Traumatic Brain Injury Types
When I did my training in Emergency Medicine, very little was known about traumatic brain injury. We were only taught two basic guidelines on how to tell if a patient had experienced a concussion. We now know that these guidelines were completely wrong.
The first guideline is that we only called an injury a concussion if there was a loss of consciousness. In other words, unless someone was actually knocked out, the injury was not considered a concussion. It is now clear that injuries where there is no actual loss of consciousness can cause the same kind of structural and cognitive damages as the more obvious loss of consciousness. We have broadened the definition of concussion to include “seeing stars”, nausea and vomiting, confusion, dizziness and other symptoms.
The second erroneous guideline that we were taught was that if symptoms appeared more than three months after a concussion that they were not concussion related. Often we were taught to look for psychological problems in these cases or consider if the patient was attempting to malinger and avoid work. There was no appreciation whatsoever for post concussion syndrome and prolonged symptoms.
I have found that there is often a misconception amongst those who are not in the field of treating traumatic brain injuries. That misconception is that anyone who has sustained a concussion will have long lasting problems. Actually, the opposite is true. Most people with head injures either don’t have symptoms or they resolve within 3 months. There are a relatively small percentage of people that have persisting symptoms beyond that 3-month window. So, while everyone should be very concerned about concussions, it is important to have some assurance that the majority of those with concussions will recover.
Below I have outlined the different Traumatic Brain Injury types and some of the facts associated with each as well as new approaches to treatment of concussion.
- A concussion is the most common type of traumatic brain injury. A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, a sudden momentum or movement change, and whiplash.
- A person may experience a brief loss of consciousness.
- A person may remain conscious but feel dazed.
- Repeated blows to the head, none of which may cause a concussion, can still cause damage to the brain’s white matter and cause cognitive deficits. Research is accumulating that just a single season of high school football without a concussion or symptoms of head injury can still cause damage to the white matter of the brain. This suggests that we should be looking not just at concussions but how many repeated blows to the head were there.
- Even mild TBI occurring repeatedly within a short period of time (i.e., hours, days, or weeks) can be catastrophic.
- A concussion can but usually does not show up on a diagnostic imaging test, such as a CAT Scan.
- A specific type of MRI can sometimes demonstrate a concussion. This type of MRI is called diffusion tensor imaging, and it can show damage to the white matter, the neurofibers transmitting the electrical impulses in the brain.
- Skull fracture, brain bleeding, or swelling may or may not be present. It is unusual to see these injuries in contact sports.
- A concussion can cause diffuse axonal (white matter) injury resulting in temporary or permanent damage. Most individuals who sustain such head injuries either have no symptoms or symptoms that last a short period of time.
- It can take a few months and even a few years for a concussion to heal.
- At the present time most people with concussions do not get referred to brain injury specialists of any sort.
- Concussions generally benefit only modestly from most forms of rehabilitation. Therapeutic modalities, with some exceptions (see the end of this article), are generally only modestly effective at best.
- The importance of follow up to a clinician knowledgeable about brain injuries is largely a combination of educating the patient and careful oversight of how much activity and concentration/study are allowed as the patient improves and not allowing premature return to sports.
- Studies show that complete bed rest is not beneficial for concussion healing.
- Ideally activity levels are increased as improvement occurs.
- Most concussions resolve within 3 months, but it is possible for the effects to last much longer.
- Several studies show that there is still damage to the brain four and six months after symptoms have resolved. It is still not established when it is fully safe to return to play in a contact sport, in large part because we don’t know if the brain changes that we can detect indicate that the brain is still more vulnerable to another injury or not.
- Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits.
- Persisting TBI symptoms are also known as post concussive syndrome (PCS).
- Post-Concussion Syndrome (PCS) emotional symptoms include irritability, frustration, anxiety, and depression.
- PCS cognitive symptoms include poor memory and concentration and taking longer to think and respond.
- PCS physical and sensory symptoms include headaches, sensitivity to light and noise, insomnia, fatigue, dizziness, poor balance, blurry and double vision.
- Some of these symptoms such as headache, depression, anxiety and others may not show up until years after there is no longer any head trauma. This is the case with some professional and college football players.
- Symptoms persisting longer than 3 years are less likely to significantly improve. (These symptoms have been seen to improve with CLARITY Direct Neurofeedback sessions.)
- A contusion is a bruise (bleeding) on the brain.
- A contusion can be the result of a direct impact to the head.
- A Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.
- Coup-Countercoup 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 Injury
- A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head. This is seen with Shaken Baby Syndrome or by rotational forces. These forces are seen with car accidents or occasionally in sports.
- Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.
- There can be 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 can present with a variety of functional impairments depending on where the shearing (tearing) occurred in the brain.
- Acquired Brain Injury, (ABI), results from damage to the brain caused by strokes, anoxia, hypoxia, toxins, degenerative diseases, near drowning and/or other conditions not necessarily caused by an external force.
Brain Injury Types of Treatment
Several modalities have shown varying success. Foremost among these modalities are 1) Transcranial Magnetic Stimulation (TMS), 2) Traditional Neurofeedback and 3) CLARITY Direct Neurofeedback
Of these modalities, CLARITY Direct Neurofeedback is the most efficient and dramatic in my opinion—initial results are typically seen in the very first session. Five studies using CLARITY Direct Neurofeedback for TBI corroborate its effectiveness. These studies, all clinical case series, treat TBI in 9 former NFL players, 13 former NFL players, 7 veterans, 9 veterans and 12 veterans. All studies done thus far with Direct Neurofeedback and concussion have shown very promising results.
The Dubin Clinic did a formal, self-funded IRB approved study looking at the effect of 20 sessions of Direct Neurofeedback on 10 former NFL players.
All ten players had multiple symptoms typically seen in post concussion syndrome. Pre and Post treatment evaluations were performed. This included symptom questionnaires, brain maps (qEEG), cognitive testing and balance. Results were very impressive. All 10 showed clinically and statistically very significant improvement in their symptoms. Most resistant to treatments was short-term memory. However, one player, Kermit Alexander, even showed very significant improvement with dementia.
Strong and consistent improvements were also seen in the brain maps. General but inconsistent improvements were seen in cognitive and balance testing.
If you’ve suffered a traumatic brain injury of any kind, I would recommend coming into The Dubin Clinic for a complimentary session of CLARITY Direct Neurofeedback to see if CLARITY Direct Neurofeedback can help with your road to recovery. If you need more information on brain injury types or treatment, please contact us at (323) 825-3554.