Posts Tagged TBI
According to the Mayo Clinic, a traumatic brain injury (TBI) “results from a violent blow or jolt to the head or body”. A TBI can also be caused by “an object that goes through brain tissue, such as a bullet or shattered piece of skull. Brain injuries may be caused by falls, vehicle-related collisions, violence, sports injuries, explosive blasts, penetrating wounds, or combat injuries. The degree of damage to the brain may depend on several factors, including the nature of the injury and the force of impact. A TBI can be classified as mild, moderate, or severe. A mild TBI may affect a person’s brain cells temporarily, while more serious TBIs may result in bruising, torn tissues, and other physical damage to the brain. They may result in long-term complications or death.
The physical and psychological effects of a TBI are wide-ranging. While some signs or symptoms may appear immediately after the event, others may appear days or even weeks later. The signs and symptoms of a mild TBI (also known as a concussion) may include headaches, nausea, blurred vision, sensitivity to light or sound, loss of consciousness or a state of being dazed or disoriented, mood swings, depression and anxiety, and sleep issues. The signs and symptoms of moderate to severe TBIs may include those of a mild TBI and may include coma and other disorders of consciousness, convulsions or seizures, clear fluids draining from the nose or ears, slurred speech, agitation, headaches, sensory problems, and other similar symptoms. Infants and young children with an TBI may not be able to communicate their symptoms. Caregivers of children with a TBI may observe a change in eating or nursing habits, unusual irritability, seizures, persistent crying, or a change in sleep habits, among other symptoms.
Research and Resources
Currently, NIDILRR funds over 30 projects whose research and development activities are geared toward improving various aspects of the lives of people with TBI, including interventions, employment, community participation, health, and function. These projects include the TBI Model Systems and the Model System Knowledge Translation Center (MSKTC), which houses evidence-based resources in English and Spanish for consumers with TBI, their families, and service providers.
The Centers for Disease Control and Prevention (CDC) provides information about TBI, including data and statistics, healthcare provider resources, publications, publications and reports, and more. The CDC also provides the CDC Heads Up initiative, which provides information for parents, coaches, school professionals, and healthcare providers on topics TBI and concussion prevention in sports and other TBI risks in children and adolescents.
Interested in research on TBI? NARIC’s information specialists searched REHABDATA and found over 1100 articles related to TBI research from the NIDILRR community and beyond. NARIC’s Research In Focus series discusses the latest results from NIDILRR-funded studies on TBI and disability-related topics presented in an easy to read format.
If you would like to learn more about TBI or would like TBI-related resources, please contact NARIC’s information specialists.
Please Note: See your doctor immediately if you or your child receive a blow to the head or body that concerns you or causes behavioral changes. Seek emergency medical care if there are any signs or symptoms of a TBI after a recent blow or other injury to the head. Although the terms mild, moderate, and severe are used to describe the effect of the injury, a mild TBI is still a serious injury that requires immediate attention and an accurate diagnosis.
[ARTICLE] Proposing Music-based Interventions for the Treatment of Traumatic Brain Injury Symptoms: Current Evidence and Future Directions
Regardless of the classification of initial injury severity, traumatic brain injury (TBI) can result in debilitating neurologic and psychiatric symptoms that may last months to years.1 These post-TBI symptoms can vary widely from patient to patient, but core symptoms involve depressed mood and cognitive impairment.1 The underlying pathophysiology of persistent cognitive dysfunction following TBI has yet to be fully understood, but disruptions in large scale neural networks, particularly those governing resting state functional connectivity (e.g., default mode network) and cognitive control (e.g., salience network), are strongly implicated across TBI severities.2 Furthermore, the presence of post-traumatic depression may have bi-directional interactions on prolonging the overall recovery process.3 Given the deficits in multiple domains of functioning following TBI, novel rehabilitation approaches that can target multiple symptoms simultaneously are needed for this complex neuropsychiatric patient population.
Music-based interventions (MBIs) are emerging as a new potential treatment strategy for neurologic4 and psychiatric5 patient populations, as they are safe, economic, and can be creatively tailored to meet specific functional goals. MBIs are typically selected and delivered by a credentialed music therapist based on empirically supported models and can involve active (improvisation, singing, clapping, or dancing) and/or receptive (purposeful music listening to identify emotional content emerging from music) techniques.4,5 Mechanistically, MBIs appear to engage both cortical and subcortical areas governing attention, working memory, planning, and flexibility and can modulate these areas over time.4
MBIs for TBI
A systematic review and meta-analysis published in 2020 by Mishra et al.6 identified 6 studies of patients with moderate–severe TBI that compared the effect of MBIs for rehabilitation to controls. Five studies were of low quality and 1 study was very low quality. Outcomes were focused on recovery of motor symptoms and on cognitive functioning. Three studies reported significant improvements in gait velocity and stride length with small overall effect. Mixed results were reported for cognitive outcomes with no significant improvement in memory (one study reporting overall worsening of memory), and 3 studies reporting improvement in executive functioning with small overall effect. Finally, only 2 of the included studies evaluated changes in depressed mood following MBIs, and although both reported statistically significant improvements, the heterogeneity of outcome measures used between these studies limits any generalizability. Overall, this meta-analysis was limited by the low number of studies, low study quality, small sample sizes (n < 30) within included studies, heterogeneity in outcome measures used, and lack of follow-up data.6
A recent crossover randomized control trial not included in the above systematic review found significant improvements in general executive functioning and set shifting skills in moderate-severe TBI (n = 39) following 3 months of MBIs.7 Each session occurred twice weekly and included three 20-minute modules involving rhythmic training (playing sequences of rhythms on a drum), structured cognitive-motor training (playing musical exercises on drum set with different movement in composition elements while accompanied by the MT on piano), and assisted music playing (learning to play participants’ favorite songs on piano). The executive function improvements were maintained at 6-month follow up, and the investigators found significant increases in grey matter volume in the right inferior frontal gyrus, which correlated with improvements in set shifting.7 This evidence further supports that MBIs can influence cognitive outcomes following TBI and that this could be due to engagement of corresponding neural networks.
Although injury severity was not reported in the following study, Gardiner and Horwitz8 reported significant improvements in planning (as measured by a series of mazes from the Weschler Intelligence Scale-III), and mental flexibility (Trail making test-B) in 22 veterans with TBI after employing specific MBI protocols targeting attention, executive function, and memory. Notably, the conclusions of these findings are limited by the open-label pretest–posttest design with no randomization or control/comparator group.
Only one study was found that evaluated the effects of MBIs on mild TBI. Vik et al.9 evaluated the effects of biweekly 30-minute piano instruction for patients (n = 7) following mTBI compared with 2 healthy control groups (musicians, n = 11, and non-musicians, n = 12). Piano exercises gradually progressed in difficulty, and patients were additionally required to practice at home for 15 minutes per day. All 7 mTBI patients had received traditional cognitive rehabilitation during their hospital stay without improvement and were all on leave from work, despite being on average 2 years post injury. Patients with mTBI not only experienced significant improvements in California Verbal Learning Test performance, but 6 of the 7 patients returned to work in their full pre-morbid capacity. Furthermore, these clinical changes were coupled with increased connectivity between right middle prefrontal cortex, right anterior insular cortex, left rostral anterior cingulate cortex, and the right supplementary motor cortex,9 which are important nodes in the salience and frontal-executive neural networks.2
Conclusions and Future Directions
Cognitive impairment and depression in TBI are commonly reported symptoms and there are limited interventions available to effectively manage them.1,3 MBIs are emerging as a novel multimodal therapeutic strategy with the potential to target several symptom domains simultaneously.4 There is promising evidence to suggest that MBIs may have potential in rehabilitating cognitive impairments across various levels of TBI severity with most evidence for moderate–severe TBI.6,7 However, conclusions on efficacy are limited at this time given the lack of randomized trials for each level of injury severity (e.g., only 1 study for mild TBI9) small sample sizes, lack of active control groups, and overall poor study quality. It is possible that MBIs exert their effects by engaging dysfunctional neural networks implicated in TBI, but at this time, only 2 studies have investigated this relationship with fMRI; one for mild TBI9 and one for moderate–severe.7
With regards to post-TBI depression, only 2 studies included in the meta-analysis for moderate–severe TBI included mood outcomes, but they both reported statistically significant improvements.6 MBIs have been shown to have a large effect with moderate quality evidence for depression (not specific to TBI) according to a recent Cochrane review.5 Since depression is recognized as a common symptom across TBI severity that impacts functional outcomes,1,3 it is critical that future studies of MBIs for TBI include pre–post measures of validated depression scales.
Overall, further studies are needed to determine if MBIs can demonstrate efficacy with randomized controlled trial designs and to further understand underlying neurobiological mechanisms of this therapy with use of pre/post neurophysiological measures. Preferably, future studies will employ traditional cognitive rehabilitation strategies as a comparator group, as the above studies only compared MBIs to standard care or waitlist, as well as longer follow-up periods and evaluation of transfer to real-world functioning. Given that TBI-related cognitive impairment has limited treatment options and MBIs have no major risk of harm, we would recommend that integrated inpatient and outpatient treatment programs for moderate-severe TBI consider incorporating MBIs into their clinical management plans. The relative lack of available evidence of MBIs for mild TBI limits the generalizability of recommendations at this time, although, given the safety profile and similar limited treatment options, MBIs could be offered where resources are available. Ideally, delivery of MBIs would be carried out by a trained music therapist in collaboration with either an occupational or physical therapist following a validated protocol.8,9,7 There is potential to deliver MBIs by a credentialed music therapist virtually as well. However, many communities may not have access to therapists of specialized resources, and modified protocols could be developed that are self-directed (e.g., learning an instrument via internet or phone-based applications, memorizing lyrics and singing along to favourite songs, or tapping along to the beat while listening to their favourite pieces of music, for at least 15 minutes daily), although collaboration among local university-based music therapy departments (if applicable) would be recommended. Additional resources and information on university-based music therapy programs and credentialed therapists can be found at https://www.musictherapy.ca/ or www.nmtacademy.co
Rhythmic auditory stimulation (RAS) has been well researched with stroke survivors and individuals who have Parkinson’s disease, but little research exists on RAS with people who have experienced traumatic brain injury (TBI). This pilot study aimed to (1) assess the feasibility of the study design and (2) explore potential benefits. This single-arm clinical trial included 10 participants who had a 2-week control period between baseline and pretreatment. Participants had RAS daily for a 2-week treatment period and immediately completed post-treatment assessments. Participants then had a 1-week control period and completed follow-up assessment. The starting cadence was evaluated each day of the intervention period due to the variation in daily functioning in this population. All 10 participants were 1-20 years post-TBI with notable deviations in spatial-temporal aspects of gait including decreased velocity, step symmetry, and cadence. All participants had a high risk of falling as defined by achieving less than 22 on the Functional Gait Assessment (FGA). The outcome measures included the 10-m walk test, spatial and temporal gait parameters, FGA, and Physical Activity Enjoyment Scale. There were no adverse events during the study and gait parameters improved. After the intervention, half of the participants achieved a score of more than 22 on the FGA, indicating that they were no longer at high risk of experiencing falls.
Have there been challenges post injury for your traumatic brain injury employment?
In a recent interaction about this topic with someone in a Facebook group, I was reminded of some very raw feelings I had after my TBI.
When my TBI happened, I was single with no children. I had so many confidence issues and concerns after my injury, that I wasn’t sure if I would ever get married.
I grew up expecting to be (and wanting to be) the breadwinner and provider for my family. In the early stages of my recovery, I was very worried that I might never be able to do that.
For nearly a year, going to work was so hard for me. My boss allowed me to continue working, but I was floundering. Around 13 months post injury, my work performance started to improve, but I still wasn’t where I wanted to be.
When I met my wife (2 years post injury), I knew that I wanted to marry her, but I was still hesitant about being able to meet the the expectations I had for myself. After dating, we took the leap of faith and decided to get married. Things have worked out well, and we’ve started our family. Our daughter is a little over a year old.
There is a strong combination of societal, environmental, and religious influences that can cause us (men and women) to place a lot of self esteem on providing for ourselves and our families, and excelling at work. Whether that is healthy or not is another discussion. Regardless, it is a common occurrence.
So when our cognitive abilities are scrambled after a TBI, and we can no longer function at work, our ego, identity, and confidence often take a big hit. That can add to the depression and frustration that are already prevalent after a TBI.
Complications can also come if your spouse has to become the sole breadwinner for the family and then is your caregiver when they come home from work. For most people, it tugs at our heart to watch our spouse shoulder so much by themselves.
When we are not being the husbands/wives/providers that we expected to be, it can be helpful to look for other ways that we CAN contribute to our family relationships. Here are some things I learned in my journey that might be useful for others walking the path of TBI recovery:
Remember how LUCKY your loved ones are to have you
You are someone that continues to fight their inner battles valiantly, even though a traditional victory (being the pre-TBI version of yourself) may not happen. Remember the example that you are setting for them of perseverance, hard work, and grit.
Victory with a TBI often means not giving up and hanging in there to win the war, even when we feel like we may lose the battles. The challenges you face on a daily basis make you a FREAKING HERO. Your children might not see it now, but in the future they will realize how much you worked to be the best you could for them.
Explore the resources to help TBI survivors
You may or may not be able to continue in your current career. In some situations, working at all is not possible. However, some people can find benefit in rehabilitation or vocational services. They can help match a person’s abilities post injury to available work opportunities and programs. One resource is this page from BrainLine. They provide ideas and case studies about working with a TBI. They also provide information about the disability laws that affect a TBI.
Remember what type of men and women will your children become as they watch the example of you and your spouse set facing life’s challenges together? Caring, kind, patient, service minded, hard working? This can help them be successful in their future relationships as they date and marry.
Reimagine your role
Brainstorm what you can do, whatever your limitations are, to build your relationship with your spouse and children. This list will be different for each TBI survivor, depending on you limitations. Some things that work for me are:
- Helping with the housework (however little of it you can do)
- Writing notes
- A kiss or a hug
- Saying “I love you” or “thank you for what you do for our family”
Fill up the tank
Do what you can on your good days for fill the emotional tanks of those closest to you, and it can help them be more forgiving on the days you are not who you want to be. If you need some ideas check out my other article about relationships after a TBI.
Be open and honest about what’s going on
Have a frank conversation with your partner. Go ahead and layout that you know you can’t do what you could before. And reassure them that you want to help and take active part in what’s going on. Then share the ideas that you came up with. This will help on several levels
- It lets them know that you know things aren’t the same
- It lets them know that you want to help and are actively trying to come up with ideas within your limitations
- If they accept what you are offering, it can help release you from guilt you are carrying around about your contributions to the family.
Please know that I admire you. The occupational limitations of a TBI can hit us very hard to many working spouses/parents who experience them. I admire that you’re not giving up. I admire that you want to do what you can to make things better. Your family really is lucky to have you.
If you found this guide useful you can sign up here to get get ideas and support to help with your recovery from TBI. Starting tomorrow, you will receive my 4 part email series where I cover several techniques to help you (or your loved one) with the TBI recovery journey.
What is fatigue?
Fatigue is a feeling of exhaustion, tiredness, weariness or lack of energy. After TBI, you may have more than one kind of fatigue:
- Physical fatigue: “I’m tired and I need to rest. I’m dragging today.”
- Psychological fatigue: “I just can’t get motivated to do anything. Being depressed wears me out; I just don’t feel like doing anything.”
- Mental fatigue: “After a while, I just can’t concentrate anymore. It’s hard to stay focused. My mind goes blank.”
Why is fatigue important?
When you are fatigued, you are less able to think clearly or do physical activities. If you are overwhelmed by fatigue, you have less energy to care for yourself or do things you enjoy. Fatigue can have a negative effect on your mood, physical functioning, attention, concentration, memory and communication. It can interfere with your ability to work or enjoy leisure activities. It can make activities such as driving dangerous.
How common is fatigue after TBI?
Fatigue is one of the most common problems people have after a traumatic brain injury. As many as 70% of survivors of TBI complain of mental fatigue.
What causes fatigue?
Fatigue is normal for anyone after hard work or a long day. In persons with TBI, fatigue often occurs more quickly and frequently than it does in the general population. The cause of fatigue after TBI is not clear but may be due to the extra effort and attention it takes to do even simple activities such as walking or talking clearly. Brain function may be less “efficient” than before the injury.
- Physical fatigue can come from muscle weakness. The body needs to work harder to do things that were easy before the TBI. Physical fatigue gets worse in the evening and is better after a good night’s sleep. Often this kind of fatigue will lessen as the individual gets stronger, more active and back to his or her old life.
- Psychological fatigue is associated with depression, anxiety and other psychological conditions. This type of fatigue gets worse with stress. Sleep may not help at all, and the fatigue is often at its worst when you wake up in the morning.
- Mental fatigue comes from the extra effort it takes to think after your brain is injured. Many common tasks take much more concentration than they did before. Working harder to think and stay focused can make you mentally tired.
- Certain conditions are known to cause or increase fatigue:
- Sleep problems, such as sleep apnea
- Seasonal allergies
- Hypothyroidism or other endocrine gland disorders
- Respiratory or cardiac problems
- Lack of physical exercise
- Vitamin deficiency/poor nutrition
- Low red blood cell counts (anemia)
- Medications commonly used after TBI, such as muscle relaxers and pain medication
What can be done to decrease fatigue?
- Pay attention to what triggers your fatigue, and learn to identify the early signs of fatigue, such as becoming more irritable or distracted. Stop an activity before getting tired.
- Get more sleep and rest. If you have insomnia, tell your doctor. There may be a medical condition causing this, or there may be useful treatments.
- Set a regular schedule of going to bed and awakening the same time every day: your body and mind will be more efficient. Include some regular rest breaks or naps. Be careful to limit naps to 30 minutes and avoid evening naps.
- Alcohol and marijuana will generally make fatigue worse.
- Caffeine (coffee, cola products) should be avoided after lunch if sleeping is a problem
- Resume activities gradually, over weeks or even months.
- Start with familiar tasks at home or work that you can complete without fatigue. Gradually increase the complexity of each task, taking breaks as needed.
- Improve your time management:
- Plan and follow a daily schedule. Using a calendar or planner can help manage mental fatigue.
- Prioritize activities. Finish what is most important first
- Do things that require the most physical or mental effort earlier in the day, when you are fresher.
- Avoid over-scheduling.
- If visitors make you tired, limit time with them.
- Exercise daily. Research has shown that people with TBI who exercise have better mental function and alertness. Over time, exercise and being more active helps lessen physical and mental fatigue and builds stamina. It also may decrease depression and improve sleep.
- Talk to your doctor:
- Discuss medical or physical problems that may be causing fatigue.
- Have your doctor review all your current medications.
- Tell your doctor if you think you might be depressed so treatment can be started.
- Ask your doctor if there are any blood tests that could help to find out what is causing your fatigue.
Fatigue and Traumatic Brain Injury was developed by Kathleen R. Bell, MD, in collaboration with the Model Systems Knowledge Translation Center. Portions of this document were adapted from materials developed by the Rocky Mountain Regional Brain Injury System, Carolinas Traumatic Brain Injury Rehabilitation and Research System, and the Mayo Clinic Traumatic Brain Injury Model System.
Source: Our health information content is based on research evidence and/or professional consensus and has been reviewed and approved by an editorial team of experts from the TBI Model Systems.
Holding On To Hope, Chapter 1.blog.pdf
INTRODUCTION: Comorbidities in persons with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients’ functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.
EVIDENCE ACQUISITION: A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase, and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.
EVIDENCE SYNTHESIS: Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.
CONCLUSIONS: Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).
Diffusion tractography magnetic resonance imaging (MRI) can infer changes in network connectivity in patients with traumatic brain injury (TBI), but the pathological substrates of disconnected tracts have not been well defined because of a lack of high-resolution imaging with histopathological validation. We developed an ex vivo MRI protocol to analyze tract terminations at 750-μm isotropic resolution, followed by histopathological evaluation of white matter pathology, and applied these methods to a 60-year-old man who died 26 days after TBI. Analysis of 74 cerebral hemispheric white matter regions revealed a heterogeneous distribution of tract disruptions. Associated histopathology identified variable white matter injury with patchy deposition of amyloid precursor protein (APP), loss of neurofilament-positive axonal processes, myelin dissolution, astrogliosis, microgliosis, and perivascular hemosiderin-laden macrophages. Multiple linear regression revealed that tract disruption strongly correlated with the density of APP-positive axonal swellings and neurofilament loss. Ex vivo diffusion MRI can detect tract disruptions in the human brain that reflect axonal injury.