Traumatic Brain Injury
Post Concussion Syndrome
Rehabilitation and Treatment
By Harold L. Burke, Ph.D.
Acquired brain injury (e.g., traumatic brain injury), treatment (e.g., rehabilitation), current research, resources, and helpful hints
Acquired brain injury can result from internal or external causes including external physical forces, hypoxia (lack of sufficient oxygen), stroke, disease, or tumor. It is not due to congenital (i.e., genetic or birth defects) or degenerative causes (e.g., Alzheimer’s Disease). Specific examples are:
1) Traumatic brain injury (TBI) or concussion from a blow to the head; (tramatic brain injury [sp.])
2) Hypoxia due to near-drowning, prolonged seizures, or drug overdose;
3) Stroke due to hemorrhage (e.g., bleeding from a ruptured aneurysm or trauma) or ischemia (insufficient blood supply from a blockage of a blood vessel);
4) Disease due to inflammation (e.g., infections), toxicity, metabolic abnormalities (e.g., liver or kidney dysfunction), seizures, demyelinating disorders (e.g., multiple sclerosis), or increased intracranial pressure;
5) Tumors (malignant or nonmalignant).
Regardless of the cause, parts of the brain are no longer able to function normally. This can result in cognitive, emotional, behavioral, or physical impairments. These may be either temporary or permanent and may cause partial or total functional disability or psychosocial difficulties. The Brain Therapy Center provides free information, neuropsychological assessment, treatment, current research information, and helpful tips.
Currently, 5.3 million Americans are living with a disability caused by brain injury. Fortunately there are numerous sources of information for patients and their families, accessible rehabilitation programs, and many research studies being conducted about the brain in general and brain injury in particular. In fact, the field of brain research, known as neuroscience, is one of the hottest areas in all science. Insights into the workings of the brain are guiding clinicians toward increasingly better techniques for rehabilitating patients with brain injury.
What are some of the major developments that give hope to those with brain injury?
- Since the late 60’s, the field of neuropsychology (i.e., the study of brain-behavior relationships) has grown significantly. This has generated hundreds of studies and has provided patients with the benefits of clinical neuropsychological assessment.
- In 1972, CT (computed tomography) was invented. This technology yielded pictures of the structure of the brain that were impossible before this development. Essentially CT imaging involves taking many x-rays of a patient’s brain in 360 degrees and combining them by a computer into detailed images. Currently, CT is in at least its 4th generation with pictures that even allow the radiologist to “travel” virtually inside a body structure. This is what happens during a virtual colonoscopy in which the radiologist is able to view the inside of a patient’s colon without invading the colon with a scope.
- In 1982, MRI (magnetic resonance imaging) was introduced. This revolutionary technology provided even greater details of the brain and without the exposure of the patient to x-rays. The patient is placed inside a magnetic field so that various kinds of atoms can be selected for viewing. Since water is the most abundant molecule in the brain, hydrogen is usually selected. This allows images of brain structures with such resolution that the pictures often resemble the ideal illustrations in anatomy textbooks! This has allowed not only more understanding about the normal brain but has allowed much greater precision of diagnostic pathology. A fairly recent development is fMRI (functional magnetic resonance imaging) in which the brain’s neurophysiology or functioning can be studied. This is similar to PET (positron emission tomography) that also provides images of the working brain. An fMRI is accomplished by injecting a particular type of molecule with a radioactive “tag” into the brain. The molecule is often glucose (the basic sugar molecule of the body) that will be used up in greater quantities by more active areas as they require more fuel for their activity. This procedure in turn allows the scientist/clinician to understand more fully which areas of the brain are involved in a particular task or which areas are abnormally inactive in a given patient.
- Molecular biology offers continued insights into how cells, such as neurons, function. More specifically, there has been an explosion of knowledge generated about the neurochemistry of the brain and how the brain actually works at the cellular and biochemical levels. Such knowledge has helped pharmaceutical companies to develop ever-improved pharmaceutical drugs, known as psychoactive drugs, which can improve brain function. New drugs are being developed that can actually decrease the biochemical damage that may occur after a stroke or traumatic brain injury. Other drugs are being developed that can stimulate the brain into recovering from an injury.
- One of the most revolutionary discoveries is how plastic the adult brain is and how much it can recover and reorganize itself after brain injury. There is clear evidence that neurogenesis (i.e., the growth of new neurons) does occur throughout the human lifespan, especially under conditions of stimulation and activity. This has profound implications for rehabilitation in general and neuropsychological rehabilitation in particular.
- Neuropsychological rehabilitation is a treatment modality that is offering hope to many with brain injury. It is employed by a neuropsychologist to assist patients who have sustained cognitive, emotional, and behavioral impairments as the result of an acquired brain injury. At the Brain Therapy Center, such rehabilitation often utilizes a cutting-edge technology known as EEG biofeedback (neurofeedback) that uses operant conditioning to alter brain waves. This in turn helps the patient’s brain to achieve more flexibility and stability in its attempt to return to pre-injury levels.
The bottom line is that new and advanced research is providing more hope than ever before for brain-injured patients.
Some Helpful Hints
- If you or a loved one has sustained a brain injury and is still suffering from cognitive, emotional, or behavioral symptoms, you may be a candidate for continued rehabilitation. Even if shortly after your injury you or your loved one was treated in a rehabilitation program (e.g., an inpatient program of a general hospital or of a rehabilitation hospital), there might still be untreated conditions that were not sufficiently addressed. This could happen because many such programs focus on the most obvious symptoms that are most troubling to patients and families immediately following an injury. Such symptoms usually include grossly-impaired attention and arousal (e.g., being disoriented), impaired motor functions (e.g., paralysis), and difficulties with language. Fortunately, physical therapy, occupational therapy, and speech therapy are normally offered in these programs. Unfortunately, these programs are typically offered for only very limited periods of time usually due to severe restrictions from insurance carriers; and more complicated aspects of cognitive, emotional, and behavioral functions may go untreated. Many times, insurance policy exclusions prevent ongoing care. In either case, the patient is often left with significant impairments in various aspects of attention, information processing speed, working memory, the ability to learn and retain new information, visuospatial ability, more subtle aspects of language, and executive functions (e.g., planning, organizing, inhibiting inappropriate behaviors, cognitive flexibility, the ability to benefit from and adjust to feedback from one’s senses or from others). In addition, emotional and behavioral problems often become more apparent after the initial “critical” stage of recovery. Fortunately, neuropsychological rehabilitation (sometimes combined with other modalities) is particularly geared to addressing these kinds of symptoms and impairments. (See Benefits of Neuropsychological Rehabilitation). In some cases, you may have to be a strong advocate for yourself or for your loved one when trying to receive reimbursement from insurance companies. This is in spite of clear controlled research that demonstrates the efficacy of neuropsychological and cognitive rehabilitation.
- In the case of brain injuries, be especially attentive to emotional and behavioral problems observed in the injured person. Often these may become more serious after the first year following a brain injury. Studies have shown that caregivers often rate emotional and behavioral problems as even more troublesome than cognitive impairments and that divorce and unemployment often occur approximately 1-2 years following brain injury. Anxiety, depression, anger outbursts, irritability, emotional lability (i.e., emotional ups and downs), difficulty connecting emotionally, and erratic behavior can be quite stressful for both the patient and the family. Seek professional help (preferably from someone with experience working with acquired brain injured patients) if you or your loved one is experiencing these symptoms.
- Even if an individual has sustained only a “mild” head trauma and has been told that the symptoms will likely dissipate, that person may benefit from neuropsychological assessment and rehabilitation if the symptoms are significantly interfering with a person's life or if the problems do not dissipate within a reasonable timeframe. (The period with the most rapid spontaneous recovery is the first six months with some additional recovery occurring during the next six months.) The important point to remember is that most patients with mild brain traumas will recover most or all of their functions, but there is a minority who will continue to suffer significant impairments that may lead to very severe personal consequences.
- Many patients with acquired brain injury have difficulties with attention and executive functioning. This may include the ability to deal with novel situations (i.e., cognitive flexibility). Accordingly, structure and consistency are very important for helping brain-injured patients cope with daily activities. A routine of activities and responsibilities can be very helpful, and even those with limited impairments may require extra help when they have to enter into a novel situation. This applies to individuals of all ages. Therefore, anything you can do to decrease such demands will help the affected individual. This does not mean that the individual should not be given responsibilities. In fact, it is critical that the individual be gently stimulated to perform as much as possible up to an appropriate level. However, undue pressure may cause severe behavioral problems and may create unnecessary stress for the individual.
- Creating an environment which reflects structure and consistency offers the optimal environment for the individual affected by an acquired brain injury. One of the best ways is to surround the person with an environment that has very few distractions. The affected person should be allowed to take frequent breaks because she/he may have difficulty sustaining attention and concentration for long periods of time. If the individual is employed, extra time may be necessary for completion of projects because information processing speed is often slow in these individuals.
- Those suffering from acquired brain injury should be surrounded with an environment where the stress level has been lowered as much as possible. This applies whether you are the patient or your loved one is. Stress may exacerbate symptoms and may decrease the injured person’s ability to cope with such injuries. Psychotherapy, biofeedback, exercise (e.g., aerobic, yoga, Tai Chi) and meditation/prayer have been shown to be effective in decreasing stress.
- The person who has cognitive symptoms from a brain injury should try to practice good healthy sleep hygiene. As examples of good sleep hygiene, get sufficient amounts of sleep, keep a regular sleep schedule, avoid stimulants (e.g., coffee, tea, chocolate) late in the day, exercise regularly, and avoid activities in the bedroom that may interfere with sleep (e.g., making business contacts on the telephone, working on your laptop in bed).
- It is important to watch for any signs of drug abuse since some brain-injured patients may attempt to self-medicate their anxiety, depression, or behavioral dyscontrol by abusing drugs.