Recent research suggests that survivors of moderate to severe traumatic brain injury (TBI) are at risk of long-term cognitive, emotional, and behavioral problems.

Dr. Torun Gangaune Finnanger and colleagues at Trondheim University Hospital in Norway looked at self-reported problems among 67 individuals two to five years after moderate or severe TBI.

Compared to healthy similar individuals, those with TBI suffered significantly more attentional, emotional regulation, and psychological difficulties. Their backgrounds were examined, and it was found that fewer years of education and depressive symptoms were linked to greater psychological problems. Younger age at the time of injury predicted more aggressive and rule-breaking behavior.

Traumatic axonal injury, that is, extensive damage to white matter, was linked to “internalizing problems and greater executive dysfunction.”

The team concludes in the journal Behavioural Neurology that, “Age, education, traumatic axonal injury, and depression appear to elevate risk for poor long-term outcome, emphasizing the need for long-term follow-up of patients presenting with risk factors.”

TBI is an important public health problem in the United States and worldwide. It occurs when a sudden trauma causes damage to the brain either by the force of impact or by piercing the skull and entering brain tissue.

An estimated 5.3 million Americans are living with disability caused by TBI, and face numerous challenges in their efforts to live a full and productive life. It is the top cause of death and disability in people between the ages of one to 44 years.

Brain injuries are most often caused by motor vehicle crashes, sports injuries, assaults, or simple falls, at work or in the home. They cause about 52,000 deaths a year and raise the risk of developing Alzheimer’s disease.

TBI has been defined by Segun Toyin Dawodu, M.D., of Albany Medical College, N.Y., as “a nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.”

But he points out that the definition has not been consistent and tends to vary according to specialties or circumstances.

Brain injury can sometimes go unnoticed while a medical team is focused on lifesaving, although the use of technology to control breathing with respirators and decrease intracranial pressure has helped reduce mortality from TBI. It is classified as either mild or severe. If loss of consciousness or confusion and disorientation lasts less than 30 minutes the brain injury is classed as mild.

While MRI and CAT scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings, and frustration. These injuries are commonly overlooked. Even though this type of TBI is called “mild,” the effect on the family and the injured person can be devastating.

Severe brain injury is associated with loss of consciousness for more than 30 minutes and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits range from impairment of higher level cognitive functions to comatose states.

Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability, or emotional problems. The range of injuries and degree of recovery varies on an individual basis.

The effects of TBI can be profound. Individuals with severe injuries can be left in long-term unresponsive states. For many people with severe TBI, long-term rehabilitation is often necessary to maximize function and independence. Even with mild TBI, the consequences to a person’s life can be dramatic. Change in brain function can have a dramatic impact on family, job, social, and community interaction.

According to the World Health Organization’s Violence and Injury Prevention and Disability program, “Traumatic brain injury usually requires long-term care and therefore incurs economic cost to health systems. For this reason, many countries need to develop surveillance systems and conduct epidemiologic studies to measure the impact of neurotrauma among their people to guide the development of more effective preventive methods.

“A number of methods have already proven effective, such as the use of motorcycle helmets, head supports in vehicles, or on sports equipment.”

The WHO also warns that low- and middle-income countries in particular face higher risk factors at the same time as having inadequately prepared health systems to manage the consequences.

Prevention efforts mostly focus on common sense measures such as always wearing seat belts in motor vehicles, and using appropriate child safety seats. Public health messages aimed at preventing brain injury also focus on driving under the influence of alcohol or drugs, and wearing a helmet when necessary. This includes when using a bicycle, motorcycle, scooter, playing contact sports, horseback riding, skiing, snowboarding, or skating.

For people with poor vision or who have difficulty walking, adequate lighting and rails should always be provided on stairways. Bars may be needed on windows to prevent children falling, and obstacles should be cleared from pathways. Guns should be kept in a locked cabinet, unloaded, and ammunition should be stored separately from guns.