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A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity (ranging from mild traumatic brain injury [mTBI/concussion] to severe traumatic brain injury), mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area).^[5]Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.

Causes include falls, vehicle collisions and violence. Brain trauma occurs as a consequence of a sudden acceleration or deceleration within the cranium or by a complex combination of both movement and sudden impact. In addition to the damage caused at the moment of injury, a variety of events following the injury may result in further injury. These processes include alterations in cerebral blood flow and pressure within the skull. Some of the imaging techniques used for diagnosis include computed tomography (CT) and magnetic resonance imaging (MRIs).

Prevention measures include use of seat belts and helmets, not drinking and driving, fall prevention efforts in older adults and safety measures for children.^[6] Depending on the injury, treatment required may be minimal or may include interventions such as medications, emergency surgery or surgery years later. Physical therapy, speech therapy, recreation therapy, occupational therapy and vision therapy may be employed for rehabilitation. Counseling, supported employment and community support services may also be useful.

TBI is a major cause of death and disability worldwide, especially in children and young adults.^[7] Males sustain traumatic brain injuries around twice as often as females.^[8] The 20th century saw developments in diagnosis and treatment that decreased death rates and improved outcomes.

Classification

Traumatic brain injury is defined as damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile.^[9] Brain function is temporarily or permanently impaired and structural damage may or may not be detectable with current technology.^[10]

TBI is one of two subsets of acquired brain injury (brain damage that occur after birth); the other subset is non-traumatic brain injury, which does not involve external mechanical force (examples include stroke and infection).^[11][12] All traumatic brain injuries are head injuries, but the latter term may also refer to injury to other parts of the head.^[13][14][15] However, the terms head injury and brain injury are often used interchangeably.^[16] Similarly, brain injuries fall under the classification of central nervous system injuries^[17] and neurotrauma.^[18] In neuropsychology research literature, in general the term 'traumatic brain injury' is used to refer to non-penetrating traumatic brain injuries.

TBI is usually classified based on severity, anatomical features of the injury, and the mechanism (the causative forces).^[19] Mechanism-related classification divides TBI into closed and penetrating head injury.^[9] A closed (also called nonpenetrating, or blunt)^[13] injury occurs when the brain is not exposed.^[14] A penetrating, or open, head injury occurs when an object pierces the skull and breaches the dura mater, the outermost membrane surrounding the brain.^[14]

Severity

Brain injuries can be classified into mild, moderate, and severe categories.^[19] The Glasgow Coma Scale (GCS), the most commonly used system for classifying TBI severity, grades a person's level of consciousness on a scale of 3–15 based on verbal, motor, and eye-opening reactions to stimuli.^[21] In general, it is agreed that a TBI with a GCS of 13 or above is mild, 9–12 is moderate, and 8 or below is severe.^[10][15][22] Similar systems exist for young children.^[15] However, the GCS grading system has limited ability to predict outcomes. Because of this, other classification systems such as the one shown in the table are also used to help determine severity. A current model developed by the Department of Defense and Department of Veterans Affairs uses all three criteria of GCS after resuscitation, duration of post-traumatic amnesia (PTA), and loss of consciousness (LOC).^[20] It also has been proposed to use changes that are visible on neuroimaging, such as swelling, focal lesions, or diffuse injury as method of classification.^[9]Grading scales also exist to classify the severity of mild TBI, commonly called concussion; these use duration of LOC, PTA, and other concussion symptoms.^[23]

Pathological features

Systems also exist to classify TBI by its pathological features.^[19] Lesions can be extra-axial, (occurring within the skull but outside of the brain) or intra-axial (occurring within the brain tissue).^[24] Damage from TBI can be focal or diffuse, confined to specific areas or distributed in a more general manner, respectively.^[25] However, it is common for both types of injury to exist in a given case.^[25]

Diffuse injury manifests with little apparent damage in neuroimaging studies, but lesions can be seen with microscopy techniques post-mortem,^[25][26] and in the early 2000s, researchers discovered that diffusion tensor imaging (DTI), a way of processing MRI images that shows white matter tracts, was an effective tool for displaying the extent of diffuse axonal injury.^[27][28] Types of injuries considered diffuse include edema (swelling), concussion and diffuse axonal injury, which is widespread damage to axons including white matter tracts and projections to the cortex.^[29][30]

Focal injuries often produce symptoms related to the functions of the damaged area.^[17] Research shows that the most common areas to have focal lesions in non-penetrating traumatic brain injury are the orbitofrontal cortex (the lower surface of the frontal lobes) and the anterior temporal lobes, areas that are involved in social behavior, emotion regulation, olfaction, and decision-making, hence the common social/emotional and judgment deficits following moderate-severe TBI.^{[31][32][33][34]} Symptoms such as hemiparesis or aphasia can also occur when less commonly affected areas such as motor or language areas are, respectively, damaged.^[35][36]

One type of focal injury, cerebral laceration, occurs when the tissue is cut or torn.^[37] Such tearing is common in orbitofrontal cortex in particular, because of bony protrusions on the interior skull ridge above the eyes.^[31] In a similar injury, cerebral contusion (bruising of brain tissue), blood is mixed among tissue.^[22] In contrast, intracranial hemorrhage involves bleeding that is not mixed with tissue.^[37]

Hematomas, also focal lesions, are collections of blood in or around the brain that can result from hemorrhage.^[10]Intracerebral hemorrhage, with bleeding in the brain tissue itself, is an intra-axial lesion. Extra-axial lesions include epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and intraventricular hemorrhage.^[38] Epidural hematoma involves bleeding into the area between the skull and the dura mater, the outermost of the three membranes surrounding the brain.^[10] In subdural hematoma, bleeding occurs between the dura and the arachnoid mater.^[22] Subarachnoid hemorrhage involves bleeding into the space between the arachnoid membrane and the pia mater.^[22] Intraventricular hemorrhage occurs when there is bleeding in the ventricles.^[38]

Signs and symptoms

Symptoms are dependent on the type of TBI (diffuse or focal) and the part of the brain that is affected.^[40] Unconsciousness tends to last longer for people with injuries on the left side of the brain than for those with injuries on the right.^[14] Symptoms are also dependent on the injury's severity. With mild TBI, the patient may remain conscious or may lose consciousness for a few seconds or minutes.^[41] Other symptoms of mild TBI include headache, vomiting, nausea, lack of motor coordination, dizziness, difficulty balancing,^[42] lightheadedness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, and changes in sleep patterns.^[41] Cognitive and emotional symptoms include behavioral or mood changes, confusion, and trouble with memory, concentration, attention, or thinking.^[41] Mild TBI symptoms may also be present in moderate and severe injuries.^[41]

A person with a moderate or severe TBI may have a headache that does not go away, repeated vomiting or nausea, convulsions, an inability to awaken, dilation of one or both pupils, slurred speech, aphasia (word-finding difficulties), dysarthria (muscle weakness that causes disordered speech), weakness or numbness in the limbs, loss of coordination, confusion, restlessness, or agitation.^[41] Common long-term symptoms of moderate to severe TBI are changes in appropriate social behavior, deficits in social judgment, and cognitive changes, especially problems with sustained attention, processing speed, and executive functioning.^{[34][43][44][45][46]}Alexithymia, a deficiency in identifying, understanding, processing, and describing emotions occurs in 60.9% of individuals with TBI.^[47] Cognitive and social deficits have long-term consequences for the daily lives of people with moderate to severe TBI, but can be improved with appropriate rehabilitation.^{[46][48][49][50]}

When the pressure within the skull (intracranial pressure, abbreviated ICP) rises too high, it can be deadly.^[51] Signs of increased ICP include decreasing level of consciousness, paralysis or weakness on one side of the body, and a blown pupil, one that fails to constrict in response to light or is slow to do so.^[51]Cushing's triad, a slow heart rate with high blood pressure and respiratory depression is a classic manifestation of significantly raised ICP.^[10]Anisocoria, unequal pupil size, is another sign of serious TBI.^[39]Abnormal posturing, a characteristic positioning of the limbs caused by severe diffuse injury or high ICP, is an ominous sign.^[10]

Small children with moderate to severe TBI may have some of these symptoms but have difficulty communicating them.^[52] Other signs seen in young children include persistent crying, inability to be consoled, listlessness, refusal to nurse or eat,^[52] and irritability.^[10]

Causes

The most common causes of TBI in the U.S. include violence, transportation accidents, construction, and sports.^[42][53] Motor bikes are major causes, increasing in significance in developing countries as other causes reduce.^[54] The estimates that between 1.6 and 3.8 million traumatic brain injuries each year are a result of sports and recreation activities in the US.^[55] In children aged two to four, falls are the most common cause of TBI, while in older children traffic accidents compete with falls for this position.^[56] TBI is the third most common injury to result from child abuse.^[57] Abuse causes 19% of cases of pediatric brain trauma, and the death rate is higher among these cases.^[58] Although men are twice as likely to have a TBI. Domestic violence is another cause of TBI,^[59] as are work-related and industrial accidents.^[60] Firearms^[14] and blast injuries from explosions^[61] are other causes of TBI, which is the leading cause of death and disability in war zones.^[62] According to Representative Bill Pascrell (Democrat, NJ), TBI is 'the signature injury of the wars in Iraq and Afghanistan.'^[63] There is a promising technology called activation database-guided EEG biofeedback, which has been documented to return a TBI's auditory memory ability to above the control group's performance^[64][65]

Mechanism

Physical forces

The type, direction, intensity, and duration of forces all contribute to the characteristics and severity TBI.^[9] Forces that may contribute to TBI include angular, rotational, shear, and translational forces.^[37]

Even in the absence of an impact, significant acceleration or deceleration of the head can cause TBI; however in most cases, a combination of impact and acceleration is probably to blame.^[37] Forces involving the head striking or being struck by something, termed contact or impact loading, are the cause of most focal injuries, and movement of the brain within the skull, termed noncontact or inertial loading, usually causes diffuse injuries.^[19] The violent shaking of an infant that causes shaken baby syndrome commonly manifests as diffuse injury.^[67] In impact loading, the force sends shock waves through the skull and brain, resulting in tissue damage.^[37] Shock waves caused by penetrating injuries can also destroy tissue along the path of a projectile, compounding the damage caused by the missile itself.^[22]

Damage may occur directly under the site of impact, or it may occur on the side opposite the impact (coup and contrecoup injury, respectively).^[66] When a moving object impacts the stationary head, coup injuries are typical,^[68] while contrecoup injuries are usually produced when the moving head strikes a stationary object.^[69]

Primary and secondary injury

A large percentage of the people killed by brain trauma do not die right away but rather days to weeks after the event;^[70] rather than improving after being hospitalized, some 40% of TBI patients deteriorate.^[71]Primary brain injury (the damage that occurs at the moment of trauma when tissues and blood vessels are stretched, compressed, and torn) is not adequate to explain this deterioration; rather, it is caused by secondary injury, a complex set of cellular processes and biochemical cascades that occur in the minutes to days following the trauma.^[72] These secondary processes can dramatically worsen the damage caused by primary injury^[62] and account for the greatest number of TBI deaths occurring in hospitals.^[39]

Secondary injury events include damage to the blood–brain barrier, release of factors that cause inflammation, free radical overload, excessive release of the neurotransmitterglutamate (excitotoxicity), influx of calcium and sodium ions into neurons, and dysfunction of mitochondria.^[62] Injured axons in the brain's white matter may separate from their cell bodies as a result of secondary injury,^[62] potentially killing those neurons. Other factors in secondary injury are changes in the blood flow to the brain; ischemia (insufficient blood flow); cerebral hypoxia (insufficient oxygen in the brain); cerebral edema (swelling of the brain); and raised intracranial pressure (the pressure within the skull).^[73] Intracranial pressure may rise due to swelling or a mass effect from a lesion, such as a hemorrhage.^[51] As a result, cerebral perfusion pressure (the pressure of blood flow in the brain) is reduced; ischemia results.^[39][74] When the pressure within the skull rises too high, it can cause brain death or herniation, in which parts of the brain are squeezed by structures in the skull.^[51] A particularly weak part of the skull that is vulnerable to damage causing extradural haematoma is the pterion, deep in which lies the middle meningeal artery, which is easily damaged in fractures of the pterion. Since the pterion is so weak, this type of injury can easily occur and can be secondary due to trauma to other parts of the skull where the impact forces spreads to the pterion.

Diagnosis

Diagnosis is suspected based on lesion circumstances and clinical evidence, most prominently a neurological examination, for example checking whether the pupils constrict normally in response to light and assigning a Glasgow Coma Score.^[22] Neuroimaging helps in determining the diagnosis and prognosis and in deciding what treatments to give.^[75] DSM-5 can be utilized to diagnose TBI and its psychiatric sequelae.^[76][77][78]

The preferred radiologic test in the emergency setting is computed tomography (CT): it is quick, accurate, and widely available.^[79] Follow-up CT scans may be performed later to determine whether the injury has progressed.^[9]

Magnetic resonance imaging (MRI) can show more detail than CT, and can add information about expected outcome in the long term.^[22] It is more useful than CT for detecting injury characteristics such as diffuse axonal injury in the longer term.^[9] However, MRI is not used in the emergency setting for reasons including its relative inefficacy in detecting bleeds and fractures, its lengthy acquisition of images, the inaccessibility of the patient in the machine, and its incompatibility with metal items used in emergency care.^[22] A variant of MRI since 2012 is High definition fiber tracking (HDFT).^[80]

Other techniques may be used to confirm a particular diagnosis. X-rays are still used for head trauma, but evidence suggests they are not useful; head injuries are either so mild that they do not need imaging or severe enough to merit the more accurate CT.^[79]Angiography may be used to detect blood vessel pathology when risk factors such as penetrating head trauma are involved.^[9]Functional imaging can measure cerebral blood flow or metabolism, inferring neuronal activity in specific regions and potentially helping to predict outcome.^[81]Electroencephalography and transcranial doppler may also be used. The most sensitive physical measure to date is the quantitative EEG, which has documented an 80% to 100% ability in discriminating between normal and traumatic brain-injured subjects.^[82][83]

Neuropsychological assessment can be performed to evaluate the long-term cognitive sequelae and to aid in the planning of the rehabilitation.^[75] Instruments range from short measures of general mental functioning to complete batteries formed of different domain-specific tests.

Prevention

Since a major cause of TBI are vehicle accidents, their prevention or the amelioration of their consequences can both reduce the incidence and gravity of TBI. In accidents, damage can be reduced by use of seat belts, child safety seats^[55] and motorcycle helmets,^[85] and presence of roll bars and airbags.^[37] Education programs exist to lower the number of crashes.^[75] In addition, changes to public policy and safety laws can be made; these include speed limits, seat belt and helmet laws, and road engineering practices.^[62]

Changes to common practices in sports have also been discussed. An increase in use of helmets could reduce the incidence of TBI.^[62] Due to the possibility that repeatedly 'heading' a ball practicing soccer could cause cumulative brain injury, the idea of introducing protective headgear for players has been proposed.^[86] Improved equipment design can enhance safety; softer baseballs reduce head injury risk.^[87] Rules against dangerous types of contact, such as 'spear tackling' in American football, when one player tackles another head first, may also reduce head injury rates.^[87]

Falls can be avoided by installing grab bars in bathrooms and handrails on stairways; removing tripping hazards such as throw rugs; or installing window guards and safety gates at the top and bottom of stairs around young children.^[55] Playgrounds with shock-absorbing surfaces such as mulch or sand also prevent head injuries.^[55] Child abuse prevention is another tactic; programs exist to prevent shaken baby syndrome by educating about the dangers of shaking children.^[58] Gun safety, including keeping guns unloaded and locked, is another preventative measure.^[88] Studies on the effect of laws that aim to control access to guns in the United States have been insufficient to determine their effectiveness preventing number of deaths or injuries.^[89]

Recent clinical and laboratory research by neurosurgeon Julian Bailes, M.D., and his colleagues from West Virginia University, has resulted in papers showing that dietary supplementation with omega-3 DHA offers protection against the biochemical brain damage that occurs after a traumatic injury.^[90] Rats given DHA prior to induced brain injuries suffered smaller increases in two key markers for brain damage (APP and caspase-3), as compared with rats given no DHA.^[91] 'The potential for DHA to provide prophylactic benefit to the brain against traumatic injury appears promising and requires further investigation. The essential concept of daily dietary supplementation with DHA, so that those at significant risk may be preloaded to provide protection against the acute effects of TBI, has tremendous public health implications.'^[92]

Furthermore, acetylcysteine has been confirmed, in a recent double-blind placebo-controlled trial conducted by the US military, to reduce the effects of blast induced mild traumatic brain and neurological injury in soldiers.^[93] Multiple animal studies have also demonstrated its efficacy in reducing the damage associated with moderate traumatic brain or spinal injury, and also ischemia-induced brain injury. In particular, it has been demonstrated through multiple studies to significantly reduce neuronal losses and to improve cognitive and neurological outcomes associated with these traumatic events. Acetylcysteine has been safely used to treat paracetamol overdose for over forty years and is extensively used in emergency medicine.

Treatment

It is important to begin emergency treatment within the so-called 'golden hour' following the injury.^[94] People with moderate to severe injuries are likely to receive treatment in an intensive care unit followed by a neurosurgical ward.^[95] Treatment depends on the recovery stage of the patient. In the acute stage, the primary aim is to stabilize the patient and focus on preventing further injury. This is done because the initial damage caused by trauma cannot be reversed.^[95] Rehabilitation is the main treatment for the subacute and chronic stages of recovery.^[95] International clinical guidelines have been proposed with the aim of guiding decisions in TBI treatment, as defined by an authoritative examination of current evidence.^[9]

Acute stage

Tranexamic acid within three hours of a head injury decreases the risk of death.^[96] Certain facilities are equipped to handle TBI better than others; initial measures include transporting patients to an appropriate treatment center.^[51][97] Both during transport and in hospital the primary concerns are ensuring proper oxygen supply, maintaining adequate blood flow to the brain, and controlling raised intracranial pressure (ICP),^[10] since high ICP deprives the brain of badly needed blood flow^[98] and can cause deadly brain herniation. Other methods to prevent damage include management of other injuries and prevention of seizures.^[22][75] Some data supports the use of hyperbaric oxygen therapy to improve outcomes.^[99] Further research is required to determine the effectiveness and clinical importance of positioning the head at different angles (degrees of head-of-bed elevation) while the person is being treated in intensive care.^[100]

Neuroimaging is helpful but not flawless in detecting raised ICP.^[101] A more accurate way to measure ICP is to place a catheter into a ventricle of the brain,^[39] which has the added benefit of allowing cerebrospinal fluid to drain, releasing pressure in the skull.^[39] Treatment of raised ICP may be as simple as tilting the person's bed and straightening the head to promote blood flow through the veins of the neck. Sedatives, analgesics and paralytic agents are often used.^[51] Propofol and midazolam are equally effective as sedatives.^[102]

Hypertonic saline can improve ICP by reducing the amount of cerebral water (swelling), though it is used with caution to avoid electrolyte imbalances or heart failure.^{[9][103][104]}Mannitol, an osmoticdiuretic,^[9] appears to be as effective as hypertonic saline at reducing ICP.^{[105][106][107][108]} Some concerns, however, have been raised regarding some of the studies performed.^{[109][specify]}Diuretics, drugs that increase urine output to reduce excessive fluid in the system, may be used to treat high intracranial pressures, but may cause hypovolemia (insufficient blood volume).^[39]Hyperventilation (larger and/or faster breaths) reduces carbon dioxide levels and causes blood vessels to constrict; this decreases blood flow to the brain and reduces ICP,^[110] but it potentially causes ischemia^{[10][39][111]} and is, therefore, used only in the short term.^[10]

Giving corticosteroids is associated with an increased risk of death, and so their routine use is not recommended.^[112][113] There is no strong evidence that the following pharmaceutical interventions should be recommended to routinely treat TBI: magnesium, monoaminergic and dopamine agonists, progesterone, aminosteroids, excitatory amino acid reuptake inhibitors, beta-2 antagonists (bronchodilators), haemostatic and antifibrinolytic drugs.^{[102][114][115][116][117]}

Endotracheal intubation and mechanical ventilation may be used to ensure proper oxygen supply and provide a secure airway.^[75]Hypotension (low blood pressure), which has a devastating outcome in TBI, can be prevented by giving intravenous fluids to maintain a normal blood pressure. Failing to maintain blood pressure can result in inadequate blood flow to the brain.^[22] Blood pressure may be kept at an artificially high level under controlled conditions by infusion of norepinephrine or similar drugs; this helps maintain cerebral perfusion.^[118] Body temperature is carefully regulated because increased temperature raises the brain's metabolic needs, potentially depriving it of nutrients.^[119] Seizures are common. While they can be treated with benzodiazepines, these drugs are used carefully because they can depress breathing and lower blood pressure.^[51] Anti-convulsant medications have only been found to be useful for reducing the risk of an early seizure.^[102]Phenytoin and leviteracetam appear to have similar levels of effectiveness for preventing early seizures.^[102] People with TBI are more susceptible to side effects and may react adversely to some medications.^[95] During treatment monitoring continues for signs of deterioration such as a decreasing level of consciousness.^[9][10]

Traumatic brain injury may cause a range of serious coincidental complications that include cardiac arrhythmias^[120] and neurogenic pulmonary edema.^[121] These conditions must be adequately treated and stabilised as part of the core care.

Surgery can be performed on mass lesions or to eliminate objects that have penetrated the brain. Mass lesions such as contusions or hematomas causing a significant mass effect (shift of intracranial structures) are considered emergencies and are removed surgically.^[22] For intracranial hematomas, the collected blood may be removed using suction or forceps or it may be floated off with water.^[22] Surgeons look for hemorrhaging blood vessels and seek to control bleeding.^[22] In penetrating brain injury, damaged tissue is surgically debrided, and craniotomy may be needed.^[22] Craniotomy, in which part of the skull is removed, may be needed to remove pieces of fractured skull or objects embedded in the brain.^[122]Decompressive craniectomy (DC) is performed routinely in the very short period following TBI during operations to treat hematomas; part of the skull is removed temporarily (primary DC).^[123] DC performed hours or days after TBI in order to control high intracranial pressures (secondary DC) has not been shown to improve outcome in some trials and may be associated with severe side-effects.^[9][123]

Chronic stage

Once medically stable, people may be transferred to a subacute rehabilitation unit of the medical center or to an independent rehabilitation hospital.^[95] Rehabilitation aims to improve independent functioning at home and in society, and to help adapt to disabilities.^[95] Rehabilitation has demonstrated its general effectiveness when conducted by a team of health professionals who specialize in head trauma.^[124] As for any person with neurologic deficits, a multidisciplinary approach is key to optimizing outcome. Physiatrists or neurologists are likely to be the key medical staff involved, but depending on the person, doctors of other medical specialties may also be helpful. Allied health professions such as physiotherapy, speech and language therapy, cognitive rehabilitation therapy, and occupational therapy will be essential to assess function and design the rehabilitation activities for each person.^[125] Treatment of neuropsychiatric symptoms such as emotional distress and clinical depression may involve mental health professionals such as therapists, psychologists, and psychiatrists, while neuropsychologists can help to evaluate and manage cognitive deficits.^[95][126] Social workers, rehabilitation support personnel, nutritionists, therapeutic recreationists, and pharmacists are also important members of the TBI rehabilitation team.^[125] After discharge from the inpatient rehabilitation treatment unit, care may be given on an outpatient basis. Community-based rehabilitation will be required for a high proportion of people, including vocational rehabilitation; this supportive employment matches job demands to the worker's abilities.^[127] People with TBI who cannot live independently or with family may require care in supported living facilities such as group homes.^[127]Respite care, including day centers and leisure facilities for the disabled, offers time off for caregivers, and activities for people with TBI.^[127]

Pharmacological treatment can help to manage psychiatric or behavioral problems.^[128] Medication is also used to control post-traumatic epilepsy; however the preventive use of anti-epileptics is not recommended.^[129] In those cases where the person is bedridden due to a reduction of consciousness, has to remain in a wheelchair because of mobility problems, or has any other problem heavily impacting self-caring capacities, caregiving and nursing are critical.The most effective research documented intervention approach is the activation database guided EEG biofeedback approach, which has shown significant improvements in memory abilities of the TBI subject that are far superior than traditional approaches (strategies, computers, medication intervention). Gains of 2.61 standard deviations have been documented. The TBI's auditory memory ability was superior to the control group after the treatment.^[64]

Effect on the gait pattern

In patients who have developed paralysis of the legs in the form of spastic hemiplegia or diplegia as a result of the traumatic brain injury, various gait patterns can be observed, the exact extent of which can only be described with the help of complex gait analysis systems. In order to facilitate interdisciplinary communication in the interdisciplinary team between those affected, doctors, physiotherapists and orthotists, a simple description of the gait pattern is useful. J. Rodda and H. K. Graham already described in 2001 how gait patterns of CP patients can be more easily recognized and defined gait types which they compared in a classification. They also described that gait patterns can vary with age.^[130] Building on this, the Amsterdam Gait Classification was developed at the free university in Amsterdam, the VU medisch centrum. A special feature of this classification is that it makes different gait patterns very recognizable and can be used in patients in whom only one leg and both legs are affected. The Amsterdam Gait Classification was developed for viewing patients with cerebral palsy. However, it can be used just as well in patients with traumatic brain injuries. According to the Amsterdam Gait Classification, five gait types are described. To assess the gait pattern, the patient is viewed visually or via a video recording from the side of the leg to be assessed. At the point in time at which the leg to be viewed is in mid stance and the leg not to be viewed is in mid swing, the knee angle and the contact of the foot with the ground are assessed on the one hand.^[131]

Classification of the gait pattern according to the Amsterdam Gait Classification: In gait type 1, the knee angle is normal and the foot contact is complete. In gait type 2, the knee angle is hyperextended and the foot contact is complete. In gait type 3, the knee angle is hyperextended and foot contact is incomplete (only on the forefoot). In gait type 4, the knee angle is bent and foot contact is incomplete (only on the forefoot). With gait type 5, the knee angle is bent and the foot contact is complete.^[131]

Gait types 5 is also known as crouch gait.

Orthotics

To improve the gait pattern, orthotics can be included in the therapy concept.^[132] An Orthosis can support physiotherapeutic treatment in setting the right motor impulses in order to create new cerebral connections.^[133] The orthosis must meet the requirements of the medical prescription. In addition, the orthosis must be designed by the orthotist in such a way that it achieves the effectiveness of the necessary levers, matching the gait pattern, in order to support the proprioceptive approaches of physiotherapy. The orthotic concepts of the treatment are based on the concepts for the patients with cerebral palsy. The characteristics of the stiffness of the orthosis shells and the adjustable dynamics in the ankle joint are important elements of the orthosis to be considered.^[134] The orthotic concepts of the treatment are based on the concepts for the patients with cerebral palsy. Due to these requirements, the development of orthoses has changed significantly in recent years, especially since around 2010. At about the same time, care concepts were developed that deal intensively with the orthotic treatment of the lower extremities in cerebral palsy.^[135] Modern materials and new functional elements enable the rigidity to be specifically adapted to the requirements that fits to the gait pattern of the patient.^[136] The adjustment of the stiffness has a decisive influence on the gait pattern and on the energy cost of walking.^{[137][138][139]} It is of great advantage if the stiffness of the orthosis can be adjusted separately from one another via resistances of the two functional elements in the two directions of movement, dorsiflexion and plantar flexion.^[140]

Prognosis

Prognosis worsens with the severity of injury.^[8] Most TBIs are mild and do not cause permanent or long-term disability; however, all severity levels of TBI have the potential to cause significant, long-lasting disability.^[141] Permanent disability is thought to occur in 10% of mild injuries, 66% of moderate injuries, and 100% of severe injuries.^[142] Most mild TBI is completely resolved within three weeks. Almost all people with mild TBI are able to live independently and return to the jobs they had before the injury, although a small portion have mild cognitive and social impairments.^[88] Over 90% of people with moderate TBI are able to live independently, although some require assistance in areas such as physical abilities, employment, and financial managing.^[88] Most people with severe closed head injury either die or recover enough to live independently; middle ground is less common.^[9] Coma, as it is closely related to severity, is a strong predictor of poor outcome.^[10]

Prognosis differs depending on the severity and location of the lesion, and access to immediate, specialised acute management. Subarachnoid hemorrhage approximately doubles mortality.^[143] Subdural hematoma is associated with worse outcome and increased mortality, while people with epidural hematoma are expected to have a good outcome if they receive surgery quickly.^[75] Diffuse axonal injury may be associated with coma when severe, and poor outcome.^[9] Following the acute stage, prognosis is strongly influenced by the patient's involvement in activity that promote recovery, which for most patients requires access to a specialised, intensive rehabilitation service. The Functional Independence Measure is a way to track progress and degree of independence throughout rehabilitation.^[144]

Medical complications are associated with a bad prognosis. Examples of such complications include: hypotension (low blood pressure), hypoxia (low blood oxygen saturation), lower cerebral perfusion pressures, and longer times spent with high intracranial pressures.^[9][75] Patient characteristics also influence prognosis. Examples of factors thought to worsen it include: abuse of substances such as illicit drugs and alcohol and age over sixty or under two years (in children, younger age at time of injury may be associated with a slower recovery of some abilities).^[75] Other influences that may affect recovery include pre-injury intellectual ability, coping strategies, personality traits, family environment, social support systems and financial circumstances.^[145]

Life satisfaction has been known to decrease for individuals with TBI immediately following the trauma, but evidence has shown that life roles, age, and depressive symptoms influence the trajectory of life satisfaction as time passes.^[146] Many people with traumatic brain injuries have poor physical fitness following their acute injury and this may result with difficulties in day-to-day activities and increased levels of fatigue.^[147]

Complications

Improvement of neurological function usually occurs for two or more years after the trauma. For many years it was believed that recovery was fastest during the first six months, but there is no evidence to support this. It may be related to services commonly being withdrawn after this period, rather than any physiological limitation to further progress.^[9] Children recover better in the immediate time frame and improve for longer periods.^[10]

Complications are distinct medical problems that may arise as a result of the TBI. The results of traumatic brain injury vary widely in type and duration; they include physical, cognitive, emotional, and behavioral complications. TBI can cause prolonged or permanent effects on consciousness, such as coma, brain death, persistent vegetative state (in which patients are unable to achieve a state of alertness to interact with their surroundings),^[149] and minimally conscious state (in which patients show minimal signs of being aware of self or environment).^[150][151] Lying still for long periods can cause complications including pressure sores, pneumonia or other infections, progressive multiple organ failure,^[95] and deep venous thrombosis, which can cause pulmonary embolism.^[22] Infections that can follow skull fractures and penetrating injuries include meningitis and abscesses.^[95] Complications involving the blood vessels include vasospasm, in which vessels constrict and restrict blood flow, the formation of aneurysms, in which the side of a vessel weakens and balloons out, and stroke.^[95]

Movement disorders that may develop after TBI include tremor, ataxia (uncoordinated muscle movements), spasticity (muscle contractions are overactive), myoclonus (shock-like contractions of muscles), and loss of movement range and control (in particular with a loss of movement repertoire).^[95][152] The risk of post-traumatic seizures increases with severity of trauma (image at right) and is particularly elevated with certain types of brain trauma such as cerebral contusions or hematomas.^[142] People with early seizures, those occurring within a week of injury, have an increased risk of post-traumatic epilepsy (recurrent seizures occurring more than a week after the initial trauma).^[153] People may lose or experience altered vision, hearing, or smell.^[10]

Hormonal disturbances may occur secondary to hypopituitarism, occurring immediately or years after injury in 10 to 15% of TBI patients. Development of diabetes insipidus or an electrolyte abnormality acutely after injury indicate need for endocrinologic work up. Signs and symptoms of hypopituitarism may develop and be screened for in adults with moderate TBI and in mild TBI with imaging abnormalities. Children with moderate to severe head injury may also develop hypopituitarism. Screening should take place 3 to 6 months, and 12 months after injury, but problems may occur more remotely.^[154]

Cognitive deficits that can follow TBI include impaired attention; disrupted insight, judgement, and thought; reduced processing speed; distractibility; and deficits in executive functions such as abstract reasoning, planning, problem-solving, and multitasking.^[155]Memory loss, the most common cognitive impairment among head-injured people, occurs in 20–79% of people with closed head trauma, depending on severity.^[156] People who have suffered TBI may also have difficulty with understanding or producing spoken or written language, or with more subtle aspects of communication such as body language.^[95]Post-concussion syndrome, a set of lasting symptoms experienced after mild TBI, can include physical, cognitive, emotional and behavioral problems such as headaches, dizziness, difficulty concentrating, and depression.^[10] Multiple TBIs may have a cumulative effect.^[151] A young person who receives a second concussion before symptoms from another one have healed may be at risk for developing a very rare but deadly condition called second-impact syndrome, in which the brain swells catastrophically after even a mild blow, with debilitating or deadly results. About one in five career boxers is affected by chronic traumatic brain injury (CTBI), which causes cognitive, behavioral, and physical impairments.^[157]Dementia pugilistica, the severe form of CTBI, affects primarily career boxers years after a boxing career. It commonly manifests as dementia, memory problems, and parkinsonism (tremors and lack of coordination).^[158]

TBI may cause emotional, social, or behavioral problems and changes in personality.^{[159][160][161][162]} These may include emotional instability, depression, anxiety, hypomania, mania, apathy, irritability, problems with social judgment, and impaired conversational skills.^{[159][162][163][164]} TBI appears to predispose survivors to psychiatric disorders including obsessive compulsive disorder, substance abuse, dysthymia, clinical depression, bipolar disorder, and anxiety disorders.^[165] In patients who have depression after TBI, suicidal ideation is not uncommon; the suicide rate among these persons is increased 2- to 3-fold.^[166] Social and behavioral symptoms that can follow TBI include disinhibition, inability to control anger, impulsiveness, lack of initiative, inappropriate sexual activity, asociality and social withdrawal, and changes in personality.^{[159][161][162][167]}

TBI also has a substantial impact on the functioning of family systems^[168] Caregiving family members and TBI survivors often significantly alter their familial roles and responsibilities following injury, creating significant change and strain on a family system. Typical challenges identified by families recovering from TBI include: frustration and impatience with one another, loss of former lives and relationships, difficulty setting reasonable goals, inability to effectively solve problems as a family, increased level of stress and household tension, changes in emotional dynamics, and overwhelming desire to return to pre-injury status. In addition, families may exhibit less effective functioning in areas including coping, problem solving and communication. Psychoeducation and counseling models have been demonstrated to be effective in minimizing family disruption.^[169]

Epidemiology

TBI is a leading cause of death and disability around the globe^[7] and presents a major worldwide social, economic, and health problem.^[9] It is the number one cause of coma,^[171] it plays the leading role in disability due to trauma,^[75] and is the leading cause of brain damage in children and young adults.^[14] In Europe it is responsible for more years of disability than any other cause.^[9] It also plays a significant role in half of trauma deaths.^[22]

Findings on the frequency of each level of severity vary based on the definitions and methods used in studies. A World Health Organization study estimated that between 70 and 90% of head injuries that receive treatment are mild,^[172] and a US study found that moderate and severe injuries each account for 10% of TBIs, with the rest mild.^[71]

The incidence of TBI varies by age, gender, region and other factors.^[173] Findings of incidence and prevalence in epidemiological studies vary based on such factors as which grades of severity are included, whether deaths are included, whether the study is restricted to hospitalized people, and the study's location.^[14] The annual incidence of mild TBI is difficult to determine but may be 100–600 people per 100,000.^[62]

Mortality

In the US, the case fatality rate is estimated to be 21% by 30 days after TBI.^[97] A study on Iraq War soldiers found that severe TBI carries a mortality of 30–50%.^[62] Deaths have declined due to improved treatments and systems for managing trauma in societies wealthy enough to provide modern emergency and neurosurgical services.^[119] The fraction of those who die after being hospitalized with TBI fell from almost half in the 1970s to about a quarter at the beginning of the 21st century.^[75] This decline in mortality has led to a concomitant increase in the number of people living with disabilities that result from TBI.^[174]

Biological, clinical, and demographic factors contribute to the likelihood that an injury will be fatal.^[170] In addition, outcome depends heavily on the cause of head injury. In the US, patients with fall-related TBIs have an 89% survival rate, while only 9% of patients with firearm-related TBIs survive.^[175] In the US, firearms are the most common cause of fatal TBI, followed by vehicle accidents and then falls.^[170] Of deaths from firearms, 75% are considered to be suicides.^[170]

The incidence of TBI is increasing globally, due largely to an increase in motor vehicle use in low- and middle-income countries.^[9] In developing countries, automobile use has increased faster than safety infrastructure could be introduced.^[62] In contrast, vehicle safety laws have decreased rates of TBI in high-income countries,^[9] which have seen decreases in traffic-related TBI since the 1970s.^[54] Each year in the United States, about two million people suffer a TBI,^[20] approximately 675,000 injuries are seen in the emergency department,^[176] and about 500,000 patients are hospitalized.^[173] The yearly incidence of TBI is estimated at 180–250 per 100,000 people in the US,^[173] 281 per 100,000 in France, 361 per 100,000 in South Africa, 322 per 100,000 in Australia,^[14] and 430 per 100,000 in England.^[60] In the European Union the yearly aggregate incidence of TBI hospitalizations and fatalities is estimated at 235 per 100,000.^[9]

Demographics

TBI is present in 85% of traumatically injured children, either alone or with other injuries.^[177] The greatest number of TBIs occur in people aged 15–24.^[12][37] Because TBI is more common in young people, its costs to society are high due to the loss of productive years to death and disability.^[9] The age groups most at risk for TBI are children ages five to nine and adults over age 80,^[8] and the highest rates of death and hospitalization due to TBI are in people over age 65.^[141] The incidence of fall-related TBI in First-World countries is increasing as the population ages; thus the median age of people with head injuries has increased.^[9]

Regardless of age, TBI rates are higher in males.^[37] Men suffer twice as many TBIs as women do and have a fourfold risk of fatal head injury,^[8] and males account for two thirds of childhood and adolescent head trauma.^[178] However, when matched for severity of injury, women appear to fare more poorly than men.^[98]

Socioeconomic status also appears to affect TBI rates; people with lower levels of education and employment and lower socioeconomic status are at greater risk.^[14] Approximately half of those incarcerated in prisons and jails in the United States have had TBIs.^[179]

History

Head injury is present in ancient myths that may date back before recorded history.^[180] Skulls found in battleground graves with holes drilled over fracture lines suggest that trepanation may have been used to treat TBI in ancient times.^[181] Ancient Mesopotamians knew of head injury and some of its effects, including seizures, paralysis, and loss of sight, hearing or speech.^[182] The Edwin Smith Papyrus, written around 1650–1550 BC, describes various head injuries and symptoms and classifies them based on their presentation and tractability.^[183]Ancient Greek physicians including Hippocrates understood the brain to be the center of thought, probably due to their experience with head trauma.^[184]

Medieval and Renaissance surgeons continued the practice of trepanation for head injury.^[184] In the Middle Ages, physicians further described head injury symptoms and the term concussion became more widespread.^[185] Concussion symptoms were first described systematically in the 16th century by Berengario da Carpi.^[184]

It was first suggested in the 18th century that intracranial pressure rather than skull damage was the cause of pathology after TBI. This hypothesis was confirmed around the end of the 19th century, and opening the skull to relieve pressure was then proposed as a treatment.^[181]

In the 19th century it was noted that TBI is related to the development of psychosis.^[186] At that time a debate arose around whether post-concussion syndrome was due to a disturbance of the brain tissue or psychological factors.^[185] The debate continues today.

Perhaps the first reported case of personality change after brain injury is that of Phineas Gage, who survived an accident in which a large iron rod was driven through his head, destroying one or both of his frontal lobes; numerous cases of personality change after brain injury have been reported since.^{[31][33][34][43][44][48][187][188]}

The 20th century saw the advancement of technologies that improved treatment and diagnosis such as the development of imaging tools including CT and MRI, and, in the 21st century, diffusion tensor imaging (DTI). The introduction of intracranial pressure monitoring in the 1950s has been credited with beginning the 'modern era' of head injury.^[119][189] Until the 20th century, the mortality rate of TBI was high and rehabilitation was uncommon; improvements in care made during World War I reduced the death rate and made rehabilitation possible.^[180] Facilities dedicated to TBI rehabilitation were probably first established during World War I.^[180] Explosives used in World War I caused many blast injuries; the large number of TBIs that resulted allowed researchers to learn about localization of brain functions.^[190] Blast-related injuries are now common problems in returning veterans from Iraq & Afghanistan; research shows that the symptoms of such TBIs are largely the same as those of TBIs involving a physical blow to the head.^[191]

In the 1970s, awareness of TBI as a public health problem grew,^[192] and a great deal of progress has been made since then in brain trauma research,^[119] such as the discovery of primary and secondary brain injury.^[181] The 1990s saw the development and dissemination of standardized guidelines for treatment of TBI, with protocols for a range of issues such as drugs and management of intracranial pressure.^[119] Research since the early 1990s has improved TBI survival;^[181] that decade was known as the 'Decade of the Brain' for advances made in brain research.^[193]

Research directions

Medications

No medication is approved to halt the progression of the initial injury to secondary injury.^[62] The variety of pathological events presents opportunities to find treatments that interfere with the damage processes.^[9]Neuroprotection methods to decrease secondary injury, have been the subject of interest follows TBI. However, trials to test agents that could halt these cellular mechanisms have met largely with failure.^[9] For example, interest existed in cooling the injured brain; however, a 2020 Cochrane review did not find enough evidence to see if it was useful or not.^[194] Maintaining a normal temperature in the immediate period after a TBI appeared useful.^[195] One review found a lower than normal temperature was useful in adults but not children.^[196] While two other reviews found it did not appear to be useful.^[197][195]

Further research is necessary to determine if the vasoconstrictor indomethacin (indometacin) can be used to treat increased pressure in the skull following a TBI.^[198]

In addition, drugs such as NMDA receptor antagonists to halt neurochemical cascades such as excitotoxicity showed promise in animal trials but failed in clinical trials.^[119] These failures could be due to factors including faults in the trials' design or in the insufficiency of a single agent to prevent the array of injury processes involved in secondary injury.^[119]

Other topics of research have included investigations into mannitol,^[199]dexamethasone,^[200]progesterone,^[201]xenon,^[202]barbiturates,^[203]magnesium (no strong evidence),^[204][205]calcium channel blockers,^[206]PPAR-γ agonists,^[207][208]curcuminoids,^[209]ethanol,^[210]NMDA antagonists,^[119]caffeine.^[211]

Procedures

In addition to traditional imaging modalities, there are several devices that help to monitor brain injury and facilitate research. Microdialysis allows ongoing sampling of extracellular fluid for analysis of metabolites that might indicate ischemia or brain metabolism, such as glucose, glycerol, and glutamate.^[212][213] Intraparenchymal brain tissue oxygen monitoring systems (either Licox or Neurovent-PTO) are used routinely in neurointensive care in the US.^[214] A non invasive model called CerOx is in development.^[215]

Research is also planned to clarify factors correlated to outcome in TBI and to determine in which cases it is best to perform CT scans and surgical procedures.^[216]

Hyperbaric oxygen therapy (HBO) has been evaluated as an add on treatment following TBI. The findings of a 2012 Cochrane systematic review does not justify the routine use of hyperbaric oxygen therapy to treat people recovering from a traumatic brain injury.^[217] This review also reported that only a small number of randomized controlled trials had been conducted at the time of the review, many of which had methodological problems and poor reporting.^[217] HBO for TBI is controversial with further evidence required to determine if it has a role.^[218][217]

Psychological

Further research is required to determine the effectiveness of non-pharmacological treatment approaches for treating depression in children/adolescents and adults with TBI.^[219]

As of 2010, the use of predictive visual tracking measurement to identify mild traumatic brain injury was being studied. In visual tracking tests, a head-mounted display unit with eye-tracking capability shows an object moving in a regular pattern. People without brain injury are able to track the moving object with smooth pursuit eye movements and correct trajectory. The test requires both attention and working memory which are difficult functions for people with mild traumatic brain injury. The question being studied, is whether results for people with brain injury will show visual-tracking gaze errors relative to the moving target.^[220]

Monitoring pressure

Pressure reactivity index is an emerging technology which correlates intracranial pressure with arterial blood pressure to give information about the state of cerebral perfusion.^[221]

Sensory processing

In animal models of TBI, sensory processing has been widely studied to show systematic defects arise and are slowly but likely only partially recovered.^[222] It is especially characterised by an initial period of decreased activity in upper cortical layers.^[223][224] This period of decreased activity has also been characterised as by specific timing effects in the patterns of cortical activity in these upper layers in response to regular sensory stimuli.^[225]

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Cited texts

• Boake C, Diller L (2005). 'History of rehabilitation for traumatic brain injury'. In High WM, Sander AM, Struchen MA, Hart KA (eds.). Rehabilitation for Traumatic Brain Injury. Oxford [Oxfordshire]: Oxford University Press. ISBN978-0-19-517355-0.
• Granacher RA (2007). Traumatic Brain Injury: Methods for Clinical & Forensic Neuropsychiatric Assessment, Second Edition. Boca Raton: CRC. ISBN978-0-8493-8138-6.
• LaPlaca MC, Simon CM, Prado GR, Cullen DR (2007). 'CNS injury biomechanics and experimental models'. In Weber JT (ed.). Neurotrauma: New Insights Into Pathology and Treatment. Amsterdam: Academic Press. ISBN978-0-444-53017-2.
• Marion DW (1999). 'Introduction'. In Marion DW (ed.). Traumatic Brain Injury. Stuttgart: Thieme. ISBN978-0-86577-727-9.

The original version of this article contained text from the NINDS public domain pages on TBI

External links

• Brain injury at Curlie

This is the story of how I met Jeff and our first date together. Dating paraplegic girls isn’t for everyone. Jeff doesn’t seem to mind dating paraplegic girls or that I’m handicapped. We have really hit it off. I still can’t believe, if I wasn’t running late for work that day, we may have never met. Being in a rush, I decided to go in my wheelchair, without the leg braces I usually wear. I am a paraplegic, paralyzed from just above my waist down to my feet. I have been a paraplegic since I was a little girl. I’ve really never known anything different.

My legs are very thin and flaccid, but I still think of myself as attractive, even sexy. I’ve have long flowing hair over a pretty face and large breasts over a tiny waist. My ample breasts are my best feature so I like to show them off a little with a tight blouse. Most men say I’m attractive but are not interested in dating paraplegic girls or dating wheelchair girls in general. I guess it’s just hard for some men to commit to a relationship with a handicapped girl. Most of the reasons I have been given for not dating paraplegic girls are based on false beliefs.

Wheelchair Friendly Workplace

I work in a big wheelchair friendly office building where I have to go from room to room a lot. About a year ago I started wearing long leg braces and using crutches to maneuver around the building. It’s much easier than getting a wheelchair through crowded hallways and elevators. The braces start at the tops of my thighs and go down to knee locks so I can bend my legs if I’m sitting. From there they go down to my ankles where I can attach any number of shoes I like to wear.

I have all kinds of shoes from athletic shoes to sandals for the summer. My favorites though are the high heels I wear at work. I have all kinds, mostly around three inch. My right leg is also a little shorter than my left one, another part of my disability. My right leg just stopped growing when I was about 13 and my left leg continued to grow until I was about 17. It’s really not that much difference, but to make up for it most of my shoes have a built-up sole on the right side, and are one size smaller since that foot is smaller.

Why Use a Wheelchair Leg Braces and Crutches

I’ve learned to use my leg braces pretty well and walk with a swing through gait. That means I put both forearm crutches out in front of me and swing both legs through the middle. Since I don’t have any control of my waist or legs my shorter right leg kind of swings first and my left drags the floor just a little as it swings through. Wearing leg braces under slacks is difficult. I am used to people staring at my legs as I am almost always in a skirt or dress. Once it would have made me uncomfortable. Now I even like to show the leg braces off a little. Sometimes my skirts barely cover the thigh straps on the tops of my braces.

I’ve become used to wearing pantyhose too which I never used to do. Without the pantyhose, the pads on the braces rub my legs too much. But that day I was just in my wheelchair wearing a little skirt just above my knees. The blouse was a little on the tight side with pantyhose and my two inch platform style heels. Getting around in my leg braces on crutches is slow and I’ve fallen many times. My wheelchair is safer and faster but I cannot stand up to reach things without the leg braces. So I mostly use both wheelchair and leg braces together. Guys into dating paraplegic girls are often into stockings and pantyhose as well.

Meeting Paraplegic Girls

When I use my wheelchair I don’t need a pair of shoes with a build-up. There’s no reason to and it’s hardly noticeable. The footrests on my chair are in the middle and close together. The right footrest plate is just a little higher to make up the difference in my leg length. I was on the way to the file room when I took a corner too fast and actually ran into this very handsome man in a suit. I was so embarrassed! Not so much because I ran into him, but when I did, my right foot actually came off the footrest, knocking my shoe off.

Not having any feeling in my legs or feet I didn’t know my shoe was off until I noticed the man kept looking down. I looked too and could see the pink polish on my toenails through my tan pantyhose. Now most everyone has seen my legs of course, but I realized at that moment no one at work has ever seen my bare feet. They are so limp and thin. I was really was embarrassed. This man had to see me pick my leg up with my hands and get my foot back on the footrest of the wheelchair.

I’ve noticed before that people like to stare. Especially men dating paraplegic girls. They like to see how a handicapped girl moves her legs with her hands getting out of a car, and things like that. Sometimes, when I know I have an audience, I put on a little show. I struggle a little more than I really have to. Not this time. After the man noticed my red face, he quickly looked away, fumbling around reaching for my shoe. He handed the shoe to me awkwardly. He looked so cute now blushing just as much as I was. I thanked him and pulled my leg up by lifting under one knee. This makes my foot point down. I hooked my toes with the shoe and pulled it onto the heel of my foot. He introduced himself as Jeff. We both made our apologies and started talking about where we were going, what our jobs were, who we knew and things like that.

Somehow we got on the subject of baseball. Jeff asked me if would like to watch the game that night with him at a bar a few blocks from the office. I really didn’t know what to say at first. I would love to go on a date with this handsome, polite man. But I get so nervous on first dates. I’m also very cautious of guys only interested in dating paraplegic girls. Being in a wheelchair we are a bit more vulnerable. I always feel like my disability is just hanging out there. Like, I know men new to dating paraplegic girls, want to ask me about my disability. But if I start offering information about my disability, or ask them about dating paraplegic girls, they seem to get uncomfortable. So I took a chance and just said yes. That I would like to see him after work. We made a meeting place and parted ways for the afternoon.

I am having a very hard time of going from one end of the desirable scale to the other virtually overnight. My ego is shot to bits as I am constantly passed over. Imagine having someone hounding you to get together but they have failed to read the profile. When they finally learn I am in a wheelchair they suddenly do a fast reverse as they run for the hills. The reality of the situation is I am still able to do most everything I did before. I downhill ski, enjoy my water access only cottage, I drive my car, I work. I still crave all the emotional and physical needs we all want. – Little Lady 57, on dating paraplegic girls.

Dating Paraplegic Girls Vulnerable to Insecurities

That evening, we met as expected and walked, well I wheeled, down to the bar for a few drinks. Nothing serious just good conversation and all to soon I was home. It wasn’t even dark! Walking me to my car I couldn’t help but think he didn’t like me. My disability was a turn-off. Oh well, just another guy not interested in dating paraplegic girls I thought. I tried to push all my insecurities to the back of my mind. Just then, he asked me how I came to be in a wheelchair. Jeff confided that he had noticed me around the office but only knew me as, “the girl who wears leg braces.” I was greatly relieved when he told me he thought I was sexy. He had wanted to approach me many times but was too shy to talk. He said he knew nothing about dating paraplegic girls.

Back at my car Jeff offered to help me get in. Of course I told him I could manage as I did it every day. We made plans for dinner the next evening. He pecked me on the cheek and walked away to where his car was parked. I slid my butt into the seat of my Volvo and put my legs in one at a time. My car has hand controls and a wheelchair lift that keeps the chair over the roof. I don’t have to get the wheelchair into the car after I get in it.

Intensions Dating Paraplegic Girls

Our dinner date the next evening couldn’t come fast enough. He dropped by my office around lunch on his way to a meeting to say hi and to make sure he was still picking me up at 7:30. That day I was in my wheelchair wearing my leg braces as usual. I couldn’t help but notice his glancing eyes when he came in my office. I was wearing a longer skirt, around mid-calf, so he could only see a little of my braces and my black three inch high heels. I was still curious about his exact intension dating paraplegic girls.

Jeff asked if I would be “walking or riding” that night (meaning was I going to be using my braces or wheelchair). We shared a laugh at his cleverness and I asked which would he prefer. He told me he was interested in seeing me use my leg braces. Admitting he had no experience dating paraplegic girls. He had never been out with a disabled woman before, only regular girls. That was exactly what I needed to hear. I immediately thought, I have just the outfit for you handsome. Again feeling aroused at the thought of him wanting to see me. Before I got to wet I eagerly agreed to use the leg braces and he went on to his meeting.

Shower and Dressing Handicapped Style

That evening when I arrived home I bathed myself in the shower. I have a special shower chair just for bathing. Most mobility handicapped folks use one. It stays in the shower. I transfer from my wheelchair into it and back out again. Sitting on just a towel, naked in my wheelchair, I dried my hair and my upper body. Then I pulled each leg up to my lap and dried them off. I put on some makeup and teased my hair then went to dress. First I needed just the right bra. A sexy bustier to push my breasts up would work. Skimpy and lingerie like enough to be inviting. If Jeff proves okay with dating paraplegic girls, he would be getting to see a whole lot more of me, than on our first date.

I went with a silky, dark purple bra with black lace over most of the cup. The mirror over my dresser told me with a close look you could actually see my nipples through the lace. My nipples hardened as my thoughts drifted off to my date seeing me in my delicate bra. I smiled taking panties that matched the bra and a pair of tan pantyhose from my dresser and wheeled to my bed. Shifted my butt to the bed and pulled my legs up behind me. One foot at a time through the panties and up my legs got them to the tops of my thighs. I bunched up the waistband and with a quick bum hop motion slid my bottom into my panties.

The pantyhose were next. Still sitting up with my lifeless paralyzed legs out in front of me, I pulled one leg up to my chest. Bunching up one leg of the hose, I worked it over my small foot and over my ankle. By letting my leg fall back into place, I pulled the nylon up along my leg to around my knee, and repeated the process with the other leg. I straightened the hose around my feet and calves, making it a little tighter. Then I worked the hose up my legs and to my thighs just like the panties. A tip for any guys dating paraplegic girls. We go to a lot of trouble to look nice for you, be sure to compliment us.

With the pantyhose, I have to lay back on the bed and kind of lift my bottom as I pull the hose to my waist. I’ve known other paraplegics my whole life, and just about all of them find it easier to wear thigh-high hose, so they only have to worry about dressing one leg at a time. My problem is my legs are so thin around my thighs. Those type of hose would actually end up sliding down my legs before I made it to my car. My legs just aren’t big enough to hold them up, so the full pantyhose are my only choice.

I rolled over to the side of the bed and picked up both leg braces, laying them on the bed beside my legs. Using one hand, I lifted my leg from just above my ankle. I could feel the pantyhose under my hand. I wondered what it felt like for a woman that could feel her legs. Wonder what it would feel like to have your legs wrapped in pantyhose. Feeling them rub against each other under your skirt, or what pantyhose felt like over your feet. I guess I’ll never know. I just enjoy the feeling that comes from my hand. I took my other hand and laid the leg brace under my leg. Where I could place my leg in the shiny steel cradle of the brace. The strap under my knee gets tightened first, then above my knee, then my thigh strap.

I do the same with my right leg, lifting the leg into the brace and fastening the straps tightly on my legs. I still can’t walk with the braces yet because I don’t keep any shoes attached to the braces. I unlock the knees so my legs will bend and slide myself back to my waiting wheelchair. I can lift my legs now using my hands on the braces, so I lift them one at a time into the footrests of the chair and go to my shoes. The dress I’ll be wearing is a cute one piece black one, so my black pumps would probably look best. I place the shoes in my lap, now it’s back to the bed. Once in the bed, knees still unlocked, I pull each leg up so I can reach my foot, still naked in its nylon.

My shoes have to be tight to support my weight with the braces so it’s a little hard getting them on. Putting a high heel shoe onto a foot that you can’t stiffen is not an easy task. So with a little work I get the shoes onto my feet and attach them to the braces. Now lowering my legs to the floor, I lock the leg braces straight and reach for my crutches. Standing, slowly at first to keep my balance, I begin to take my first swinging step to my closet. I’ve been using these leg braces for a year now, and I still can’t believe how stiff they keep my paralyzed legs.

After spending 28 years not being able to walk, sometimes I can’t actually believe it’s my legs I’m standing on. Showered and dressed in my bra pantyhose and leg braces, I can stand to wiggle into that tight black dress. I know it will make Jeff’s eyes pop! I can stand without crutches as long as I have something to balance myself on. I just can’t take any steps without crutches. So I balance against the dresser and lean the crutches against the bed. I pull the dress over my head and around my body, smoothing out the soft fabric and letting it fall just above my knees.

There’s a slit in the side that almost exposes the very top of my braces, and probably will once I sit down somewhere. After a few looks in the mirror I decided I was ready for the evening date and crutched it back to my wheelchair. I told you dating paraplegic girls go to a lot of trouble.

Pre Disability Dating Nerves

I use the wheelchair at home even if I’m wearing the braces. It’s just easier and it keeps my hands free. Since the one footrest is a little higher for my shorter leg, and I was now wearing my braces with the built up shoe on that foot, my right leg sits up higher than my left. I like to cross my right leg over my left, which I did of course by picking the right leg up and pulling it over the left. I took notice of the slit in my dress when I did that to see just how much of my leg was exposed. I could see to just under the thigh strap of my brace, perfect I grinned. It should be just enough to get Jeff wanting to see more. I was very keen to make his first time dating paraplegic girls enjoyable.

I sat staring at my disabled legs in braces wondering how the events of the evening would go. I heard the knock at my door I had been waiting on. I turned my wheelchair and headed for the door. When I got to the door, I invited Jeff in, the door was open. He entered looking great and holding flowers. He immediately complimented me on my choice of dress. It’s like this guy swallowed the book on dating paraplegic girls.

I retreated to the kitchen with the flowers for a vase as he sat down in the living room. We made typical small talk about work that day while I tended to the flowers. Then I went to the bedroom for my crutches and returned to Jeff swinging my legs a little slower than usual, and dragging that left leg a little more than usual. I had already decided that I wanted to put on a good show for Jeff. He would see just how crippled I really am, a kind of acid test to sort the men from the boys.

With my thin legs wrapped in the nylons and leg braces, and my sexiest black pumps Jeff couldn’t take his eyes off my legs. I could feel his eyes burning on me as I descended the ramp off my front porch and to his car where he held the door open. I ask him to take my crutches for me, which of course he did, and I transferred myself down into the car seat, still stiff-legged. I showed him how the leg brace knee locks work (in case he wanted to know for later). I pulled both legs in at once to keep my dress from opening up for the world to see. Jeff stowed the crutches and wheelchair and off we went.

Sexy Handicapped Women and Public Reactions

The valet at the restaurant couldn’t believe his eyes when he opened the car door. The common public reaction to seeing a sexy handicapped girl is one of confusion. Many have trouble connecting the two, sexy and handicapped. They often look my date up and down for signs of a disability. Like they think you have to be disabled to be dating paraplegic girls.

I swung my braced legs out and let the knee locks snap into place. Jeff quickly came around with my crutches and helped me to my feet. Jeff sternly pointed out to the valet how the wheelchair ramp was blocked with a sign that had fallen from the building. I told them I could manage the four steps up to the entrance. I was actually secretly excited that Jeff would get to see me conquer the steps.

I told Jeff I needed him to hold one of my crutches and stand behind me in case I slipped. With my left crutch on the first step, and my right hand on the handrail, I pushed against the crutch and let my legs drag behind me up onto the step. My right leg came first as usual, and then my left. I had to twist my body a little to get my left foot over the step. I could then stand to move my crutch to the second step. I took the steps slowly, giving Jeff plenty of time to see the braces through the slit in my skirt and enjoy my struggling up the steps. I made it to the door fine, where the doorman held the door for us both.

A True Gentleman Dating Paraplegic Girls

Dinner was perfect, with a little wine Jeff seemed to be enjoying his first experience dating paraplegic girls. Wine gets people talking and it certainly did its trick on us. Jeff confided that he had never known my legs were different lengths and was interested in the thick sole on my right shoe. I explained how my shoes were of different sizes due to my right foot being smaller. He told me how gracefully I moved in the leg braces, and how beautiful he thought I was. This one is a keeper I thought to myself. Despite never dating paraplegic girls before Jeff remained a true gentleman sensitive to my dsability. I hadn’t felt so safe and comfortable to just be me in a long time. When it comes to dating paraplegic wheelchair girls, and dating women with a disability, being called special is very different from being made feel truly special. A true gentleman knows the difference.

One time I shifted under the table and moved my leg out just far enough for him to feel my brace against his leg. I saw his cheeks blush and gave him a little smile. I quietly reassured him that I was okay with him touching the braces and that I admired him very much. I even pushed my chair in a little where the pad on the knee was rubbing the inside of his thigh. We sat like this through dinner and through our second bottle of wine by the time the check came. Jeff kept his hand around my waist as we made our way outside and down those steps to the car. Jeff took my crutches without my asking and I pulled my legs into the car.

Disability Parking and No Stopping Short

We leaned into each other on the ride back to my house. Jeff’s hand wandered over to my thigh where he politely asked, “May I?” His hand rubbed gently, first on my dress, then around through the slit and between the upright parts of my brace. His strong warm hand paused when he softy touched the skin of my silky smooth thigh making me gasp. I couldn’t exactly feel his hand, but knowing it was there gave me chills, and greatly aroused me. Even though I’m paralyzed, I can still function sexually, and feel an orgasm. The physical part is a little hard, since I can’t really move my waist or legs, but the feeling is there all the same.

When we got home, I invited him in and got out of the car where he was waiting with my crutches. I crutched up to the door, again with his hand on my waist only it was a little lower this time. We went in and I started making coffee, crutching with my braced legs around the kitchen. I told him I was going to take my braces off so we could get comfortable on the couch when he said something that shocked me. He ask me if he could help take my leg braces off. I could see that he was beginning to get aroused and thought I could have lots of fun with this, as I was aroused too. So I said he could and swung my legs through my crutches over to the couch.

I thought about getting my wheelchair first so I wouldn’t be totally helpless after my braces were off but then thought better or it. Jeff had gotten this far, perhaps he would like carrying me to my bedroom. I sat on the couch with my legs straight out in front of me with feet resting on the floor. I instructed Jeff to move my skirt to the side and unlock my knees so my legs would bend in. He released the locks and pulled the lower parts of my legs in toward the couch. He was fast becoming an expert at dating paraplegic girls.

I suggested, “I’d like to lay back if you could pull my legs to the couch for me.” With a nod I reclined and he pulled my legs to the couch and up into his lap. He did them together so as not to spread. My skirt rode up anyway past the tops of the braces and revealing the darker part of my pantyhose. He said sorry and pulled my skirt back over my legs. I told him it was okay. I kind of knew it would happen and didn’t mind one bit.

I have to say I’ve never had a man touch me like this and help me with my leg braces. I was getting extremely turned on by watching his hands on my thin flaccid legs and touching my braces. I asked if he would mind taking the upright part of the leg braces off of the shoes. Then slide my shoes off of my feet. I bit on my bottom lip as he did so eagerly but gently.

I watched him slowly ease my pumps off revealing my left foot then my smaller right foot. He took a minute to study the difference in my feet. All the things I thought were a drawback in dating paraplegic girls. My disability, spinal cord injury, the wheelchair crutches and leg braces, my flaccid legs and crippled feet. To Jeff these things are a bonus that regular girls dont come with. He noted the nail polish on my toes and rubbed my feet for a few minutes. I could tell he liked the feeling of my feet in the pantyhose.

He began undoing the straps on my calf and leaned in just far enough to kiss me when he reached up my skirt for the thigh band. One hand was caressing my leg as the other took the thigh band apart, the whole time kissing me more and more intently. After the leg brace was loose around my leg he picked my leg up letting the foot dangle. Placing the brace on the floor he moved in closer gently pushing my shoulder. I realized I was awfully tensed up and relaxed back on the couch.

He has the most beautiful smile. He lay on top of me with his hands around my face. Caressing my waist and my legs he slowly began coming closer to my breasts. I wanted him to touch my breasts and lick my nipples so badly I could hardly stand it. Since my right hand was already pulling his shirt from his pants, I used my left to guide his hands into my blouse.

Here I was on the couch, one leg brace on and one off, still pretty much dressed, under this man I couldn’t wait to get to my bedroom. My blouse was off and on the floor, sexy bra not far behind. My nipples stood erect with pleasure. I had his shirt off admiring is shoulders and chest. The bulge in his pants told me he was erect with pleasure as well. He pulled away just long enough to take my other brace from my leg. My skirt bunched up around my waist revealing both thin limp legs in tan pantyhose.

I now felt Jeff was very comfotable with dating paraplegic girls. I whispered to him to carry me down the hall to the bed, and with much pleasure he did just that. One hand around my waist, the other under my knees letting my legs fall where they wanted, he carried me down the hall to my bedroom. He moved my wheelchair with his leg so he could place me on the bed, then fell on top of me. He pulled my skirt off first, sliding it slowly down my nylon-clad legs and letting is slip under my feet and off to the floor. We rolled in the bed a little longer, me just in my hose and panties underneath now, which were becoming more wet with every minute.

Paralyzed Legs Don’t Disable Lovers

Paralyzed and lusting heavily my lover took control. His willingness to dating paraplegic girls was about to pay off. We were ready to shift up a gear to sex with paraplegic girls. He rolled me over wrapping my legs around his waist where I would be comfortable. I tugged his belt off unfastened the front of his bulging pants and pulled him hard against my naked breasts. He was huge now fully erect. I slid his pants and shorts off his waist. He pulled and kicked them the rest of the way off and began pulling at the waist of my pantyhose.

He slid my pantyhose down both legs at once thin and pale they are. As he was sliding my feet out of the nylons I was already pulling my panties down, eager for him to enter me. He was on top and had spread my legs wide at first, pulling them together around him as he came in at me. He was lunging harder and harder. It wasn’t long sex but I’ve never had better. We moved together in furious rhythm. Reaching orgasm at the same time both collapsing exhausted.

Sea Of Love Dating Site

We lay laughing together for a long time talking about the act we had so passionately committed. Jeff went to the bathroom to wash off. I waited for him to finish and had him to bring me a towel for my wheelchair. I put the towel in the chair and slid over into it. My paralyzed legs followed. Wrapping the towel around my midsection I put my feet in their rests. Naked except for the towel, I too washed off and returned to bed where we both slept. Knowing soon we both would have to prepare for work.

Disability Lovers Finding New Legs

This morning was almost as exciting as last night. I got to do something I’ve never done before. Jeff had a change of clothes in his car which he got while I was bathing. While he showered I went about getting ready as usual. I chose my outfit for the day: Red skirt and black top, jet-black pantyhose, and the same black pumps from the night before. I retrieved my braces and heels from the front room using my wheelchair. As I was returning to the bedroom Jeff came in. His hair wet and oh so sexy fresh from the shower. He took my leg braces and put them on the bed for me, asking if he could put them on. Wow I thought, of course I didn’t mind, I was excited by the idea. I had to keep reminding myself Jeff was actually new to dating paraplegic girls. I had to take things slowly.

To Be In Love Dating Site For People With Tbi's Name

I needed to get my panties and pantyhose on as I was still naked except for the towel. He picked me up from the wheelchair like the night before and laid me on the bed. He actually picked up the clothes I laid out and began dressing me! First the panties which he slid one foot at a time through them and pulled them up my legs. He stopped me when I tried to help and I couldn’t help but smile. I laid back, and let him lift my bottom while his free hand pulled the panties around my waist. He took the black pantyhose, and lifting one foot at a time, pulled each stocking onto my feet and legs, and up to my thighs where he had to lift my bottom again.

To Be In Love Dating Site For People With Tbi's Images

He smoothed my legs out and picked up the brace for my left leg. He placed my thin leg into its brace and fastened the straps in reverse order from the night before. Lifting my foot a little, he wiggled it into the high heel pump and attached it to the brace. Then he ask me if I could walk using only one leg brace. Well I didn’t know if I could or not as I had never tried. Thinking it might turn him on to see me try I wanted to see if I could. My man would there to catch me if I couldn’t.

Jeff retrieved my crutches from the front room and I lowered my leg onto the floor. The knee clicked into its locked position. I balanced on the one stiff leg at first. Noticing with the three inch heel, my shorter right leg dangled about five inches above the floor. So I extended the crutches, and pulled my body forward letting my right leg swing freely. Pulling my left behind it dragged a little more than before on the floor. My firm naked breasts jiggled as I struggled around the bedroom. Dating paraplegic girls does have its perks. My bouncing boobs were two of them.

I could actually do this I thought. Walking on one brace only if I wanted, leaving my shorter leg hanging. I got Jeff to take another one of my high heels without the brace attachment made into it and slide it over my right foot. This almost made up the difference to the floor. Making the toe of the shoe point downward and barely touching the floor. I crutched around for a few minutes. Leaning on my one stiff braced leg and dragging the other limp leg behind. I let the toe of the pump slide on the floor.

Like the night before I could see Jeff becoming aroused at the sight of my frail paralyzed legs. I realized he was attracted not only to me but my disability as well. I became excited at the idea. It was nice to know I didn’t have to try and be like any other woman he had been with. I could be comfortable about my handicap knowing Jeff liked dating paraplegic girls. He was more than okay with my spinal cord injury. He liked my wheelchair, leg braces, crutches and my disability.

After crutching around a bit I went back to the bed and pulled myself bottom first onto it. I pulled my right leg to my chest and took off the smaller pump revealing my foot in only the pantyhose. I took the other leg brace and laid it under my leg. Jeff helped me with the straps and put my other pump on. The one with the build-up on the bottom and attached it to the brace. He also helped me on with my skirt while I put my bra and blouse on.

Jeff thoroughly enjoyed his first time dating paraplegic girls. I’m so glad it was with me! We didn’t bother asking about taking separate cars to work. He drove and I’m sure after work today he’ll drive me home. We’ll spend another exciting night together as disability lovers. Maybe tonight I’ll show him how I sometimes drag myself from room to room in the house. Let him see me pull my thin lifeless legs around without the braces crutches or the wheelchair. Dating paraplegic girls does require a little patience and understanding. And with that, I wish you all the happiness and love in dating paraplegic girls, that I have come to find.

To Be In Love Dating Site For People With Tbi's Pictures

Kristi Eden

Resources

• Dating a Paraplegic: http://forums.plentyoffish.com/datingPosts4094222.aspx
• Dating Disabled: http://www.datingdisabled.net
• Dating Paraplegic Girls: http://answers.yahoo.com/question/index?qid=20110612052155AAB2tao
• Disabled Passions: http://www.disabledpassions.com/groups/Paraplegic.html