REHABILITATION IN TBI

BY DR KHIU FU LUNG MD

Traumatic brain injury (TBI), also known as

intracranial injury, occurs when an external 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.

Epidemiology:
TBI is a major cause of death and disability worldwide, especially in
children and young adults. Males sustain traumatic brain injuries
more frequently than do females. Causes include falls, vehicle
accidents, and violence. Prevention measures include use of
technology to protect those suffering from automobile accidents,
such as seat belts and sports or motorcycle helmets, as well as efforts
to reduce the number of automobile accidents, such as safety
education programs and enforcement of traffic laws.

Burden of the disease in today society:

TBI can cause a host of physical, cognitive, social, emotional, and
behavioral effects, and outcome can range from complete recovery to
permanent disability or death. The 20th century saw critical
developments in diagnosis and treatment that decreased death rates
and improved outcome. Some of the current imaging techniques used
for diagnosis and treatment include CT scans computed tomography
and MRIs magnetic resonance imaging. Depending on the injury,
treatment required may be minimal or may include interventions
such as medications, emergency surgery or surgery years later.
Physical therapy, speech therapy, recreation therapy, occupational
therapy and vision therapy may be employed for rehabilitation.

ACQUIRED BRAIN
INJURY

TRAUMATIC
BRAIN INJURY

NON
TRAUMATIC
BRAIN INJURY

TBI is usually classified based on severity, anatomical features of the injury, and the mechanism (the
causative forces). Mechanism-related classification divides TBI into closed and penetrating head
injury. A closed (also called nonpenetrating, or blunt) injury occurs when the brain is not exposed.
A penetrating, or open, head injury occurs when an object pierces the skull and breaches the dura
mater, the outermost membrane surrounding the brain.

Severity of traumatic brain injury

GCS

PTA

LOC

MILD

13-15

LESS THAN 1 DAY

0-30MIN

MODERATE

9-12

1-7 DAYS

30MIN-24H

SEVERE

3-8

MORE THEN 7 DAYS

MORE THAN 24H

A current model developed by the Department of Defense and Department of Veterans Affairs uses
all three criteria of GCS after resuscitation, duration of post-traumatic amnesia (PTA), and loss of
consciousness (LOC). It also has been proposed to use changes that are visible on neuroimaging,
such as swelling, focal lesions, or diffuse injury as method of classification. Grading scales also exist
to classify the severity of mild TBI, commonly called concussion; these use duration of LOC, PTA, and
other concussion symptoms.

DIAGNOSIS
Diagnosis is suspected based on lesion circumstances and clinical evidence, most
prominently a neurological examination, for example checking whether the pupils
constrict normally in response to light and assigning a Glasgow Coma Score.
Neuroimaging helps in determining the diagnosis and prognosis and in deciding what
treatments to give.

The preferred radiologic test in the emergency setting is computed tomography (CT): it is
quick, accurate, and widely available. Followup CT scans may be performed later to
determine whether the injury has progressed.
Magnetic resonance imaging (MRI) can show more detail than CT, and can add
information about expected outcome in the long term. It is more useful than CT for
detecting injury characteristics such as diffuse axonal injury in the longer term. However,
MRI is not used in the emergency setting for reasons including its relative inefficacy in
detecting bleeds and fractures, its lengthy acquisition of images, the inaccessibility of the
patient in the machine, and its incompatibility with metal items used in emergency care.
A variant of MRI since 2012 is High definition fiber tracking (HDFT).

 Other techniques may be used to confirm a particular diagnosis. X-rays are still
used for head trauma, but evidence suggests they are not useful; head injuries
are either so mild that they do not need imaging or severe enough to merit the
more accurate CT. Angiography may be used to detect blood vessel pathology
when risk factors such as penetrating head trauma are involved. Functional
imaging can measure cerebral blood flow or metabolism, inferring neuronal
activity in specific regions and potentially helping to predict outcome.
Electroencephalography and transcranial doppler may also be used. The most
sensitive physical measure to date is the quantitative EEG, which has documented
an 80% to 100% ability in discriminating between normal and traumatic braininjured subjects.
Neuropsychological assessment can be performed to evaluate the long-term
cognitive sequelae and to aid in the planning of the rehabilitation. Instruments
range from short measures of general mental functioning to complete batteries
formed of different domain-specific tests.

EDH

Facility and Program Types

A) ICU
After receiving emergency medical treatment, persons with a moderate to
severe brain injury may be admitted to a hospitals Inpatient Intensive Care
Unit. The goals in the ICU include achieving medical stability, medical
management, and prevention of medical crisis. Some preventive
rehabilitation may be initiated in the Intensive Care Unit such as body
positioning, splinting, and range of motion (a therapist moves the persons
limbs).
Persons treated in the ICU may be unconscious, in a coma, and medically
unstable. Many tubes, wires, and pieces of medical equipment may be
attached to the patient to provide life sustaining medical care. Medical
equipment frequently used in the ICU includes:

 A Ventilator (also called a Respirator) is a machine that helps a person

breathe.
A person who has sustained a brain injury may be unable to breathe on
his or her own.To use a ventilator, a tube is placed through the persons
mouth to the breathing passage, (trachea, windpipe). This procedure is
called intubation.
Intubation with the use of a ventilator allows a person to breathe and
receive oxygen, which is necessary for life.
Intravenous lines (IVs) are tubes placed in a persons veins to deliver
medications and fluids to the persons body.
Arterial lines are tubes placed in a persons arteries to measure blood
pressure.

 An ECG machine monitors a persons heart.

Wires with sticky ends are placed on the body.
An Intracranial Pressure (ICP) Monitor is a device attached to a persons
head with a monitor that indicates the amount of pressure in the brain.
When the brain is injured it may swell.
When the brain swells, the brain has no place to expand. This can cause
an increase in intracranial pressure (the pressure within the skull).
If the brain swells and has no place to expand, this can cause brain tissues
to compress, causing further injury.
A Pulse Oximeter is a small, clamp-like device placed on a persons finger

 A Foley Catheter is used to collect and monitor a persons urine output.

A person who has sustained a brain injury may be unable to control
bladder functions.
A rubber tube is inserted into the persons bladder. This allows urine to
move from the bladder, through the tube, and to a container at the end of
the tube.
A Nasogastric Tube (NG Tube) is used to deliver medication and nutrients
directly to a persons stomach.
A person who has sustained a brain injury may be unable to swallow.
A tube is placed through a persons nose or mouth and ran through the
swallowing passage (the esophagus), to the stomach.

B)Acute Rehabilitation
As early as possible in the recovery process, individuals who sustain
brain injuries will begin acute rehabilitation. The treatment is
provided in a special unit of the trauma hospital, a rehabilitation
hospital or another inpatient setting. During acute rehabilitation, a
team of health professionals with experience and training in brain
injury work with the patient to regain as many activities of daily living
as possible. Activities of daily living including dressing, eating,
toileting, walking, speaking and more.

C)Postacute Rehabilitation
When patients are well enough to participate in more intensive
therapy, they may be transferred to a postacute rehabilitation setting,
such as a residential rehabilitation facility. The goal of postacute
rehabilitation is to help the patient regain the most independent level
of functioning possible. Rehabilitation channels the body's natural
healing abilities and the brain's relearning processes so an individual
may recover as quickly and efficiently as possible. Rehabilitation also
involves learning new ways to compensate for abilities that have
permanently changed due to brain injury. There is much that is still
unknown about the brain and about brain injury rehabilitation.
Treatment methods and technologies are rapidly advancing as
knowledge of the brain and its function increases.

D)Subacute Rehabilitation
Patients who cannot tolerate intensive therapy may be transferred to
a subacute rehabilitation facility. Subacute rehabilitation programs
are designed for persons with brain injury who need a less intensive
level of rehabilitation services over a longer period of time. Subacute
programs may also be designed for persons who have made progress
in the acute rehabilitation setting and are still progressing but are not
making rapid functional gains. Subacute rehabilitation may be
provided in a variety of settings, often a skilled nursing facility or
nursing home.

E)Day Treatment (Day Rehab or Day Hospital)

Day treatment provides rehabilitation in a structured group setting during the

day and allows the person with a brain injury to return home at night.
F)Outpatient Therapy
Following acute, postacute or subacute rehabilitation, a person with a brain
injury may continue to receive outpatient therapies to maintain and/or enhance
their recovery. Individuals whose injuries were not severe enough to require
hospitalization or who were not diagnosed as having a brain injury when the
incident occurred may attend outpatient therapies to address functional
impairments.

G)Home Health Services

Some hospitals and rehabilitation companies provide rehabilitation therapies
within the home for persons with brain injury.

H)Community Re-entry

Community re-entry programs generally focus on developing higher level motor,

social, and cognitive skills in order to prepare the person with a brain injury to
return to independent living and potentially to work. Treatment may focus on
safety in the community, interacting with others, initiation and goal setting and
money management skills. Vocational evaluation and training may also be a
component of this type of program. Persons who participate in the program
typically live at home.
I)Independent Living Programs
Independent living programs provide housing for persons with brain injury with
the goal of regaining the ability to live as independently as possible. Usually,
independent living programs will have several different levels to meet the needs
of people requiring more assistance and therapies as well as those who are living
independently and being monitored.

Medications
Medications for persons with brain injury are carefully selected, prescribed, and
monitored by the physician on an individual basis. The physician or pharmacist can
explain a medications purpose, side effects and precautions to you. A general
explanation of medication groups is described below.

Analgesics may be used for pain relief and pain management.

Anti-Anxiety Agents may lesson feelings of uncertainty, nervousness, and fear.
Anti-Coagulants may be used to prevent blood clots.

Anti-Convulsants may be used to prevent seizures.

Anti-Depressants may be used to treat symptoms of depression.
Anti-Psychotics may be used to target psychotic symptoms of combativeness, hostility,
hallucinations, and sleep disorders.

Muscle Relaxants may be used to reduce muscle spasms or spasticity.

Sedative-Hypnotic Agents may be used to induce sleep or depress the central nervous
system in areas of mental and physical response, awareness, sleep, and pain.
Stimulants may be used to increase levels of alertness and attention.

Q&A SESSIONS