The neuropsychology specialist María Teresa explains in this article what is traumatic brain injury and its neuropsychological rehabilitation in executive functions.

What are Traumatic Brain Injuries (TBI)?

It is defined as an alteration in brain functioning caused by an external force (Menon, Schwab, Wright, and Maas, 2010).

Traumatic brain injuries (TBI) are a critical public health problem, both due to their high mortality rates and the disabilities experienced by patients who survive, manifesting difficulties at:

• cognitive,
• emotional,
• family,
• social,
• work-related levels,

Affecting 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, rehabilitation programs are designed from a cognitive approach, as it is considered that improving the mental capacity of traumatic brain injury patients has a direct effect on their functionality.

Types of traumatic brain injury (TBI):

Open TBIs:

Open traumatic brain injuries occur when there is a fracture or perforation of the cranial vault, causing a wound in the brain tissue and exposing or leaving the brain mass in contact with the air.

Closed TBIs:

Closed traumatic brain injuries only affect the brain tissue (León-Carrión, 1995).

Both types of trauma usually result in a focal and a diffuse impact. The first corresponds to the injury generated at the site of the brain that received the impact. The second is one that does not occupy a well-defined volume within the intracranial compartment but, like the focal injury, causes neurological sequelae (González, Pueyo, and Serra, 2004).

Focal damage is commonly characterized by alterations in frontal and temporal lobe functioning, as these are the most susceptible areas in closed TBI; in open TBI, it will depend on where the skull bone may be affected. On the other hand, diffuse damage tends to generate loss in complex cognitive functions such as processing speed, concentration and cognitive efficiency in general (Kolb and Whishaw, 2014).

Severity of traumatic brain injury

Severity of traumatic brain injury

The severity of traumatic brain injury is usually classified into three levels, according to the duration a person remains unconscious or experiences traumatic amnesia:

• mild,

• moderate,

• severe.

Glasgow Coma Scale (GCS)

The standard measure to define the severity level of TBI is known as the Glasgow Coma Scale (GCS). It assesses three independent parameters that define the conscious responsiveness of the patient:

• verbal response,

• motor response,

• eye opening.

Scores

Higher scores indicate a better level of consciousness in the patient (Hoffmann et al., 2012; Muñana-Rodríguez and Ramírez-Elías, 2013; Santa Cruz and Herrera, 2006; Poca, 2006):

• Scores between 14-15: correspond to a mild traumatic brain injury,

• Scores between 9-13: moderate,

• Scores lower than or equal to 8: severe.

Evaluation of brain injury

The severity of brain injury should be evaluated as soon as possible, preferably immediately after the injury, to provide a baseline for future assessments and to take timely action, both to medically stabilize the patient and to initiate rehabilitation processes if necessary (Hoffmann et al., 2012; Muñana-Rodríguez and Ramírez-Elías, 2013; Santa Cruz and Herrera, 2006; Poca, 2006).

Intervention after experiencing a TBI

Post-TBI intervention often includes physical and cognitive rehabilitation. In the latter, it is advisable to focus on higher-level cognitive functions such as executive functions, as they tend to be among the most affected in both focal and diffuse brain injuries caused by TBI (García-Molina, Enseñat-Cantallops, Sánchez-Carrión, Tormos, and Roig-Rovira, 2014).

Executive functions in individuals with traumatic brain injury

The concept of executive functioning refers to a set of higher-order cognitive operations such as planning, decision making, and flexibility, among others, which control and regulate behavior, directing it towards a goal, forming objectives, and planning how they can be achieved.

These same functions are also recognized as essential mental capacities for engaging in creative and socially accepted behavior.

Furthermore, executive functions become more complex throughout development, with some of them appearing early on, enabling the emergence and complexification of other executive functions (Bombín-González et al., 2014; Tirapu-Ustárrez, García-Molina, Luna-Lario, Verdejo-García, and Rios-Lago, 2012).

For Tirapu-Ustárrez et al. (2017), a systematic review of factorial analyses of executive functions resulted in an integrative proposal of executive control processes, such as:

• Processing speed: the amount of information that can be processed per unit of time or the speed of cognitive operations;

• Working memory: the capacity to register, encode, maintain, and manipulate information in real time;

• Verbal fluency: the ability to access information retrieval from semantic memory and activate word search;

• Inhibition: control of interference and distractors or selective attention;

• Dual task performance: the ability to attend to multiple stimuli simultaneously;

• Cognitive flexibility: alternation;

• Planning: monitoring and behavioral control;

• Decision-making: the role of emotions in reasoning.

Executive function plays a fundamental role in human life, as it represents a set of cognitive processes with distinct yet intimately related components that control and modulate behavior.

Once these functions are impaired by neurological damage, such as in traumatic brain injury, executive deficits give rise to a variety of cognitive, behavioral, and emotional manifestations that interfere with the individual’s daily life, creating difficulties in recovering a normal and productive life.

Neuropsychological rehabilitation in TBI patients

Rehabilitation can be defined as a systematic application of therapeutic activities, aimed at improving the patient’s functionality, based on the understanding of his or her deficits (Cicerone et al. as cited in van Heugten, Gregório and Wade, 2012).

The intervention must have ecological validity, so that it has a real impact on the patient’s daily life, with the objective that he/she can extrapolate and generalize in his/her daily life, what was learned in consultation (Carvajal-Castrillón and Restrepo, 2013).

Personalized evaluation and rehabilitation programs

The proposals of cognitive rehabilitation, from contemporary neuropsychology, suggest the development of individualized assessment and rehabilitation programs for each pathology, with clear and common expectations and objectives for the patient and his family (Calderón, Cadavid-Ruiz, & Santos, 2016; Carvajal-Castrillón & Restrepo, 2013; Ríos, Muñoz, & Paúl-Lapedriza, 2007; Tate, Aird, & Taylor, 2013).

Their rehabilitation programs consist of tasks hierarchically organized by level of difficulty and requiring the repetitive use of impaired functions. These programs clarify that the degree of functional recovery of the patient, will depend on the number of repetitions and the type of task performed during treatment (Garcia-Rudolph and Gibert, 2015).

In neuropsychology, the design of rehabilitation programs is based on the cognitive approach, since it is considered that improving the mental capacity of patients has a direct effect on their functionality.

In addition, these programs emphasize the importance of adjusting the programs to the individual needs of the patient based on restorative or compensatory techniques. The former refers to the reinforcement, strengthening or restoration of impaired cognitive processes; the latter, presents ways to compensate for the altered function, through the use of resources external to the patient, for example, reminders or alarms, among others (Barman et al., 2016; Evald, 2015; Tsaousides, D’Antonio, Varbanova, & Spielman, 2014).

Now, cognitive rehabilitation must keep in mind that traumatic brain injury is a medical condition that concerns various fields of health; it requires:

• A neurological management to modulate and monitor the damage generated on the brain tissue,

• neuropsychological intervention to recover the highest possible degree of functionality in the patient,

• social management to support the patient’s functionality in the daily contexts in which he/she can develop.

Research findings

Research findings on rehabilitation in patients with traumatic brain injury indicate that the best results are achieved when the intervention programs aim at a global and interdisciplinary management of the medical and psychosocial condition experienced by the patient, which includes intervention in the cognitive, emotional, family and social spheres.

These initiatives should not only aim at the rehabilitation of the TBI patient, but should also be directed towards health promotion, which implies the implementation of measures to assume healthy lifestyles.

References

• 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. y 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. y 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-Rudolpht, A. y Giber, 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. y 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. y 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.

More references

• Park, HY., Maitra, K. y 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., y 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 Rios-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. y 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. y 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.

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