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Traumatic  brain injury (TBI): Is there anything we can do? A review

[version 1; peer review: awaiting peer review]
Umaima Cheema
https://orcid.org/0009-0003-4863-9698
1, Tehreem Fatima1, Muhammad Bilal1, Ayeza Nawaz1, Huzaifa Nadeem1, Ammar Khalid1
Umaima Cheema
https://orcid.org/0009-0003-4863-9698
1, Tehreem Fatima1, [...] Muhammad Bilal1, Ayeza Nawaz1, Huzaifa Nadeem1, Ammar Khalid1
PUBLISHED 22 Oct 2024
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW

Abstract

Introduction

Traumatic brain injury (TBI) is considered a global health crisis. It results in injury to the brain from an external impact leading to severe disability, with higher incidence statistics recently observed in young adults and elderly individuals.

Purpose

The review aims to analyze current research findings explaining the prevalence, incidence, and demographics of such injuries stressing the need for enhanced prevention and management techniques. The pathophysiology involves a complex cascade of biochemical and cellular events, which results in necrotic-apoptotic neuronal cell death.

Method

The review synthesizes current research on TBI, highlighting epidemiological data, advanced diagnostics, and effective rehabilitation strategies like physical and cognitive therapy.

Findings

Traumatic Brain Injury is an important public health issue with high morbidity and mortality rates causing extreme damage to a person, such as comas, catatonic states for various years, or lifelong injury or demolition. Early diagnostic imaging techniques include CT, MRI, advanced neuroimaging methods, and blood-based biomarkers. In the acute setting, initial management is directed toward stabilizing and preventing secondary injuries and early mobilization. The goals of rehabilitation are to promote the highest level of functional independence and physical function, cognitive functions, and social integration.

Conclusion

This review highlights that the use of new rehabilitation technologies, such as VR-based and robot-assisted therapies, might lead to improved recovery. Long-term supportive care combined with community integration is mandatory for enhancing quality of life. A systematic multidisciplinary team approach and family support are needed for traumatic brain injury survivors.

Keywords

traumatic, brain, injury, rehabilitation, traumatic brain injury, therapy, rehabilitation

Corresponding author: Umaima Cheema
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright:  © 2024 Cheema U et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Cheema U, Fatima T, Bilal M et al. Traumatic  brain injury (TBI): Is there anything we can do? A review [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1264 (https://doi.org/10.12688/f1000research.157134.1) First published: 22 Oct 2024, 13:1264 (https://doi.org/10.12688/f1000research.157134.1) Latest published: 22 Oct 2024, 13:1264 (https://doi.org/10.12688/f1000research.157134.1)

Introduction

TBI is a very severe problem in the present-day global healthcare system. This can be described by disruptions in brain activities, and in this case, it is caused by external physical impacts. The incidence of TBI has also been increasing over the years, and TBI has a great effect on morbidity and mortality. Previous research indicates that TBI is prevalent and occurs in millions of victims, including young adults and elderly people, globally. These injuries included falls, automobile accidents, and sports-related injuries. TBIs can cause coma, a vegetative state, severe disability, or even death. Gender disparities also exist, and males are more frequently affected than females. The cost implications of TBI across the socioeconomic perspective are enormous; therefore, there is a need to advance interventions regarding the cause and management of TBI. Newly published epidemiological papers describe the nature of TBI injury and enumerate the risk factors and demographic characteristics implicated in traumatic injury cases. This has, in turn, called for a more specific way of dealing with and intervening in cases of this.1

Mechanism and pathophysiology

A complex cascade of biochemical and cellular events is triggered at the moment of impact. First, primary injury occurs due to mechanical forces such as direct impact or rotational forces. This leads to brain tissue damage. Neuroinflammation, oxidative stress, excitotoxicity, and disruption of the blood–brain barrier are some examples of neurodegeneration caused by TBI. These events exacerbate the initial type of injury and lead to neuronal cell death. Recent research has shown that microglial activation and cytokine release are major factors leading to neuroinflammation. The application of newer fMRI and DTI technologies has provided insight into the pathophysiology of TBI. This has shown how mechanical injury causes various pathophysiological profiles. The focus on the creation of new treatments that target secondary injury cascades will open up further possibilities for enhancing the results of TBI treatment.2

Symptoms and diagnosis

Each person who has had a TBI usually demonstrates various signs. The symptoms range from mild cognitive impairment to severe neurological deficits. The most common symptoms include headache, confusion, memory loss, dizziness, and mood changes. However, in some critical cases, prolonged unconsciousness, motor deficits, and extreme cognitive dysfunction also occur. First, the diagnosis of TBI depends heavily on the clinical evaluation and neuroimaging techniques that we employ. CT scans as well as MR images are the standard types of imaging used to determine brain injury severity. This sensitivity and specificity have been significantly improved by the use of new advanced diagnostic methods for detecting subtle brain injuries, such as diffusion tensor imaging (DTI) and blood-based biomarkers. Early diagnosis is critical for optimizing treatment outcomes and mitigating long-term consequences. More advanced diagnostic methods, particularly neuroimaging and molecular biomarkers, could significantly help in the diagnosis of TBI through the use of individual and precise interventional methods.3

Acute management & initial treatment

For acute management, there should be a systematic approach to the stabilization and reduction of secondary injury followed by early rehabilitation strategies. Multidisciplinary care and long-term follow-up are key for improving outcomes and enhancing recovery after TBI. Since its acute symptoms and severity vary widely, it has been called a silent epidemic, and both patients and treatment facilities are responsible for underdiagnosis and underreporting.4

The Basic Assessment of TBI involves the use of the Glasgow Coma Scale (GCS) to assess the extent of impaired consciousness. However, there is an ongoing debate in the medical community regarding the use of GCSs as an assessment tool. The GCS measures mild (GCS 13-15), moderate (GCS 9-12) and severe (GCS 3-8) TBI.4 However, one-third of TBI patients with a GCS score of 13 were found to have intracranial lesions, which raised concerns that patients should not be categorized as having mild TBI.4 Another assessment method is cervical spine immobilization, which is checked to determine whether there is spinal cord injury. For diagnosis, MRI and CT should be performed to check for any edema or contusion.

There are currently no international guidelines regarding treatment in the early rehabilitation phase for patients with severe TBI. Only a few studies have investigated the effect of integrating rehabilitation into acute TBI care.5 Initial medical treatment should be to keep the patient’s head elevated. Mannitol should be given to reduce cerebral edema. Hypoxia, hypotension, and hyperthermia, if present, are treated immediately. Surgically, hematomas are removed, and a craniectomy is performed. The guidelines of an international group of researchers and clinicians (INCOG) recommend multidisciplinary cognitive rehabilitation tailored to patients’ neuropsychological profiles, premorbid cognitive characteristics, and goals for life activities and participation.5 Speech therapy, occupational therapy, and physical therapy are administered depending on the severity of the injury. The patient showed agitation. The role of family is to support the patient in every aspect. Recent qualitative research with clinicians highlighted the importance of involving families in patient care and educating families about recovery during PTA for the effective management of agitation.6 Based on the severity of the injury, follow-up of the patient is necessary.

Functional impairments in patients after TBI

Post-TBI patients exhibit functional impairments in many ways, which significantly affect a person’s quality of life and ability to perform everyday tasks.

  • 1. Difficulty standing and walking is one of the major consequences of brain injuries. For instance, more than 63% of stroke survivors suffer from half-mild to severe motor and cognitive disabilities. Additionally, 30–36% of patients are unable to walk without assistive aids. Additionally, 30–36% of patients are unable to walk without assistive aids.7 Cognitive disturbances after TBI are often accompanied by behavioral changes such as a lack of initiative, irritability, and poor emotional control. However, symptoms such as headache, dizziness, fatigue, sleep disturbances, and balance problems are common complaints and persist in a large number of patients in the long term. Furthermore, psychological distress, depression, anxiety disorders, and substance abuse were highly prevalent, with up to 75% of patients affected in one study.5

  • 2. TBI is also called posttraumatic amnesia (PTA) because of the acute period of amnesia and disorientation. Individuals with brain injuries can exhibit common motor impairments, such as paralysis, spasticity, or abnormal muscle synergies, leading to compensatory movements and gait asymmetries. This pathological gait hinders skillful, comfortable, safe, and metabolically efficient ambulation.7 Sensory losses such as visual loss, hearing loss or altered perception of touch and proprioception can also be observed. After acute injury, prolonged chronic inflammation may persist for years after TBI, increasing the susceptibility of patients to developing disorders such as dementia.8 Chronic encephalopathy is thought to be caused by a similar pathophysiology.8

    • 1. Functional impairments following traumatic brain injury (TBI) can vary widely depending on the severity and location of the injury, which can include neurological and somatic dysfunction. Abrupt brain injury (TBI) results in significant neurological impairments as well as psychological suffering. According to recent studies, many individuals with recurrent mild traumatic brain injuries (TBIs), both in sports and nonsport contexts, may have permanent, incapacitating neurocognitive and neurobehavioural consequences. Many physical illnesses, cognitive impairments, and mental concerns are common in patients with persistent traumatic brain injury (TBI). Similar to moderate-to-severe TBI, complete or partial hypopituitarism (with isolated growth hormone (GH) insufficiency being the most common) can occur after mild TBI.9

    • 2. The term “somatic symptoms” describes bodily changes that mainly result from traumatic brain injury. Cognitive dysfunction typically subsides within a few days in patients with mild traumatic brain injury and does not always lead to unconsciousness or posttraumatic amnesia. Traumatic brain injury may cause behavioral changes such as personality, anxiety, and depression. Personality changes include impulsivity, apathy, irritability, emotional instability, and anger. Major depression is one of the behavioral effects of traumatic brain injury and is reported most frequently.10

Core principles and objectives of rehabilitation in TBI patients

To prepare for community re-entry, these persons’ joint effort generally involves the family and/or significant others in the individual’s life. This enables ongoing reinforcement and evaluation of treatment goals. In addition, this multidisciplinary and holistic approach is required for patient recovery. The available evidence seems to support the use of medication, particularly methylphenidate, in trials to help people with severe attention and memory impairment. While there is evidence to support the use of cholinesterase inhibitors in treating patients with memory problems, there is also evidence to suggest that this technique may exacerbate the behavioral consequences of injury. To enable an individual to function independently in the community, they must be trained in the use of compensatory equipment, such as memory books or more advanced technology gadgets, to support their everyday tasks. Even though cutting-edge therapies (such as virtual reality environments) have some potential to be incorporated into TBI rehabilitation, more thorough testing in controlled trials is required to fully assess them.11

Furthermore, as the objectives of rehabilitation are concerned, it aims to maximize functional independence to enable individuals to carry out activities of daily living (ADLs) on their own, enhancing physical function, strength, balance, and coordination. The goal of cognitive rehabilitation is to treat any deficiencies in cognitive abilities. Rehabilitation treats communication impairments by enhancing people’s social integration and addressing the emotional and behavioral abnormalities frequently linked to traumatic brain injury (TBI). Counseling, behavioral therapy, and psychosocial interventions may also help in this process. Rehabilitation also reduces the consequences of bowel and bladder dysfunction, skin breakdown, immobility, contractures, and sleep disturbances. The goal of the neurorehabilitation team’s meetings with patients and their families is to assist in controlling expectations and easing the transition between different phases of recovery.12

Physical therapy and rehabilitation methods

Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide, particularly in children and young adults. To guarantee physical activity and the restoration of cognitive functioning, physical therapy must be administered to these patients. Physical therapy is a component of rehabilitation that aims to enhance motor function, train balance and coordination, improve cognition, and prevent various consequences (such as contractures and thromboembolism). The physical treatment regimen included positioning as well as passive and active physical therapies to improve range of motion, strengthen the muscles in the trunk and limbs, enhance balance and movement coordination, and teach functional motions. The use of specialized tools and a variety of physical therapy techniques improved motor function.13 Exercises were performed while lying, sitting, standing, and walking using the concepts of motor learning applied to functional exercise training. The objectives were to improve postural stability, gait patterns, and intra- and interlimb coordination in the upper and lower extremities.14

The medications amantadine and bromocriptine, two dopaminergic medications, have been shown to enhance executive function in people with brain injuries. Speech and language therapy, such as computer-assisted therapy, melodic intonation therapy, constraint-induced aphasia therapy, and neurostimulation methods such as transcranial direct current stimulation, have been shown to improve dysarthria and aphasia in people with acquired brain injuries. Behavioral therapy has been proven to be effective in treating anosognosia. Research shows that playing VR games improves self-awareness and focus.15 However, an integrated approach must be taken to apply these strategies.

Rehabilitation of speech and language in traumatic brain injury patients

Much research on speech and language rehabilitation for traumatic brain injury (TBI) patients explains the importance of early therapeutic intervention and personalized treatment. One study concluded that administering zolpidem to patients with severe TBI significantly improved speech recovery and articulation.16 Additionally, advancements in genetics have enhanced rehabilitation efforts. Specifically, genes such as brain-derived neurotrophic factor (BDNF) and apolipoprotein E (APOE) are believed to play critical roles in aphasia recovery.17 Thus, early therapy is needed for patients with TBI. Additionally, studies have explored the use of mobile apps designed to support speech and language exercises in patients with language and speech disorders. The study assessed 70 apps using the Mobile App Rating Scale (MARS)18 and explained the promising role of evidence-based and high-quality apps in facilitating the effective treatment of adults with language disorders after traumatic brain injury.18

Innovative rehabilitation techniques and technologies for traumatic brain injury patients

The field of traumatic brain injury rehabilitation has transformed to include innovative techniques and technologies that enhance recovery and health outcomes. The systematic review on innovative technologies for the neurorehabilitation of traumatic brain injury (TBI) emphasizes the advantages of new and advanced interventions such as virtual reality, telerehabilitation, social robots and neuromodulation devices in cognitive rehabilitation for TBI patients, while evidence on their effectiveness in motor rehabilitation is limited.19 Moreover, the use of virtual reality as an innovative rehabilitation method for TBI patients provides a great environment for patients to practice physical activity and movement. VR tools such as VR gaming may improve cognitive functions such as memory and executive functions in patients with TBI(19). EEG can also play a role in neurorehabilitation. EEG signals are a significant input in brain-computer interfaces (BCIs) for patients with TBI.20 Furthermore, the use of robotic technologies has shown excellent results in improving motility and functional independence in TBI patients. Advancements in robot-assisted rehabilitation may help in motor learning and can provide consistent, repetitive movement exercises by decoding the brain activity of patients during therapy.21

Long-term care and community integration

Many people with brain injuries need long-term care, usually in nursing homes and rehabilitation facilities, which can offer the kind of care necessary for their disabilities. Brain injury centers offer a range of specialized inpatient and outpatient care, such as individualized, goal-specific rehabilitation. Physical interventions for patients with poor consciousness to address posture and muscle tone. Family support, therapeutic recreation, speech, music, and art therapy, as well as psychological therapies, should be provided. Caregivers can also actively participate in the rehabilitation process and receive tools to support them.22 Young adults with traumatic brain injury may require long-term care. Follow-ups and frequent visits to medical teams, which include neurological, endocrinological, orthopedic, and psychiatric specialists. Ongoing diagnostic procedures include CT scans, MRIs, X-rays, and laboratory testing. Vocational assessments, which examine possible earnings losses. Long-term rehabilitation strategies and checkups should be performed.

TBI frequently leads to a decrease in social interaction. The severity and length of time since the accident had no bearing on this decline in social involvement. Several characteristics, such as executive dysfunction and emotional dysregulation, have been linked to changes in social participation.23 Factors such as tiredness symptoms, physical environment, and social support are associated with the community integration of TBI survivors. It has a detrimental impact on their capacity to live in the community.24 In an assessment, it was discovered that those who had suffered a TBI reported having fewer close friends. Additionally, they reported not meeting new acquaintances, not seeing family and friends as much, attending fewer social events, and spending most of their time alone.23 Social assistance could make it easier for them to interact with people in the community. Support from friends and family has been found to positively correlate with a high degree of CI. Both inpatient and community rehabilitation are available to TBI survivors, who aid in their healing process and help them reintegrate into their homes, communities, and productive lives. Healthcare professionals, especially community or rehabilitation nurses, should develop and execute methods for traumatic brain injury (TBI) survivors, such as follow-up appointments or at-home rehabilitation, to improve the degree of care integration.24

Conclusion

After investigating the epidemiology, results, and rehabilitation of patients with traumatic brain injury in Pakistan, this study elucidated the incidence, prevalence, and demographics of traumatic brain injury (TBI).25,26 This review focused on long-term impairments, survival rates, and factors influencing recovery, such as the availability of medical care and rehabilitation programs.27,28 Through this review, we aim to increase awareness of the challenges TBI patients face while undergoing rehabilitation.29 This could involve issues with financing, societal conventions, cultural components that affect the efficacy of rehabilitation, and difficulties obtaining specialized care.30,31 This also includes recommendations for preventive measures, improvements to emergency medical services, and strategies to fortify rehabilitation initiatives.32 Thus, this study provides an in-depth analysis of the prevalence, outcomes, and rehabilitation challenges faced by TBI patients, offering useful information to researchers, legislators, and healthcare providers.

Ethical approval

The review did not use any human or animal subjects and thus no ethical approval was required. Also, no work was copy-pasted and thus no permission was required.

Data availability

No data are associated with this article.

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Comments on this article Comments (1)

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  • Reader Comment 28 Feb 2025
    Laith Thamer Al-Ameri, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq
    28 Feb 2025
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    Dear author, editors and readers

    I have read this review with interest as it emphasizes the importance of early diagnosis and management of the possible complications of traumatic brain ... Continue reading
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Cheema U, Fatima T, Bilal M et al. Traumatic  brain injury (TBI): Is there anything we can do? A review [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1264 (https://doi.org/10.12688/f1000research.157134.1)
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Version 1
VERSION 1 PUBLISHED 22 Oct 2024
  • Reader Comment 28 Feb 2025
    Laith Thamer Al-Ameri, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq
    28 Feb 2025
    Reader Comment
    Dear author, editors and readers

    I have read this review with interest as it emphasizes the importance of early diagnosis and management of the possible complications of traumatic brain ... Continue reading
    Report a concern
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