Traumatic Brain Injury
...urred to speech that is unintelligible. Vocal cord dysfunction may also affect voice quality. Swallowing reflexes could be affected, resulting in excessive saliva accumulation in the mouth. Difficulty swallowing reflexes usually result in the build up of saliva with subsequent drooling. In severe cases, tube feedings may be necessary in order to prevent aspiration. Traumatic Brain Injury 5 Walker further maintained that other speech and language problems may result from articulation disorders. In this instance, no significant weakness or incoordination for reflexive action, but rather, the inability to position and sequence muscle movements. For example, the individual may be able to scrape a food particle off the teeth with the tongue but may be unable to position the tongue to the teeth in order to produce a “t” sound. This condition is known as apraxia of speech. Individuals have more difficulty with complex speech tasks and with longer words. Apraxia of speech rarely occurs in isolation and is frequently associated with aphasia. Aphasia, impairment in the ability to comprehend and use language, can affect verbal or written communication and is the result of dysfunction of language centers in the brain. Echeverri (1999) stated a traumatic brain injury may alter a variety of cognitive skills. Memory encompasses the ability to analyze and store perceptions of the external world and to categorize those perceptions for later recognition and recall. Memory impairments caused by severe brain injuries may involve recent or remote memory. Individuals may be unable to complete simple daily tasks, such as dressing, because they are unable to remember the steps involved or because, after completing the first steps of the task, they forget their original goal. Individuals with remote memory impairments may have forgotten their own personal history or may be unable to remember skills that were once familiar. Other possible cognitive impairments include decreased organizational skills, attention or concentration deficits, and decreased reasoning and problem-solving ability. Traumatic Brain Injury 6 Echeverri (1999) also stated there are behavioral and emotional signs as well as personality changes are associated with almost all severe brain injuries. The development of a personality and emotional disorder may be the most disabling factor in traumatic brain injury. At times, it is difficult to distinguish the extent to which personality changes are the direct consequence of physiologic damage to the brain and the extent to which they are a personal reaction to the losses associated with the disability itself. After a traumatic brain injury, individuals may exhibit sudden mood swings from happy to sad, or complacent to unstable, with little or no provocation. Davidson (2000) agreed that individuals may experience difficulties in initiating behavior or carrying out self-directed behavior. They may behave impulsively, appearing to act quickly without thinking or without anticipating the consequences of their behavior. According to Cambell (2000), poor self-awareness may also be a direct physiologic result of a severe brain injury. Individuals may lack insight into the inappropriateness of their behavior or performance. They may show disinhibition and lack the social skills needed to function adequately within the environment. With experience and appropriate feedback, however, some degree of self-awareness may be achieved. S. Walker (1998) wrote aggressive behavior may be a sequel to traumatic brain injury. It can result from frustration, or it can be a direct physiologic consequence of the injury. Aggression can be expressed actively or passively, verbally or physically. Traumatic Brain Injury 7 Aggressive behaviors may include violent verbal or physical acts toward people or objects, lack of cooperation, and failure to perform certain tasks or duties. Bethesda (2000) said depression, anxiety, and reduced self-esteem are commonly associated with traumatic brain injury. As individuals become increasingly aware of the losses, restrictions, and alterations in lifestyle that frequently follow traumatic brain injury, they may be overwhelmed by hopelessness and anxiety. They may become preoccupied with feelings of worthlessness and grief. Suicide ideation is not uncommon and should always be taken seriously. Frazier (2001) stated that most individuals who have experienced a TBI must abstain from alcohol or other substances that have not yet been medically prescribed. The use of alcohol and other substances can increase the potential for seizures after a TBI, however, and the interaction of such substances with prescribed medications can have dangerous effects. In addition, alcohol and other substances potentiate any existing impairment of psychomotor and cognitive function, thus increasing the chances of accident and additional injury. An individual may view such restrictions as further losses caused by injury, and may need considerable education and support in order to adhere to these limitations. S. Walker (2001) stated the initial treatment after a TBI is intended to stabilize the condition and to enhance the recovery process. Special attention is given to maintaining the individual’s nutritional status and preventing complications such as infections and contractures. Careful observation is essential to detect early signs of increased intracranial pressure, which, unless relieved, can cause additional damage or even death. Traumatic Brain Injury 8 Intracranial pressure is monitored by inserting a catheter through the skull into a ventricle of the brain, into the subarachoid space around the brain, or into the epidural space around the brain. Walker further stated that the treatment of increased intracranial pressure can be surgical or nonsurgical. Surgical intervention may involve the placement of a shunt that allows excess cerebrospinal fluid to drain into the general body circulation. If the individual has an open fracture, surgery may be necessary to remove fragments of bone or other foreign materials and to repair the skull. When blood clot or hemorrhage is responsible for the increased intracranial pressure, two small holes, called burr holes, may be placed into the skull and the blood clot removed or the bleeding controlled. In other instances, individuals with these injuries may undergo a craniotomy, a surgical procedure in which the skull is opened and the clot or foreign object removed or bleeding controlled through the surgical incision. Nonsurgical interventions for increased intracranial pressure consist of giving medications such as diuretics to remove fluid from the brain, thus helping to relieve the pressure. Steroids also may be used, although the exact reason that they work is unknown. Walker also stated that after the condition has stabilized, appropriate treatment requires early active intervention by a complete team that includes specialists in physical and occupational therapy, speech and language therapy, psychological evaluation and therapy, and cognitive retaining. In the early phases of brain injury, physical therapy focuses on activities to prevent joint and muscular complications. Later, physical therapy may be directed toward improving balance, muscle control, and ambulation and other Traumatic Brain Injury 9 physical movements. Occupational therapy may help individuals with brain injury to integrate available sensory information so that they can use it as a basis for motor activity and to increase their ability to perform activities of daily living. Individuals may also need assistance to increase their awareness or orientation to time, place, and person. Bethesda (2000) agreed that speech and language therapies may focus on the mechanical difficulties of speech, as well as on the formation and execution of language, or on the development of alternative communication systems. Psychotherapy may be directed toward both the individual and the family in order to facilitate the adjustment process. P. Walker (1999) stated that cognitive deficits, rather than physical deficits, hamper effective daily functioning of individuals with brain injury. Cognitive remedy strategies that are designed to improve sensory and perceptual, language-related, and problem solving deficits of individuals with brain injury may be a major focus of the rehabilitation effort. The goal of therapy is to return individuals with brain injury to as much independent functioning as possible in as many areas as possible. In some instances, depending on their individual life circumstances and the extent of the brain damage, long-term supportive care may be needed. Walker further stated that individuals with brain injury who are medically stable and have good potential for independent living may be placed in residential community reentry or transitional living programs. These programs offer individual therapies designed to improve functioning or assistance in developing social behaviors, or they may provide care and supervision for individuals who require some assistance in meeting basic needs, as in a supervised liv...