WHAT IS TRAUMATIC BRAIN INJURY AND WHAT CAUSES IT?
Traumatic Brain Injury (TBI) is one of the most serious consequences of trauma and may temporarily or permanently affect brain function.
It is most commonly caused by falls and road traffic accidents, but may also result from work-related or sporting accidents, assaults and other injuries.
In Greece, as internationally, the frequency and causes of TBI have changed. Road traffic accidents remain an important cause, particularly in younger people, while falls are now very common, especially in older people.
HOW IS TRAUMATIC BRAIN INJURY MANAGED?
Management of TBI begins immediately at the scene of the injury, continues during transport and in the Emergency Department and, when required, in the Intensive Care Unit or Neurosurgical Department.
Once the patient has been stabilised, Rehabilitation is initiated according to their clinical condition.
The immediate priorities are to secure breathing and circulation, protect the cervical spine and prevent secondary brain injury, particularly from hypoxia and hypotension.
The level of consciousness is assessed systematically using the Glasgow Coma Scale (GCS), which evaluates eye opening, verbal response and motor response.
According to the GCS score, TBI is conventionally classified as:
- Mild: GCS 13–15
- Moderate: GCS 9–12
- Severe: GCS 8 or less
However, the severity and prognosis of TBI are not determined by the GCS alone.
The duration of loss of consciousness and post-traumatic amnesia, age, pupillary responses, CT or MRI findings, the presence of intracranial haemorrhage or cerebral oedema, and episodes of hypoxia or hypotension are also taken into account.
In severe TBI, intensive neurological monitoring, monitoring of intracranial pressure and management of intracranial hypertension may be required and, when there is a lesion requiring surgical treatment, emergency neurosurgical intervention may be necessary.
WHEN IS A CT SCAN OF THE BRAIN REQUIRED?
A CT scan of the brain is the first-line imaging investigation for identifying significant acute traumatic brain injury.
It is not required in every case of mild TBI. The need for CT is determined by the clinical picture and specific risk factors.
In adults, an urgent CT scan is required when one or more of the following are present:
- a GCS score of 12 or less at initial assessment, or less than 15 two hours after the injury,
- focal neurological signs,
- a seizure following the injury,
- two or more episodes of vomiting,
- suspected open or depressed skull fracture,
- signs of a basal skull fracture.
When amnesia is present or there has been loss of consciousness, CT is also required when one or more of the following factors are present:
- age 65 years or older,
- a clotting disorder,
- a pedestrian or cyclist struck by a motor vehicle,
- an occupant ejected from a motor vehicle,
- a fall from a height of more than one metre or five stairs,
- inability to recall events for more than 30 minutes immediately before the injury.
Particular attention is required in patients taking anticoagulant or antiplatelet medication, because of the increased risk of intracranial haemorrhage. Even when no other indication is present, CT scanning should be considered.
Aspirin, when it is the only antiplatelet medication being taken, is not in itself an indication for CT unless another risk factor is present.
Leakage of cerebrospinal fluid from the nose or ear may indicate a basal skull fracture and requires immediate investigation and neurosurgical assessment.
A CT scan may demonstrate cerebral contusions, extradural or subdural haematoma, subarachnoid or intracerebral haemorrhage, cerebral oedema, fractures and other injuries requiring close observation and, in some cases, emergency neurosurgical intervention.
Magnetic Resonance Imaging (MRI) of the brain is not usually the first imaging investigation in the acute phase. In selected patients, however, it may demonstrate lesions that are not adequately visualised on CT, such as diffuse axonal injury, and provide additional information about the extent and severity of the injury.
WHAT HAPPENS IN MILD TRAUMATIC BRAIN INJURY?
Most patients with mild TBI do not require hospital admission, provided that their neurological status is normal, there is no evidence of significant intracranial injury and safe observation at home can be ensured.
Discharge from hospital should be accompanied by clear verbal and written instructions to the patient and family about symptoms that require immediate reassessment.
A normal CT scan does not exclude symptoms following mild TBI. Headache, dizziness, fatigue, sleep disturbance, difficulty concentrating or remembering, and other symptoms may persist for some time after the injury.
After a short period of relative rest, return to everyday physical and cognitive activities should be gradual and guided by the patient’s tolerance, while avoiding activities that could result in another injury.
Prolonged bed rest does not accelerate recovery.
When symptoms persist or significantly interfere with everyday life, reassessment and appropriate management according to the specific problem are required.
WHAT IS POST-TRAUMATIC AMNESIA?
Following TBI, a period of Post-Traumatic Amnesia may occur.
The patient may be confused and disorientated, have difficulty concentrating and be unable to retain new information and events.
They may also show restlessness, agitation or changes in behaviour.
The duration of Post-Traumatic Amnesia is an important indicator of the severity of brain injury and should be assessed daily using a standardised and validated scale, such as the Westmead Post-Traumatic Amnesia Scale, until it resolves.
WHAT IS THE ROLE OF REHABILITATION?
Following moderate or severe TBI, patients may have persistent disorders of movement, speech, language, communication and swallowing, as well as difficulties with concentration, attention, memory, information-processing speed and higher cognitive functions.
There may also be significant changes in emotion, behaviour and personality.
Rehabilitation should begin early, as soon as the patient’s general medical condition permits, and should be organised around specific and measurable goals according to the patient’s needs and abilities.
Rehabilitation of higher cognitive functions requires systematic neuropsychological assessment and structured therapeutic intervention addressing attention, memory, information-processing speed, planning and organisation of behaviour, problem solving and the patient’s awareness of their own difficulties.
Difficulties with communication, behaviour and interpersonal relationships are also addressed.
Treatment is always related to the real demands of the patient’s everyday life.
HOW DO WE MANAGE TRAUMATIC BRAIN INJURY AT ANAPLASI?
At ANAPLASI, the Multidisciplinary Rehabilitation Team assesses each patient’s neurological, cognitive, psychological and functional status and develops an individualised Rehabilitation programme with specific and measurable therapeutic goals and systematic reassessment of progress.
The programme includes:
- physiotherapy and balance and gait training,
- occupational therapy and training in activities of daily living,
- specialised aquatic therapy in the Hydrotherapy Pool,
- speech and language therapy for disorders of speech, language, communication and swallowing,
- dietetic assessment and follow-up, with feeding adapted to each patient’s needs and clinical condition,
- Clinical Psychology – Neuropsychology, with systematic assessment and Rehabilitation of higher cognitive functions and management of changes in emotion and behaviour,
- management of spasticity and pain,
- psychological support for the patient and their family,
- information, education and guidance for the patient and family regarding the course of recovery and the safe management of functional difficulties.
When indicated, the programme includes aerobic exercise, with gradual increases in intensity and duration, using specialised equipment, to improve endurance.
For inpatients, respiratory physiotherapy is provided from the time of admission, with the aim of maintaining and improving respiratory function, promoting better lung expansion and facilitating the mobilisation and clearance of bronchial secretions.
DISORDERS OF CONSCIOUSNESS
In patients with a prolonged disorder of consciousness, arousal, responsiveness to stimuli and the extent to which the patient is aware of themselves and their surroundings are assessed systematically and repeatedly.
Where feasible, assessment is also performed using standardised scales such as the Coma Recovery Scale – Revised (CRS-R), allowing even small changes in arousal and awareness to be recorded systematically.
Assessment is not based on a single examination but is repeated throughout the course of Rehabilitation and interpreted together with the patient’s overall neurological condition.
SPEECH AND LANGUAGE THERAPY – SPEECH, COMMUNICATION AND SWALLOWING
Following TBI, disorders of speech, language and communication of varying type and severity may occur.
Communication may also be affected by difficulties with attention and memory, organisation and coherence of speech, or understanding the meaning and demands of a conversation.
Speech and language therapy aims to improve these difficulties according to the needs and goals of each patient.
When a swallowing disorder is present, specialist assessment and treatment are provided.
At the ANAPLASI Dysphagia Unit, when clinically indicated, Flexible Endoscopic Evaluation of Swallowing – FEES is performed.
The examination uses a thin, flexible endoscope introduced through the nose, allowing direct assessment of swallowing function, secretion management and airway protection.
This enables assessment of the safety and efficiency of swallowing, and the findings are used to guide the individualised planning of treatment, feeding and hydration.
When required, dietetic assessment and follow-up are also provided to help ensure adequate and safe feeding and hydration.
MANAGEMENT OF SIALORRHOEA
Following TBI, particularly in patients with severe neurological injury and impaired oromotor control or swallowing, sialorrhoea may occur, usually because of difficulty managing and swallowing saliva rather than excessive saliva production.
Posterior flow of saliva towards the pharynx is particularly important because it may increase the risk of aspiration.
Management is individualised and may include therapeutic interventions to improve oromotor control and swallowing, medication and, in selected patients, botulinum toxin type A injections into the salivary glands, usually under ultrasound guidance.
Botulinum toxin injections into the salivary glands require careful patient selection and close monitoring because, in rare cases, they may cause or worsen difficulties with chewing or swallowing and increase the risk of aspiration.
CLINICAL PSYCHOLOGY – NEUROPSYCHOLOGY
Clinical Psychology – Neuropsychology is a fundamental part of Rehabilitation following TBI.
Neuropsychological assessment systematically examines attention, concentration, information-processing speed, memory, planning, organisation and problem-solving ability, visuospatial functions and the patient’s awareness of their own difficulties.
Social cognition is also assessed, including the patient’s ability to understand the emotions, intentions and behaviour of others and to adapt their own behaviour appropriately in interpersonal and social relationships.
Based on the findings, an individualised programme for the Rehabilitation of higher cognitive functions is developed, with specific goals and methods designed to help the patient manage difficulties more effectively in everyday life.
Changes in emotion, behaviour and personality, as well as difficulties adjusting to the consequences of the injury, are also assessed and treated.
Particular importance is placed on supporting and educating the family, so that they understand the changes that have occurred and can contribute effectively to their management in everyday life.
DIGITAL COGNITIVE REHABILITATION SYSTEM RehaCom
At ANAPLASI, when indicated, the programme for the Rehabilitation of higher cognitive functions following TBI is supported by the specialised digital cognitive Rehabilitation system RehaCom.
Specially designed exercises are used to train functions such as attention, memory, information-processing speed, executive functions and visuospatial abilities.
The level of difficulty is adjusted to each patient’s needs and performance, allowing individualised and systematic training and monitoring of progress.
RehaCom is used as part of the overall Rehabilitation programme and does not replace neuropsychological assessment or individualised therapeutic intervention.
ROBOTIC REHABILITATION
In appropriately selected patients with motor deficits, modern robotic Rehabilitation technology is used.
Robotic systems are used for controlled and repetitive training in standing and walking and, where there is functional impairment of the upper limb, for retraining of the upper limb and hand.
Robotic technology is used as an adjunct and does not replace active therapeutic exercise.
MANAGEMENT OF SPASTICITY
Spasticity is treated when it causes pain, restricts movement or function, interferes with care or contributes to the development of contractures and deformities.
Spasticity is always assessed in relation to the patient’s functional ability and specific therapeutic goals.
Management includes physiotherapy, appropriate positioning and mobilisation, the use of suitable aids and orthoses, specialised aquatic therapy in the Hydrotherapy Pool and medication.
In selected patients with focal spasticity, botulinum toxin type A may be injected under electromyographic guidance as part of the overall Rehabilitation programme.
This is followed, according to individual needs and therapeutic goals, by physiotherapy, occupational therapy and, when indicated, the use of appropriate aids and orthoses.
CARE OF THE SEVERELY AFFECTED PATIENT
In patients with severe TBI and major limitations in mobility, Rehabilitation and the prevention of complications begin early, as soon as the patient’s medical condition permits, even before the patient is able to get out of bed.
In the Inpatient Rehabilitation Unit at ANAPLASI, advanced therapeutic beds are used, allowing controlled and programmed changes of position, alternating lateral rotation, specialised pressure management, full-chair positioning and, when indicated, gradual progression towards a more upright position.
These functions also contribute to both the prevention and management of pressure ulcers.
They also provide percussion and vibration functions which, when clinically indicated, can be incorporated into the patient’s respiratory care.
These functions form part of the overall medical, nursing and therapeutic management and do not replace active mobilisation or a structured Rehabilitation programme.
In patients with a high level of physical dependence, electrically powered patient hoists may also be used for safer transfer from the bed to the wheelchair and to treatment areas.
SEXUAL FUNCTION AND REHABILITATION
Following Traumatic Brain Injury, changes in sexual desire and sexual function may occur. These may be related to the neurological injury, motor or sensory difficulties, fatigue, disturbances of mood and behaviour, changes in higher cognitive functions or, in some patients, hormonal disorders caused by dysfunction of the hypothalamic–pituitary axis.
Sexual rehabilitation includes individualised assessment, information and practical guidance, management of underlying problems and, where required, psychological, endocrinological or other specialist medical support.
Safe behaviour, judgement and respect for consent and boundaries in interpersonal relationships are also particularly important.
RETURNING HOME AND TO EVERYDAY LIFE
Rehabilitation may be provided through Inpatient Rehabilitation, Day Rehabilitation or Rehabilitation at Home, according to the patient’s clinical, neurological and functional condition.
Before returning home, the patient’s needs and living conditions are assessed. Appropriate adaptations to the home environment and any necessary assistive devices are recommended and, where required, the family is trained so that the return home can take place with greater safety and independence.
CREATIVE ACTIVITIES, SPORT AND SOCIAL PARTICIPATION
At ANAPLASI, creative activities, sport and social participation complement the Rehabilitation programme and are adapted to each patient’s neurological and functional condition, cognitive abilities, interests and therapeutic goals.
Activities include painting, arts and crafts, cooking, music and theatre activities, group activities and adapted sport, as well as participation in cultural and social activities both within and outside ANAPLASI.
These activities provide opportunities for active participation, social interaction, taking initiative, making use of functional abilities and gradual return to everyday life and community participation.
PREVENTING ANOTHER TRAUMATIC BRAIN INJURY
Following TBI, particular importance is also placed on preventing another injury.
At ANAPLASI, we assess factors that may increase the risk of another injury and educate the patient and family regarding a safe return to everyday life.
Prevention includes the use of a seat belt in the car and an appropriate helmet when riding a motorcycle or bicycle, adherence to health and safety regulations in the workplace, avoiding driving under the influence of alcohol or other substances, and following appropriate safety measures during sport and recreational activities.
Return to driving is not automatic after TBI. When the injury has affected attention, reaction time, judgement, vision, mobility or other functions required for safe driving, appropriate medical and functional assessment is required before driving is resumed.
The patient’s risk of falls is also assessed on the basis of balance, gait, muscle strength, vision, higher cognitive functions and overall functional status.
According to the patient’s needs, individualised preventive measures, appropriate assistive devices and environmental adaptations are recommended.
The Multidisciplinary Rehabilitation Team educates the family and provides clear guidance regarding the assistance and supervision the patient requires at home and during mobility.
When the family is unable to meet these needs, support should be provided by appropriately trained carers.
Everyday support may also be provided through the Greek “Personal Assistant for Persons with Disabilities” programme, where the patient’s participation has been approved.
When nursing or other specialist care is required, it should be provided by the appropriate healthcare professional.
The aim is for the patient to live safely and as independently as possible.
WHAT IS THE AIM OF THE REHABILITATION PROGRAMME?
At ANAPLASI, the aim is to achieve the greatest possible recovery of the patient’s functional ability and independence and to support their active return to personal, family, social and working life.
