The Symptoms of Traumatic Brain Injury - Research Paper Example

Traumatic Brain Injury Traumatic brain injury (TBI) is also referred to as the "silent epidemic," since many times the symptoms themselves often appear as psychological issues not related to an obvious trauma. However, it is a significant health problem. TIB is generally defined as “brain injury from externally inflicted trauma resulting from violence or acceleration-deceleration impact injury.” (Jacobs (Bay, Kreulen, Shavers, and Currier 141) It is also generally understood that TBI is not the result from, “from strokes, tumors, infection, progressive neurological diseases, metabolic disturbances, toxic agents, and inherited or congenital conditions” (Geva, Barsky, and Westernoff 30). TBI is also associated with closed head injuries as oppose to penetrating injuries of the skull and brain stem, although not always exclusively since there can be multiple characteristics of initial injuries with both penetrating and non-penetrating effects.. (Papanicolaou) There are an estimated 20 to 50 million people [worldwide]are injured or disabled in road traffic accidents every year with those between ages 18 and 25 experiencing the greatest incidence. According to the Centers for Disease Control, individuals over age 75 are at high risk for TBI due to falls. By 2020, the World Health Organization projects that road traffic injuries will be the third leading cause of global disease or injury. Motor vehicle accidents are a major cause of TBI in less developed countries and a leading cause of morbidity and mortality (Bay, Kreulen, Shavers, and Currier 141) TBI severity is grouped into three general classifications: mild, moderate, or severe. The diagnosis is dependent upon several factors, the depth and length any coma that was induced by the TBI, the duration of any posttraumatic amnesia, the overall time to respond consistently to stimuli, as well as the neuroimaging and electrophysiological studies, and measures of brainstem function. “As severity levels increase, the range and extent of possible long-term physical, cognitive, and psychosocial impairments increases.” (Degeneffe 257) These classifications have been further codified by the introduction of the Glasgow Coma Scale, which was originally developed to help practitioners diagnose the level of consciousness of a patient after a head injury. It has now been adapted to rate TBI survivors in the mild, moderate or severe classification. The scale is reproduced in Appendix I. There is certainly a general lack of understanding regarding individual how have suffered a TBI and the resultant issues arising from it. This results in many TBI sufferers receiving treatment by medical, psycho-social or other personnel who do not have experience with TBI. This is especially true in cases of Mild TBI where the patient is presented with headache, vomiting, dizziness; work-related difficulties, forgetfulness, or mood disorders without mention any current head trauma thus impairing a proper diagnosis and treatment. By informing medical practitioners about the general symptoms of TBI, there would be a better chance of asking if the patient had suffered a recent head injury. (Bay, Kreulen, Shavers, and Currier) Once a TBI has been diagnosed often the first medical professional to be alerted is the neuropsychologist. Neuropsychology is a complex field of psychology for it incorporates a variety of other sciences such as psychiatry, neuroscience, neurology as well as cognitive psychology. The general theory of Clinical Neuropsychology will provide the basic tools and techniques necessary to assist individuals with TBI in developing the appropriate coping skills and strategies needed to reclaim their lives. This will allow them to return to a life of greater independence in order to live successfully in the community. The conducted research and readings surrounding Clinical Neuropsychology has an in depth understanding of the organic component of brain damage in those with TBI, giving a keener insight into the treatment and therapies that would be the most beneficial, for traditional therapies are often not completely constructive to this cadre. Neuropsychology is the “study of the relation between brain function and behavior.” (Stirling 2001: 21). Neuropsychologists use their tests to localize dysfunction to specific areas of the brain. A trained neuropsychologist is equipped to not only assess the insult to the brain through testing, but is also able to evaluate behavior and cognitive status thereby possessing the unique abilities to drive the rehabilitation process. The other area relating to traumatic brain injury is the area of emotional adjustment, not only for those inflicted but also how it affects their close friends and family members as well. The individual who has suffered a brain injury has problems relating to others as they had in the past, both personal and professional relationships tend to undergo dramatic changes. The emotional adjustment is often the most difficult and stressful component to manage, for the entire family unit must adjust to the survivor’s current physical and mental condition. This requires great patience for the rehabilitation process is extremely challenging and arduous for all involved; patient, family as well as the rehabilitation team. In the article, Coping and Emotional Adjustment Following Traumatic Brain Injury, the authors have this to say: The present study has highlighted the poor emotional outcomes common after brain injury and has suggested a relation between coping style and emotional adjustment. The presence of a strong association between coping and adjustment suggests the possibility that emotional adjustment might be improved by the facilitation of more adaptive coping styles. (Anson & Ponsford, 2006, p. 257) Anson & Ponsford study garnered information from a large cadre of TBI patients and applied several standardized test in order to analyze the facts on a formal basis of their study. Those tests were: The Coping Scale for Adults (CSA), The Hospital Anxiety and Depression Scale (HADS), The Rosenberg Self-Esteem (RSE) Scale, Sickness Impact Profile (SIP), Self-awareness, The Patient Competency Rating Scale (PCRS), The State-Trait Anger Expression Inventory, National Adult Reading Test (NART). A cross sample of these finding can be found in Appendix II. The first step in their study was the following information: Poor awareness of brain-injury-related impairments and their functional implications is relatively common following TBI. Awareness of deficits has been associated with level of emotional distress experienced, with greater awareness linked to higher rates of depression and anxiety. (Anson & Ponsford 250) This study has also examined the post injury psychology of the patient. This may have great impact on the future prognosis of the patient, as they state, “The coping style used by an individual prior to injury has also been proposed to influence post injury coping and adjustment” (Anson & Ponsford 250). Their future is also greatly determined by the amount of damage and areas of injury: “The cognitive sequelae of TBI, including difficulties thinking through problems, generating ideas, and flexibly adapting to new situations, may influence coping style” (Anson & Ponsford 251). Their analysis draws this conclusion: The present study has highlighted the poor emotional outcomes common after brain injury and has suggested a relation between coping style and emotional adjustment. The presence of a strong association between coping and adjustment suggests the possibility that emotional adjustment might be improved by the facilitation of more adaptive coping styles. (Anson & Ponsford, 2006, p. 257) Cognitive and linguistic deficits are among the most predominant and persistent result of a TBI. The complex nature of the injury often requires the coordinated management strength of a team of rehabilitative, medical, educational, social services, as well as legal professionals to provide the long term care needs of the TBI client. Trauma-induced brain injury causes widespread damage to the brain's surface tissue, as well as to tissue deep inside the brain. Consequently, Communication disorders frequently overlay deficits in the cognitive substrates of language, including, but not limited to, disordered perception, reduced attention, and altered memory' (Geva, Barsky, and Westernoff 31) The cognitive deficits suffered by TBI patients are also grouped into categories or stages, four which are based upon their appearances as related to the time of the initial injury. The first stage consists of a period of alteration of consciousness or coma, which may occur upon, or soon after, impact. The second phase is characterized by a combination of cognitive and behavioral abnormalities, agitated psychomotor activity, an inability to recall or sequence events and/or acquire new information. These two phases, lasting several days, involve a form of posttraumatic delirium. They are followed by a 6- to a 12-month period of rapid recovery of cognitive functioning, with stabilization of recovery over the next year. The fourth phase is characterized by permanent deficits in a variety of cognitive functions (e.g., speed of information processing, attention and vigilance, memory and new learning, verbal skills, executive functions, self- regulation of mood and emotional reactions, and awareness of one's limitations. (Papanicolaou 156-7) Lingering memory deficits, both short and long term, are certainly the most common and often in many ways the most debilitating consequences of a TBI. Not only may these deficits make simple activities of daily living insurmountable for some, but there is also an emotional component that results in not being able to remember family and friends. (Papanicolaou; Rapoport, et. al.) TBI impairs problem-solving abilities to varying extents, depending on the site(s) of the lesion(s), on whether the injury is a focal skull-penetrating one or a diffuse one, and on the length of unconsciousness… Such injuries result in poor judgment, decreased abstract thinking, and difficulty with changing cognitive sets. (Geva, Barsky, and Westernoff 33) This can create a cascade effect and evince many psychological and emotional problems that make ongoing therapy and recovery daunting to both the health care provider as well as the family. Interestingly, previously acquired semantic memories are often left intact in a TBI patient, as with an amnesiac. The memory of how to drive a car, read, etc. usually remains unimpaired (although physically they may no longer be able to do the task). However, new semantic memories are more difficult to acquire and sustain, especially in the presence of anterograde episodic amnesia: The latter expresses itself in prospective and source memory difficulties. One of the most frequent complaints of survivors of a TBI is impairment in prospective memory, that is in the ability to remember to carry out an action at a particular time in the future; (Papanicolaou 162) This directly affects an individual’s ability to successfully manage most of the common activities of daily living such as, getting to appointments, remembering to take medications and so on. Thus it becomes nearly impossible to go through the day without prompting and assistance from caregivers and/or family. The varying degree to which a TBI can affect and individual is also acutely associated with the specific area of the brain that has been most affected by the initial injury. The following chart illustrates the resultant injuries in regards to whether the left, right or both sides of the brain are affected: Chart 1: Reproduced from the Brain Injury Association of America’s website These injuries and the concomitant disabilities all result in what has been termed, impaired executive function, which can be lumped into the overall category of frontal lobe syndrome. “Persons with frontal lobe syndrome have difficulty planning, executing, and self-monitoring routine and novel activities. The ability to filter out irrelevant information and to shift attention to and between different tasks may also be impaired.” (Geva, Barsky, and Westernoff 33) Impairments in Self-monitoring are one of the distinctive features of this syndrome and possibly the most disturbing. Having one’s executive functions impaired, impulses that arise through the limbic systems, anger, sexual urges, disinhibited behaviors such as the use of profanity, inappropriate sexualized language and gestures, are given expression and often in embarrassing or even dangerous ways. The TBI victim may be unable to return to work, they may exhibit distinct behavioral changes and mood disorders as well as oppositional defiant disorder, obsessive-compulsive disorder (checking and rechecking a locked door having forgotten it was locked), and some learning disorders directly related to short term memory deficits. There can also be signs of post-traumatic stress disorder suffered from the initial accident plus the traumatic experience of the loss of the patient previous faculties. “Following TBI, there is increased unemployment or underemployment, decreased social connectedness, and reduced environmental resources, thereby depleting resources and increasing the likelihood of a decline in health status.” (Bay, Kreulen, Shavers, and Currier 145) Following the lack of executive function, the caregivers and health care providers are faced with the task of constantly reminding the TBI patient of their daily functions. There also the psycho-social component of having to reconnect, not only with others, but with the new self that their TBI has left them with. This is also the difference that providers of services need to be trained in. Reminding is not only for the traumatically brain injured, but the caregivers and health care providers must be reminded that they are not dealing with someone who is less tha a human being because of their deficits. Reminding is changing the environment and the external support system that surrounds the person so that different abilities do not become the absence of abilities. Reminding, as the play on words suggests, is remembering who and where one is, most fundamentally, as a human subject--a person or agent--and how one must be treated by family and society. The tragedy of TBI is not that it alters brain function and changes what people do. The real tragedy occurs when and if we allow those changes to objectify persons, reducing them to their impaired body and altered behavior, rather than working with them to "re-mind" themselves and to be "re-membered" among us. (Jennings 33) Quality of life becomes the paramount issues when dealing with victims of a TBI. This quality has to extend from the health practitioners as well as the familial caregivers who need to be trained on what to expect and how to deal with someone with a TBI: "Instead, familial and caregiving ethical duties should revolve around the practices needed to sustain the person's human flourishing or quality of life as a person. Providing comfort and safety, mere guardianship, is not enough." (Jennings 36) In fact this silent epidemic is not as silent as it used to be. In 1996 the federal courts passed The Traumatic Brain Injury Act. This piece of legislation not only helps to allot specific agencies and create specific funding for treating TBI, but also defines it and seeks to improve the education and further development of treatments to, “Identify common therapeutic interventions which are used for the rehabilitation of individuals with such injuries.” The entire act is reproduced in Appendix III. Works Cited Anson, K. & Ponsford, J. “Coping and Emotional Adjustment Following Traumatic Brain Injury.” Journal of Head Trauma Rehabilitation, May/Jun 21.3 (2006): 248-259. Bay, Esther, Grace J. Kreulen, Clarissa Agee Shavers, and Connie Currier. "A New Perspective: a Vulnerable Population Framework to Guide Research and Practice for Persons with Traumatic Brain Injury." Research and Theory for Nursing Practice 20.2 (2006): 141-160. Brundage, Shelley B., Melissa L. Bowers, Sandra K. Garcia-Barry, and Michelle M. Schierts. "An Analysis of Clinicians' Verbal Behaviors in a Community Reintegration Program for Traumatic Brain Injury Survivors." Journal of Allied Health 35.2 (2006): 81-97. Degeneffe, Charles Edmund. "Family Caregiving and Traumatic Brain Injury." Health and Social Work 26.4 (2001): 257-269. Geva, Esther, Allan Barsky, and Fern Westernoff, eds. Interprofessional Practice with Diverse Populations: Cases in Point. Westport, CT: Auburn House, 2000. Jennings, Bruce. "The Ordeal of Reminding: Traumatic Brain Injury and the Goals of Care." The Hastings Center Report 36.2 (2006): 29-41 Larrabee, Glenn J., ed. Forensic Neuropsychology: A Scientific Approach. New York: Oxford University Press, 2005. Papanicolaou, Andrew C. The Amnesias: A Clinical Textbook of Memory Disorders. New York: Oxford University Press, 2006. Rapoport, Mark J., Nathan Herrmann, Prathiba Shammi, and Alex Kiss. "Outcome after Traumatic Brain Injury Sustained in Older Adulthood: a One-year Longitudinal Study." The American Journal of Geriatric Psychiatry 14.5 (2006): 456-467. Stirling, John. Introducing neuropsychology. Great Britian: Psychology Press, 2001 Appendix I Reproduced from the Brain Injury Association of America’s website Appendix II Appendix II Traumatic Brain Injury Act of 1996 The US Congress passed the Traumatic Brain Injury Act of 1996 H.R.248 One Hundred Fourth Congress of the United States of America AT THE SECOND SESSION Begun and held at the City of Washington on Wednesday, the third day of January, one thousand nine hundred and ninety-six An Act To amend the Public Health Service Act to provide for the conduct of expanded studies and the establishment of innovative programs with respect to traumatic brain injury, and for other purposes. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,  SECTION 1. PROGRAMS OF CENTERS FOR DISEASE CONTROL AND PREVENTION. Part J of title III of the Public Health Service Act (42 U.S.C. 280b et seq.) is amended by inserting after section 393 the following section: PREVENTION OF TRAUMATIC BRAIN INJURY SEC. 393A. (a) IN GENERAL- The Secretary, acting through the Director of the Centers for Disease Control and Prevention, may carry out projects to reduce the incidence of traumatic brain injury. Such projects may be carried out by the Secretary directly or through awards of grants or contracts to public or nonprofit private entities. The Secretary may directly or through such awards provide technical assistance with respect to the planning, development, and operation of such projects. (b) CERTAIN ACTIVITIES- Activities under subsection (a) may include-- (1) the conduct of research into identifying effective strategies for the prevention of traumatic brain injury; and (2) the implementation of public information and education programs for the prevention of such injury and for broadening the awareness of the public concerning the public health consequences of such injury. (c) COORDINATION OF ACTIVITIES- The Secretary shall ensure that activities under this section are coordinated as appropriate with other agencies of the Public Health Service that carry out activities regarding traumatic brain injury. (d) DEFINITION- For purposes of this section, the term traumatic brain injury' means an acquired injury to the brain. Such term does not include brain dysfunction caused by congenital or degenerative disorders, nor birth trauma, but may include brain injuries caused by anoxia due to near drowning. The Secretary may revise the definition of such term as the Secretary determines necessary.'. SEC. 2. PROGRAMS OF NATIONAL INSTITUTES OF HEALTH. Section 1261 of the Public Health Service Act (42 U.S.C. 300d-61) is amended-- (1) in subsection (d)-- (A) in paragraph (2), by striking `and' after the semicolon at the end; (B) in paragraph (3), by striking the period and inserting `; and'; and (C) by adding at the end the following paragraph: (4) the authority to make awards of grants or contracts to public or nonprofit private entities for the conduct of basic and applied research regarding traumatic brain injury, which research may include-- (A) the development of new methods and modalities for the more effective diagnosis, measurement of degree of injury, post-injury monitoring and prognostic assessment of head injury for acute, subacute and later phases of care; (B) the development, modification and evaluation of therapies that retard, prevent or reverse brain damage  after acute head injury, that arrest further deterioration following injury and that provide the restitution of function for individuals with long-term injuries; (C) the development of research on a continuum of care from acute care through rehabilitation, designed, to the extent practicable, to integrate rehabilitation and long-term outcome evaluation with acute care research; and (D) the development of programs that increase the participation of academic centers of excellence in head injury treatment and rehabilitation research and  training.'; and (2) in subsection (h), by adding at the end the following paragraph: (4) The term `traumatic brain injury' means an acquired injury to the brain. Such term does not include brain dysfunction caused by congenital or degenerative disorders, nor birth trauma, but may include brain injuries caused by anoxia due to near drowning. The Secretary may revise the definition of such term as the Secretary determines necessary.'. SEC. 3. PROGRAMS OF HEALTH RESOURCES AND SERVICES ADMINISTRATION. Part E of title XII of the Public Health Service Act (42 U.S.C. 300d-51 et seq.) is amended by adding at the end the following section: SEC. 1252. STATE GRANTS FOR DEMONSTRATION PROJECTS REGARDING TRAUMATIC BRAIN INJURY. (a) IN GENERAL- The Secretary, acting through the Administrator of the Health Resources and Services Administration, may make grants to States for the purpose of carrying out demonstration projects to improve access to health and other services regarding traumatic brain injury. (b) STATE ADVISORY BOARD-  (1) IN GENERAL- The Secretary may make a grant under subsection (a) only if the State involved agrees to establish an advisory board within the appropriate health department of the State or within another department as designated by the chief executive officer of the State. (2) FUNCTIONS- An advisory board established under paragraph (1) shall advise and make recommendations to the State on ways to improve services coordination regarding traumatic brain injury. Such advisory boards shall encourage citizen participation through the establishment of public hearings and other types of community outreach programs. In developing recommendations under this paragraph, such boards shall consult with Federal, State, and local governmental agencies and with citizens groups and other private entities. (3) COMPOSITION- An advisory board established under paragraph (1) shall be composed of-- (A) representatives of-- (i) the corresponding State agencies involved; (ii) public and nonprofit private health related organizations; (iii) other disability advisory or planning groups within the State; (iv) members of an organization or foundation representing traumatic brain injury survivors in that State; and (v) injury control programs at the State or local level if such programs exist; and (B) a substantial number of individuals who are survivors of traumatic brain injury, or the family members of such individuals. (c) MATCHING FUNDS-  (1) IN GENERAL- With respect to the costs to be incurred by a State in carrying out the purpose described in subsection (a), the Secretary may make a grant under such subsection only if the State agrees to make available, in cash, non-Federal contributions toward such costs in an amount that is not less than $1 for each $2 of Federal funds provided under the grant. (2) DETERMINATION OF AMOUNT CONTRIBUTED- In determining the amount of non-Federal contributions in cash that a State has provided pursuant to paragraph (1), the Secretary may not include any amounts provided to the State by the Federal Government. (d) APPLICATION FOR GRANT- The Secretary may make a grant under subsection (a) only if an application for the grant is submitted to the Secretary and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this section. (e) COORDINATION OF ACTIVITIES- The Secretary shall ensure that activities under this section are coordinated as appropriate with other agencies of the Public Health Service that carry out activities regarding traumatic brain injury. (f) REPORT- Not later than 2 years after the date of the enactment of this section, the Secretary shall submit to the Committee on Commerce of the House of Representatives, and to the Committee on Labor and Human Resources of the Senate, a report describing the findings and results of the programs established under this section, including measures of outcomes and consumer and surrogate satisfaction. (g) DEFINITION- For purposes of this section, the term traumatic brain injury' means an acquired injury to the brain. Such term does not include brain dysfunction caused by congenital or degenerative disorders, nor birth trauma, but may include brain injuries caused by anoxia due to near drowning. The Secretary may revise the definition of such term as the Secretary determines necessary. (h) AUTHORIZATION OF APPROPRIATIONS- For the purpose of carrying out this section, there is authorized to be appropriated $5,000,000 for each of the fiscal years 1997 through 1999.'. SEC. 4. STUDY; CONSENSUS CONFERENCE. (a) STUDY-  (1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the `Secretary'), acting through the appropriate agencies of the Public Health Service, shall conduct a study for the purpose of carrying out the following with respect to traumatic brain injury: (A) In collaboration with appropriate State and local health-related agencies-- (i) determine the incidence and prevalence of traumatic brain injury; and (ii) develop a uniform reporting system under which States report incidents of traumatic brain injury, if the Secretary determines that such a system is appropriate. (B) Identify common therapeutic interventions which are used for the rehabilitation of individuals with such injuries, and shall, subject to the availability of information, include an analysis of-- (i) the effectiveness of each such intervention in improving the functioning of individuals with brain injuries; (ii) the comparative effectiveness of interventions employed in the course of rehabilitation of individuals with brain injuries to achieve the same or similar clinical outcome; and (iii) the adequacy of existing measures of outcomes and knowledge of factors influencing differential outcomes. (C) Develop practice guidelines for the rehabilitation of traumatic brain injury at such time as appropriate scientific research becomes available. (2) DATES CERTAIN FOR REPORTS-  (A) Not later than 18 months after the date of the enactment of this Act, the Secretary shall submit to the Committee on Commerce of the House of Representatives, and to the Committee on Labor and Human Resources of the Senate, a report describing the findings made as a result of carrying out paragraph (1)(A). (B) Not later than 3 years after the date of the enactment of this Act, the Secretary shall submit to the Committees specified in subparagraph (A) a report describing the findings made as a result of carrying out subparagraphs (B) and (C) of paragraph (1). (b) CONSENSUS CONFERENCE- The Secretary, acting through the Director of the National Center for Medical Rehabilitation Research within the National Institute for Child Health and Human Development, shall conduct a national consensus conference on managing traumatic brain injury and related rehabilitation concerns. (c) DEFINITION- For purposes of this section, the term `traumatic brain injury' means an acquired injury to the brain. Such term does not include brain dysfunction caused by congenital or degenerative disorders, nor birth trauma, but may include brain injuries caused by anoxia due to near drowning. The Secretary may revise the definition of such term as the Secretary determines necessary. (d) AUTHORIZATIONS OF APPROPRIATIONS- For the purpose of carrying out subsection (a)(1)(A), there is authorized to be appropriated $3,000,000 for each of the fiscal years 1997 through 1999. For the purpose of carrying out the other provisions of this section, there is authorized to be appropriated an aggregate $500,000 for the fiscal years 1997 through 1999. Amounts appropriated for such other provisions remain available until expended. SEC. 5. TECHNICAL AMENDMENTS. Title XXVI of the Public Health Service Act (42 U.S.C. 300ff-11 et seq.), as amended by Public Law 104-146 (the Ryan White CARE Act Amendments of 1996), is amended-- (1) in section 2626-- (A) in subsection (d), in the first sentence, by striking `(1) through (5)' and inserting `(1) through (4)'; and (B) in subsection (f), in the matter preceding paragraph (1), by striking `(1) through (5)' and inserting `(1) through (4)'; and  (2) in section 2692-- (A) in subsection (a)(1)(A)-- (i) by striking `title XXVI programs' and inserting `programs under this title'; and (ii) by striking `infection and'; and (B) by striking subsection (c) and all that follows and inserting the following: (c) AUTHORIZATION OF APPROPRIATIONS-  (1) SCHOOLS; CENTERS- For the purpose of grants under subsection (a), there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 1996 through 2000. (2) DENTAL SCHOOLS- For the purpose of grants under subsection (b), there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 1996 through 2000.'. Speaker of the House of Representatives. Vice President of the United States and  President of the Senate. Reproduced from http://www.tbihelp.org/tbi_act_of_1996.htm Read More