Chapter 15: Traumatic Brain Injury

Chapter 15: Traumatic Brain Injury

Kicking off this week with a review of traumatic brain injury.

What is traumatic brain injury?

A traumatic brain injury (TBI) involves any injury to the brain from an external force (Tipton-Burton, 2018). A TBI may be caused by a fall, motor vehicle accident, gun shot wound, or assault, among other causes. Any impact to the head may cause a TBI of varying severity. Fatal TBIs are more common in men and adults older than 65 see the highest rate of TBI (mostly due to falls) (Tipton-Burton, 2018).

Two words that you should know include coup (pronounced “coo”) and contrecoup (pronounced “counter-coo”). Coup involves the directly injured area where contrecoup involves the indirectly injured area (Tipton-Burton, 2018). Another way to think about this is that coup is the first impact of the brain against the skull and the contrecoup is the second impact of the brain against the skull. Think of it like whiplash.

Experiencing a TBI may or may not result in coma. The Glasgow Coma Scale is used to assess an individual’s level of consciousness (Tipton-Burton, 2018). This scale takes into consideration the individual’s verbal response, motor response, and eyes opening. The Ranchos Los Amigos Scale is then used to measure levels of awareness and cognitive function for individuals who are emerging from a coma and throughout their length of recovery (Tipton-Burton, 2018).

In one of my fieldwork experiences, I got to work with several individuals who were recovering from TBI. Some individuals were in their 20s, some were in their 60s, 70s, and 80s. TBI knows no age. Some individuals were in tragic motor vehicle accidents, some were assaulted, some were caused by poor decisions, some were caused by pregnancy complications. We must remember that the brain is the control center of the body. Any damage to the control center can affect many areas of one’s life.

What does TBI “look like”?

Individuals recovering from TBI may experience physical, cognitive, visual, emotional, and behavioral symptoms. The severity of the symptoms depends on the severity of the TBI and the location of the damage to the brain. Every individual recovering from a TBI will present with a different combination of symptoms. Some may be stronger physically but struggle with cognitive functions, or vice versa.

Physical challenges may include rigidity, muscle spasticity, re-emergence of primitive reflexes (the reflexes we all had when we were babies), decreased muscle strength and endurance, changes in range of motion and/or sensation, and postural deficits (Tipton-Burton, 2018).

Cognitive challenges may include difficulty with executive functioning (decision making), attention, concentration, memory, self-awareness/judgement, safety, processing, and initiation/termination of activities (being able to start and stop activities in an appropriate timeframe and/or with/without need for cueing) (Tipton-Burton, 2018). The cognitive aspect of TBI is extremely interesting to me and I was privileged to be able to work on cognition with clients during my fieldwork experience.

Visual challenges may include changes in acuity (ability to see clearly), accommodation (ability to adjust to near/far objects), convergence (ability to fixate vision on a single object), and scanning (ability to look around one’s environment in an organized manner) (Tipton-Burton, 2018). Other visual diagnoses related to TBI include nystagmus (“shaky” eyes), hemianopia (vision field cuts), reduced blink rates, ptosis (drooping eyelid), lagophthalmos (incomplete eyelid closure) (Tipton-Burton, 2018).

Emotional and behavioral symptoms are related to emotional regulation, changes in social roles and independent living, and dealing with loss. Often, upon emerging from a coma an individual may be angry and threatening. This will eventually lessen as an individual continues to recover. Other behavioral symptoms may include impulsivity, yelling, swearing, or displaying inappropriate gestures. An individual may experience depression and anxiety as a result of changes in social roles (i.e. changes in friend groups as a result of one’s disability or changes in one’s ability to take care of their children).

As mentioned previously, these challenges related to TBI recovery vary from individual to individual and may include more or less than what I just reviewed.

How do OTs help individuals with TBI?

OTs are part of the recovery process from the beginning. If the individual is still in a coma, the OT can help maintain range of motion, prevent pressure sores, and provide family education to keep the family involved and informed throughout the recovery process. Depending on the severity of the coma, sensory stimulation may also be utilized to start the “rewiring” process of the brain.

When the individual emerges from a coma, further treatment can be provided to assist with the presenting physical, cognitive, emotional/behavioral symptoms. Additional family education would be provided to keep the family involved in the recovery process.

As the continuum of care progresses, OTs can be involved with cognitive and visual retraining by teaching compensatory strategies. Cognitive strategies may include using phone reminders for important appointments/occasions, breaking down instructions into smaller chunks, and keeping important identifying information readily available in the case of emergency (among many many others!).

One of my favorite visual strategies is called the lighthouse strategy. Think of the eyes as the light of a lighthouse. When reading the eyes should start left, scan the right, then return to the left side, just like a lighthouse. Back and forth.

Family education is imperative throughout the continuum of treatment and recovery. I have read several books (true stories) this summer about traumatic brain injury recovery. Most of the books were told from a family member’s perspective (often the spouse). These books have taught me a lot about the impact TBI has on family members. Often, the family member will grieve the loss of their spouse/parent/child/sibling as a brain injury often changes many aspects of one’s personality and their related family roles. The severity of the brain injury may cause the individual to appear like a whole new person. I highly recommend these books for both clinicians and family members of an individual recovering from brain injury as I believe these books provide wonderful insight to brain injury recovery. The books are listed below:

Left Neglected by Lisa Genova – This book provides insight from both the individual and family’s perspective after a tragic motor vehicle accident.

Where is the Mango Princess? by Cathy Crimmins  – This book provides insight from the family’s perspective after a tragic boating accident.

In an Instant: A Family’s Journey of Love & Healing by Bob Woodruff & Lee Woodruff – This book provides insight from both the individual and family’s perspective after Bob Woodruff, an ABC world news reporter, experiences an IED explosion in Iraq.

I feel like this post doesn’t dive deep enough and it’s a little all over the place considering how I find this population to be so interesting to work with. For that, I apologize. However, I hope you found this post informative and learned at least one thing. If you didn’t, pick up one of those books to get a glimpse into the world of traumatic brain injury. It will enlighten you!

Stay tuned for more posts this week.

*Note: These examples of OT involvement are strictly my own. Information on this post was provided through the reference referred to below.


Tipton-Burton, M. (2018). Traumatic brain injury. In H. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy practice skills for physical dysfunction (8th ed., pp. 841-870). St. Louis, MO: Elsevier.



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