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What is a Brain Injury?

Brain Injuries are the “multiple disabilities arising from damage to the brain acquired after birth. It results in deterioration in cognitive, physical, emotional or independent functioning. It can be as a result of accidents, stroke, brain tumours, infection, poisoning, lack of oxygen, degenerative neurological disease etc.”

The National Community Services Data Dictionary (Australian Institute of Health and Welfare, Canberra, 2012)

Contrary to what many people believe, brain injuries are actually quite common, with more than 700,000 Australians suffering from some form of brain injury, according to the Australian Bureau of Statistics. Brain injuries often result in daily “activity limitations” and “participation limitations”.

Of these people, three in four are aged 65 or under, and two out three of them acquired their brain injury before the age of 25. Brain injuries are also more common among men – three quarters to be exact.

Types of Brain Injury

 

Traumatic Brain Injury

 

Concussion

 

Even an injury as minor as a concussion can cause lifelong disabilities or impairments. Whiplash can also cause symptoms and difficulties that are usually associated with a head injury. These issues can usually be fixed with rehabilitation; however, more often than not patients are released from treatment without any referrals for rehabilitation.

Any of the following incidences can result in a concussion:

  • A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.
  • Both closed and open head injuries can produce a concussion. A concussion is the most common type of traumatic brain injury.
  • A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged.
  • A person may or may not experience a brief loss of consciousness.
  • A person may remain conscious, but feel dazed.
  • A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan.
  • Skull fracture, brain bleeding, or swelling may or may not be present. Therefore, concussion is sometimes defined by exclusion and is considered a complex neurobehavioral syndrome.
  • A concussion can cause diffuse axonal type injury resulting in temporary or permanent damage.
  • A blood clot in the brain can occur occasionally and be fatal.
  • It may take a few months to a few years for a concussion to heal.

Contusion

  • A contusion can be the result of a direct impact to the head.
  • A contusion is a bruise (bleeding) on the brain.
  • Large contusions may need to be surgically removed.

 

Coup-Contrecoup

  • Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.
  • This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion.

Diffuse Axonal

  • A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident.
  • Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.
  • There is extensive tearing of nerve tissue throughout the brain. This can cause brain chemicals to be released, causing additional injury.
  • The tearing of the nerve tissue disrupts the brain’s regular communication and chemical processes.
  • This disturbance in the brain can produce temporary or permanent widespread brain damage, coma, or death.
  • A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.

Penetration

A penetrating brain injury often occurs as a result of a bullet, knife, or sharp object forcing hair, skin, bones, and fragments from the weapon into the brain.

Other common causes include:

  • Objects traveling at a low rate of speed through the skull and brain can ricochet within the skull, which widens the area of damage.
  • A “through-and-through” injury occurs if an object enters the skull, goes through the brain, and exits the skull. Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue. (Brumback R. (1996). Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd Ed.). New York: Springer.)
  • The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall. (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate,]).
  • Firearms are the single largest cause of death from traumatic brain injury. (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate,]).

Acquired Brain Injury

An Acquired Brain Injury usually occurs after the brain has been damaged from a stroke, tumor, anorexia, and hypoxia, as well as toxins, degenerative diseases, near drowning and/or other conditions that aren’t necessarily resultant of a trauma.

Anoxia

When the brain doesn’t receive the oxygen it needs to survive and function, people are put at risk of developing Anoxic Brain Injury.

There are three types of Anoxic Brain Injury:

  • Anoxic Anoxia: Brain injury from no oxygen supplied to the brain
  • Anemic Anoxia: Brain injury from blood that does not carry enough oxygen
  • Toxic Anoxia: Brain injury from toxins or metabolites that block oxygen in the blood from being used.

Hypoxic

If the brain is receiving some, but not enough, oxygen, a Hypoxic Brain Injury will likely occur. Known as Hypoxic Ischemic Brain Injury, which is sometimes referred to as either Stagnant Hypoxia or Ischemic Insult, this type of brain injury occurs as a result of a lack of blood flow to the brain because of a critical reduction in the body’s blood flow or pressure.

Resources: Brain Injury Association of America, Causes of Brain Injury. www.biausa.org

Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor

Levels of Brain Injury

 

Mild Traumatic Brain Injury (Glasgow Coma Scale score 13-15)

Mild traumatic brain injuries can occur as a result of a brief loss of consciousness, usually only a few seconds or minutes. A person doesn’t have to lose consciousness; they may just be dazed or confused

Diagnosing a mild brain injury can be difficult, as:

  • Testing or scans of the brain may appear normal
  • A mild traumatic brain injury is usually only diagnosed when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion

 

Moderate Traumatic Brain Injury (Glasgow Coma Scale core 9-12)

The most common causes of brain injuries are mild and moderate head injuries, which are usually a result of a non-penetrating blow to the head, or violent shaking that affects the head. The aforementioned causes won’t always result in a brain injury, as many people who have a blow to the head will be perfectly fine, however, for others, mild or moderate traumas can result in lifelong, disabling impairments.

A moderate traumatic brain injury occurs when:

  • A person loses consciousness for a few minutes to a few hours
  • Confusion lasts from days to weeks
  • Physical, cognitive, and/or behavioral impairments last for months or are permanent

People who suffer from moderate traumatic brain injuries will usually make a full recovery and can learn to cope with their deficits, when they receive proper treatment.

Severe Brain Injury

Crushing blows or penetrating wounds to the head can cause severe brain injuries. This is because these type of injuries crush, rip, and shear delicate brain tissue, which can be potentially life threatening and the most intractable type of brain injury.

Severe head traumas often result in open head wounds, which occur when the skull has been crushed or badly fractured. To treat more serious injuries, long-term hospitalisation will be required, as well as extensive rehabilitation.

TBI can cause a wide range of functional short- or long-term changes that affect thinking, sensation, language, or emotions. TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.

Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (hours, days, or weeks) can be catastrophic or fatal.

Resources:

National Institute of Neurological Disorders and Stroke. Traumatic brain injury: hope through research. Bethesda (MD): National Institutes of Health; 2002 Feb. NIH Publication No.: 02-158.

Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.

Brain Injury Association of America, Causes of Brain Injury. www.biausa.org

Physical Symptoms of a Brain Injury May Include:

◦       headache

◦       difficulty coordinating balance

◦       blurred vision in one or both eyes

◦       milder vision problems

◦       seizures

◦       changes in sensory perception

◦       trouble speaking and swallowing

◦       changes in sleep pattern

◦       lack of bowel and bladder control

◦       changes in sexual function

◦       motor impairment (trouble moving body normally)

 

Functional/Emotional Changes of a Brain Injury May Include:

◦       personality changes

◦       difficulty forming sentences or choosing vocabulary

◦       confusion

◦       trouble communicating

◦       difficulty with reason, focus and logic

◦       memory impairments

◦       depression

◦       poor concentration

◦       mood swings

◦       limited attention span

◦       disorientation

◦       difficulty remembering conversations/forgetfulness

◦       acting inappropriately

The Role of Physiotherapy

Following a Traumatic Brain Injury, physiotherapy rehabilitation is essential for making the best recovery possible.

The neuroplasticity of the brain and nervous system allows injured brain cells to modify in response to stimuli and external therapeutic information. This means an individual can relearn skills because their nerve pathways and brain activity levels are essentially re-programmed as therapeutic movements and actions open up and optimise new pathways within the nervous system.

Neuro-physiotherapy is therefore directed at providing the most appropriate stimuli at the most appropriate time, in order to harness the neuroplastic ability of the brain. Ideally this occurs as soon as possible after an injury has occurred.

Rehabilitation following TBI is unlike any other field of rehabilitation. The injuries sustained can often be severe and may require a longer recovery than other types of neurological conditions. Additionally, the nature of the injury may have caused other physical problems, such as fractures and soft tissue damage that can occur alongside the brain injury. Improvements are often rapid during the immediate few weeks post-injury, followed by a slower period of recovery over the coming months and years. Although the majority of a person’s recovery is achieved within the first 12 months, there is evidence to show that improvements can continue, given the appropriate therapy and rehabilitation for several years after.

Physiotherapy Management Can Help With:

  • Restoring muscle strength and joint stability
  • Reducing muscle spasms, contractures, stiff joints and associated pain
  • Improving balance (in sitting and standing), co-ordination and normal patterns of movement
  • Re-education of walking
  • Re-training of functional tasks, for example sit-to-standing, turning in bed, activities of daily living
  • Reducing the risk of falls
  • Restoring independence and quality of life

•        Training and teaching of family members / carers involved with the rehabilitation process, for example manual handling, bed / bath / chair / toilet transfers, positioning techniques and exercise programs to maintain muscle strength, co-ordination and flexibility of soft tis

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