Preventing Traumatic Brain Injuries

We will wrap up our discussion of traumatic brain injuries (TBI) this week by discussing things that we can do to help prevent these injuries.

How can traumatic brain injuries be prevented?

We cannot prevent all brain injuries, but there are things that you can do to help reduce the risk of a traumatic brain injury. This includes:

• Always wear a seat belt in a motor vehicle.
• Don't drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive. Warn your children, particularly teenagers, never to ride with a driver who is impaired in any way.
• Always wear a helmet when riding a bicycle, skateboard, motorcycle, snowmobile, or any all-terrain vehicle.
• Always wear appropriate head protection when playing baseball or contact sports, skiing, skating, snowboarding, or riding a horse.
• Never use your phone while driving. Distracted driving is just as bad as driving under the influence of substances when it comes to causing accidents.
• Pay attention to your surroundings. Distractions are not only a problem when driving, but also when walking. Don't walk or especially cross the street while looking at your phone. Even talking on the phone using headphones, without looking at the screen, can often distract you from paying attention to things going on around you. Distractions can lead to falls, getting hit by a passing car, or wandering into dangerous situations unaware.

Special considerations for preventing TBI in children include:

• Children should always ride in the back seat of a car, properly secured in a child safety seat or booster seat that is appropriate for their height and weight. Many parents allow children to ride without a booster seat or in the front seat much earlier than is recommended. Read the American Academy of Pediatrics guidelines here: Child Passenger Safety (aap.org)
• Young children should not ride all-terrain vehicles such as 4 wheelers, even with an adult driver.
• Install safety gates at the top of a stairway.
• Install window guards to prevent falls from windows.
• Don't let children play on fire escapes or balconies.
• Use a nonslip mat in the bathtub or shower.
• When possible, choose playgrounds that have shock-absorbing materials on the ground.
• Regarding sports:
  • Young children should not play tackle football, they should play flag football instead. When playing soccer, they should not be using their head to hit the ball. This way they can learn the game and have fun without risking a TBI during a critical time of brain development.
  • All children should wear appropriate head protection when playing baseball or contact sports, skiing, skating, snowboarding, or riding a horse.
  • Headband devices promoted as "protection" for soccer players have not been shown to significantly decrease the risk of TBI or concussion. Read more here: Headbands for soccer players: Pros and Cons.: SportsSafe: Pediatric Concussion Clinics (sportssafect.com) and here Study: 'Protective' headgear does not prevent sport-related concussions in soccer players (wisc.edu)

Special considerations for older adults to help prevent falls include:

• Install handrails or grab bars in bathrooms.
• Put a nonslip mat in the bathtub or shower.
• Make sure there is adequate lighting in the home, particularly around stairways.
• Keep stairs and floors clear of clutter.
• Make sure stairways have adequate handrails.
• Remove throw rugs.
• Get regular vision checkups and always wear prescribed glasses.
• Get regular exercise. Core strengthening exercises, as well as exercise such as Tai Chi and Yoga, are particularly helpful in improving balance as we get older.

If you have any questions about brain injuries, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Brain Injury – Part III

This week, we will continue our discussion of brain injuries with a discussion of the diagnosis and treatment of traumatic brain injury (TBI).

How are TBIs diagnosed?

Remember that TBIs can be emergencies. Severe brain injuries can worsen rapidly if not treated appropriately and quickly. Doctors need to make a quick assessment of the situation.

If you see someone sustain a head injury, or arrive on the scene immediately after, you may be able to provide valuable information to help health care providers assess the situation. Try your best to remember and pass on details of the injury, such as:

• How the injury happened
• What part of their head was hit, and how hard, and if other body parts were struck
• If there was a fall, from what height the person fell
• Whether or not the person lost consciousness, and for how long
• Whether the person had trouble speaking or seemed confused immediately after the injury
• Whether the person's body was whipped around or severely jarred

What is the Glasgow Coma Scale?

This is a checklist that assesses and gives a certain number of points to things such as how well a person can follow directions, move their eyes, move their limbs, and speak coherently. It helps a doctor to make an initial assessment of the severity of the brain injury.

Are imaging tests required for diagnosis?

Tests such as a CT scan or MRI may or may not be used, depending on the severity of the injury. Mild TBIs usually do not require imaging unless there are underlying risk factors, such as being on blood thinner medication.

How is TBI treated?

Treatment for a TBI, particularly in the acute stage, depends on the severity of the injury.

Mild TBI treatment may include:

• Rest - Limited (but not complete avoidance of) both physical and mental activity
• Avoiding screen time, including television and electronic devices
• Over the counter pain relievers for headache
• Close monitoring to watch for any worsening signs or symptoms or persistent symptoms

Moderate to severe TBI treatment may include one or more of the following:

• Medications or fluids to maintain blood pressure
• Assuring the patient gets adequate oxygen, which may include a ventilator in severe cases
• Monitoring the pressure inside the skull
• Medications to prevent seizures
• Medication to help reduce pressure inside the brain
• Medication to temporarily induce a coma - because a comatose brain needs less oxygen and nutrients to function
• Emergency surgery - to remove blood clots, repair skull fractures, stop bleeding in the brain, or sometimes to open a window in the skull to help relieve pressure on the brain

What happens after the acute phase of treatment?

After a mild TBI, or concussion, a person is usually able to gradually return to normal activities over a period of a few days to several weeks.

After moderate to severe TBI, most people will require some type of rehabilitation. This may be done initially in a hospital or rehabilitation facility. Most people will require continued rehabilitation in the outpatient setting after returning home. Treatment may include:

• Physical therapy - to work on mobility, relearning movement patterns, strengthening, balance, and walking, including learning to use any mobility devices needed
• Occupational therapy - to work on fine motor skills, hand function, and skills to perform everyday activities
• Speech therapy - to improve communication skills and use any new communication devices that might be needed
• Neuropsychology - to assess and improve thinking and behavioral challenges, and help with emotional well being and coping with the injury
• Vocational retraining - may be necessary to help a person to return to work

I thought we might be able to discuss prevention today but I seem to have run out of space! We will discuss the important subject of how to decrease the risk of TBI next week.

If you have any questions about brain injuries, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Brain Injury Part II

Let's continue our discussion of brain injury. In Part I, we talked about some functions of the brain, defined some terms that apply to brain injuries, and talked about some common causes of acquired brain injuries. Today we will talk more specifically about TBIs including concussion.

How does the brain get injured in a closed head injury?

It seems obvious how the brain is injured in an open (penetrating) injury, but it may not be so obvious how the brain is injured when nothing penetrates the brain. The brain is enclosed by the skull, which is a very strong bony structure. The cerebrospinal fluid surrounds the brain within the skull. Most of the time, this fluid protects the brain from impact with the skull. However, when there is rapid acceleration or deceleration of the head, the brain may hit the inside of the skull with enough force to cause injury. Rapid rotational movement of the head can also result in damage to the brain.

This bouncing or twisting of the brain inside the skull may cause:

• Blood vessels in the brain to stretch or bleed
• Cranial nerves and brain cells to be damaged
• Tearing or stretching of the connections between brain/nerve cells
• Chemical changes in the brain

What is a concussion?

There are three main types of traumatic brain injury (TBI): mild, moderate, or severe. A mild TBI is also called a concussion. Although they are considered "mild" TBIs, this is because they are usually not life-threatening. It is not because they are not serious injuries. Here are some facts about concussions.

• Concussions should always be taken seriously.
• Concussion is the most common type of TBI.
• Both closed and open head injuries can lead to a concussion.
• An imaging test of the brain, such as a CAT scan is not needed to diagnose a concussion. In fact, concussion may or may not show up on these tests.
• Brain imaging may sometimes be used for patients at risk for bleeding in the brain after mild trauma.
• Falls are the most common cause of concussion. Concussions are also common if you play a contact sport, such as football or soccer.
• Skull fracture, brain bleeding, or swelling may or may not be present.
• A concussion can cause injury that results in temporary or permanent damage.
• It may take a few months to a few years for a concussion to heal. Nerve and brain cells, and the connections between them, take longer to heal than other types of cells in the body.
• Most people usually recover fully after a concussion.
• A person with a history of multiple or repeated mild TBI/concussions may experience longer recovery time, or more severe symptoms. This is especially true if the second concussion happens before the initial concussion has had time to heal.

What are the symptoms of concussion?

Here are some of the common signs and symptoms of a concussion. Keep in mind that a person with concussion may not experience all of these symptoms.

• Brief loss of consciousness immediately after the injury (which would not exceed 20 minutes)
• Feeling or appearing dazed or confused
• Headache or feeling of pressure in the head
• Memory loss surrounding the traumatic event
• Dizziness
• Ringing in the ears
• Nausea or vomiting
• Slurred speech
• Delayed response to questions
• Double vision
• Fatigue

If you or someone you know experiences symptoms of concussion, seek medical attention immediately. Any brain injury needs to be evaluated and treated promptly.

Next week, we will talk about treatment and prevention of TBIs.

If you have any questions about brain injuries, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Tips to Cope with the Change to Daylight Saving Time

Daylight Saving Time starts at 2 am this Sunday, March 12th. Springing forward will cost us an hour of sleep. This can adversely affect your health. Let's talk about some tips that might help you cope with that lost hour of sleep.

How does the loss of sleep affect us?

The clock in your brain that regulates sleep and wakefulness is typically a very reliable clock. It controls your circadian rhythm, which is about a 24-hour rhythm that responds to sunlight and darkness. For millions of years, it has helped us to slowly adapt to the gradual changes in the natural lighting throughout the year. It doesn't adjust itself easily to rapid shifts just because the clocks in your home change.

Your rhythm gets reset every day based on light exposure. The light in the morning is particularly important. After the time change, that morning light exposure suddenly happens at a later time relative to the nominal clock time. So, if you normally wake up at 7:00 in the morning, your internal clock, may want to have a certain amount of light, but you won't get that light until about 8:00 in the morning. Your internal clock takes anywhere from a few days up to a couple of weeks to adjust fully to the new external clock. And yet you still have the same obligations every day at a certain time of day. So, you have a bit of a disconnect between your own internal rhythm and the external world. Even a one-hour shift can affect us significantly. This is even more of a problem for most Americans who are already a little sleep-deprived on a regular basis.

Medical experts have noted the following adverse effects from the Daylight Saving Time change:

• Increase in car accidents
• Increase in strokes
• Increase in heart attacks
• Sleep deprivation and daytime drowsiness lasting up to weeks after the time change
• Changes in mood can also last up to weeks
• Poor performance on tests of alertness

Here are some tips to help you adjust:

• Make sure you are getting enough sleep on a consistent basis both before and after the time change. Ideally, you should try to go to bed and get up at the same time every morning, weekdays and weekends (within about 15-30 minutes). Aim for 8 hours of sleep each night.
• Try to plan ahead for the time change. Go to bed 15 minutes earlier each night for 2-3 nights leading up to the time change.
• Set a bedtime alarm to remind you to start your bedtime routine every night.
• Avoid drinking alcohol before bed. It may seem to make you drowsy initially, but it can lead to nighttime awakenings and poor-quality sleep.
• Avoid caffeine after midday.
• Do not eat a heavy meal late at night.
• Avoid sleeping an extra hour this Sunday morning. This will just delay your symptoms until Monday when you will need to go to work!
• If you feel sleepy on Sunday after the time change, you can take a short nap during the day, 20 minutes or so. Do not nap after 3-4 pm as this can affect your nighttime sleep.
• Try to get extra exposure to morning sunlight as early as possible. You may consider an alarm clock that mimics sunrise by slowly increasing light for 30 minutes before your alarm goes off.
• Minimize screen time in the evening. Most importantly, do not watch TV or use electronic devices in bed.
• Avoid bright lights in the evening. Lower the lights in your home for instance.
• Be aware of changes in your mood or changes in your alertness and adjust your activities accordingly.

If you have any questions about adjusting to the time change, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Brain Injury

March is Brain Injury Awareness Month. Did you know that there are more than 5.3 million people in the US who are living with a disability cause by a permanent brain injury? At least 2.8 million Americans sustain a traumatic brain injury in the US every year. Some of them will recover fully, with no long-term effects but some will live with the residual effects for the rest of their lives. There were also over 64,000 deaths related to traumatic brain injury (TBI) in the US in 2020. That is about 176 TBI-related deaths every day. With so many people affected, I thought it was a good subject for us to explore.

Let's start by talking about some of the functions of the brain.

The human brain is a complex organ. It is made up of many parts, which each have a specific important function. There are four different lobes of the brain (they make up the cerebrum), plus the cerebellum, and the brain stem. The brain controls our ability to walk, talk, eat, balance. It regulates/coordinates our breathing, blood circulation, and heart rate. It allows us to speak, to process and remember information, make decisions, and feel emotions. The brain is always changing. Every person's brain is unique, even though they may look very similar. The brain is very sensitive to its environment and to injury. It also has the ability to adapt and can be "trained" in new ways to perform tasks when a part of it is damaged. Overall, I would say the brain is a magnificent structure!

Now let's learn some terms that apply to brain injuries.

An acquired brain injury (ABI) is an injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma. Essentially, ABI refers to any brain injury that occurs after birth. There are two different types of ABI. They are traumatic and non-traumatic.

A traumatic brain injury (TBI) is defined as an alteration in brain function or other evidence of brain pathology, caused by an external force or trauma. There are two types of TBI. They are:

• Closed head injury, also called non-penetrating, is an injury that does not cause anything to penetrate the outer coating of the brain. This would include things like concussion. Even a skull fracture would be considered a closed injury if nothing penetrates to the brain.
• Open head injury, or penetrating injury, is a head injury in which the outer layer of the brain is breached. Penetrating injury can be caused by high-velocity projectiles, such as gun shot wounds, or lower velocity objects such as knives, or bone fragments from a skull fracture that are pushed into the brain from the force of impact.

A non-traumatic type of acquired brain injury is one in which damage to the brain is caused by internal factors. This could include lack of oxygen, pressure from a tumor, bleeding inside the skull, increased fluid inside the skull, etc.

Secondary brain injury is caused by swelling and release of chemicals that increase inflammation and lead to injury or death of brain cells. The primary injury is the trauma. The secondary injury leads to swelling in the brain, which may increase the pressure within the skull. This may prevent the cerebrospinal fluid from draining out of the skull, which further increases the pressure leading to more brain cell damage. If the secondary injury is not prevented or recognized, and controlled, the lower portion of the brain can be pushed through the base of the skull. This causes all basic functions of the body, such as breathing, to stop, leading to death.

The only way to prevent the primary injury is to prevent the trauma. Prevention of secondary brain injury is the focus of the acute medical care after the injury. It is the reason why quick and competent medical care is essential after a head injury.

What are some common causes of acquired brain injuries?

Traumatic brain injury causes include:

• Falls
• Assaults
• Motor vehicle crashes
• Sports or recreation injuries
• Abusive head trauma (such as shaken baby syndrome, other child abuse, or domestic violence)
• Gunshot wounds
• Workplace injuries
• Power tool injuries at home (woodworking, chainsaws, etc.)
• Military injuries (such as blast injury)

Non-traumatic brain injury causes include:

• Stroke
• Infections (including meningitis or encephalitis)
• Seizure
• Electric shock
• Tumors
• Exposure to certain toxins (such as lead, carbon monoxide, drug overdose, etc)
• Lack of oxygen (such as drowning, choking, etc.)
• Aneurysm rupture

Next week, we will explore this topic more.

If you have any questions about brain injuries, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor