Traumatic Brain Injury

Traumatic brain injury (TBI) occurs when a sudden, external, physical injury damages the brain. It is one of the most common causes of disability and death in adults. The damage can be focal (confined to one area of the brain) or diffuse (affecting more than one area of the brain). The severity of a brain injury can range from a mild concussion to a severe injury that results in coma or death.

The damage caused by TBI can occur in phases. Primary brain injury is the immediate damage to the brain at the time of impact (such as a car accident, gunshot wound, or fall). Secondary brain injury refers to the changes that evolve over hours or days after that impact, which includes a cascade of cellular, chemical, tissue, or blood vessel changes that further destroy brain tissue.

Types of Brain Injuries

A brain injury may occur in several ways, including the following:

  • Closed brain injury: Occurs without a break in the skull. The brain is instead damaged by rapid movement or shaking that bruises or tears tissue and blood vessels. Closed brain injuries are caused by car accidents, falls, playing sports, and by shaking a baby (called shaken baby syndrome).
  • Penetrating brain injury: Occurs when there is a break in the skull, such as when a bullet pierces the brain.
  • Diffuse axonal injury (DAI): Involves the tearing of the brain's connecting nerve fibers (axons) that occurs when the brain is injured as it shifts inside the skull. DAI usually causes injury to different parts of the brain and coma. The changes in the brain are often microscopic and may not be seen on a CT or MRI scan.

Causes of Traumatic Brain Injury

There are many causes of head injury. The most common are car accidents, violence, falls, or the shaking of a child (as seen in cases of child abuse).

When there is a direct blow to the head, the bruising of the brain and damage to the internal tissue and blood vessels is due to a mechanism called “coup-countercoup.” A bruise at the site of impact is called a coup (“coo”) lesion. As the brain jolts backwards, it can hit the skull on the opposite side and cause a bruise called a countercoup lesion. The jarring of the brain against the sides of the skull can cause shearing (tearing) of the internal lining, tissues, and blood vessels leading to internal bleeding, bruising, or swelling of the brain.

Symptoms and Effects of Traumatic Brain Injury

Some brain injuries are mild, with symptoms disappearing over time with proper attention. Others are severe and may cause permanent disability. The long-term or permanent results of brain injury may require post-injury and possibly lifelong rehabilitation.

The effects of brain injury may include:

Cognitive deficits

  • Coma
  • Confusion
  • Shortened attention span
  • Memory problems
  • Problem-solving deficits
  • Problems with judgment
  • Inability to understand abstract concepts
  • Loss of sense of time and space
  • Decreased awareness of self and others
  • Inability to accept more than one- or two-step commands simultaneously

Motor deficits

  • Paralysis or weakness
  • Spasticity (tightening and shortening of the muscles)
  • Poor balance
  • Decreased endurance
  • Inability to plan motor movements
  • Delays in initiation
  • Tremors
  • Swallowing problems
  • Poor coordination

Perceptual or sensory deficits

  • Changes in hearing, vision, taste, smell, and touch
  • Loss of sensation or heightened sensation of body parts
  • Left- or right-sided neglect
  • Difficulty understanding where limbs are in relation to the body
  • Vision problems

Communication and language deficits

  • Difficulty speaking and understanding speech (aphasia)
  • Difficulty reading (alexia) or writing (agraphia)
  • Difficulty knowing how to perform common actions, like brushing teeth (apraxia)
  • Slow, hesitant speech and decreased vocabulary
  • Difficulty forming sentences that make sense
  • Problems identifying objects and their function
  • Problems with reading, writing, and ability to work with numbers

Functional deficits

  • Impaired ability with activities of daily living (ADLs), such as dressing, bathing, and eating
  • Problems with organization, shopping, or paying bills
  • Inability to drive a car or operate machinery

Social difficulties

  • Difficulty with interpersonal relationships
  • Difficulties in making and keeping friends
  • Difficulties understanding and responding to the nuances of social interaction

Regulatory disturbances

  • Fatigue
  • Changes in sleep patterns and eating habits
  • Dizziness
  • Headache
  • Loss of bowel and bladder control

Personality or psychiatric changes

  • Apathy
  • Decreased motivation
  • Mood swings
  • Irritability
  • Anxiety and depression
  • Disinhibition, including temper flare-ups, aggression, cursing, and inappropriate sexual behavior
  • Possible increased likelihood of developing certain psychiatric disorders

Traumatic epilepsy

Epilepsy can occur with a brain injury, but more commonly with severe or penetrating injuries. While most seizures occur immediately after the injury, or within the first year, it is possible for epilepsy to surface years later.


In some patients, traumatic brain injury may result in a coma. Coma is an altered state of consciousness that may be very deep (unconsciousness) so that no amount of stimulation will cause the patient to respond. Or it can be a state of reduced consciousness, so that the patient may move or respond to pain. The depth of coma, and the time a patient spends in a coma, varies greatly depending on the location and severity of the brain injury. Some patients emerge from a coma and have a good recovery; others have significant disabilities.

Depth of the coma is usually measured in the emergency room using a Glascow coma scale (from 3 to 15), which assesses eye opening, verbal response, and motor response. A high score indicates greater consciousness. Rehabilitation settings use several scales to rate a patient’s progress, including the following:

  • Rancho Los Amigos 10 Level Scale of Cognitive Functioning: Rates how the patient reacts to external stimuli. The scale consists of 10 levels that each patient progresses through.
  • Disability Rating Scale (DRS): Measures cognitive and physical functional change during recovery, rating a patient’s disability level from extreme to none.
  • Functional Independent Measure (FIM): Measures a person's level of independence in activities of daily living from 1 (complete dependence) to 7 (complete independence).
  • Functional Assessment Measure (FAM): Used along with FIM and was developed specifically for people with brain injury.

Treatment and Rehabilitation for TBI

Most studies suggest that once brain cells are destroyed or damaged, they do not regenerate. However, recovery after brain injury can take place. In some cases, other areas of the brain compensate for the injured tissue, or the brain learns to reroute information around the damaged areas. Each person’s brain injury and rate of recovery are unique. Recovery from a severe brain injury often involves a prolonged or lifelong process of treatment and rehabilitation.

TBI rehabilitation begins during the acute treatment phase. As the patient's condition improves, a more extensive rehab program is often begun. The success of rehabilitation depends on many variables, including the severity of the injury, the type of resulting disabilities, the patient’s overall health, and family support.

It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence.

The goal of brain injury rehabilitation is to help the patient return to the highest possible level of function while improving daily life physically, emotionally, and socially.

Specific areas covered in a TBI rehabilitation program may include:

  • Self-care skills, such as feeding, grooming, bathing, and dressing
  • Physical care, such as nutrition and skin care
  • Mobility, such as walking, transfers, and self-propelling in a wheelchair
  • Communication skills, such as speech, writing, and alternative methods of communication
  • Cognitive skills, such as memory, concentration, judgement, problem-solving, and organization
  • Socialization skills
  • Vocational training
  • Pain management, including medication and alternative methods of managing pain
  • Psychological testing and counseling
  • Family support, such as assistance with lifestyle changes and financial concerns
  • Education, such as training about home care and adaptive techniques
  • Spasticity management, including oral medications, botulinum toxin and other injections, and intrathecal baclofen pumps.

There are a variety of brain injury treatment programs, including:

  • Acute rehabilitation programs
  • Subacute rehabilitation programs
  • Long-term rehabilitation programs
  • Transitional living programs
  • Behavior management programs
  • Day-treatment programs
  • Independent living programs

Why Choose Columbia for TBI Rehabilitation

Our expert team is highly skilled in partnering with patients and families to help individuals who have experienced a TBI achieve their best possible outcomes. Combining clinical expertise and personalized attention, our specialists have extensive experience in all areas of TBI rehabilitation, including mobility, cognitive and behavioral issues, physical care, spasticity management, and helping the patient and their family adjust to lifestyle changes.