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DEFINITION OF BRAIN INJURY
by Sezer Domac

ntroduction:

It is often referred to as “the hidden disability” because the effects of acquired or traumatic brain injury are not necessarily visible or immediately apparent. Brain injury can happen to anyone, and the consequences can be devastating and long lasting (Powell 2000).

Traumatic or acquired brain injury can significantly affect many cognitive, physical, and psychological skills. Physical problems can include mobility, balance, coordination, fine motor skills, strength, and endurance. Cognitive deficits of language and communication, information processing, memory, and perceptual skills are common. Psychological status is also often altered. Adjustment to disability issues are frequently encountered by people with brain injury.

 What is brain injury?

 

The definition of brain injury is any injury to the brain that results in damage to living tissue of the brain causing permanent or temporary changes to the structure of the brain.

Even though the brain is well protected, it may be injured. Every injury is different. Most injuries are a result of bruising, bleeding, twisting, or tearing of brain tissue. Damage to the brain may occur at the time of injury. It may also develop after the injury due to swelling or further bleeding. People may have more than one type of brain injury. Severity of injury is an important indicator but there remains no absolute measure of severity of the brain injury. Glascow Coma Score (GCS) score, duration of coma, and the length of post-traumatic amnesia (PTA) are the most commonly used criteria (Jennett & Teasdale, 1981).

Severe brain injury is defined as leading GCS score 3-8, coma in excess of 1 hour or of 6 hours or to PTA in excess of 24 hours (Jennett & Teasdale, 1981). The injured person is likely to be hospitalised and receive post acute rehabilitation. Depending on the length of time in coma, the person tends to have more serious physical deficits. A further category of very severe brain injury is defined by a period of unconsciousness of 48 hours or more. The longer the length of coma and PTA the poorer will be the outcome. However, several researches indicated that there are exceptions to this rule and there is a small group of people who have a mild brain injury who make a poor recovery. There is also group of people who have a severe or very severe injury who do exceptionally well.

 

Moderate Brain Injury: Loss of consciousness between 15 min to 6 hours and a period of post-traumatic amnesia (PTA) up to 24 hours. The most commonly reported symptoms include tiredness, headaches, dizziness, difficulties with thinking, attention, memory, planning, organising (executive functions) and concentration, word finding problems and irritability. The majority of people these residual problems gradually improve although this takes time depending on each individual. The above symptoms are accompanied by worry and anxiety. This could be particularly pronounced if the person has not been warned that these problems likely to arise.

 

Mild Brain injury: This means a person experiencing a brief loss of consciousness. A person with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following:

1. any period of loss of consciousness;

2. any loss of memory for events immediately before or after the accident;

3. any alteration in mental state at the time of the accident (e.g., feeling dizzy, disoriented, or confused);

4.         a. loss of consciousness of approximately 30 minutes or less;

b. after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and

c. posttraumatic amnesia (PTA) not greater than 24 hours. (Journal of Brain Trauma Rehabilitation, 8(3), pages 86-87).

 

·          Every year, out of every 100 000 of the population there is likely to be between

10-15 Severe Brain Injury

                        15-20 Moderate Brain Injury

                        250-300 Mild Brain Injury. (DoH 2001, Powell 2000)

Causes

An acquired brain injury can be caused by a number of insults to the brain. The most common causes include:

• Accident

• Assault

• Fall

• Tumour/Cyst

• Anoxia resulting from cardio problem, drowning, strangulation etc

• Haemorrhage

• Aneurism

• Encephalitis / Meningitis

 

The following functions can be affected as a result of brain injury:

• Breathing

• Consciousness

• The ability to sleep

• Heartbeat

• Blood pressure

• Temperature control

• Digestion

• Swallowing

• Startle responses

• Sense of balance

• A reduction in breathing capacity

• Vertigo

• Changes in sleep (insomnia, sleep apnoea)

• Problems with movement and balance

• Difficulties with perception / organisation of surroundings

• Difficulties with attention (problems with dividing, selective, multi-tasking, visual)

• Memory problems

• Loss of various simple movements of body parts

• Sequencing difficulties in tasks involving a series of tasks (e.g. cooking, crossing  a street)

• Loss of spontaneity in interacting with other people

• Inflexibility of thought

• Perseveration - persistence with one line of thought

• Inability to attend adequately to a task

• Mood changes (emotional liability)

• Changes in social behaviour

• Changes in personality

• Difficulties with solving problems

• Inability to express language

• Inability to attend to more than one thing at a time

• Naming difficulties

• Problems with reading

• Problems with writing - due to inability to find the right word

• Difficulty drawing objects

• Difficulty distinguishing left from right

• Difficulties with maths

• Lack of awareness of body parts or surrounding space

• Difficulties with hand and eye co-ordination

 Types of Brain Injury:

Skull Fracture: a break in the bone that surrounds the brain. These fractures often heal on their own. Surgery may be needed if there has been damage to the brain tissue below the fracture.

Contusion/Concussion: a mild injury or bruise to the brain that may cause a short loss of consciousness. It may cause brain aches, nausea, vomiting, dizziness, and problems with memory and concentration. This injury will not need surgery.

Coup/Contre-Coup: A French word that describes contusions that occur at two sites in the brain. When the brain is hit, the impact causes the brain to bump the opposite side of the skull. Damage occurs at the site of impact and on the opposite side of the brain.

Picture-1 Image of head hitting a wall (http://neuroskills.com)

Epidural Haematoma: a blood clot that forms between the skull and the top lining of the brain (dura). This blood clot can cause fast changes in the pressure inside the brain. Emergency surgery may be needed. The size of the clot will determine if surgery is needed.

Picture-2 Image of blood clot in the brain (http://neuroskills.com)

Subdural Haematoma: a blood clot that forms between the dura and the brain tissue. If this bleeding occurs quickly it is called an acute subdural haematoma. If it occurs slowly over several weeks, it is called a chronic subdural haematoma. The clot may cause increased pressure and may need to be removed surgically.

Picture-3 Image of subdural haematoma (http://neuroskills.com)

Intracerebral Haemorrhage: A blood clot deep in the middle of the brain that is hard to remove. Pressure from this clot may cause damage to the brain. Surgery may be needed to relieve the pressure.

Picture-4 Image of an intracerebral haemorrhage (http://neuroskills.com)

Diffuse Axonal Injury (DAI): Damage to the pathways (axons) that connect the different areas of the brain. This occurs when there is twisting and turning of the brain tissue at the time of injury. The brain messages are slowed or lost. Treatment is aimed at managing swelling in the brain because torn axons cannot be repaired.

Picture-5 Image of a diffuse axonal injury (http://neuroskills.com)

Anoxic (Hypoxic) Brain Injury: An injury that results from a lack of oxygen to the brain. This is most often from a lack of blood flow due to injury or bleeding.

 Population

·          1970s 90 per cent of all severe brain- injured patients died, now the majority survive.

·          It is estimated that on a million people attend hospital every year as a result of having brain injury in Britain.

·          Every year, out of every 100 000 of the population there is likely to be between

10-15 Severe Brain Injury

                        15-20 Moderate Brain Injury

                        250-300 Mild Brain Injury.

·          The long-term effects of brain injury will affect one family in every 300. That is prevalence rate of 100-150 disabled survivors per 100 000 of the population at any one time, or more than 120 000 people in the UK suffering from long – term effects of severe brain injury. This figure is increasing year by year and the victims of brain injury tend to be at young age between 20-35 (DoH 2001, Powell 2000).

·          Males are two or three times more likely to have a brain injury than females. In the age range 15-29, males are five times more likely to do so.

 

Need:

·          Person with brain injury may require cognitive, physical, emotional and social support.

·          The individual with the brain injury to be re-integrated into the community from where they came. This means gradually and progressively taking on appropriate social activities and responsibilities for example retraining, education, voluntary work and employment.

·          Service users with degrees of independence require an accessible accommodation or a group home with some supervision. The move from high dependency (hospital, specialist residential homes) to a lower dependency (group homes, sheltered accommodation) to independence should be the ultimate goal for the individuals to achieve to live independently.

·          Information and emotional support both for the service users and carers are needed.

·          Dedicated trained carers to provide consistency for those with brain injury who experienced cognitive problems.

·          Relatives/carers/partners of people who have had a brain injury report that the most difficult problems are personality changes, slowness, poor memory, irritability, bad temper, tiredness, depression, rapid mood changes, tension and anxiety, threats of violence, impulsivity, lack of motivation.

 

“Rehabilitation following serious brain injury improves the likelihood of the reintegration into the community of such patients. As a matter of good practice there should be a strategy for the transition from active intervention to a long term support which should include the handover to other agencies such as Social Services and the GP” (DoH-2001).

 Bibliography:

 Department of Health (2001) Government response to the Health Select Committee: Inquiry into Head Injury Rehabilitation. htpp://www. doh.gov.uk/headinjuries. (Accessed on 5th June 2003)

Jennett B. & Teasdale G.(1981) Management of Head Injuries in Rose F.D and Johnson D.A. (1996) Brain Injury and after improved outcome. Wiley. Chichester. 

Liepert J., Bauder H., Miltner H.R. and Weiller C (2003) Rehabilitation Helps Brain Rewire Itself. “Inside View” in http://neuroskills.com (Accessed on 5th June 2003). 

Powell T. (2000) Head Injury: A Practical Guide. Headway National Injuries Association Limited: Nottingham.  

Ragnarsson K., Thomas J.P., Zasler N. (1993) Model Systems of Care for Individuals with Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. Vol 8 (2) pages 1-11.  

Rose F.D and Johnson D.A. (1996) Brain Injury and after improved outcome. Wiley. Chichester.