Traumatic Brain Injury

Traumatic brain injury (TBI) refers to damage to the brain caused by external physical force. It is the leading cause of long-term disability in young adults. Approximately 1.5 million Americans survive brain injuries each year, and an estimated 70,000 to 90,000 of these survivors are left with long-term impairments that interfere with their psychosocial adjustment and reintegration into the community. In the United States, an estimated five million individuals live with residual symptoms of TBI severe enough to interfere with basic activities of daily living. TBI is most prevalent under age 24 and more than twice as common among men as among women.

Causes and Mechanisms of Injury

TBI differs from other types of brain damage in its noncongenital and nondegenerative etiology and sudden occurrence during the course of normal health and development. Nearly half of all TBI occurs as a result of motor vehicle accidents; other common causes include falls, assault, and sporting accidents.

In open head injuries, damage to brain tissue tends to be localized at the site of injury. In contrast, closed head injuries tend to produce damage that is more diffuse. In incidents involving a blow to the head, the injury typically involves abrasions, lacerations, and contusions to the brain caused by impact with bony protrusions and rough membranes within the skull. A coup-contrecoup injury occurs when bruising occurs both at the site of impact and on the opposite side, as the brain bounces backwards in the skull.

In vehicular accidents, strong inertial forces can cause rotation of the brain within the skull. This twisting motion can strain fragile nerve fibers and blood vessels, and diffuse axonal shearing may result from the stretching and tearing of these microscopic structures. On the cellular level, disruptions in chemical connections between neurons and changes in basic metabolic processes may occur. The accumulation of molecules related to the cellular response to injury can create a toxic environment for surrounding neurons, leading to degeneration of these cells.

Sequelae of Traumatic Brain Injury

Advances in emergency medicine and neurosurgery have led to increases in the TBI survival rate and a corresponding increase in the number of TBI survivors living with long-term adjustment problems. Typical problems include motor, perceptual, communication, and cognitive deficits.

Even with full physical and medical recovery, TBI survivors may experience persistent cognitive deficits in attention, concentration, memory, and higher-level executive functions involved in reasoning, planning, problem solving, emotional self-regulation, and judgment. In general, it is such cognitive and emotional changes, rather than any physical impairment per se, that contribute most to the disruption of life activities for people with TBI. These impairments can compromise the individual’s capacity to resume preinjury work and social roles, and the impact on quality of life can be profound. Long-term adjustment issues following TBI include unemployment, criminal behavior, loneliness, substance abuse, and loss of important social and family roles. Because the typical TBI survivor is a young adult with a normal life expectancy, cognitive deficits may lead to many years of social, vocational, and familial dysfunction, in which a person who may well be physically able is nonetheless dependent on others.

Rehabilitation Methods

The Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury, convened in 1998 by the National Institutes of Health, recommended that rehabilitation be individualized, based on the person’s residual strengths and limitations. Depending on severity of injury and the individual’s needs, the rehabilitation team may include physiatrists, psychologists, speech and language pathologists, physical and occupational therapists, social workers, and vocational counselors. Rehabilitation may be provided on an inpatient, outpatient, or home-based basis or as part of a comprehensive day treatment program. Whatever the setting, counselors and psychologists face unique challenges in addressing the varied rehabilitation needs of people with TBI.

Cognitive Rehabilitation

Cognitive rehabilitation is a systematic intervention designed to improve functional abilities and increase levels of independence following TBI. Prior to beginning cognitive rehabilitation, the individual typically completes a comprehensive neuropsychological evaluation to identify specific cognitive deficits, develop measurable goals, and guide treatment planning.

There are two general approaches to cognitive rehabilitation: restoration and compensation. The restoration approach is based on the premise that repetitive exercise can restore compromised cognitive abilities. Techniques include visual and auditory exercises, numerical tasks, computer-assisted exercises, feedback on performance, practice, and reinforcement. The compensation approach reinforces the individual’s residual cognitive strengths while teaching strategies to circumvent (or compensate for) impaired cognitive abilities, with the goal of increasing independent functioning. Compensatory strategies include the use of cues, written instructions, notes, calendars, date books, and electronic devices such as beepers and pagers. The individual is taught to minimize distractions, break complex tasks down into steps, and to self-monitor and self-regulate behavior. The two approaches are not mutually exclusive; both techniques are usually employed as necessary, depending upon the individual’s needs.

Psychological issues and interventions

Although there has been general support for the overall effectiveness of cognitive rehabilitation, evidence-based reviews have cited the need for more systematic study of treatment outcomes to determine practice guidelines. Despite obvious issues in impaired brain-behavior functions following TBI, accumulating data indicate that long-term adjustment is influenced by individual differences and by behavioral and social mechanisms to the extent that these factors account for more variance in any given outcome variable than diagnostic indicators of severity (particularly among persons with mild to moderate TBI). For example, persons with preinjury substance abuse histories are more likely to experience an array of personal and social problems after TBI. In general, individuals with a preinjury history of optimal personal, vocational, and social adjustment fare better than persons who do not. Current research indicates that persons who report more effective social problem-solving abilities following TBI are less distressed and less impaired than persons who report ineffective problem-solving styles, consistent with the extant literature concerning social problem-solving abilities among people in general.

Families are affected by TBI. Qualitative research has found that husbands of women with TBI report specific problems with their wives’ loss of autonomy, mood swings, insecurities, overprotectiveness, reluctance to leave home, and change in lifestyle as particularly stressful. Wives of men with TBI report specific problems with husbands’ personality changes, memory loss, lack of insight, lack of acceptance, reduction in financial resources, loss of emotional support, and feeling unable to meet children’s needs. Family members who assume caregiver duties for a loved one with TBI have many concerns about interpersonal relationships, quality of life, and emotional commitments. Community-residing individuals with TBI report ongoing needs with improving memory, solving problems, managing stress and emotional upsets, and in managing money and paying bills; these needs are particularly complicated by cognitive abilities, unemployment, and substance abuse.

Structured employment strategies appear to have the most promise in helping individuals with TBI return to work. Although other strategies exist, vocational rehabilitation efforts are hampered by decreasing financial support and the amount of time often required for successful training, placement, and work adjustment.

Cognitive-behavioral interventions have demonstrated some effectiveness for persons living with TBI. Problem-solving training has been associated with decreases in distress in psychoeducational group sessions with persons with TBI and in web-based programs for families living with TBI. It should be noted, however, there has been a long-standing interest in interpersonal group formats that could promote personal awareness and insight in a social context and could improve self-concept. Motivational interviewing has been espoused as an efficient and strategic method for addressing substance abuse issues among persons with TBI.

Future Directions

The steady rate of growth in TBI in modern society constitutes a major healthcare and socioeconomic concern. Experts recently have witnessed an increase in TBI sustained by soldiers fighting in Afghanistan and Iraq, prompting Veterans Affairs hospitals to set up special TBI treatment and rehabilitation centers. As the number of TBI survivors continues to grow, millions, in the United States alone, now live with residual symptoms and long-term adjustment problems.

Researchers are optimistic that ongoing studies will lead to further advances in treatment and rehabilitation for people with TBI. Early research has indicated that cholinesterase inhibitors (currently used to treat early symptoms of Alzheimer’s disease), may prove to be an effective treatment for TBI-related deficits in attention, concentration, and memory. Recent advances in genetics are also promising. For example, the apolipoprotein E4 (apoE-e4) genotype appears to increase the risk of poor outcome following TBI. Discoveries such as this may lead to the development of targeted medications or gene therapy for TBI treatment and rehabilitation.

Functional magnetic resonance imaging (fMRI) appears to be an important tool for understanding the neurobiological changes that occur in the brain during cognitive rehabilitation. Preliminary research suggests that fMRI has the potential to identify changes that occur in functional neural networks during cognitive rehabilitation, thereby allowing for more targeted rehabilitative interventions. Finally, developments in stem cell research indicate potential benefits for people with TBI. Researchers have used adult human stem cells to grow functioning brain cells. Although this research is still in its infancy, stem cells from a patient’s own bone marrow one day may be used to regrow and replace brain cells that have been damaged by TBI.

References:

Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S., et al. (2005). Evidence-based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Archives of Physical Medicine and Rehabilitation, 86, 1681-1692.
National Institute of Neurological Disorders and Stroke. (2002). Traumatic brain injury: Hope through research (NIH Publication No. 02-158). Bethesda, MD: Author.
NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury. (1999). Rehabilitation of persons with traumatic brain injury. Journal of the American Medical Association, 282, 974-983.
Rath, J. F., Simon, D., Langenbahn, D. M., Sherr, R. L., & Diller, L. (2003). Group treatment of problem-solving deficits in outpatients with traumatic brain injury: A randomized outcome study. Neuropsychological Rehabilitation, 13, 461-188.
Willer, B. S., Allen, K., Liss, M., & Zicht, M. (1991). Problems and coping strategies of individuals with traumatic brain injury and their spouses. Archives of Physical Medicine and Rehabilitation, 72, 460-164.