Abstract
Traumatic brain injury (TBI) is the bruising of the brain due to an impact received on the head. The brain injury can be termed as primary if its caused directly by the impact blow or secondary if its caused by reaction processes such as swelling due to inflammation. Common types TBI include hematomas, contusions, diffuse axonal injury (DAI), concussion, and coup/contrecoup lesions. The type of injuries are characterized by symptoms such as dizziness, headaches, amnesia, loss of consciousness, going into a vegetative state or a coma or death in extreme cases. There is no clearly defined body of knowledge that links the type of injury and the resulting symptoms. As such, doctors are unable to identify the type of injury based of the symptoms, which leads to the exacerbation of the injury due to development of secondary bruises. This research proposal recommends a strategy that can be used to identify a probable link between the type of injury and symptoms, which would help doctors in giving TBI related prognosis.
Introduction
Traumatic brain injury (TBI) is damage to the brain caused by an external force. Common causes of TBI include a jolt to the head or a violent blow. Such blows to the head fracture the skull and cause entry of foreign materials or skull fragments into the brain. Mild TBI causes some parts of the brain to dysfunction while serious cases of TBI causes bruising, bleeding, torn tissue, and other types of serious brain damage that eventually results in death. TBI symptoms can be classified as mild, severe, or moderate. An individual suffering from a mild case of TBI may experience momentarily loss of consciousness, blurred vision, headache, lightheadedness, tired eyes, confusion, or a ringing noise in the ears. Other symptoms that may be experienced include a bad taste in the mouth, a change in sleeping patterns, loss of memory, mood changes, lowered concentration, perception, and attention levels (Cifu, Caruso, & Buschbacher, 2010). Severe and moderate cases of TBI are characterized by chronic headaches, seizures and convulsions, nausea and vomiting, dilation of the pupils, loss of coordination, restlessness, agitation, and slurred speech.
Individuals who exhibit TBI symptoms should seek medical attention as fast as possible. This is because little can be done to correct brain damage resulting from the trauma and doctors can only stabilize a patient with TBI and focus on preventing further brain damage. Common approaches used in TBI treatment and stabilization include restoring proper blood and oxygen flow to the brain and controlling blood pressure. Medical imaging techniques, such as magnetic resonance imaging (MRI), are used for diagnosis and prognosis. Skull and neck X-ray images are taken to reveal fractures and spinal instability. In severe and moderate TBI cases, computed tomography (CT) imaging tests are done (In Grafman & In Salazar, 2015). The correctional treatment for such severe and moderate cases includes physical therapy, speech/language therapy, occupational therapy, physiatry, psychiatry, and social support.
In some severe cases of TBI, surgery is needed to remove contusions, which result from damaged brain tissue, hematomas, which are caused by ruptured blood vessels, and other foreign objects. Disability caused by TBI depends on such factors such as location of the injury, the age of the patient, and the general severity of the bruises. Common disabilities that result from TBI include mental health issues such as depression, personality change, anxiety, aggression, and social inappropriateness (Gillard, 2012). Also, some form of disabilities may manifest themselves through the loss of sensory processes such as sight, hearing, smell, taste, and touch. In addition, TBI can impair cognition abilities leading to memory loss and poor reasoning and thinking, and loss of communication skills such as perception and expression. Serious TBI may result in a stupor in which the patient can be aroused through application of a strong stimulus such as a sharp pain. Also, the TBI can result in a coma in which the patient is unconscious, unresponsive, unarousable, and unaware (Marion, 1999). The third probable result of a severe case of a TBI is the patient going into a vegetative state which can last for more than a month.
While it is well understood that TBI leads to brain damage, the biological mechanisms that underlie brain damage have not been fully researched and explained. As such, it is difficult to determine what type of symptom will result from a given brain injury. Due to this limitation in knowledge, doctors are unable to treat TBI as the available information is not enough to formulate a conclusive prognosis. As a result, the doctors are unable to prevent primary or secondary brain damage resulting from a TBI. This research proposal will try to establish the link between the brain damage and the resulting symptoms. Such information will be instrumental in helping doctors and researchers in treating TBI conditions and possibly prevent primary and secondary brain damage.
The aims of this research project include:
Create a possible link between brain injury type and resulting symptoms.
Identify ways trough which TBI causes damage to the brain
Establish methods of preventing primary and secondary brain damage after a TBI
Objective
The objective of this research project is to identify the ways in which TBI damages the brain and the resulting symptoms.
Literature review
Previous research
Previous research in the field of TBI has been centered on improving the effectiveness of treatments and ways of helping the family members of the affected persons. Most of the research in TBI is aimed at assisting were veterans who have received concussions and other forms of brain injuries from explosives. In the United States, this is done under the department of veteran affairs. The department has a research facility, Brain Rehabilitation Resource Center, located at the Malcolm Randall VA Medical Center in Florida. The facility is charged with the mandate of finding ways through which veterans can recover cognition, motor, and emotional functions after a TBI. Also, the department has another facility, Traumatic Brain Injury Center of Excellence, located in the Michael E. DeBakey VA Medical Center in Houston that focuses on containing the symptoms of mild TBI such as confusion or being dazed.
Another organization that is driving research in TBI is the National Institute of Neurological Disorders and Stroke (NINDS). The organization supports research through undertakings such as offering grants to medical research institutions in American. Also, the organization conducts TBI research at the National Institutes of Health (NIH) Clinical Center. The Center for Neuroscience and Regenerative Medicine (CNRM) is a result of collaborative effort between the Uniformed Services University for the Health Sciences (USUHS) and the intramural NIH. Research projects funded by NINDS are aimed at clinical and laboratory study of TBI to enhance a better understanding of how TBI occur and the mechanism of brain damage. The organization hopes that the availability of such knowledge will enable scientists to devise strategies to limit the formation of primary and secondary brain injuries.
Traumatic brain injury can result from an impact on the head. Common causes of TBI include walking into a low doorway, slipping and hitting the head on concrete floors, or a knock on the head when getting into a car. In moderate cases of BTI, the patient may lose consciousness for a period lasting between 15 minutes and six hours or lose memory for a period of 24 hours. Also, patients suffering from moderate BTI can develop residual symptoms. Severe cases of BTI causes unconsciousness lasting for more than six hours or post traumatic amnesia that lasts form more than 24 hours (High 2005). In such situations, the patients are usually hospitalized and placed under rehabilitation programs once the acute phase of program has subsided. If a patient goes into a coma, the physical functioning of the body is negatively affected and increased rehabilitation activities will be required.
The effects that BTI has on a patient depend on several factors such as location, type, and severity of injury. Likewise, the symptoms vary and can range from dizziness, headaches, balance problems, behavioral, and emotional. Rehabilitation is used to correct problems caused by brain injury and it’s aimed at helping the brain find optional routes of working other than the damaged part (Zollman, 2011). This helps eliminate the long term effects of BTI and enables the patient cope better with residual disability resulting from the injury.
Immediately after a brain injury occurs, the patient, whether unconscious or not, is able to perceive the objects in the direct environment but he or she is disoriented and confused. Such patients are unable to recall common things, event, or people and do orsay strange things. The length of post traumatic amnesia is important as it indicates the severity of the injury (Varney, & Roberts, 1999). A coma refers to prolonged periods of unconsciousness. Table 1 below indicates the correlation between the duration of unconsciousness and severity of the injury.
Figure 1: Table showing the relationship between loss of consciousness and severity of brain injury. Source: In Anzai, & In Fink, 2015.
Traumatic brain injury is the leading cause of death amoung the youth in the United States. TBI also affects the elderly and has led to deaths and hospitalization resulting from falls in people aged around 75 years old. It is estimated that TBI causes $76 billion of losses each year in the form of direct and indirect healthcare expenses. The Centers for Disease Control and Prevention (CDC) in the United States estimated that in 2010, TBI caused more than 50,000 deaths in the country and that 280,000 people with TBI were hospitalized. Also, 2.2 million people with TBI visited health facilities. Treatment and rehabilitation of persons with TBI costs more than $56 billion each year (McDonald, Togher & Code, 1999). Also, over 5 million people in America are suffering from TBI related bodily dysfunctions and need assistance to perform daily basic routines.
Damage to the brain can occur through two ways. These include a focal injury, whereby a given section of the brain is affected, or diffuse injury, whereby the injury is spread all over the brain. Also, the injury can be said to be primary if it’s directly caused by the trauma or secondary if it results from the reaction mechanism such as the swelling of the brain. Secondary injuries occur in a matter of hours, days, or weeks after the trauma (Lawhorne, Philpott, & Government Institutes, 2010). Primary brain injuries are manifested by bleeding, tearing of nerve fibers thereby causing inflammation, brain swelling, and metabolic changes. Some of the common primary injuries are discussed below.
Diffuse axonal injury (DAI)
DAI are a common type of brain injury. DAI is the damage of the white matter in the brain, which is carries bundles of axons that deliver electric impulses. The axons functions like electric cables by connecting various parts of the brain to one another. DAI results when a blow to the head induces shearing forces in the brain, which cause the axons to stretch and tear. Common causes of DAI include sport injuries and car accidents that cause sudden deceleration or rotational forces in the brain. Breakage of axons can cause disruption of communication among nerve cells and neurons (Winslade, 1998). Also, it can cause the spillage of brain chemicals that can cause permanent or temporary damage to the brain, which may further hinder recovery.
Concussion
Concussions are a form of a mild TBI that are temporary. Concussions can take minutes or several months to heal and can result from a blow, bump, sporting injury, weapon blast, auto accident, or jolt to the head. A person who has suffered a concussion gets dazed or loses consciousness. A second consecutive concussion after the first one has occurred can lead to permanent brain damage or death, and is usually referred to as the second hit phenomenon (In Anzai, & In Fink, 2015).
Hematomas
Hematoma is the collection of blood outside the blood vessels. Hematomas develop when the blood vessels in the brain are raptured leading to internal bleeding. The type of hematoma formed depends on the site of blood collection relative to meninges. The meninges are the three layers that surround and protect the brain. The inner meninges is referred to as pia mater while the middle layer is referred to as arachnoid mater and the outer layer is the dura mater. Epidural hematomas occur when bleeding takes place between the dura mater and the skull (In Anzai, & In Fink, 2015). These kinds of injuries occur after a skull fragment tears a blood vessel. Bleeding in such cases can occur within minutes or hours after the blood vessel has been raptured and the resulting hematomas are life threatening. On the other hand, subdural hematomas occur when there is bleeding in the region between the arachnoid mater and the dura. Subdural hematomas bear pressure on the outside of the brain and their effects depends on the amount of pressure applied on the brain. These hematomas usually occur after a fall or in the elderly people. Lastly, subarachnoid hemorrhage is a type of bleeding that occurs between the pia mater and the arachnoid mater (In Anzai, & In Fink, 2015). The effects of subarachnoid hemorrhage depend on the amount of bleeding that the brain is exposed to. Bleeding that occurs inside the brain is referred to as intracerebral hematoma and it can damage the surrounding brain tissue.
Contusions
Contusions are a swelling or bruising of the brain that occur when small vessels rapture and bleed onto the brain. Contusions on the direct site of impact, which is referred to as coup injury, or on the opposite side of the head, referred to as countercoup injury. Contusions can develop after one or two days from the time of impact.
Coup/Contrecoup lesions
Coup or Contrecoup lesions are a result of subdural hematomas or contusions on both the site of impact and on the side opposite the coup lesion. These injuries occur when the body suddenly decelerates causing the brain to move back and forth within the skull. Also, the injury occurs in babies when they are violently shaken such that the brain is knocked about within the skull (Dambinova, Hayes, & Wang, 2012).
Methodology
Quantitative research is a powerful tool of research as it presents actual figures that can be used to grade or quantify data. Also, statistically presented data commands credibility with people in power, who might be willing to act on it thereby influencing change. Also, statistical data analysis using statistical software is less time consuming. In addition, the approach provides accurate, precise, and numerical data. Quantitative is instrumental in validating theories and hypothesis (Vogt, 2011). Furthermore, the research results cannot be influenced by the opinion of the researcher as they represent factual results. Lastly, data collection through quantitative method is quick as it can be done remotely such as through the phone.
Also, the quantitative approach is more desirable over the qualitative method of research as it enables the simplification of a complex problem to several numbers of variables. Also, this approach can be used to determine the relationship between variables such as the link between cause and effect in a given subject, such as the TBI and its symptoms. Lastly, in quantitative approach, the sample is taken as a representative of the whole population, which reduces the work load for the researcher.
During the research process, various groups of people associated with TBI will be sampled. These include doctors, nurses, patients and the relatives of the patients. The test subjects will be randomly sampled in a given manner. For example, for every TBI patient selected, the other test subjects must be tied to his case such as the doctor who treated him or her and the direct relatives. This will help ascertain the condition of the patient right from the occurrence of the injury and how the injury has progressed with time. By examining the position and extent of the injury and the ensuing symptoms, it’s expected a pattern will be identified that will help formulate a relationship between the type of injury and its effects on the brain. Also, the pattern is also expected to reveal the long term effects of the various types of brain damage such a physical and mental disability or the loss of speech.
Discussion of results
Chi-square analysis will be used to analyze the data. The chi-square method is used to investigate distribution of discrete variables. A chi square test is a type of a statistical hypothesis whereby the sampling distribution of the empirical research data is a chi square distribution given that the null hypothesis is true. Chi square tests are based on the sum of squared errors or through the variances in the sample. Statistical data that follow a chi-squared distribution is based on the assumption that the data is normally distributed data, which is valid in many instances as a result of the central limit theorem.
Data presentation in a Chi square is done through the use of rows and columns to represent the various categorical variables. Chi square tests similarity between the expected outcome and the observed outcome. Since the expected results are depicted by the cell count in the table, then the expected cell count is given by the formula
row total x column totaltable total.
The observed counts are the actual recorded data. The chi square gives statistical measures such as standard deviation and standard error by estimating the difference between the expected count and the observed counts.
In measuring TBI study, it is expected that there is a covariance between types of injuries and the symptom. The cells in the Chi square shall be used to determine this correlation by representing the symptoms in the vertical columns and the injuries will be represented in the rows. Then the formula shown above shall be used to determine the correlation. Based on this approach, it is expect the correlation coefficient between the symptoms and the associated injuries will be +1.
Ethical issues that can arise during the research process
Collection of data for the research process involves interviewing doctors, patients, and relatives of the patients. Ethical issues may arise while interviewing patients in case such persons experience difficulties recalling previous events. As such, the patient’s relatives might feel as if the researcher is antagonizing the patient or making him feel bad about his illness. Also, the patient’s next of kin might find it difficult to discuss intimate details about the disability resulting from the TBI and how their lives have been affected by its symptoms. Also, the researcher has to be awake to the fact that patient’s personal details and medical records are private and as such publishing such information could be construed as a form of privacy violation. To avoid violating the patient’s privacy or derailing the rehabilitation process, the researcher should seek for permission from both the hospital authority and the patient or the patient’s next of kin.
Work plan
Expected outcomes
It is expected that the research project will offer a deep understanding of the formation TBI. Also, by studying TBI patients, the nature of their injuries, and the cause of the injuries, it is expected that the researcher will get a deeper understanding of the correlation between the type of injuries and the type of accidents. Furthermore, it is expected that a pattern will be identified which shall reveal a correlation between the type of injuries suffered by a patient and the symptoms that result from the injury. It is also expected that this information will create a holistic understanding of TBI and as a result, doctors will be in a better position to give prognosis and design and administer an effective curative and rehabilitation program. Lastly, it is expected that the research process will provide a concrete body of knowledge on BTI that will lead to further advancements in the medical field.
References
Cifu, D., Caruso, D., & Buschbacher, R. (2010). Traumatic Brain Injury. New York: Demos Medical Pub., LLC.
Dambinova, S. A., Hayes, R. L., & Wang, K. K. W. (2012). Biomarkers for traumatic brain injury. Cambridge, U.K: Royal Society of Chemistry.
Gillard, A. (2012). Traumatic brain injury. Detroit: Greenhavn Press.
High, W. M. (2005). Rehabilitation for traumatic brain injury. Oxford: Oxford University Press.
In Anzai, Y., & In Fink, K. R. (2015). Imaging of traumatic brain injury.
In Grafman, J., & In Salazar, A. M. (2015). Traumatic brain injury: Part I.
Lawhorne, S. C., Philpott, D., & Government Institutes. (2010). Combat-related traumatic brain injury and PTSD: A resource and recovery guide. Lanham: Government Institutes.
Marion, D. W. (1999). Traumatic brain injury. New York: Thieme Medical.
McDonald, S., Togher, L., & Code, C. (1999). Communication disorders following traumatic brain injury. Hove, East Sussex, UK: Psychology Press.
Varney, N. R., & Roberts, R. J. (1999). The evaluation and treatment of mild traumatic brain injury. Mahwah, N.J: Lawrence Erlbaum Associates.
Vogt, W. P. (2011). SAGE quantitative research methods: 1. London: SAGE.
Winslade, W. J. (1998). Confronting traumatic brain injury: Devastation, hope, and healing. New Haven: Yale University Press.
Zollman, F. S. (2011). Manual of traumatic brain injury management. New York, NY: Demos Medical Pub.
