity of TBI12,30

Severity

Initial GCS

Post-traumatic amnesia

Mild

13–15

<1 hour

Moderate

9–12

1–24 hours

Severe

3–8

1–7 days

Very severe

1–4 weeks

Extremely severe

>4 weeks

GCS, Glasgow Coma Scale

Consequences of TBI

A TBI can affect the way a person thinks, feels and behaves. However, these sequelae vary in nature and severity. Physical consequences are less common. Common health issues related to TBI are presented in Table 2. These health issues affect quality of life and functioning of individuals. The association of mild TBI with post-traumatic stress disorder (PTSD) and post-concussion syndrome (PCS) are debated.16–18 PCS is the term used to describe a collection of symptoms that can last for several weeks or months after the concussion.5

In most patients with moderate-to-severe TBI, cognitive difficulties are the most prominent impairments. However, functional difficulties can occur and are more much more common in patients with very severe TBI. Functional and cognitive status is dynamic but generally improves over the first 2 years after a TBI. Family support, work and socialisation have a pivotal role in quality of life after a TBI.19

Table 2. Common health issues in TBI5
Health issues Diagnostic features Treatment Prognosis
Common physical health issues

Seizures:

  • early
  • late

Increased risk of post-traumatic epilepsy with:

  • TBI with history of early seizures
  • single CT lesion
  • a focal EEG at 1 month

GCS is not significantly correlated with post-traumatic epilepsy

Post-acute phase:

  • phenytoin may reduce early post-traumatic seizures

Prophylactic:

  • phenytoin, carbamazepine and valproate have no effect on prevention of late post-traumatic seizures

Post-traumatic epilepsy is more likely to be associated with:

  • disinhibition
  • irritability
  • aggression
  • agitated behaviour

Somatic complaints:

  • headaches
  • dizziness
  • pain
  • sleep disturbances
  • Self-reports of dizziness are sensitive and specific in TBI patients
  • Dizziness Handicap Inventory is a useful and reliable method for evaluating the efficacy of antivertigo/dizziness drugs
  • No TBI-specific treatment for headache and sleep disturbances
  • Vestibular rehabilitation (including exercise therapy) is effective in the early stages of dizziness
  • Betahistine 48 mg/day for 8 weeks has been reported to significantly reduce dizziness
  • Somatic complaints usually persist for the long term in many patients

Post-concussion syndrome (PCS)

Useful tools for diagnosis:

  • Rivermead Post Concussional Symptoms Questionnaire (RPQ)
  • WHO criteria
  • Early cognitive and educational interventions are effective
  • Most cases of PCS resolve within 3 months of injury
Common mental health issues

Depression

Beck Depression Inventory scale is a useful tool

Sertraline:

  • studied in patients with TBI and depression
  • effective and well tolerated

Community-based outreach rehabilitation:

  • effective in improving depression scores in initial years post-injury

Spontaneous recovery from depression without treatment in >50% of patients with TBI

Anxiety

No validated tools for diagnosing anxiety within TBI population

CBT:

  • acute stress disorder following mild TBI

CBT combined with neuro-rehabilitation:

  • may be effective for generalised anxiety symptomatology

Telephone counselling has also been found to be helpful

An extended period of unconsciousness may be protective against the development of PTSD

Schizophrenia

Likely presentation:

  • paranoia
  • auditory hallucinations of gradual onset
  • Antipsychotic medications are the standard treatment
  • Specific treatments in TBI populations have not been investigated

No longitudinal evidence available

Cognitive and behavioural issues

Cognitive impairment

Self-reported problems:

  • impaired memory
  • language difficulties
  • planning
  • writing

Other useful tools:

  • Cognitive subscale of TIRR
  • Rancho Los Amigos Levels of Cognitive Functioning (RLCF)

Cognitive rehabilitation focusing on remediation and compensation is helpful

Cognitive impairment:

  • most cases resolve within 3 months in mild TBI
  • continues for ≥2 years in moderate-severe TBI

Personality and behavioural changes

Presentation:

  • depressive temperament
  • irritability
  • impatience
  • socialisation problems

Potentially useful tools for assessing and monitoring behavioural outcomes of TBI:

  • The Neurobehavioural Functioning Inventory (carer-rated)*
  • Neurobehavioural Rating Scale-Revised NRS-R (clinician-administered)*
  • TIRR (self-report)*

No definitive evidence for the effectiveness of drug therapy for behavioural problems in TBI patients

Behavioural problems post-TBI are often chronic

CBT, cognitive behaviour therapy; GCS, Glasgow Coma Scale; TBI, traumatic brain injury
*Bias in these measures is likely and it may be useful to use more than one in practice

Recovery from TBI

Mechanisms of recovery are poorly understood and there is considerable variability in patterns of recovery. People with very mild and mild TBIs can be expected to recover quickly. However, some will have psychological consequences of the injury that will require assessment and management. Most people experiencing mild TBI recover fully within days to months, but a small percentage (1–20%) of individuals continue to experience symptoms 3 months after injury.14,15 Recovery from moderate or severe TBI tends to follow a negatively accelerating curve, which is most rapid in the first 3–6 months, but may continue for several years.20

Much of the early spontaneous recovery after TBI is explained by the resolution of temporary physiological changes. In addition there are regenerative neuronal changes that have been associated with behavioural improvement. However, the potential for regenerative growth is limited, particularly in the case of severe injuries. It is thought that most recovery beyond this occurs through the substitution or reorganisation of neural structures and/or functions. There is a growing body of evidence to suggest that environmental stimulation, and specifically behavioural therapies, can alter brain function and organisation after injury.

This is termed neuroplasticity,21 which may occur by the reorganisation of neural circuits within or associated with the damaged area, or via reorganisation of the remaining circuits. The capacity for reorganisation decreases as the size of the damaged area increases because presence of intact tissue seems to be important to allow this reorganisation of function to occur.22 It also varies according to genetic differences, pre-injury experience and age. There is some evidence that sensory or motor stimulation results in reorganisation of sensory–motor functions, but the evidence relating to cognitive functions is much more limited. However, task-specific engagement as relevant to the individual, and stimulation to encourage neuroplasticity should be the underlying principles in assisting the person with severe TBI.

Rehabilitation after TBI

For individuals with identified TBI (usually severe), a period of acute care stabilisation occurs within the hospital. Because recovery after TBI is often greater than expected initially, people with TBI who have some level of responsiveness are routinely referred to rehabilitation services to maximise potential for recovery.

Rehabilitation settings are typically characterised by a treatment team approach to meet the complex needs of the person recovering from severe or extremely severe TBI. TBI rehabilitation physicians are responsible for the overall coordination of care both in the inpatient and outpatient settings, and provide specific expertise with reference to prognosis, monitoring and selected interventions. Other team members are neuropsychologists; rehabilitation nurses; physical therapists; occupational therapists; speech therapists; recreational, art and music therapists; vocational counsellors and social workers/care coordinators/case managers.4 In most regions of Australia there are specialised brain injury rehabilitation services that will accept referrals for people with persisting disability after TBI.

Carers and families

The impact of TBI on the person and family carers is significant and long term, such that people with TBI require continuing support and care in various aspects of their lives many years after the injury. Children of affected parents may struggle to understand the wide-reaching effects of TBI and the subsequent changes in roles and relationships in the family. TBI in a parent can cause significant emotional, behavioural and relationship difficulties. A recent analysis from the Finnish Birth Cohort study has reported that parental TBI is associated with increased use of specialised psychiatric services.23

Caregiver stress is greater if the patient has a troubled pre-injury psychosocial history and in those who have financial barriers to accessing services. General practitioners (GPs) should screen carers for depression and it would also be appropriate to screen for stress and anxiety. The use of validated tools such as the Kessler K10 Index (K-10),19 DASS-21 scale24 and the Zarit Burden Scale25 may assist in this process.

Long-term issues for people with severe TBI

The effects of severe TBI are long-lasting, and patients and their families require continued care and support, often for the rest of their lives, leading to a substantial impact at a societal level. TBI is most prevalent in young adult life and often disrupts important developmental processes, such as attaining independence from parental support, completing study and establishing a vocation/returning to work and forming social networks.26,27 The result is loss of self-esteem, social withdrawal and a considerable burden for families.

The GP is likely to be familiar with the scenario of a patient who has suffered severe TBI and has continuing disability related to challenging behaviour, hazardous drug and alcohol use, mental health problems, and housing and employment issues. It may be appropriate to coordinate support for these patients through general practice chronic disease management plans and/or mental health plans. There are other more specialised resources that may be of assistance and these are usually state-based, for example, the NSW government publication Care and Support Pathways for People with an Acquired Brain Injury.28 Table 3 provides further resources.

Table 3. Some useful resources for TBI

Organisations

Websites

Acquired Brain Injury Outreach Service Queensland

www.health.qld.gov.au/abios/

Brain Injury Rehabilitation Program New South Wales www.aci.health.nsw.gov.au/networks/brain-injury-rehabilitation/brain-injury-rehabilitation-program
Brain Injury Rehabilitation Services South Australia www.rah.sa.gov.au/birs/
Headwest Western Australia www.headwest.asn.au/
Brain injury Australia www.braininjuryaustralia.org.au/
Lifetime Care and Support Authority New South Wales www.lifetimecare.nsw.gov.au/
National Disability Insurance Scheme www.ndis.gov.au/
Acquired Brain Injury Western Australia www.abiwa.org.au/

The future development of the National Injury Insurance Scheme (NIIS) and the National Disability Insurance Scheme (NDIS)29 is intended to provide lifetime care and support to people who sustain a catastrophic injury from a motor vehicle, workplace, medical treatment injury or general accident. The full realisation of these programs would be likely to improve quality of life for people with severe disability resulting from a TBI, their families and carers through greater equity and access to care.

Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.

References

  1. Menon DK, Schwab K, Wright DW, Maas AI. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil 2010;91:1637–40.
  2. Ponsford J, Sloan S, Snow P. Traumatic brain injury: Rehabilitation for everyday adaptive living. Hove, UK: Psychology Press, 2012.
  3. Jamieson LM, Harrison JE, Berry JG. Hospitalisation for head injury due to assault among Indigenous and non-Indigenous Australians, July 1999–June 2005. Med J Aust 2008;188:576–79.
  4. Khan F, Baguley IJ, Cameron ID. 4: Rehabilitation after traumatic brain injury. Medical J Aust 2003;178:290–95.
  5. Trevena L, Cameron ID, Porwal M. Clinical practice guidelines for the care of people living with traumatic brain injury in the community: Full report. University of Sydney, 2004. Available at www.maa.nsw.gov.au/getfile.aspx?Type=document&ID=44425&ObjectType=3&ObjectID=3917 [Accessed 22 September 2014].
  6. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. New Engl J Med 2004;350:2247–56.
  7. Nichol AD, Cooper DJ. Can we improve neurological outcomes in severe traumatic brain injury? Something old (early prophylactic hypothermia) and something new (erythropoietin). Injury 2009;40:471–78.
  8. Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med 2012;20:12.
  9. Meythaler JM, Peduzzi JD, Eleftheriou E, Novack TA. Current concepts: diffuse axonal injury and associated traumatic brain injury. Arch Phys Med Rehabil 2001;82:1461–71.
  10. Hammond FM, Grattan KD, Sasser H, Corrigan JD, Bushnik T, Zafonte RD. Long-term recovery course after traumatic brain injury: a comparison of the functional independence measure and disability rating scale. J Head Trauma Rehabil 2001;16:318–29.
  11. Ponsford J, Willmott C, Rothwell A, Kelly AM, Nelms R, Ng KT. Use of the Westmead PTA scale to monitor recovery of memory after mild head injury. Brain Inj 2004;18:603–14.
  12. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;2:81–84.
  13. Arciniegas DB, Anderson CA, Topkoff J, McAllister TW. Mild traumatic brain injury: a neuropsychiatric approach to diagnosis, evaluation, and treatment. Neuropsychiatr Dis Treat 2005;1:311–27.
  14. McCrea M, Iverson GL, McAllister TW, et al. An integrated review of recovery after mild traumatic brain injury (MTBI): implications for clinical management. Clin Neuropsychol 2009;23:1368–90.
  15. Carroll L, Cassidy JD, Peloso P, et al. Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004;43(Suppl):84–105.
  16. Rees PM. Contemporary issues in mild traumatic brain injury. Arch Phys Med Rehabil 2003;84:1885–94.
  17. Iverson GL. Outcome from mild traumatic brain injury. Current Opin Psychiatry 2005;18:301–17.
  18. Ruff RM. Mild traumatic brain injury and neural recovery: rethinking the debate. NeuroRehabilitation 2011;28:167–80.
  19. Uzzell BP, Stonnington HH, editors. Recovery after traumatic brain injury. Mahwah, NJ: Lawrence Erlbaum Associates Inc, 1996.
  20. Cramer SC, Sur M, Dobkin BH, et al. Harnessing neuroplasticity for clinical applications. Brain 2011;134:1591–1609.
  21. Povlishock JT, Katz DI. Update of neuropathology and neurological recovery after traumatic brain injury. J Head Trauma Rehabil 2005;20:76–94.
  22. Pirkis J, Burgess P, Coombs T, Clarke A, Jones-Ellis D, Dickson R. Routine measurement of outcomes in Australia’s public sector mental health services. Aust N Z Health Policy 2005;2:8.
  23. Niemelä M, Kinnunen L, Paananen R, et al. Parents’ traumatic brain injury increases their children’s risk for use of psychiatric care: the 1987 Finnish Birth Cohort study. Gen Hosp Psychiatry 2014;36:337–41.
  24. Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment 1998;10:176–81.
  25. Ankri J, Andrieu S, Beaufils B, Grand A, Henrard JC. Beyond the global score of the Zarit Burden Interview: useful dimensions for clinicians. Int J Geriatr Psychiatry 2005;20:254–60.
  26. Schwartz L, Taylor HG, Drotar D, Yeates KO, Wade SL, Stancin T. Long-term behavior problems following pediatric traumatic brain injury: prevalence, predictors, and correlates. J Pediatr Psychol 2003;28:251–63.
  27. Millis SR, Rosenthal M, Novack TA, et al. Long-term neuropsychological outcome after traumatic brain injury. Journal Head Trauma Rehabil 2001;16:343–55.
  28. NSW Government. Care and Support Pathways for People with an Acquired Brain Injury Referral and Service Options in NSW. Available at www.adhc.nsw.gov.au/__data/assets/file/0007/237751/ADHC-ABIPathways-R10.pdf [Accessed 22 September 2014].
  29. National Disability Insurance Scheme. Available at www.ndis.gov.au/ [Accessed 22 September 2014].
  30. Jennett B, Snoek J, Bond M, Brooks N. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. J Neurol Neurosurg Psychiatry 1981;44:285–93.

Correspondence afp@racgp.org.au

Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No

    

 

 

 

 

Competing Interests: 

Your comment is being submitted, please wait

 

Download citation in RIS format (EndNote, Zotero, RefMan, RefWorks)

Download citation in BIBTEX format (RefMan)

Download citation in REFER format (EndNote, Zotero, RefMan, RefWorks)

For more information see Wikipedia: Comparison of reference management software