Running head: LONG TERM EFFECTS ON NEUROLOGIC FUNCTION

Long Term Effects on Neurologic Function in Patients Suffering Head Injuries

Michael Goodin, Samuel Lofaro, Preston Sirochman, William Snow & Jesse Soeun

04/05/2016

Nursing Research

Dr. Valerie ODell

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Abstract

The purpose of this research is to investigate the long-term neurological effects that can result

from suffering a traumatic brain injury. Long-term effects that are explored include personality

and behavior changes, cognitive changes, academic performance changes, effects in athletes, and

risk for cerebrovascular accidents. Research shows that traumatic brain injuries have a direct

correlation with effects on the nervous system. With all things considered, all the research

showed that patients who sustained a traumatic brain injury have an increased risk for

neurological changes that effect the day-to-day life compared to patients who have not had a

brain injury.
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Long Term Effects on Neurologic Function in Patients Suffering Head Injuries

As more research is done to prove the true severity of head injuries, many long-term

neurological problems have been noted. These changes not only affect patients, but also the care

nurses must provide to them. Many studied including a number of different variables have been

conducted proving that these patients suffer from impaired functioning in a variety of ways. This

presents an issue that nurses must be aware be considerate of these injuries and possible long-

term effects when both caring for an educating these patients due to their possible impairments.

What long term effects do traumatic brain injuries have on the patients who suffer them?

Literature Review

Introduction

To properly research and discuss this commonly overlooked issue, research was

conducted using CINHAL plus, MEDLINE, and Google Scholar. Ten sources were thoroughly

examined regarding the various long term effects on neurological functioning of patients

suffering from brain injuries and related sequelae. Personality and behavior changes, cognition

changes, academic performance changes, repeat injurys effect in athletes, and effects on

cerebrovascular accidents will be explored.

Effects on personality and behavior

A 30-year study was conducted in young adults who have experienced a TBI and the

long term effects this injury has on emotional and social functioning. During follow up visits,

patients who experienced TBIs had statistically higher chances of being diagnosed with major

depression, alcohol abuse, panic disorder, specific phobias and other psychotic disorders. Most

of these patients were also diagnosed with at least one personality disorder, the most common

being paranoia and schizoid. Brain injury does not reflect causality of these disorders, however
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after enduring a moderate to severe injury the probability of later being diagnosed with one of

these personality disorders is enhanced greatly (Fowler, McCabe 2011 p.4).

Traumatic brain injuries increase chances of behavioral deficits in patients however it has

also been seen that they also severely decrease emotional perception. Spikman et al. (2013)

tested 51 TBI patients ability to perceive facial expressions depicting emotions such as Fear,

Anger, Happiness, Sadness, and others against 51 unaffected participants. In this test, a variety of

sixty faces were shown expressing the primary emotions in which the participant has five

seconds to choose the correct emotion shown. Answer selections were recorded as well as the

time each participant takes in order to choose his or her answer. The result of this test was a

significant difference between patients afflicted with brain injuries against those who have not

sustained brain injuries. Brain injury patients not only did worse selecting correct emotional

expressions, they also responded averagely 31% slower than the comparable group (Results

section, para. 2). This is evidence of longer processing of emotional recognition. With these

results, it is possible to conclude partial reasoning behind long term behavior changes is due to

misinterpretation of face to face social cues.

According to Fowler and McCabe (2011), behavioral characteristics in TBI patients often

include inappropriate emotional responses that may include uncontrolled emotional outbursts.

Other behaviors that appear to be affected are impaired judgement and decision making abilities

as well as obvious lacking of organizational skills. Behaviors such as these are difficult to see in

brief periods and may remain absent in interviews however if considered over longer time frames

such as years or decades of observation the changes began to become more apparent. The

validity of such studies often raises much concern due to the difficulty of obtaining objective

measurements. Personality qualities are often subjective and the traits or severity of said traits
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are left to the judgement of whoever is conducting the testing. Increasing probability of being

diagnosed with personality or psychotic disorders may be evident however direct measureable

personality characteristics are often left in question.

Effects on Cognition

The first study to be discussed related brain injurys effects on cognition, conducted by

Phillip J. Dean and Annette Sterr (2013), studied four groups; participants who suffered an mTBI

and have persistent PCS(post-concussion syndrome), participants with mTBI but no PCS,

Control group with PCS and Control group with no PCS. They measured the cognitive function

of all groups using the n-Back (working memory) and the PVSAT (information processing

speed) tests. (Dean & Sterr p. 6) According to the study they determined that there were

working memory and information processing speed impairments in participants with mTBI and

persistent (>1 year post-injury) PCS. (Dean & Sterr 2013 p.6) Also according to Dean and

Sterrs (2013) findings, participants in the mTBI + PCS group, showed results of significant

impairment on even the least cognitively demanding versions of testing. They concluded the

results of their study by stating that there is significant impairment in mTBI participants with

persistent PCS compared to mTBI participants without PCS and all non-head injured patients.

(Dean & Sterr 2013 p. 8) and also These results suggest that the reduction in cognitive

performance is not due to greater symptom report itself, but is associated to some extent with the

initial injury (Dean & Sterr 2013 p. 8)

The second study to be discussed relating brain injury to its effect on cognitive function

was conducted by Dawn Senathi-Raja, Jennie Ponsford, and Michael Schnberger. Their study

examined the association of age and time lapsed following TBI in relation to healthy controls.

According to Senathi-Raja, Ponsford & Schnberger, the sample used included patients who had
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suffered a TBI at least 5 years prior, and individually matched controls paired by age, gender,

and estimated IQ. (p.1) Their study determined that the TBI group performed significantly

worse than did the individually matched control group on measures of processing speed, working

memory, verbal and visual memory, and executive function. (Sethani-Raja, Ponsford &

Schnberger 2010 p. 5) According to Senathi-Raja, Ponsford & Schnberger, Their results

showed clear evidence of long-lasting impairment in TBI participants in every measured

category. (p. 7) they also noted that impairment was significantly associated with injury

severity (Senathi-Raja, Ponsford, & Schnberger 2010 p. 5) Summarizing their research, they

added that poorer cognitive functioning appears to be associated with both older age at the time

of injury and increased time post injury. (Senathi-Raja, Ponsford, & Schnberger 2010 p. 1)

they also added that this study provides important insights into the long-term course for all adults

following TBI. (p. 8) In closing, Senathi-Raja, Ponsford & Schnberger state that with this

information in mind one must emphasize the importance of flexible management plans that allow

neuropsychological intervention, reevaluation of activity plans, and increased structured support

for long term outcomes. (p. 9)

Cognitive and Emotional consequences

A mild traumatic brain injury, also known as a concussion, is the most common type of brain

injury. The injury is considered to be mild when the initial impact causes a short change in mental status

or even a loss of consciousness for less than 30 minutes. Symptoms can range from acute such as a

headache, dizziness, or anxiety to more long-term effects relating to physical, cognitive, or emotional

impairments. Long-term symptoms are often referred to as post-concussion syndrome. Frequent

cognitive symptoms include attentional deficits, slowed information processing, reduced verbal and

working memory, and impaired executive functions. Psychiatric symptoms such as depressed mood,

anxiety, irritability, agitation; poor motivation, social withdrawal and interpersonal difficulties are also
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reported frequently (Conrad, Geburek 2010 p. 2). To further evaluate the long-term consequences of

cognitive and emotional damage from mild traumatic brain injuries, a study was initiated to evaluate

patients who had an occurrence of a TBI within the past six years. The results showed medium to large

differences in all cognitive fields such as in learning and long-term memory, working memory, and

attention in patients who received a brain injury compared to subjects who did not. It also noted that

cognitive impairments have an effect on day to day living, which includes job-related activities,

interpersonal and independent skills. In mild brain injuries, the occurrence of major depression occurs in

approximately 10-20% of the patients (Conrad, Geburek 2010 p 10).

Effect on Academic Performance

There are multiple universities across the United States that are incorporating programs to

assist students who have suffered a TBI. The article Back to School with a TBI mentions a few

programs support tools and accommodations that are helping students to achieve maximal

potential for success at a post-secondary level degree. While each individual who suffered a

TBI, will present with different challenges, many students have issues with managing time,

staying organized, learning and studying, handling social relationships and reducing anxiety

(Volkers, 2016, p. 48). According to Lyn Turkstra a professor at the University of Wisconsin

students with moderate to severe TBI receive accommodations through the Americans with

Disabilities Act. Her focus is based on the classroom environment.

How fast is the pace? How structured is it? Are their lectures online? Is there a lot of

group work? And according to Turkstra the biggest factor is-what is the instructor like? If

they are not clear in the way that they lecture, or if they talk fast, that can cause problems.

(p. 49)

According to Kristin King an assistant professor in the Department of Audiology and Speech

Pathology at the University of Tennessee.

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They tend to report trouble paying attention in class, losing track of lectures, or

multitasking-if the professor is putting things on the board and lecturing at the same time,

the student is trying to take down notes and focus on what is being said. It can become

very difficult. It is too much information to process and fatigue is another common

symptom. (p. 49)

Students classroom accommodations includes extra testing time, administering exam in a quiet

room, and postponement of assignments or test (Volkers, 2016, p. 49).

In a research study performed at the Barkley Memorial Center at the University of

Nebraska-Lincoln, it was found that a majority of survivors of severe TBI report lasting deficits

in cognitive processes such as executive functioning, memory, attention, and concentration in

addition to physical and social-emotional sequelae (Hux et al., 2010, p. 13). Students may also

have other significant issues that can affect their academic performances. For example,

unpredictable periods of improvement, day to day variability, medical complications,

pharmacological side effects, and possible presence of concomitant physical, sensory and/or

motor deficits (Hux et al., 2010, p. 14). It was also concluded that a majority of the students

who were interviewed for this research received accommodations to assist in their success. For

example, receiving note-takers, class outlines from instructors, extended time to complete

examinations, access to scribes or computer for generating written responses and option of taking

tests in a setting with minimal distractions and separate from the remainder of the class as well as

priority registrations (Hux et al., 2010, p. 24).

Effects on Cerebrovascular Accident

A stroke occurs when the blood supply to the brain is interrupted and the brain is not receiving

any oxygen or nutrients. Stroke is the second leading cause of death worldwide and the leading cause of

acquired disability in adults in most regions (Liao, Chou 2014 p163). Two nationwide studies were
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conducted to show the correlation between patients with traumatic brain injuries and an increased risk of

having a stroke. Many different factors were considered including demographic variables and associated

medical history. The results proved that patients who experienced a traumatic brain injury had an

increased risk for stroke. Other risk factors that increased the risk for stroke in brain injured patients

compared to non-brain injured were patients living in less-urbanized areas and have a low-income status,

associated mental disorders, hypertension, COPD, hyperlipidemia, diabetes, migraines, alcohol-related

diseases, Parkinsonism, epilepsy, and renal dialysis. According to Liao and Chou:

Men had higher risks of TBI, stroke, and poststoke mortality than women owing to greater

exposure to perilous jobs, dangerous activities, unhealthy lifestyles, and coexisting medical

conditions. In contrast, better outcomes in women after TBI or stroke might be due to female

hormones or supplemental estrogen therapy (p167).

In order to reduce the risk of stroke in brain injured patients, rehabilitation should include stroke

prevention strategies like increasing physical activities and regular checkups to monitor recovery.

Effects in Athletes

Chronic traumatic encephalopathy, or CTE, is a condition that is marked with

neurodegeneration that is currently believed to be triggered by repetitive injury to the head

(Gavett, Stern, & McKee, 2011 p.2). Outward signs of the condition manifest in cognitive,

linguistic, physical, and psychiatric impairment; cognitive impairment occurs later in the

progression and has been noted about 10-20 years following retirement. Psychiatric

manifestations include, but are not limited to: paranoia, depression (most common), withdrawal,

aggressive behavior, poor judgement, and agitation (Gardner, Iverson, & McCrory 2013 p.3).

Additional manifestations include: suicidal behavior, poor memory, Parkinsonism, and dementia

(Edwards & Bodle, 2014 p.3). Changes in cognition include retrogression of: orientation,

language, attention, and the speed at which the brain can process information (Gardner, Iverson,

& McCrory 2013 p.3).

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CTE in the past has been coined dementia pugilistica implying a correlation between

the condition and the sport of boxing (Gavett, Stern, & McKee, 2011 p.2). A name that has been

well deserved as the first note of the neurodegeneration was first brought to light in 1973 after

examination of 15 former boxers brains. Since then, 14 of the 15 brains previously mentioned

were reviewed along with an additional 6. Of these brains, 19 of them had shown -amyloid

deposits and -protein-positive neurofibrillary tangles. In addition, 2 of the brains that

demonstrated signs of CTE contained positive neurofibrillary tangles that had shown to be

carbon copies of those found in Alzheimers Disease (Gardner, Iverson, & McCrory, 2013 p. 3).

There have also been constant findings during autopsy examinations of neurofibrillary tangles

and neuropil threads in the brains of athletes with CTE that are related to Alzheimers (Edwards

& Bodle, 2014 p.3). While its existence was first noted as a risk of the sport of boxing, dementia

pugilistica has since been recognized as a consequence of other impact sports such as football,

hockey, wrestling, and soccer; therefore, earning the more appropriate name, chronic traumatic

encephalopathy (Gavett, Stern, & McKee, 2011 p.2).

Most study into the condition known as CTE in more modern times has been focused

around football. A study of 17 possible cases of CTE was conducted in 2011 and another in 2013

involving players from the Canadian Football League (CFL). In the 2011 study, 11 of the

suspected cases had shown pathophysiologic changes that indicated the presence of CTE. In

addition, the 2013 study involving 6 retired CFL players showed 3 out of the group fell under

diagnosis for CTE. The remaining three players were diagnosed with Alzheimers, ALS, and

Parkinsons (Gardner, Iverson, & McCrory, 2013 p.3). Of the 321 professional American

football players that have passed between February 2008 and June 2010, 12 of them were

selected for autopsies by the Boston University Center for the Study of Traumatic
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Encephalopathy. It was found that 12/12 football players autopsied by the university were

positive for signs of CTE. Even if all of the remaining deceased athletes that were not examined

were negative for CTE, this study would reveal a 3.7% rate of occurrence if generalized to the

population under question (Gavett, Stern, & McKee, 2011 p. 3). Overall, the age of onset for the

condition is 42.8 and it arises 8 years after the athlete has left the sport; however, in some cases

signs of CTE are noted when the athlete is just entering retirement (Gavett, Sterrn, & McKee,

2011 p.5)

Conclusion

When addressing what long term effects do traumatic brain injuries have on the patients

who suffer them? Research has proven that TBIs have a tremendous effect on a person

throughout their life span. With each individual there will be varying degrees of complications

that will have to be addressed. The effects on personality, behavior, cognition, emotional

consequences, academic performance, cerebrovascular accident, and athletes verifies that people

who have suffered from a TBI will have a great road ahead. There needs to be more

investigative research into the effects of TBIs and its correlation to potentially debilitating effects

on the human brain.

References
Dean, P. J., & Sterr, A. Long-term effects of mild traumatic brain injury on cognitive

performance. Frontiers in Human Neuroscience Front. Hum. Neurosci.,7. February

2013. Web. 29 Mar. 2016

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Edwards, J. C., & Bodle, J. D. (2014). Causes and consequences of sports concussion. Journal of

Law, Medicine, and Ethics, 42(2), 128-132. Retrieved March 21, 2016.

Fowler Marc, McCabe Paul C. Traumatic Brain Injury and Personality Change Pediatric

School Psychology National Association of School Psychologists, May 2011. Web. 25

Mar. 2016.

Gardner, A., Iverson, G. L., & McCrory, P. (2013). Chronic Traumatic Encephalopathy: A

Systemic Review. British Journal of Sports Medicine, 48, 84-90. Retrieved March 21,

2016.

Gavett, B. E., Stern, R. A., & McKee, A. C. (2011). Chronic traumatic enchephalopathy: A

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Sports Medicine, 30(1), 179-188. Retrieved March 21, 2016.

Hux, K., Bush, E., Zickerfoose, S., Holmeberg, M., Henderson, A., & Simanek, G. (2010).

Exploring the Study Skills and Accommodations Used by College Student Survivors of

Traumatic Brain Injury. Informa Healthcare, 24(1), 13-26. Retrieved March 15, 2016.

Konrad, C., Geburek, A. J., Rist, F., Blumenroth, H., Fischer, B., Husstedt, I., . . . Lohmann, H.

(2010). Long-term cognitive and emotional consequences of mild traumatic brain injury.

Psychological Medicine Psychol. Med., 41(06), 1197-1211. Web. Retrieved March 28,

2016.

Liao, C., Chou, Y., Yeh, C., Hu, C., Chiu, W., & Chen, T. (2014). Stroke Risk and Outcomes in

Patients With Traumatic Brain Injury: 2 Nationwide Studies. Mayo Clinic Proceedings,

89(2), 163-172. Web. Retrieved March 28, 2016.

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Senathi-Raja, D., Ponsford, J., & Schnberger, M. (2010). Impact of age on long-term cognitive

function after traumatic brain injury. Neuropsychology, 24(3). May 2010. Web. 30 Mar.

2016

Spikman, Jacoba M., Maarten V. Milders, Annemarie C. Visser-Keizer, Hemma J. Westerhof-

Evers, Meike Herben-Dekker, and Joukje Van Der Naalt. "Deficits in Facial Emotion

Recognition Indicate Behavioral Changes and Impaired Self-Awareness after Moderate to

Severe Traumatic Brain Injury." PLOS ONE:. N.p., 12 June 2016. Web. 26 Mar. 2016.

Volkers, N. (2015, December). Back to School- With a TBI. The Asha Leader. Retrieved March

15, 2016, from leader.pubs.asha.org