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Traumatic Brain Injury
Types of Brain Injuries:
? Epidural Hematoma
? An accumulation of
blood between the skull and the dura mater.
? Characterized by high pressure bleeding.
? Common in individuals under the age of 45 years.
? Common with a fall.
? Subdural Hematoma
? A collection of blood beneath the dura mater and above the
arachnoid mater.
? Characterized by low pressure bleeding.
? Typically caused by a head injury in
which the head moved rapidly forward
and stopped.
? More common in elderly and alcoholics.
? Subarachnoid Hemorrhage
? Bleeding within the subarachnoid space.
? It can have a genetic component.
? It can be caused by alcohol or drug abuse.
? Intracerebral Hemorrhage
? Bleeding inside the brain.
? Characterized by a sudden onset of neurological deficit.
Brain Injury Severity:
? The most significant indicator or severity is the depth and
duration of a comma and/or post-traumatic amnesia.
Common TBI Symptoms:
? Headache
? Neck Stiffness
? Confusion
? Drowsiness
? Nausea / Vomiting
? Seizure
? Coma
Criteria Mild Moderate Severe
Structural
Imaging
Normal Normal or
Abnormal
Normal or
Abnormal
Loss of
Consciousness
< 30 minutes 30 minutes to
24 hours
> 24 hours
Alteration of
Consciousness
/ Mental State
A moment to
24 hours
> 24 hours > 24 hours
Post-Traumatic
Amnesia
0��1 day >1 and <7 days > 7 days
Glascow Coma
Scale
13��15 9��12 4��6
More Severe
Less Severe

Arteries of the Brain and the Lobes they Supply:
? Circle of Willis:
? Supplies the anterior, middle, and posterior cerebral arteries.
? Basilar Artery:
? Forms from the vertebral arteries and becomes the Circle of Willis.
? The arteries off of the basilar artery supplies the brain stem.
? Anterior Cerebral Artery :
? Supplies the anterior-medial cerebrum.
? Frontal Lobe
? Parietal Lobe
? Middle Cerebral Artery:
? Supplies the lateral cerebrum.
? Frontal Lobe
? Parietal Lobe
? Temporal Lobe
? Posterior Cerebral Artery:
? Supplies the posterior cerebrum.
? Parietal Lobe
? Temporal Lobe
? Occipital Lobe
? Supplies the Cerebellum.
Brain Lobe Responsibilities:
? Frontal Lobe:
? Personality, thinking, planning, motor execution, and executive functions.
? Parietal Lobe:
? Attention, sensory perception, and spatial perception.
? Temporal Lobe:
? Language, auditory perception, long-term memory, recognition, identification, and emotion.
? Occipital Lobe:
? Visual perception and spatial processing.
? Cerebellum: Coordination.

? Left Hemisphere Injury:
? Language (speech, reading, & writing)
deficits
? Logic deficits
? Depression
? Anxiety
? Insight of deficits
? Slow, cautious behavior
? Easily distractible
? Perseveration
? Right Hemisphere Injury:
? Spatial-temporal deficits
? Visual-spatial deficits
? Poor body scheme / neglect
? Lack insight / poor judgment
? Increased safety risk
? Difficulties with abstract reasoning
? Euphoria
? Difficulty perceiving emotions
? Impulsive
? Bilateral Brain Injury:
? Impaired vision
? Emotion abnormalities
? Confusion
? Short attention span
? Memory loss
? Poor executive functioning
? Brain-Stem Injury:
? Swallowing and speech difficulty
? Unstable vitals
? Potential organ failure
? Frontal Brain Injury:
? Personality changes
? Body scheme deficits
? Poor problem solving skills
? Parietal Brain Injury:
? Attention deficits
? Contralateral neglect
? Temporal Brain Injury:
? Agnosia
? Prosopagnosia
? Occipital Brain Injury:
? Vision impairments.
? Cerebellum Brain Injury:
? Dysmetria
? Delayed reaction time
? Ataxia
? Tremor
Behaviors to Expect with
Different Brain Injuries

References
Clerkship Directors in Emergency Medicine. (2010). Intracranial hemorrhage [Website]. Retrieved
from http://www.cdemcurriculum.org/ssm/neurologic/ich/ich.php
Healthline Networks Inc. (2015) Intracranial hemorrhages [Website]. Retrieved from
http://www.healthline.com/health/extradural-hemorrhage#Overview1
McDonough, V. T. & King, B. (2015). What is the difference between a subdural and epidural
hematoma? [PDF handout]. Retrieved from http://www.brainline.org/multimedia/video/
transcripts/Dr.Jane_Gillett-whats_the_Difference_Between_a_Subdural_and_E pidural_
Hematoma.pdf
O'Sullivan, S.B., & Schmitz, T.J., & Fulk, G.D. (2014). Physical rehabilitation (6th ed.).
Philadelphia: F. A. Davis.
Purves, D., Augustine, G. J., Fitzpatrick, D., Hall, W.C., LaMantia, A-S., McNamara, J.O. &
Williams, S. M. (2012). Neuroscience (5th ed.). Sunderland, MA: Sinauer Associates, Inc
Teach Me Anatomy. (2015). Arterial supply to the brain [Website]. Retrieved from
http://teachmeanatomy.info/neuro/vasculature/arterial-supply-brain/
The Internet Stroke Center. (2015) Blood vessels of the brain [Website]. Retrieved from
http://www.strokecenter.org/professionals/brain-anatomy/blood-vessels-of-the-brain/

TBI Outcome Measures
A Useful Resource:
? The Center for Outcome Measurement in Brain Injury (COMBI): http://www.tbims.org/combi/
Berg Balance Test
? Valid in the TBI population.
? Predictor of falls.
? Has ceiling and floor effects.
? Falls Risk: <46/56.
? MDC for elderly population:
? MDC for the acute stroke population:
? Entire group: 6.9
? Individuals who ambulate with assistance: 8.1
? Individuals who ambulate with stand-by-assist: 6.0
? Individuals who ambulate independently: 6.3
? MDC for the chronic stroke population:
? Values range from 2.50 �C 4.66 points.
? Normative Data:
Berg Balance Scale
Initial Score
MDC
0 - 24 4.6
25 - 34 6.3
35 - 44 4.9
45 - 56 3.3
Age Gender Mean SD
60-69 Male 55 1
Female 55 2
70-79 Male 54 3
Female 53 4
80-89 Male 53 2
Female 50 3

Functional Gait Assessment
? Valid in the stoke population.
? Has not been tested with the TBI population.
? MDC = 5 points (stroke population).
? Falls Risk: �� 22/30.
? Normative Data:
Community Balance and Mobility Scale
? Valid in the TBI population.
? Assesses higher level balance (balance usually associated with community mobility).
? Evaluates the ability for individuals to return to community living.
? Normative Data:
6 Minute Walk Test
? Valid in the stroke and TBI population.
? MDC: Varies by study but it ranges from 112.76 �C 200.01 feet for the stroke population.
? Normative Data:
Age Mean Score SD
40-49 28.9 1.5
50-59 28.4 1.6
60-69 27.1 2.3
70-79 24.9 3.6
80-89 20.8 4.7
Age Group Mean Value SD
20-29 88.71 3.53
30-39 86.33 5.78
40-49 84.35 4.03
50-59 77.43 6.55
60-69 64.94 8.22
70-79 49.75 6.95
Mean Distance by Age & Gender
Age Male Female
60-69 yrs 572 m (1716 ft) 538 m (1614 ft)
70-79 yrs 527 m (1581 ft) 471 m (1413 ft)
80-89 yrs 417 m (1251 ft) 392 m (1176 ft)

10-Meter Walk Test
? Valid for self-pace and fast-pace in the TBI and
stroke populations.
? MDC: >.05 seconds.
? Has been used to identify ambulation classifications in
the stroke population.
? Household Ambulators: < 0.4 meters/second
? Limited Community Ambulators: 0.4 - 0.8 meters/second
? Community Ambulators: > 0.8 meters/second
? Normative Data:
Agitated Behavior Scale
? Shown to be predictive of a change in cognitive status.
? Valid with 30 minute therapy sessions and 8 hour nursing shifts.
? MCD has not been established.
? Agitation Values:
? Normal: </= 21
? Mild Agitation: 22��28
? Moderate Agitation: 29��35
? Severe Agitation: > 35
? The test also measures disinhibition, aggression, and lability with subscales.
? Take the subscale and multiplied by fourteen to compare the subscales to the total score.
? Ways to calculate the subscales:
? Disinhibition: Sum of items 1, 2, 3, 6, 7, 8, 9, &10.
? Aggression: Sum of items 3, 4, 5, & 14.
? Lability: Sum of items 11, 12, & 13.
Male Female
Age Comfortable Fast Comfortable Fast
20's 1.39 2.53 1.41 2.47
30's 1.46 2.45 1.42 2.34
40's 1.46 2.46 1.39 2.12
50's 1.39 2.07 1.40 2.01
60's 1.36 1.93 1.30 1.77
70's 1.33 2.08 1.27 1.74

References
Bogner, J. (2000). The agitated behavior scale [Outcome measure]. Retrieved from http://www.tbims.org/
combi/abs/index.html
Howe, J, Inness EL, & Wright, V. (2011). The community balance & mobility scale [Outcome measure]. Retrieved
from http://www.tbims.org/combi/cbm/index.html (accessed October 25,2015).
O'Sullivan, S.B., & Schmitz, T.J., & Fulk, G.D. (2014). Physical rehabilitation (6th ed.). Philadelphia: F. A. Davis.
Rehabilitation Measures Database. (2014). Rehab measures: Agitated behavior scale [Outcome measure].
Retrieved from http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?
ID=1071&Source=http%3A%2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%
2Easpx%3FPageView%3DShared
Rehabilitation Measures Database. (2015). Rehab measures: Berg balance scale [Outcome measure]. Retrieved f
rom http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=888&Source=http%3A%
2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FPageView%3DShared
Rehabilitation Measures Database. (2014). Rehab measures: Community balance and mobility scale [Outcome
measure]. Retrieved from http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?
2Easpx%3FPageView%3DShared
Rehabilitation Measures Database. (2014). Rehab measures: Functional gait assessment [Outcome measure].
Retrieved from http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?
2Easpx%3FPaged%3DTRUE%26p_Title%3DFukuda%2520Stepping%2520Test%2520%2528Unterberger%
2520Step%2520Test%2529%26p_ID%3D1153%26View%3D%257b0C859D90%252d7478%252d4C9B%
252d9575%252d784C4A9A2D85%257d%26PageView%3DShared%26PageFirstRow%3D101
Rehabilitation Measures Database. (2014). Rehab measures: 10 meter walk test [Outcome measure]. Retrieved
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=901&Source=http%3A%2F%
2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FPageView%3DShared
Rehabilitation Measures Database. (2015). Rehab measures: 6 minute walk test [Outcome measure]. Retrieved
from http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=895&Source=http%3A%
2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FPageView%3DShared
Santa Clara Valley Medical Center (2006). The Center for Outcome Measurement in Brain Injury [Outcome tool
database]. Retrieved from http://www.tbims.org/combi/

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