FAQ'S (Frequently Asked Questions)

The CDC defines a TBI as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury. Everyone is at risk for a TBI, especially children and older adults.¹ Not all blows or jolts to the head result in a TBI. The severity of such an injury may range from "mild" - a brief change in mental status or consciousness - to "severe" - an extended period of unconsciousness or amnesia after the injury. A TBI can result in short or long-term problems with independent function.²

There are an estimate 2.8 million brain injuries reported every year. Although the vast majority of those patients are treated and released (2.5 million), 282,000 are hospitalized and a staggering 56,000 result in death.³

• Falls
• Motor Vehicle / Traffic Accidents
• Sports Related Injuries
• Assaults (Domestic Violence (DV), Gunshot Wounds to the Head, Shaken Baby Syndrome (SBS))
• Military related Blast Injuries (a leading cause of TBI for active duty military personnel in war zones or training environments)²

• Males are about 1.5 times as likely as females
• Military duties increase the risk of sustaining a TBI²

Yes, a concussion is often referred to by doctors as a “mild TBI". Both terms are used when a person experiences a change in normal brain function for no longer than a minutes following trauma. Concussions are usually not life-threatening, but their effects can be serious.⁴

All brain injuries are unique. The brain can receive several different types of injuries depending on the type of force and amount of force that impacts the head. The type of injury the brain receives may affect just one functional area of the brain, various areas, or all areas of the brain.

1. Traumatic Brain Injury
   
   • Concussion
     Even a concussion can cause substantial difficulties or impairments that can last a lifetime. Whiplash can result in the same difficulties as head injury. Such impairments can be helped by rehabilitation, however many individuals are released from treatment without referrals to brain injury rehabilitation, or guidance of any sort.
   • • Can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury
     • Both closed and open head injuries can produce a concussion
     • A concussion is the most common type of traumatic brain injury
     • A concussion is the most common type of traumatic brain injury
     • A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change
     • • The blood vessels in the brain may stretch and cranial nerves may be damaged
     • A person may or may not experience a brief loss of consciousness
     • A person may remain conscious, but feel dazed
     • A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan
     • Skull fracture, brain bleeding, or swelling may or may not be present
     • • Therefore, concussion is sometimes defined by exclusion and is considered a complex neuro-behavioral syndrome
     • A concussion can cause diffuse axonal type injury resulting in temporary or permanent damage
     • A blood clot in the brain can occur occasionally and be fatal
     • It may take a few months to a few years for a concussion to heal
       
       
   • Contusion
   • • A contusion can be the result of a direct impact to the head
     • A contusion is a bruise (bleeding) on the brain
     • Large contusions may need to be surgically removed
       
       
   • Coup-Contrecoup
   • • Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain
     • This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion
       
       
   • Diffuse Axonal
   • • A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident
     • Injury occurs because the un-moving brain lags behind the movement of the skull, causing brain structures to tear
     • There is extensive tearing of nerve tissue throughout the brain
     • • This can cause brain chemicals to be released, causing additional injury
     • The tearing of the nerve tissue disrupts the brain’s regular communication and chemical processes
     • This disturbance in the brain can produce temporary or permanent widespread brain damage, coma, or death
     • A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain
       
       
   • Penetration
     Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bones and fragments from the object into the brain.
   • • Objects traveling at a low rate of speed through the skull and brain can ricochet within the skull, which widens the area of damage
     • A “through-and-through” injury occurs if an object enters the skull, goes through the brain, and exits the skull
     • • Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue. (Brumback R. (1996). Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd Ed.). New York: Springer.)
     • The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall. (Center for Disease Control. [Online August 22, 2002])
     • Firearms are the single largest cause of death from traumatic brain injury⁷
       
       
2. Acquired Brain Injury (ABI)

   Acquired Brain Injury (ABI) results from damage to the brain caused by strokes, tumors, anoxia, hypoxia, toxins, degenerative diseases, near drowning and/or other conditions not necessarily caused by an external force.

   • Anoxia
     Anoxic Brain Injury occurs when the brain does not receive any oxygen. Cells in the brain need oxygen to survive and function.
   • • Types of Anoxic Brain Injury:
     • • Anoxic Anoxia - Brain injury from no oxygen supplied to the brain
       • Anemic Anoxia - Brain injury from blood that does not carry enough oxygen
       • Toxic Anoxia- Brain injury from toxins or metabolites that block oxygen in the blood from being used
         
         
   • Hypoxic
     A Hypoxic Brain Injury results when the brain receives some, but not enough oxygen.
   • • Types of Hypoxic Brain Injury:
     • • Hypoxic Ischemic Brain Injury, also called Stagnant Hypoxia or Ischemic Insult- Brain injury occurs because of a lack of blood flow to the brain because of a critical reduction in blood flow or blood pressure⁷

There are 3 levels for a TBI - Mild/Concussion, Moderate and Severe. TBI classification is based on the length of time a person is unconscious, the presence of memory loss or Post-traumatic Amnesia (PTA), and the results of neuro-imaging tests²

The Glasgow Coma Scale (GCS) is used by healthcare providers to help determine the level of consciousness of a person with TBI. The test is easy to administer, reliable, and serves as a good indicator or prognosis for recovery following severe TBI. Responses are scored using three measures (eye opening, best verbal response, and best motor response) and are scored separately, and then combined.²

The GCS scale is as follows:

1. Motor Response (M)
   • 6 = Obeys verbal commands fully
   • 5 = Responds to localized pain
   • 4 = Normal flexion
   • 3 = Abnormal flexion (i.e. decorticate posturing)
   • 2 = Extension (i.e. decerebrate posturing)
   • 1 = None / No Response
   • NT = Not Testable
     
     
2. Verbal Response (V)
   • 5 = Alert and Oriented
   • 4 = Confused, yet coherent, speech
   • 3 = Inappropriate words and jumbled phrases consisting of words, but not Coherent
   • 2 = Incomprehensible sounds - No words
   • 1 = None / No sounds
   • NT = Not Testable
     
     
3. Eye Opening (E)
   • 4 = Spontaneous
   • 3 = Open to speech or sound
   • 2 = Open to pain or pressure
   • 1 = None / No eye opening
   • NT = Not Testable

A patient's GCS should be documented on a coma scale chart. This allows for improvement or deterioration in a patient's condition to be quickly and clearly communicated.

Individual elements, as well as the sum of the score, are important. The individual elements of a patient's GCS can be documented numerically (e.g. E2V4M6) as well as added together to give a total Coma Score (e.g E2V4M6 = 12). For example, a score may be expressed as GCS 12 = E2 V4 M6 at 4:32.²

The final score is determined by adding the values of Eye score (E) + Motor score (M) + Verbal score (V). The GCS score is used to classify TBI severity as follows:

1. Mild:
   • Final GCS = 13 to 15
2. Moderate:
   • Final GCS = 9 to 12
3. Severe:
   • Final GCS = 3 to 8
4. Vegetative State:
   • Final GCS Less than 3
   • Sleep wake cycles
   • Arousal, but no interaction with environment
   • No localized response to pain
   • Persistent Vegetative State
5. Vegetative State lasting longer than one month. Brain Death:
   • No brain function
   • Specific criteria needed for making this diagnosis⁵

Limitations of the Glasgow Coma Scale

Factors like drug use, alcohol intoxication, shock, or low blood oxygen can alter a patient’s level of consciousness. These factors could lead to an inaccurate score on the GCS.³

The GCS is usually not used with children, especially those too young to have reliable language skills. The Pediatric Glasgow Coma Scale (PGCS), a modification of the scale used on adults, is used instead. The PGCS still uses the three tests (Eye, Verbal, and Motor responses) and the three values are considered separately as well as together.

Here is the slightly altered grading scale for the PGCS:³

1. Motor Response (M)
   • 6 = Moves spontaneously or purposefully
   • 5 = Localizing (withdraws from touch)
   • 4 = Normal flexion (withdraws to pain)
   • 3 = Abnormal flexion (decorticate response)
   • 2 = Extension (decerebrate response)
   • 1 = None / No Response
   • NT = Not Testable
     
     
2. Verbal Response (V)
   • 5 = Smiles, oriented to sounds, follows objects, interacts
   • 4 = Cries but consolable, inappropriate interactions
   • 3 = Inconsistently inconsolable, moaning
   • 2 = Inconsolable, agitated
   • 1 = None / No sounds
   • NT = Not Testable
     
     
3. Eye Opening (E)
   • 4 = Spontaneous
   • 3 = Open to voice or sound
   • 2 = Open to pain or pressure
   • 1 = None / No eye opening
   • NT = Not Testable

Pediatric brain injuries are classified by severity using the same scoring levels as adults, i.e. 8 or lower reflecting the most severe, 9-12 being a moderate injury and 13-15 indicating a mild TBI. As in adults, moderate and severe injuries often result in significant long-term impairments.³

Mild Traumatic Brain Injury (GCS score = 13 to 15)

1. Mild TBI's occur when:
   • Loss of consciousness is very brief, usually a few seconds or minutes (Loss of consciousness does not have to occur)
   • Headache
   • Confusion
   • Lightheadedness
   • Dizziness
   • Irritability
   • Concentration problems
   • Blurred or Double Vision
   • Ringing in the ears
   • Excessive Fatigue / Tiredness or sleepiness / Change in Sleep Habits
   • A bad taste in the mouth
   • Behavior or mood changes
   • Balance problems
   • Trouble with memory, concentration, attention, or thinking
   • Sensitivity to light or sound
   • Nausea or vomiting
   • Testing or scans of the brain may appear normal
   • Diagnosed only when there is a change in the mental status at the time of injury
   • • The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion^2,5,7

Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.

Moderate Traumatic Brain Injury (GCS score = 9 to 12)

Most brain injuries result from moderate and minor head injuries. Such injuries usually result from a non-penetrating blow to the head, and/or a violent shaking of the head. As luck would have it many individuals sustain such head injuries without any apparent consequences. However, for many others, such injuries result in lifelong disabling impairments.⁷

1. Moderate TBI's occur when:
   • Any of the symptoms listed for Mild TBI / Concussion
   • A loss of consciousness lasts from a few minutes to a few hours
   • Confusion lasts from days to weeks
   • Physical, cognitive, and/or behavioral impairments last for months or are permanent
   • Severe headaches / Headache that gets worse or won't go away
   • Repeated vomiting or nausea
   • Slurred speech
   • Convulsions or seizures
   • An inability to wake up from sleep / Sleep disturbances
   • Enlargement of the pupil (dark center) of one or both eyes
   • Numbness or tingling of arms or legs
   • Loss of coordination
   • Increased confusion, restlessness, or agitation
   • Inability or difficulty speaking, understanding and concentrating
   • Memory loss / Amnesia
   • Vision changes or loss of vision
   • Paralysis and/or muscle spasticity
   • Chronic pain
   • Inability or changes in ability to use senses of taste, touch, sight, sound, and smell
   • Loss of bowel and/or bladder control^2,5,7

Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits.⁶

Severe Traumatic Brain Injury (GCS score = 3 to 8)

Severe head injuries usually result from crushing blows or penetrating wounds to the head. Such injuries crush, rip and shear delicate brain tissue. This is the most life threatening, and the most intractable type of brain injury.⁷

Typically, heroic measures are required in treatment of such injuries. Frequently, severe head trauma results in an open head injury, one in which the skull has been crushed or seriously fractured. Treatment of open head injuries usually requires prolonged hospitalization and extensive rehabilitation. Typically, rehabilitation is incomplete and for most part there is no return to pre-injury status. Closed head injuries can also result in severe brain injury.

1. Severe TBI's occur when:
   • Any of the symptoms listed for Mild TBI / Concussion
   • Any of the symptoms listed for Moderate TBI^2,7
2. Severe TBI's can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.
3. Severe TBI's can cause epilepsy
4. Severe TBI's increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age

• Symptoms of mild TBI or concussion typically improve within hours to days and almost always resolve completely over a relatively short period of time (one to three months).
• Patients with moderate to severe TBI may have long-term medical, physical, and cognitive problems that require specialized attention.
• Keep in mind that the symptoms and effects will vary greatly from one patient to another depending on the severity of the TBI and location of the injury.²

• When the effects of TBI are prolonged, severe, and interfere with normal functioning, they may be considered disabilities, but it’s important to remember that problems caused by TBI may not be disabling for everyone.
• Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury in the brain, and the age and general health of the patient.
• Some common disabilities include:
• • Problems with mobility and motor skills
  • Cognition
  • • Thinking
    • Memory / Dementia
    • Reasoning
  • Sensory processing
  • • Sight
    • Hearing
    • Touch
    • Taste
    • Smell
  • Communication
  • • Expression
    • Understanding
  • Behavior or mental health
  • • Depression
    • Anxiety
    • Personality changes
    • Aggression
    • Acting out
    • Social inappropriateness

Yes! One of the long-term consequences of a TBI can be the development of dementia, a progressive neurological disorder characterized by a decline in cognitive function.

Below, we will explore the types of dementia that can result from a TBI, the risk factors for developing dementia after a TBI, and the steps you can take to reduce your risk.

• Types of Dementia Resulting from a TBI
• • A TBI can lead to several types of dementia, including:
  • • Alzheimer's disease: This is the most common form of dementia and is characterized by the accumulation of plaques and tangles in the brain.
    • Vascular dementia: This type of dementia is caused by a blockage or damage to blood vessels in the brain.
    • Lewy body dementia: This type of dementia is characterized by the presence of abnormal protein deposits called Lewy bodies in the brain.
    • Frontotemporal dementia: This type of dementia is caused by damage to the frontal and temporal lobes of the brain.
    • Chronic traumatic encephalopathy (CTE): This is a type of dementia that is caused by repeated head injuries, such as those sustained by athletes who play contact sports.
• Risk Factors for Developing Dementia after a TBI
• • Several factors can increase the risk of developing dementia after a TBI, including:
  • • Severity of the injury: The more severe the injury, the greater the risk of developing dementia.
    • Age at the time of the injury: Individuals who are older at the time of the injury are at a higher risk of developing dementia.
    • Number of injuries: Individuals who have had multiple TBIs are at a higher risk of developing dementia.
    • Genetics: Some individuals may be genetically predisposed to developing dementia after a TBI.
• Steps to Reduce Your Risk of Developing Dementia after a TBI
• • While there is no guaranteed way to prevent dementia after a TBI, there are several steps you can take to reduce your risk, including:
  • • Wear a helmet: Wearing a helmet when engaging in activities that could result in a head injury can reduce your risk of sustaining a TBI.
    • Avoid contact sports: If you have already sustained a TBI, it is recommended that you avoid contact sports to reduce your risk of sustaining further head injuries.
    • Seek prompt medical attention: If you sustain a head injury, it is important to seek medical attention immediately to minimize the risk of long-term consequences.
    • Manage chronic conditions: Managing chronic conditions such as high blood pressure and diabetes can reduce your risk of developing vascular dementia.
    • Stay mentally active: Engaging in mentally stimulating activities such as reading, playing games, and learning new skills can help keep your brain healthy.

In conclusion, TBI's can have long-term consequences, including the development of dementia. While there is no guaranteed way to prevent dementia after a TBI, taking steps to reduce your risk can help minimize the impact of the injury on your long-term health.

** If you have sustained a TBI, it is important to seek immediate medical attention and to follow your healthcare provider's recommendations for minimizing your risk of developing dementia. **

1. What is PTSD?

   Post-traumatic stress disorder (PTSD) is a condition that may occur to people who have lived through or witnessed events perceived by the person to be life-threatening.

   Examples of traumatic events include:

   • Military/combat exposure
   • Physical/sexual assault or abuse
   • Terrorist attacks
   • Natural disasters
   • • Fires
     • Floods
     • Hurricanes
     • Earthquakes
   • Serious accidents
   • • Auto Accidents
     • Explosions
     • Collisions
       
       
2. What are some of the symptoms of PTSD?
   • Re-living the traumatic event/experience
   • Avoiding situations/environments that remind you of the event
   • Feeling numb or detached
   • Hyperarousal
   • • Constantly alert
     • On edge
     • Jittery
     • On the look out
   • Sleep problems
   • Personality changes
   • Other possible symptoms
   • • Chronic pain
     • Depression
     • Problems with personal, professional and social relationships
     • Substance abuse
       
       
3. Does PTSD occur in patients with TBI's?

   Yes, PTSD and concussion can occur together and can be caused by the same traumatic event. Some patients with a concussion may also have PTSD, but not everyone does. Both medical conditions involve physical changes and psychological symptoms. The symptoms of PTSD and concussion are similar and may make it hard for your healthcare provider to determine which condition you have.

   
   
4. How is PTSD treated?

   Treatments for PTSD may include taking medications to control or minimize symptoms. Cognitive-Behavioral Therapy (CBT) is a form of counseling which has been shown to be very effective for treating PTSD. Your provider will customize your treatment to meet your personal symptoms and needs.²

   
   
5. TBI and PTSD: Navigating the Perfect Storm

   TBI and PTSD: Navigating the Perfect Storm³

There are a variety of therapies available and your medical team will make recommendations depending on your personal needs.

A few therapies that may be prescribed are:

• Physical therapy
• Speech therapy
• Cognitive therapy
• Neuropsychological assessment/therapy
• Occupational therapy
• Recreational therapy²

A case manager is typically a nurse or a social worker who will help guide you and your family through the TBI journey. The case manager will coordinate the services and therapies needed for your optimal recovery by working with you and your healthcare team. They will also assist you with finding available local resources for medical, social and financial issues.²

¹ Center for Disease Control and Prevention

² CEMM Library

³ Brainline

⁴ The University of Alabama At Birmingham

⁵ Traumatic Brain Injury Website

⁶ Eunice Kennedy Shriver National Institute of Child Health and Human Development

⁷ Brain Injury Alliance of Utah