- 1 What is traumatic brain injury (TBI)?
- 2 Types of traumatic brain injury (TBI):
- 3 Severity of traumatic brain injury
- 4 Executive functions in people with traumatic brain injury
- 5 Neuropsychological rehabilitation in patients with TBI
- 6 References
Traumatic brain injury (TBI) is a critical public health problem due to both its high mortality rates and the disabilities experienced by TBI survivors such as cognitive, emotional, familial, social and occupational difficulties that affect their quality of life (Arango-Lasprilla, Quijano and Cuervo, 2010); Corrigan, Selassie and Orman, 2010; García-Rudolph and Gibert, 2015; Park et al., 2015; Santana et al., 2015). In neuropsychology, the design of rehabilitation programs is based on a cognitive approach since improving the mental capacity of patients with traumatic brain injury has a direct effect on their function.
What is traumatic brain injury (TBI)?
TBI is defined as an alteration in brain function caused by an external force (Menon, Schwab, Wright and Maas, 2010).
Types of traumatic brain injury (TBI):
Openhead injuryoccurs when the skull is fractured or perforated, resulting in damage to the brain tissue and exposure ofthe brain substancetothe environment.
Closedhead injury only affectsthe brain tissue(León-Carrión, 1995).
Both types of injurycan befocal or diffusedepending on the location of the damage. Focal injuries areconfined to one area of the brain while diffuse injuriesdo not occupy a well-defined volume within the intracranial compartment but, just as focal injuries do, cause neurological sequelae (González, Pueyo and Serra, 2004). Commonly, focal brain injury is characterized by functional alterations in the frontal and temporal lobes, as these are the most susceptible regions in closed TBIs; in open head injuries, it will depend onthe region of the skull that isimpacted. In turn, diffuse brain injury often leads to loss of complex cognitive functions such as processing speed, concentration and overall cognitive efficiency (Kolb &Whishaw, 2014).
Severity of traumatic brain injury
Traumatic brain injury severity is commonly classified into mild, moderateor severe categories, based on duration of loss of consciousness orpost-traumatic amnesia.The Glasgow Coma Scale (GCS) is the most common instrument for classifying TBI severity. The GCS assesses a person’s level of consciousness based on three parameters (verbal response, motor response, and eye opening). The higher the score, the higher the patient’s level of consciousness.This scale classifies traumatic brain injuriesas mild (14-15), moderate (9-13), or severe,with scores less than or equal to 8(Hoffmann et al., 2012; Muñana-Rodríguez and Ramírez-Elías, 2013; Santa Cruz and Herrera, 2006; Poca, 2006).
Ideally, assessment of brain injury severityshould occur immediately following the injury event or as soon as possible to provide a baseline for future assessments and to actpromptly, both to stabilize the patient medically and to initiate rehabilitation interventions if required(Hoffmann et al., 2012; Muñana-Rodríguez and Ramírez-Elías, 2013; Santa Cruz and Herrera, 2006; Poca, 2006).
InterventionfollowingTBIoften includes physical and cognitive rehabilitation. Cognitive rehabilitation should be directed toward higherlevel cognitive functions such as executive function, for this is usually one of the most often affected by TBI as a result of both focal and diffuse injury(García-Molina, Enseñat-Cantallops, Sánchez-Carrión, Tormos and Roig-Rovira, 2014).
Executive functions in people with traumatic brain injury
Executive functions (EFs)refer tohigher-ordercognitive processes(such as planning, decision making, and flexibility) involved in the control and regulation of goal-directed behavior, thus allowing humans to formulate goals and planfor their achievement.
These mental capacities are also considered essential for performing creative and socially acceptable behavior. In addition, EFs becomemore complex overthe life span; some executive functions begin to emerge early, thereby enabling the development of more complex executive functions(Bombín-González et al., 2014; Tirapu-Ustárroz, García-Molina, Luna-Lario, Verdejo-García and Ríos-Lago, 2012).
The systematic reviewof factorialmodels of executive control carried outby Tirapu-Ustárroz et al. (2017) resulted in an integrative proposal ofexecutive functionssuch as:
- Speed of information processing:the amount of information that can be processed per unit of time, or the speed at which a variety of cognitive processes can be carried out.
- Working memory: the online maintenance and manipulation of information.
- Verbal fluency: facilitates retrieval of information from semantic memory and word search.
- Inhibition: resistance to distractor interference or selective attention.
- Dual-task performance: the ability to pay attention to more than onestimulus at a time.
- Cognitive flexibility: shifting.
- Planning: monitoring and control of behavior.
- Devision-making: the role of emotions in reasoning.
Executive functions play a key role in human life, since they are a set of cognitiveprocesses with independent yet interconnected components to control and regulate behavior. Whenexecutive function is affected by brain damage, as in a traumatic brain injury, deficitscause a multiplicity of cognitive, behavioral and emotional manifestations which interfere with the person’s adequatefunctioningin daily life thereby compromising the person’s capacityto return to a normal, productive life.
Neuropsychological rehabilitation in patients with TBI
Cognitive rehabilitation can be defined as “a systematic, functionally oriented service of therapeutic activities that is based on assessment and understanding the patients’ brain– behavioral deficits” (Cicerone et al., as cited in Van Heugten, Gregório and Wade, 2012). Interventions must have ecological validity so to have a real impact on patients’daily livesso that patientsare able to extrapolate and generalize what they have learned during rehabilitationin their everyday life (Carvajal-Castrillón and Restrepo, 2013).
A contemporary neuropsychology perspective on cognitive rehabilitation proposes the development of individualized assessment and rehabilitation programs for each condition, with clear and common expectations and goals for patients and their families(Calderón, Cadavid-Ruiz y Santos, 2016); Carvajal-Castrillón and Restrepo, 2013; Ríos, Muñoz and Paúl-Lapedriza, 2007; Tate, Aird and Taylor, 2013). Cognitive rehabilitation programsconsist of tasks organized hierarchically by levels of difficulty that requirerepetitive use of impaired functions.To these programs is clear that the degree of functional recovery of the patient will depend on the number of repetitions and the type of task performed throughout treatment (García-Rudolph and Gibert, 2015).
In neuropsychology, the design of rehabilitation programs is based on a cognitive approach since improving the mental capacity of patients has a direct effect on their function. In addition, these programs emphasize the importance of tailoring programs to individualneedsthrough restorative and compensatory techniques.Restorative strategies aim at reinforcing, strengthening, or restoring the impaired cognitive processes; compensatory techniquesteach ways of compensating for the impaired function with the use of assistive devices such as reminders or alarms, among others (Barman et al., 2016; Evald, 2015; Tsaousides, D’ Antonio, Varbanova and Spielman, 2014).
Cognitive rehabilitation, however, should keep in mind that traumatic brain injury is a medical condition that affects differentareas of health; it requires:
- Neurological intervention: to monitor brain tissue damage.
- Neuropsychological intervention: to restore as much function as possible in patients.
- Social intervention: to improvepatients’ functioning in the everyday context.
Research findings from rehabilitation research in patients with traumatic brain injury indicate that the greatest improvement in psychosocial functioning is achieved when intervention programs are based on an integrated and interdisciplinary approach, including patients’ cognitive, emotional, familial and social contexts. These initiatives should not only aim at the rehabilitation of patients with TBI, but should also aim at the promotion of health, which involves the implementation of measures to adopt healthy lifestyles.
If you liked this post, you might find the following interesting as well:
Arango-Lasprilla, J.C., Quijano, M.C. y Cuervo, M.T. (2010). Alteraciones Cognitivas, Emocionales y Comportamentales en pacientes con Trauma Craneoencefálico en Cali, Colombia. Revista Colombiana de Psiquiatría, 39 (4), 716-731.
Barman, A., Chatterjee, A. and Bhide, R. (2016). Cognitive Impairment and Rehabilitation Strategies After Traumatic Brain Injury. Indian Journal of Psychological Medicine, 38 (3), 172-81. doi:10.4103/0253-7176.183086.
Bombín-González, I., Cifuentes-Rodríguez, A., Climent-Martínez, G., Luna-Lario, P., Cardas-Ibáñez, J., Tirapu-Ustárroz, J. y Díaz-Orueta, U. (2014). Validez ecológica y entorno multitarea en la evaluación de las funciones ejecutivas. Revista Neurología, 59(2), 77-87.
Calderón, A., Cadavid-Ruiz, N. y Santos, O. (2016). Aproximación Práctica a la Rehabilitación de la Atención. Revista Neuropsicología, Neuropsiquiatría y Neurociencias, 16 (1), 69-89.
Carvajal-Castrillón, J., Henao, E., Uribe, C., Giraldo, M. y Lopera, F. (2009). Rehabilitación cognitiva en un caso de alteraciones neuropsicológicas y funcionales por Traumatismo Craneoencefálico severo. Revista Chilena de Neuropsicología, 4 (1), 52-63.
Corrigan, J.D, Selassie, A.W. and Orman, J.A. (2010). The epidemiology of traumatic brain injury. Journal of Head Trauma Rehabilitation, 25 (2), 72–80. doi: 10.1097/HTR.0b013e3181ccc8b4.
Evald, L. (2015). Prospective memory rehabilitation using smartphones in patients with TBI: What do participants report? Neuropsychological Rehabilitation, 25 (2), 283–297. doi:10.1080/09602011.2014.970557.
García-Molina, A., Enseñat-Cantallops, R., Sánchez-Carrión, R., Tormos, J.M. y Roig-Rovira, T. (2014). Rehabilitación de las Funciones Ejecutivas en el Traumatismo Craneoencefálico: Abriendo la Caja Negra. Revista Neuropsicología, Neuropsiquiatría y Neurociencias, 14 (3), 61-76.
García-Rudolph, A. and Gibert, K. (2015). A Data Mining Approach for Visual and Analytical Identification of Neurorehabilitation Ranges in Traumatic Brain Injury Cognitive Rehabilitation. Abstract and Applied Analysis, 1-14. doi:10.1155/2015/823562.
González, M., Pueyo, R. y Serra, J. (2004). Secuelas neuropsicológicas de los traumatismos craneoencefálicos. Anales de Psicología, 20, 303-316.
Hoffmann, M., Lefering, R., Rueger, J.M., Kolb, J.P., Izbicki, J.R., Ruecker, A.H., …Lehmann, W. (2012). Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. British Journal of Surgery, 99, 122-130. doi:10.1002/bjs.7707.
Kolb, B. & Whishaw, L.Q. (2014). An introduction to brain and behavior.New York, N.Y.: Worth Publishers.
León-Carrión, J. (1995). Manual de Neuropsicología Humana. Madrid: Siglo XXI de España Editores.
Menon, D.K., Schwab, K., Wright, D.W. and Maas, A. (2010). Position statement: definition of traumatic brain injury.Archives of physical medicine and rehabilitation, 91(11), 1637-40. doi: 10.1016/j.apmr.2010.05.017.
Muñana-Rodríguez, J. E. y Ramírez-Elías, A. (2013). Escala de coma de Glasgow: origen, análisis y uso apropiado. Enfermería Universitaria, 11(1), 24-35. doi:10.1016/S1665-7063.
Park, HY., Maitra, K. and Martínez, K.M. (2015). The Effect of Occupation-based Cognitive Rehabilitation for Traumatic Brain Injury: A Meta-analysis of Randomized Controlled Trials. OccupationalTherapy International, 22, 104-116. doi:10.1002/oti.1389.
Poca, M. (2006). Actualizaciones sobre la fisiopatología, diagnóstico y tratamiento en los traumatismos craneoencefálicos. Recuperado de http://www.academia.cat/societats/dolor/arxius/tce.PDF.
Ríos, M., Muñoz, J. y Paúl-Lapedriza, N. (2007). Alteraciones de la atención tras daño cerebral traumático: evaluación y rehabilitación. Revista de Neurología, 44, 291-297.
Santacruz, L.F. y Herrera, A.M (2006). Trauma Craneoencefálico. Recuperado en http://salamandra.edu.co/CongresoPHTLS2014/Trauma%20Craneoencef%E1lico.pdf
Santana, L., Yukie, C., Alves, S., Costa, A.L., Pérez, J., Moura, L., … Silva, W. (2015). Repetitive Transcranial Magnetic Stimulation (rTMS) for the cognitive rehabilitation of traumatic brain injury (TBI) victims: study protocol for a randomized controlled trial. BioMed Central, 16 (440), 1-7. doi:10.1186/s13063-015-0944-2.
Tate, R.L., Aird, V., and Taylor, C. (2013). Bringing Single-case Methodology into the Clinic to Enhance Evidence-based Practices. Brain Impairment,13 (3), 347–359. doi:10.1017/BrImp.2012.32.
Tirapu-Ustárroz, J., Cordero-Andrés, P., Luna-Lario, P. y Hernáez-Goñi, P. (2017). Propuesta de un modelo de funciones ejecutivas basado en análisis factoriales. Revista de Neurología, 64 (2), 75-84.
Tirapu-Ustárroz, J., García-Molina, A., Luna-Lario, P., Verdejo-García, A. y Ríos-Lago, M. (2012). Corteza prefrontal, funciones ejecutivas y regulación de la conducta. En J. Tirapu-Ustárroz, A.G. Molina, M. Ríos-Lago y A.A. Ardila (Eds.), Neuropsicología de la corteza prefrontal y las funciones ejecutivas (pp. 87-120). Barcelona: Viguera.
Tsaousides, T., D’Antonio, E., Varbanova, V. and Spielman, L. (2014). Delivering group treatment via videoconference to individuals with traumatic brain injury: A feasibility study. Neuropsychological Rehabilitation, 24 (5), 784–803. doi:10.1080/09602011.2014.907186.
VanHeugten, C., Gregório, G.W. and Wade, D. (2012). Evidence-based cognitive rehabilitation after acquired brain injury: A systematic review of content of treatment. Neuropsychological Rehabilitation, 22 (5), 653–673. doi:10.1080/09602011.2012.680891.