Traumatic Brain Injury (TBI)

Brain injuries were quite common in our earlier civilization. The Edwin Smith Surgical Papyrus, a copy of a manuscript dating back 5,000 years, is the oldest recorded medical document. It shows us that the ancient Egyptians were well aware of the myriad of disturbances brought about by injury to the brain. The ancient Greeks also understood that intellect and reasoning had their seat within the brain. Physicians of the Hippocratic school some 2,400 years ago discovered that incising a wound on one side of the brain caused, "a spasm in the opposite side of the body." Galen wrote that, "a loss of memory for words," might follow head injury.[1]

What is it?

Definition: Traumatic Brain Injury

Traumatic brain injury is an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment. [5] 

A healthy brain

It's important to realize what a healthy brain is made of, what it does and what happens when it is injured. Most are already aware that brain is a very delicate structure housed inside the protective skull. The human brain weighs only three pounds but is estimated to hold about 100 billion cells. These nerve cells (neurons) form tracts and route millions of messages to every tissue and organ in the body. These may include instructions for functions in coordinating our body’s systems, such as breathing, heart rate, body temperature, and metabolism; thought processing; body movements; personality; behavior; and the senses, such as vision, hearing, taste, smell, and touch. Each part of the brain serves a specific function and links with other parts of the brain to form more complex functions.

An injured brain 

When injured, the functions of the nerves can become impaired. This may render nerves incapable of or expressing difficulty in carrying the messages that tell the brain and body what to do. The way a person thinks, acts, feels, and moves the body can be affected. Brain injury can also change the complex internal functions of the body, such as regulating body temperature; blood pressure; bowel and bladder control. These changes can be temporary or permanent. They may cause impairment or a complete inability to perform a function.

How does injury occur? 

A force causing the skull to break or a blow or jolt to the head hard enough to cause the brain to move within the skull can directly hurt the brain. Both can disrupt its normal functions. Doctors often call the latter a “concussion” or a “closed head injury.” The severity of the injury may range from mild, a brief change in mental status or consciousness, to severe, an extended period of unconsciousness (30 minutes or more), prolonged amnesia after the injury, or a penetrating skull injury. Any TBI can result in short- and long-term disabilities. Brain injuries are among the most likely types of injury to cause death or permanent disability. [6]  Such injuries can occur from falls or sports.  Motor vehicle trauma is probably the single most important agent in both fatal and mild brain injuries. From 40 percent to 60 percent of all mild brain injuries are caused by motor vehicle accidents (MVAs) with the most common diagnosis given being concussion. These injuries affect a very extensive subgroup of patients. From within this subgroup, the spectrum of injury ranges from subclinical concussion (i.e., without a loss of consciousness or LOC)[7] or posttraumatic amnesia (PTA), to a fully developed postconcussion syndrome (PSC).[8] Mild Traumatic Brain Injury (MTBI) presents a risk of Post Traumatic Headaches (PTHA) of about 40-60%.[9]

Many of these MVA-related injuries are the result of blunt head injury (a.k.a. soft head injury) which describes contact with some object but without penetration of the skull. An example would be striking the steering wheel or door post.

A rapid acceleration and deceleration of the head in motor vehicle accident can force the brain to move back and forth across the inside of the skull.[10] The stress from the rapid movements pulls apart nerve fibers and causes damage to brain tissue. This type of injury is also often seen with Shaken Baby Syndrome.

Several journals have published articles on various aspects of head injury in sports. The Journal of the American Medical Association (JAMA) and the American Journal of Sports Medicine have published articles of particular interest focusing on high school and collegiate athletes and concerns regarding the long-term consequences of repeated concussion. The literature also addresses what is known about the physiological reactions to head trauma. Recent evidence is emerging that demonstrates differences in physical and psychological impairments between individuals who recover from the injury and those who develop persistent pain and disability.

Symptoms

Mild brain injury and PCS (Post-concussion syndrome) share most but not necessarily all of the following symptoms, which manifest themselves more or less completely and more or less intensely in different patients following closed head trauma: headache, floaters, hyper-sensitivity to light and/or noise, lightheadedness, dizziness, blurry or dimmed vision, double vision, nausea, vomiting, poor short term memory, insomnia, fatigue, apathy, decreased libido, social withdrawal, irritability, sudden outbursts of anger and profanity, emotional liability, slowed thinking, having to re-read material over and over, inability to execute routine task sequences on automatic pilot, inability to learn new facts, disorganization, loss of ability to manage one’s paperwork and appointments, diminished attention span with easy distractibility and inability to maintain divided attention to two or more stimuli, muscle weakness, altered sensations to pain and a host of other symptoms. These are present soon after injury in all whiplash injured persons irrespective of recovery.

Treatment

This information is not intended to be a substitute for medical advice or examination. A person with a suspected brain injury should contact a physician immediately, go to the emergency room, or call 911 in the case of an emergency. These claims have not been evaluated by the FDA. These products are not intended to treat, prevent, cure, or diagnose disease. If you feel that you must take supplements, make sure you clear them with your doctor, especially if taken in conjunction with prescription medication.

Over the past fifteen years researchers and clinicians working with individuals recovering from traumatic brain injury have begun to examine the possible role various classes of medication may play in either accelerating recovery or providing compensation for cognitive impairments.

Coincidentally, medication and dietary changes are usually the first things to consider in MTBI.  A gradual reduction in caffeine intake, in particular, for individuals with irritability or sleep disruption should be considered. Certain pain medications should be avoided which can cause dependence or rebound headache. Studies reviewed suggest that early treatment of MTBI with antioxidants, such as vitamins C, E, A, bioflavonoids, zinc, selenium, super oxide dismutase, and essential fatty oils in addition to those nutrients known to be critical for CNS function, such as the B vitamins, biotin, inositol, and choline, can limit the amount of nerve damages, often in conjunction with other anti-inflammatory drugs.^{[11], [12]} Ginkgo biloba is believed to produce mild improvements in cognitive functioning. Medicinal use of ginkgo can be traced back almost 5,000 years in Chinese herbal medicine. The medical benefits of Ginkgo biloba extract (GBE) are attributed primarily to support the brain and central nervous system.[13] Ginkgo is also well-known for its effect on memory and thinking (cognitive function). It may enhance cognitive performance in healthy older adults,[14] in people with age-related cognitive decline, and in people with Alzheimer’s disease.   More information here.

Treatment designed to improve ability to maintain focus of attention, ability to shift focus of attention, ability to maintain vigilance, perceptual feature identification, categorization, cognitive rigidity, cognitive flexibility, speed of processing are very important as well.

Headache management should be conducted following careful differentiation of potential etiologies with appropriate consults for headaches arising from sinusitis, temporomandibular joint dysfunction, or cervical strain/sprain. Additionally, the contribution of vestibular hypersensitivity to increased tension in the cervical musculature should be considered. Long-standing cervical strain/sprain is often associated with temporomandibular joint dysfunction and headache as a symptom triad. Consideration should be given to augmenting the above treatments with relaxation, visual imagery, or hypnotherapy.

Physical therapy should be aimed to increase flexibility, improve strength, improve cardiorespiratory endurance, improve muscular endurance, improve range of motion, decrease pain, and treat vestibular hypersensitivity. Physical therapy should carefully evaluate sleep positions in cases involving back pain. A routine exercise program to improve physical conditioning should be undertaken. If sleep problems exist, every effort should be made to undertake the exercise routine at times other than the evening hours.

Family and psychosocial issues should be addressed as well. In a study of paid attendant care to victims of TBI, the main benefit was found to be that of friendship to the victim, and the study recommended further training to stress this important component of care.[15]

In any event, some parts of the brain will work fine while others are in need of repair or are slowly being reconnected.  This can take months or years and not everything may return to normal. Careful evaluation and management, is necessary. Neuro-ophthalmologic evaluation should be undertaken for complaints of visual blurring, double vision, difficulty reading, etc. Complaints of parathesias or radiculopathy should be evaluated via sophisticated imaging of the cervical region of appropriate thoracic/lumbar region.  Management can be any one of or combinations of the above.

Traumatic Brain Injury Treatment Protocol