Understanding Traumatic Brain Injury Current Research And Future Directions Pdf

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Recent advances in traumatic brain injury

Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. The multifaceted characteristics of traumatic brain injury TBI complicate the evaluation of therapeutic interventions, including rehabilitation. The intensity, direction, and duration of external forces that cause TBI, coupled with a range of factors specific to the individual and early medical management, affect the pattern and extent of damage and the degree of recovery Maas et al.

These combined factors may determine the type and effectiveness of the rehabilitation therapy. In this chapter, the pathophysiology of TBI, injury complications, and person-specific variables are discussed in relation to outcome. Chapter 3 addresses other factors related to recovery after TBI. These chapters provide the relevant background for interpreting the cognitive and neurobehavioral sequelae of TBI.

Research indicates that TBI may manifest differently depending on the mechanism of injury. Because active duty members of the military and veterans have higher exposure to blasts than civilians, TBI incurred by military and veteran populations may determine different outcomes than non-blast-related TBI. However, civilians may be exposed to blasts due to terrorism, occupational hazards, or other acts of violence.

The committee assumes civilian versus military populations respond similarly to TBI, unless otherwise noted. TBI causes both direct, immediate physical damage and delayed, secondary changes that contribute to subsequent tissue impairment and related neuropsychiatric dysfunction.

Injury may be focal or diffuse; due to closed impact or penetrating insults; and if severe, may include other complicating factors such as hemorrhage, hypoxia, reduced blood flow, or metabolic. The following chapter does not contain exhaustive descriptions of the many factors related to TBI. The response to injury and subsequent treatment varies by multiple factors unique to the affected individual, such as age, gender, genetics, cognitive reserve, polytrauma, multiple concussions from the same impact, and history of prior brain injury Colantonio et al.

Such variability influences long-term functional outcomes, including cognitive processes. The ultimate degree of recovery likely reflects individual variability with regard to neuroplasticity, or the ability of undamaged brain regions or pathways to take over irreparably damaged cells or brain regions Cramer et al.

Although most mild injuries appear to recover completely within weeks to months after trauma, a small but not insignificant subset of mild TBIs cause longer-term symptoms, and these also may be associated with sustained or progressive neuroimaging abnormalities Vannorsdall et al.

Secondary injury processes may continue for months or years, particularly with moderate or severe injuries, which may lead to progressive long-term tissue loss Greve and Zink ; Werner and Engelhard Thus, characteristics of the injury and the individual contribute to the heterogeneity of TBI, which has implications for treatment options.

Head injuries have historically been classified using various clinical indexes that include pathoanatomical features, severity of injury, or the physical mechanisms of the injury i. Different classification systems may be used for clinical research, clinical care and management, or prevention. Additional classification schemes include those that address secondary injury. The classification systems most relevant to rehabilitation help determine pace of recovery or expected degree of impairment.

Pathoanatomical features influence outcomes for individuals with brain injuries Saatman et al. Pathoanatomical classification may aid with prognosis Saatman et al. The injury is classified based on the presence or absence of a mass lesion, which is found using diagnostic tools such as computed tomography CT and magnetic resonance imaging MRI Olson-Madden et al. Imaging helps with location of injury, which can be useful in understanding localization of deficits e. Severity of TBI is generally graded from mild to moderate or severe.

Severity can be classified in multiple ways, and each measure has different predictive utility, including determining morbidity, mortality, or long-term functional outcomes. Patients with more severe head injuries demonstrate lower cognitive functioning and have more gradual cognitive improvements following the initial injury Novack et al. The majority of TBIs are mild, consisting of a brief change in mental status or unconsciousness.

Mild TBI is also referred to as a concussion. While most people fully recover from mild TBI, individuals may experience both short- and long-term effects. Moderate-severe TBI is characterized by extended periods of unconsciousness or amnesia, among other effects. The distinction between moderate and severe injuries is not always clear; as such, individuals with moderate and severe injuries are often grouped for research purposes.

Throughout the remainder of this report, the committee refers to more severe injuries as moderate-severe TBI. Chapter 1 provides epidemiological statistics on TBI by severity. These classification systems not only determine the severity of TBI, but also may be indicative of the degree of long-term disability. The more severe the injury, the more severe and persistent the cognitive deficits—though clinical measurements do not always concur. Severity measures graded during the acute phase sometimes reflect variance due to medications used during resuscitation, substance use, and communication issues.

However, the relationship between clinical severity measures e. The utility of these measures depends on factors such as how long after the injury a patient is evaluated. Measures obtained later in time are generally better predictors of long-term outcomes; specifically, duration of PTA is more predictive than duration of LOC, which is more predictive than GCS at the time of injury Katz and Alexander, Table includes the mild, moderate, and severe classifications.

It provides a numerical index of level of consciousness that is used to grade injury severity. The point scale is based on ratings of eye opening, verbal behavior, and motor behavior Teasdale and Jennett A score of 13 to 15 is classified as mild, 9 to 12 as moderate, and 3 to 8 as severe.

Though well known and widely used, this classification scheme is most useful in predicting acute survival and gross outcome, and performs more poorly in predicting later and more detailed functional outcomes, particularly in cognitive and emotional realms.

Valid scoring has also become more difficult with earlier intubation and sedation for individuals with more severe injuries. However, more recent studies have found that the motor component of GCS may be more useful in predicting outcomes than the verbal data, which has not been found useful Healey et al. Other postinjury conditions contribute to the spectrum of severity, such as posttraumatic amnesia.

PTA is defined as the interval between injury and return of day-to-day memory. It is a state of confusion that occurs immediately following TBI, in which the injured person is disoriented and unable to remember events after the injury. PTA can be directly assessed during the subacute stage of recovery using a brief examination that tests orientation and memory for circumstances of the injury and events prior to and following the injury.

In addition, duration of PTA can be estimated retrospectively by asking the patient memory-related questions concerning. Beginning rehabilitation prior to the end of PTA may be problematic since the patient is less likely to transfer learning across sessions.

Retrograde amnesia may also be present after injury, but its duration is typically shorter than PTA. In contrast, anterograde amnesia is difficulty forming new memories after the trauma, and it can sometimes lead to a decreased attention span and inaccurate perception.

After a loss of consciousness, anterograde memory is often one of the last cognitive functions to return Cantu The natural process of recovery following TBI depends upon the initial injury severity, as described with the GCS, though there can be considerable variability even within categories. With most injuries there is a gradual resolution of symptoms.

For most mild, single concussive injuries, the majority of patients are symptom-free within several weeks Belanger and Vanderploeg ; Carroll et al.

Several meta-analyses indicate the path to preinjury symptom levels following a mild TBI is 2 weeks, approximately, and no more than 3 months Iverson ; McCrea et al. Development of new symptoms following resolution of the initial symptoms in civilians with mild TBI occurs infrequently.

However, with multiple mild TBIs, both the number and duration of symptoms are likely to increase. The course of recovery from severe TBI is more prolonged, with greatest function recovery occurring within 1 to 2 years of injury. One study Corrigan et al. In another study assessing recovery in people with severe TBI, approximately 22 percent of individuals were found to have improved from year 1 to year 5; however, 14 to 15 percent declined, and approximately 62 percent remained unchanged Millis et al.

At the present time, the course and pattern of recovery following blast-related TBI is not well characterized, with no published longitudinal studies. Heterogeneity of the injury is important to consider because it may help determine those who will benefit from cognitive rehabilitation therapy CRT.

Participation in CRT generally requires patients to be stable and recovered well enough to participate effectively in goal-oriented treatment programs. This generally occurs after the acute care phase. Some of the most important heterogeneous factors to consider are physical mechanisms, pathobiology, severity, presence of polytrauma, multiple impacts, and other factors including age, gender, cognitive reserve, and genetic variation.

The physical mechanism of TBI, which determines the forces involved in the injury, represents an alternate way of classifying head injury based on the causative forces of the injury. Injuries can be classified according to whether the head makes contact with an object also called impact loading and whether the brain moves within the skull due to acceleration or deceleration forces inertial loading Gennarelli Lesions can form when the brain is brought into contact with the skull, when an object strikes the head, or as a result of acceleration or deceleration.

Medical records often only indicate the acute injury classification of a trauma, not its cause. In addition to severity, anatomical features of the injury i. Mechanisms of injury may manifest in different ways, and include focal versus diffuse injuries as well as penetrating versus closed head injuries.

Another way to characterize the physical mechanisms of TBI is to compare those that are commonly seen in military populations with those most commonly seen in civilian populations.

These physical mechanisms of injury may occur in various combinations. Whether an injury is focal, diffuse, or both contributes to the degree of heterogeneity of the resulting damage. A focal injury refers to a wound at a specific location, which affects the grey matter of the brain; a diffuse injury refers to more widespread damage, causing degeneration of white matter.

Focal injuries most commonly reflect cerebral contusion resulting. Diffuse injuries often result from rapid rotations of the head, which cause tissue distortion, typical in automobile accidents. Diffuse axonal injury, now superseded by the term traumatic axonal injury TAI , can occur with either focal or diffuse brain injury, most commonly following rapid acceleration or deceleration of the head.

TAI, which is often caused by blasts Mac Donald et al. TAI can serve as a predictor of outcome Graham et al. Focal and diffuse injuries also may occur in combination Povlishock and Katz , which is often the result of a penetrating brain injury caused by severe whiplash or blast Hynes and Dickey ; these features are commonly seen in military wounded with moderate-severe TBI.

Blunt injuries can be either focal or diffuse—or, in some cases, mixed. Both static and dynamic forces cause blunt head injuries. Static loading occurs in crush-type injuries e. This type of injury generally causes skull fracture, and in more severe cases can cause brain laceration and coma. More often, blunt force injuries to the head are caused by dynamic forces: direct impact or rapid acceleration, deceleration, or rotational movement, which significantly strain the brain tissue Graham et al.

Penetrating injuries involve an object entering or lodging within the cranial cavity. In civilian populations, these most often result from projectile or knife wounds; in the military setting, blast-related shrapnel or missile injuries are the most common causes Warden Penetrating injuries have been less studied than closed models.

Traumatic Brain Injury

Language: English Spanish French. Michael K. Cognitive, emotional, behavioral, and sensorimotor disturbances are the principal clinical manifestations of traumatic brain injury TBI throughout the early postinjury period. These post-traumatic neuropsychiatric disturbances present substantial challenges to patients, their families, and clinicians providing their rehabilitative care, the optimal approaches to which remain incompletely developed. In this article, a neuropsychiairically informed, neurobiologically anchored approach to understanding and meeting challenges is described. The foundation for thai approach is laid, with a review of clinical case definitions of TBI and clarification of their intended referents. The differential diagnosis of event-related neuropsychiatric disturbances is considered next, after which the clinical and neurobiological heterogeneity within the diagnostic category of TBI are discussed.


PDF | On Feb 1, , Patrick S Ledwidge published Review of 'Understanding Traumatic Brain Injury: Current Research and Future Directions.


Global Outcome Trajectories up to 10 Years After Moderate to Severe Traumatic Brain Injury

Aims: Based on important predictors, global functional outcome after traumatic brain injury TBI may vary significantly over time. This study sought to: 1 describe changes in the Glasgow Outcome Scale—Extended GOSE score in survivors of moderate to severe TBI, 2 examine longitudinal GOSE trajectories up to 10 years after injury, and 3 investigate predictors of these trajectories based on socio-demographic and injury characteristics. Methods: Socio-demographic and injury characteristics of 97 TBI survivors aged 16—55 years were recorded at baseline. Conclusion: A larger proportion of survivors experienced deterioration in GOSE scores over time, supporting the concept of TBI as a chronic health condition.

Trauma tic brain injury TBI is a leading cause of death and disability among young adults. CT remains the imaging modality of choice in the acute setting, in order to triage patients requiring emergent surgical intervention or conservative medical management. Some patients with mild TBI or concussion have a wide variety of neurological and psychological symptoms where CT and MR remain normal.

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Understanding Traumatic Brain Injury in Females: A State-of-the-Art Summary and Future Directions

Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. The multifaceted characteristics of traumatic brain injury TBI complicate the evaluation of therapeutic interventions, including rehabilitation.

Join NursingCenter to get uninterrupted access to this Article. When you buy this you'll get access to the ePub version, a downloadable PDF, and the ability to print the full article. In this report, we identify existing issues and challenges related to research on traumatic brain injury TBI in females and provide future directions for research. In , the National Institutes of Health, in partnership with the Center for Neuroscience and Regenerative Medicine and the Defense and Veterans Brain Injury Center, hosted a workshop that focused on the unique challenges facing researchers, clinicians, patients, and other stakeholders regarding TBI in women.


lotusdream.org: Understanding Traumatic Brain Injury: Current Research and Future Directions (): Levin, Harvey, Shum, David, Chan, Raymond.


The system can't perform the operation now. Try again later. Citations per year. Duplicate citations. The following articles are merged in Scholar.

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4 Comments

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    A large proportion of individuals with traumatic brain injuries TBI sustain long-term physical, cognitive, and emotional impairments that have a profound impact on their everyday level of functioning, community participation, and reintegration 1.

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