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TBI: The disability in disguise

July 20, 2011
by Nick Zubko, Associate Editor
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Growing knowledge and individualized treatment hold the keys to more successful recoveries

Despite its many and sometimes mysterious capabilities, the brain is essentially similar to other tissue, muscles, or organs of the body. And, like these, it can be physically damaged in ways that prevent it from operating as it once did. 

Each year, an estimated 1.7 million people suffer “traumatic brain injuries” (TBIs) in the United States. Of those, 52,000 die, 275,000 are hospitalized and 1.4 million—nearly 80 percent-are treated and released from emergency rooms.1 But for many, the release from the hospital is only the beginning. Serious trauma to the brain can often result in permanent impairments to cognition, behavior, and musculoskeletal control.

“Initially, there's no way to know how much improvement a person will make,” notes Duane Reynolds, associate director of Vinland National Center, a TBI-centered treatment facility in Minneapolis, Minn. “Most medical professionals are reticent to be negative, so they will tell the family to ‘wait and see.’ That's because in a way, everyone is unique. You can't tell exactly what's going to happen.”

Difficult to identify, easy to misdiagnose

Traumatic brain injuries can occur when “the skull is struck (by impact or blast pressure, for example), suddenly thrust out of position, or penetrated,2,3 causing a disruption of normal brain function. While initial symptoms vary widely, the injured person typically “knows” that something is wrong, but doesn't know exactly what.

“In many cases, individuals with TBI just know that they don't quite fit anymore, and they feel a bit more ‘peripheral’,” explains Reynolds. “They know something is different, so they try to cover it up and move on. But inside they're wondering why they aren't clicking on all cylinders.”

While brain imaging techniques, such as CT scans and MRIs, may capture physical evidence of a TBI, researchers at Washington University (St. Louis) observe that some brain injuries are “too subtle to be detected” by standard scans4. The difficulty of detecting physical evidence of TBIs, despite brain imaging, physical examination, and patient history information mean that many cases of TBI probably go undiagnosed.

Reynolds believes that other TBIs might be misdiagnosed or inappropriately treated if medical professionals fail to ask the right questions: Have you ever been in an accident? Have you ever had a concussion? Have you ever lost consciousness? Have you ever been in a coma?’”

Cognitive challenges are typically the “hallmark of TBI,” according to Mary R. Hibbard, PhD, a professor of rehabilitation medicine and director of psychology services at the Rusk Institute of New York's Langone Medical Center. “[These] can show up in a number of ways, including reduced concentration, impaired memory and learning, slowed processing speed, and reduced problem-solving abilities.”

Hibbard, who recently addressed a meeting of the American Psychological Association, says many individuals with TBI must confront “lifelong physical, emotional and cognitive challenges that impact their maximal return to former community and social roles.”

Reynolds adds that individuals with a TBI “often have issues with stamina and impulse control.” He says the condition can also affect important job and leadership skills, noting that many individuals “have trouble organizing, planning, and unfolding a series of steps to meet a specific goal” while those with more severe cases “might have trouble with numbers.”

Collateral damage: The personal impact of TBI

For many individuals with TBIs, the realization of their diminished cognitive abilities, whether temporary or permanent, creates extreme frustration. Like all people, these individuals have, prior to their injuries, lived lives based on expectations shaped by their personal abilities, personal or parental aspirations, and educational or societal opportunities.

But a brain injury forces them to confront new limitations and many just don't know how to cope.

“They look at what they were, and what they were going to do, and realize that now it's not possible,” Reynolds explains. “There's a sense of loss and grief, a total lack of self-acceptance.” He warns that there's real risk that this shock can snowball into larger and more disruptive problems including substance abuse, major depression and an increased risk of suicide.

Due to common experiences with “emotional and behavioral challenges,” Hibbard explains that TBI can often result in a “delayed onset of depression and/or anxiety, as well as problems with anger management, irritability and difficulty with emotional control.”

Reynolds says that individuals with TBI tend to “irritate their social networks,” going downhill until “they have very few friends left and their family is fed up with them, because they can't understand why the individual can't go back to being the way that they once were.”