Traumatic Brain Injury (TBI) is gaining the form of ‘silent epidemic’ with rise of road traffic accidents. In India 1.5 - 2 million people sustain TBI and 1 million succumb to death annually. Here we speak to physiotherapists of the Indian Head Injury Foundation on intense rehabilitation programme after brain injury.
What are the main causes of Traumatic Brain Injury (TBI)?
Causes of Traumatic Brain Injury are
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RTA (road traffic accident )/ Motor vehicle accidents (60%)
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Fall from height (20- 25%)
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Assaults & violence (10%)
More men than women are affected and the typical patient is between the age of 15 & 24 years at the time of injury.
Traumatic Brain Injury is among the significant causes of morbidity and mortality. Is it possible to get statistics as on how many people sustain TBI and how many die annually in India?
World Health Organisation (WHO) developed a measure to estimate the burden of a particular disease by calculating Disability Adjusted Life Years “DALY”, expressed as the cumulative number of years lost due to ill heath, disability or early death. The estimated 20,300 DALYs attributable to TBI accounted for 27% of total injury-related health loss and 2.4% of DALYs from all causes. Of the total DALYs attributable to TBI, 71% resulted from fatal injuries. TBI is gaining the form of “Silent epidemic” with rise of road traffic accident, drinking (alcohol) and driving. In India 1.5 - 2 million people sustain TBI and 1 million succumb to death annually.
What are the some of the most common obstacles experienced by a person who has had a TBI?
Some of the most common obstacles experienced by TBI patients are-:
- Medical expenses.
- Physical and mental effects.
- Lifestyle changes.
- Litigation.
What does rehabilitation of brain injury involve?
It typically involves:
- Acute hospital care.
- In-patient rehabilitation.
- Skilled nursing facility /sub-acute rehabilitation.
- Long-term care facility/ Telerehabilitation
What are the potential psychological and emotional problems that can arise with head injury?
These are few potential psychological and emotional problems that can arise in patients with head injury.
- Anxiety
- Depression.
- Fatigue.
- Irritability and anger.
- Extreme mood changes.
What are the cognitive and neurobehavioral problems that can occur? What is the role of neuropsychologist in cases of head injury?
Some common cognitive problems are:
- Altered level of consciousness/alertness.
- Memory loss.
- Altered orientation.
- Attentional deficits.
- Impaired insight and safety awareness.
- Problem solving
- Perseveration.
- Impaired executive functioning.
Some common behavioural problems are:
- Disinhibition (lack of restraint).
- Impulsiveness.
- Physical and verbal aggressiveness.
- Apathy.
- Lack of concern.
- Sexual inappropriateness.
- Irritability.
- Egocentricity (the state of being self-centered).
The role of neuropsychologist in cases of head injury:
The neuropsychologist plays an important role in head injury cases. He or she will often perform neuropsychological testing when appropriate to determine the patient’s baseline cognitive functioning. The neuropsychologist also assumes the role of the team leader to assist in developing a behavioural management programme when the patient with a brain injury has severe behavioural impairments.
What is the likelihood of a person returning to a life of independence after brain injury?
The likelihood of recovery from TBI is dependent on a number of factors like age, physiological status, availability of pre-hospital care, severity and locale of brain injury, hospital interventional strategies and availability of rehabilitation services. Severity of head injuries at hospital admission is a direct determinant of recovery status according to research.
When is an intensive rehabilitation programme required? How long does a person with TBI need to continue rehab?
Patients who are minimally conscious state or in coma may receive ongoing therapy in a nursing home or other long term care facility once they are medically stable. Patient who are beginning to recover from coma with moderate to severe cognitive, behavioural and physical impairments often continue rehabilitation in either an acute or subacute in- patient rehabilitation facility. As patients progress in recovery, they will be discharged to other community based settings depending on the needs of the individual patient. Early intensive rehabilitation management might be more beneficial for neurological function and activities of daily living in patients with moderate traumatic brain injury.
Traumatic brain injury has three phases of recovery in acute stage i.e. Coma, vegetative and minimally conscious stage. It takes 6 months to several years of neuro-rehabilitation to recover from TBI. In addition to this almost 64% of TBI patients make a good cognitive recovery after 12 months.
How does one improve outcomes for patients?
With the provision of good post-hospital care one can improve outcome from TBI. Neurorehabilitation is a comprehensive and long term therapy for TBI so maintaining adherence to therapy is sometimes difficult due to several factors like distance of rehab centre and availability of family and caregivers which negatively impacts outcome. So continuing therapy through tele-rehabilitation (offered by IHIF) without the physical presence of patient at clinic can improve patient’s outcome.
What is computerized treatment as a rehabilitation tool for someone who has suffered from TBI?
With advancement in rehabilitation technology, motor training, gait training, balance and coordination training is highly yielding in terms of patient’s outcome in TBI. We at Indian Head Injury Foundation provide these training with specialized equipment like:
Pablo motor training using sensors and user interface(game mode),
Sensomove: Balance board with computer software for assessment and training including user interface having multiple challenge levels of games.
Motomed with functional electrical stimulator using cycling in forward and reverse manner depending on muscle tone of patient. With Visual-biofeedback system displaying about patients effort, bilateral symmetry, calorie/energy consumption, muscle tone/level of spasticity.
Partial Body weight support system with treadmill
- Mirror Therapy
- Bio feedback Therapy
- Cognitive therapy
What are the health complications associated with TBI? Are there delayed consequences of TBI?
Following are the health complications associated with TBI:
- Skin breakdown, decubitus ulcer and bed sore
- Infection
- Pneumonia
- Decreased bone density
- Muscle atrophy
- Decreased endurance
- Deep vein thrombosis(DVT)
- Heterotropic ossification and
- Soft tissue contractures
According to a detailed study by Natrajan et al to assess outcomes following brain injuries on 261 subjects at different intervals of time for a period of 18 months. The major consequences noticed were post-traumatic epilepsy( 11.3%), hemiparesis(15%), aphasia(5.75%), hearing impairment (3.1%), visual impairment(3.5%) and neural damages(6.2%). Around 60% of patients could not resume work following brain injury. The majority of persons had problems in social, personal, family and cognitive adjustment.
Can TBI affect personality or cause personality disorder?
Yes, in every TBI patient some or other behavioural or personality problems surface. A personality is a unique combination of individual thoughts, emotions, behaviours, and past experiences. It makes us who we are. But a TBI can damage the parts of the brain responsible for impulse control, cognition, language, communication, and memory. This trauma can trigger significant personality changes.
Examples of behavioural changes after a TBI can include:
- Mood swings
- Aggressive behaviour
- Childlike behaviour
- Obsessive thoughts or habits
- Egocentric or self-centered behaviour
- Difficulties with self-control
- Engaging in risky behaviours
- Verbal or physical outbursts
- Social challenges
- Inappropriate sexual behaviour
Studies indicate a link between traumatic brain injuries and the development of mood, personality, and anxiety disorders. One medical study suggests people diagnosed with a TBI are 28 times more likely to be diagnosed with bipolar disorder. Bipolar disorder is a mental health condition that can cause extreme mood swings characterized by manic highs and depressive lows. There are several bipolar conditions, including:
- Bipolar I disorder
- Bipolar II disorder
- Cyclothymic disorder
