Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury

OBJECTIVE: To assess which social activities were still impaired 5 years after a traumatic brain injury (TBI) in adults, and which neuropsychological impairments were associated with this loss of social autonomy. DESIGN: Cross-sectional study of 79 patients selected from the follow-up cohort of an epidemiologic survey of 2,116 TBI patients. SETTING: The present study was of ambulatory patients seen at hospital or at their homes. The inception cohort was from the trauma center of a university hospital and from a general hospital that is representative of level II trauma centers in Aquitaine, France. PATIENTS: Seventy-nine patients selected from a representative sample of 407 patients who were included in the 5-year follow-up study of the initial cohort (convenience sample). MAIN OUTCOME MEASURES: Glasgow Outcome Scale (GOS) and loss of social autonomy as assessed by the European Brain Injury Society's European Head Injury Evaluation Chart; assessment of neurobehavioral impairments by means of the Neurobehavioral Rating Scale-Revised. RESULTS: Up to 16 patients suffered disability for at least one social skill because of cognitive/behavioral reasons. Seven needed full-time supervision. Performing administrative tasks and financial management, writing letters and calculating, driving, planning the week, and using public transport were the most impaired social abilities. Loss of social autonomy was mainly observed in severely injured patients. Univariate analysis showed that mental fatigability, motor slowing, memory difficulties, and disorders of executive function were associated with low scores on the GOS, unemployment, and difficulties in shopping, using public transport, and performing financial management and administrative tasks. CONCLUSION: Persistent impairments of executive functions and speed of psychomotor processing are major factors associated with loss of social autonomy and inability to return to work long after TBI in adults. Improving these impairments in concrete social situations represents a major challenge for cognitive rehabilitation.     

Long-term follow-up of post-acute traumatic brain injury rehabilitation: a statistical analysis to test for stability and predictability of outcome

A high percentage of the estimated 500,000 traumatic brain injuries (TBI) in the US every year occur with young people who will face many years of neurobehavioral and economic consequences. This study examined the long-term stability of outcome after post-acute TBI rehabilitation and possible predictors of long-term outcome based on a 127-item survey of 332 clients up to 14 years post-discharge. Correlational, factor, and multiple regression analysis indicated positive long-term outcome stability following rehabilitation with the exception of vocational status, which decreased over the same time period. A number of possible explanations for this occupational anomaly are suggested. Rating scale scores and latency-to-rehabilitation proved to be better predictors of long-term outcome than demographic data.     

Oral hygiene following traumatic brain injury: a programme to promote dental health

In spontaneously beating sinus venosus of the frog Caudiverbera caudiverbera the effects of bekanamycin and dibekacin, two aminoglycoside antibiotics, on action potentials of cardiac primary pacemaker cells were studied by intracellular recording. Bekanamycin and dibekacin induced a concentration-dependent decrease of the amplitude, overshoot and the rate of rise of the action potential. Both also flattened the slow diastolic depolarization leading to a marked decrease in beat rate. At the highest concentration used (1 x 10(-3) M), the aminoglycosides produced a complete inhibition of primary cells action potentials. It was preceded by the appearance of subthreshold oscillations of the membrane potential which were observed for a few minutes until the electrical activity of pacemaker cell ceased. During absence of impulse initiation a stable membrane potential about -40 mV was observed. Aminoglycoside effects, excepting those on SCL, were completely suppressed when external calcium was increased to 3.6 mM. The results support the conclusion that bekanamycin and dibekacin depress the electrical activity of pacemaker cells. It is suggested that this effect is induced by aminoglycosides blockade of the slow calcium current involved in both upstroke and slow diastolic depolarization and through modification of potassium outward current. Bekanamycin at a lower concentration than that needed to induce electrophysiological effects potentiated verapamil 1 x 10(-8) effects on cardiac pacemaker cells.     

Neuropsychological testing and functional outcome for individuals with traumatic brain injury

The relationship between performance on neuropsychological measures and the vocational and independent living functioning of individuals with traumatic brain injury was examined. The Wechsler Adult Intelligence Scale-Revised (WAIS-R) IQ and Stroop Color and Word Test scores differentiated individuals who required no assistance with activities of daily living from those requiring some level of assistance. Only the Stroop Color and Word Test scores differentiated individuals who were competitively employed or engaged in degree-oriented education from those who were unemployed or in sheltered or supported employment. Wechsler Memory Scale-Revised (WMS-R) scores did not differentiate these groups.     

Towards a more integrated approach to job placement and retention for persons with traumatic brain injury and premorbid disadvantages

Health is part of our own personal well-being, as well as that of the community and of our nation: clinician-investigators lead us forward in new medical developments, and may even be of assistance in developing innovative programs of cost control and outcome analysis. Canada now devotes close to 10% of its gross national product to health expenditures, second only to the United States, and yet there is still the widespread perception within this country that "there is not enough." The issues are how to do more with less, and how to recruit more clinician-investigators from the diminishing pool of potential recruitees. Academic medicine, with its research focus, is well-suited to bring together newer perspectives of education and health, and these clinician-investigators may improve major areas of our health care partnership.     

Traumatic brain injury: Psychological and medical factors related to rehabilitation outcome.

Examined the relationship of medical and psychological factors of adaptive physical functioning (APF) at discharge and length of rehabilitation stay following traumatic brain injury. 32 Ss (aged 16–55 yrs) with severe traumatic brain injury underwent interdisciplinary rehabilitation evaluations, including the MMPI, WAIS, and the Wechsler Memory Scale, at admission to and discharge from an inpatient rehabilitation program. Results suggest that the actual status of APF at discharge was related to initial assessments of medical, not psychological, factors. However, psychological factors were related to relative improvement in APF when change occurred. Even Ss who were minimally aware of their physical abilities and limitations at admission improved in their APF during treatment. Length of rehabilitation stay was determined by both physical and psychological functioning. (13 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Measuring outcome in community-based rehabilitation services for people who have suffered traumatic brain injury: the Community Outcome Scale

OBJECTIVE: To develop a way of measuring long-term outcomes after traumatic brain injury (TBI) that takes account of individual circumstances. DESIGN: Reports by head-injured people and their families about problems and coping strategies were elicited via semi-structured interviews. Specially designed computer software was used to record problems and strengths and to measure their impact for the individual on four handicap dimensions. SETTING: Interviews took place in the respondents' homes. SUBJECTS: Between 1992 and 1997 the services at 10 rehabilitation centres in England were evaluated. Subjects were men and women aged between 16 and 65 who had suffered TBI and who had been referred for treatment to one of the centres under study. INTERVENTIONS: Head-injured people and their families were interviewed three months, 18 months and in some cases 36 months after recruitment. MAIN OUTCOME MEASURES: The Hospital Anxiety and Depression Scale (HAD) and the Functional Independence/Assessment Measure (FIM/FAM) were used to validate relevant dimensions of the new scale. RESULTS: A measure of long-term outcome was developed and called the Community Outcome Scale. Relevant dimensions of the scale showed significant correlation with the HAD and with items of the FIM/FAM. CONCLUSION: The scale captures information which no other instrument does, and merits further validation.     

Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome

To determine what consequences cognitive, behavioural or somatic impairments had on disabilities and recovery after a head injury (HI), a population-based sample of 231 adult patients was studied 5 years after an HI. Eighty lower-limb-injured (LLI) patients were considered as controls. Sixty-four LLI and 176 HI patients were reviewed (114 minor, 35 moderate, and 27 severe HI). Prevalence values of headaches (44-54%), dizziness (26-37%), and anxiety (47-63%) were not significantly different in the three HI severity groups, but were significantly lower in patients with an isolated limb injury (12-15%). Memory problems and depressive mood increased with injury severity. Mental impairments were frequent in severe HI patients (18-40% of patients). In minor and moderate HI patients, most disabilities were related to associated injuries. According to the Glasgow Outcome Scale (GOS), recovery was not considered as good because of somatic, behavioural or cognitive complaints in 2.5%, 5.7% and 59.2% of surviving patients in each of the above HI groups. Somatic or behavioural complaints may have considerable consequences in some minor HI patients, and the long-term management of certain patients needs improvement because these impairments are misunderstood.     

Diller lecture: Impaired awareness, finger tapping, and rehabilitation outcome after brain injury.

Speed of finger tapping after traumatic brain injury has been related to the problem of impaired self-awareness as well as to rehabilitation outcome. This article summarizes selected literature that documents the potentially rich information this "simple" task can provide. It supports Leonard Diller's emphasis on using developmentally sensitive tasks that allow for simple inferences to be applied to issues of diagnosis and rehabilitation after brain injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Return to work for patients with traumatic brain injury. Analysis of costs

This brief report describes staff time commitment and program cost outcomes for a return to work program of supported employment for persons with brain injuries. The mean cost of providing services was $10,198 for the first year of service (median, $6,942). Clients achieved job stabilization after an average of 18 wk of time-limited job coaching services, during which they received mean intervention time of 245.7 h (median, 219) at a cost of $7,789. A mean of 2.24 h/wk of extended services intervention was required to maintain clients in employment for the remainder of the first year of service, at a mean weekly cost of $71.01. Results are compared with findings reported in a previous study using a smaller sample.     

Clinical course and remission rate in patients with early rheumatoid arthritis: relationship to outcome after 5 years

OBJECTIVE: To investigate the clinical course in early rheumatoid arthritis (RA) patients followed prospectively, to relate course to outcome after 5 yr, and to try to identify prognostic features. METHODS: A total of 183 patients with definite RA and a mean disease duration of 11 months were included. Of these, 75% were rheumatoid factor (RF) positive; 85% carried the shared epitope, 32% on both alleles. Most patients were assessed every 6 months. Disability was evaluated with the Health Assessment Questionnaire (HAQ) and radiographic findings according to Larsen. Remission was defined in two ways: with the American Rheumatism Association (ARA) criteria and as 'no arthritis at least at one follow-up visit'. RESULTS: Twenty per cent achieved ARA-defined remission periods of at least 6 months duration; 21 were spontaneous and 18 drug induced. Average length of remission was 20.5 months. The remission periods constituted 7% of follow-up for all patients. Another 36% achieved remission according to the second definition. All 56% were considered to have a relapsing-remitting disease pattern, in contrast to the remaining 44% with a persistent disease pattern. More patients with persistent disease were treated with disease-modifying anti-rheumatic drugs (DMARDs) and had also received a larger number of different drugs. Outcome after 5 yr regarding disability, joint inflammation and joint damage was worse for patients with persistent disease. Neither ARA-defined remission nor disease pattern could be accurately predicted. CONCLUSIONS: Long-term ARA-defined remission was rare, constituting 7% of follow-up for the entire cohort. For those 20% achieving remission, this period represented 34% of their follow-up. A total of 56% had a relapsing-remitting disease pattern and 44% had a persistent disease pattern. This classification had prognostic implications with persistency being a bad prognostic sign.     

Assessment of strategic self-regulation in traumatic brain injury: Its relationship to injury severity and psychosocial outcome.

Standard neuropsychological tests administered in a constrained and artificial laboratory environment are often insensitive to the real-life deficits faced by patients with traumatic brain injury (TBI). The Revised Strategy Application Test (R-SAT) creates an unstructured environment in the laboratory in which environmental cues and internal habits oppose the most efficient strategy, thus mimicking the real-life situations that are problematic for patients with TBI. In this study, R-SAT performance was related both to severity of TBI (i.e., depth of coma) sustained 2–3 years earlier and to quality of life outcome as assessed by the Sickness Impact Profile. This relationship held after accounting for variance attributable to TBI-related slowing and inattention. These findings support the validity of the R-SAT and suggest that behavioral correlates of quality of life outcome in TBI can be assessed in the laboratory with unstructured tasks. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Structured habituation training for movement provoked vertigo after severe traumatic brain injury: a single-case experiment

The purpose of this study was to evaluate the effect of structured habituation training (HT) for movement provoked vertigo (PV) secondary to unilateral peripheral hypofunction in a 16 year old patient who had sustained a severe TBI. Treatment of PV with severe TBI patients can be quite different from other patients with vestibular deficits because of the physiological, behavioural and cognitive sequelae of brain trauma. A single-subject experimental paradigm using an ABA protocol was used to assess efficacy of HT. The data were submitted to C statistic analysis. The transformed data were submitted to combined visual and statistical analysis by the celeration line with a directional one-tailed test and the two-standard deviation band method. Significant change in duration from sitting to supine without triggering vertigo was found between baseline phase (A) and structured HT phase (B) and was maintained for 1 month after the end of treatment. This single-case experiment demonstrates successful structured HT for PV for a 16 year old severe TBI patient. Important clinical decisions (time of introduction of treatment, type of activity, pacing, frequency, intensity, repetition, support and education) necessary to achieve optimal resolution of PV with HT in severe TBI patients are discussed.     

99mTc-HMPAO SPECT of the brain in mild to moderate traumatic brain injury patients: compared with CT--a prospective study

Single photon emission computed tomography (SPECT) with Technetium-99m hexamethyl propylenamine oxime (Tc-99m-HMPAO) was used in 20 patients with mild to moderate traumatic brain injury (TBI) to evaluate the effects of brain trauma on regional cerebral blood flow (rCBF). SPECT scan was compared with CT scan in 16 patients. SPECT showed intraparenchymal differences in rCBF more often than lesions diagnosed with CT scans (87.5% vs. 37.5%). In five of six patients with lesions in both modalities, the area of involvement was relatively larger on SPECT scans than on CT scans. Contrecoup changes were seen in five patients on SPECT alone, two patients with CT alone and one patient had contrecoup lesions on CT and SPECT. Of the eight patients (50%) with skull fractures, seven (43.7%) had rCBF findings on SPECT scan and five (31.3%) demonstrated decrease in rCBF in brain underlying the fracture. All these patients with fractures had normal brain on CT scans. Conversely, extra-axial lesions and fractures evident on CT did not visualize on SPECT, but SPECT demonstrated associated changes in rCBF. Although there is still lack of clinical and pathological correlation, SPECT appears to be a promising method for a more sensitive evaluation of axial lesions in patients with mild to moderate TBI.     

Outcomes 5 years post-traumatic brain injury (with further reference to neurophysical impairment and disability)

The assessment of recovery and outcomes post-traumatic brain injury (TBI) has often been poorly researched and reported in past literature. Indeed, an accurate documentation of outcomes in this population had never been performed in the state of South Australia. To redress this situation this study collected data on people who had sustained a TBI 5 years previously, using medical records, personal interview/questionnaire and neurophysical assessment in order to investigate broad outcomes as well as the specific nature and prevalence of any residual physical impairment and disability. The results (n = 67) indicate that the subjects' living arrangements had not altered significantly, and nearly half had returned to some form of paid work, though over 50% were reliant on the welfare system. The majority (57%) felt they had improved in all areas, 19% partially improved and 8% felt they had actually deteriorated. Considering the physical data, the most frequent areas of residual impairment were headaches, followed by balance difficulties and fatigue/weakness. Functionally, 30% had some degree of deficit in upper limb activity and 9% required assistance for particular transfer tasks. Overall balance was impaired in 34% and gait was altered in 24% with 9% reliant on wheelchairs for mobility. Such data may be used in the education of people with TBI and those who live and/or work with them, as well as in future studies assessing the impact of various factors on recovery and outcomes. Evidence was also provided that residual physical issues should be considered along with the more researched areas of cognition and psychosocial issues.     

Measuring progress and outcome in community rehabilitation after brain injury with a new assessment instrument--the BICRO-39 scales. Brain Injury Community Rehabilitation Outcome

OBJECTIVE: Construction and validation of a new instrument, the Brain Injury Community Rehabilitation Outcome scales, to assess problems experienced by brain-injured patients living in the community. DESIGN: Seventy-six items describing aspects of personal and social functioning were generated. Two hundred thirty-five patients and/or their carers (separately) rated the items on 6-point scales, and patients retrospectively rated their functioning before injury. Seven scales were derived from factor analysis; one was included a priori. Thirty-nine items with high factor loadings were retained. Test-retest reliability, interrater reliability, and construct validity were examined in subsamples. SETTING: Patients were recruited from four centers: two community-based teams, a day-patient clinic, and an outpatient clinic. PATIENTS: Of the patients, 127 had traumatic brain injury, 72 had cerebrovascular accidents, 15 had multiple sclerosis, and 21 had acquired brain injury of other origins. Mean time since brain injury was 2.6 years; mean age was 43 years; 164 were men and 71 were women. RESULTS: All scales showed good test-retest reliability, and agreement between patient and carer ratings was moderate to high. They showed predicted moderate correlations with other relevant scales. Postinjury scores differed significantly from preinjury scores, and 6 of the 8 scales showed change over a period of recovery/rehabilitation. CONCLUSIONS: The scales appear reliable and easy to complete. They may have utility as quantitative measures of outcome for clinical and treatment evaluations.     

The mental health of men with a psychiatric disorder or traumatic brain injury: Wives' labeling and husbands' perceived control.

Objective: To investigate the relations among wives' labeling of their husbands' psychiatric disorder or brain injury as an organic illness, the husbands' perceived control over their disabilities, and the husbands' mental health. Participants: 57 male clients of the Department of Rehabilitation, Israel's Ministry of Defence (26 with a psychiatric disorder and 31 with a traumatic brain injury) and their wives. Measures: Illness Labeling Questionnaire, the Perceived Control Over Illness Questionnaire, and the Mental Health Inventory. Results: Husbands' mental health was low but did not differ according to disability; wives' labeling of husbands' condition was negatively related to the husbands' mental health; husbands' perceived control was positively related to their mental health for both disabilities. Conclusion: Organic illness labels, even when adopted by the wives of the persons with the disability, seem to be negatively related to that person's mental health, whereas perceived control over a mental disorder or a brain injury seems to contribute positively to mental health, independently of how the disorder or injury is labeled. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quality of life 10 years after a very severe traumatic brain injury (TBI): the perspective of the injured and the closest relative

This study is a further follow-up of a group of 15 very severely injured TBI patients who have earlier been followed-up 5 years after the injury, and their closest relatives. The aim of this study was to evaluate the factors related to the quality of life of the injured and the strain felt by the relatives. The information was gathered by questionnaires for the injured and the relative and clinical ratings based on the observations of a clinician. The self-reported quality of life of both the injured and their closest relatives was rather high in spite of the various physical, cognitive and emotional/behavioral disturbances. However, the strain felt by many of the relatives was still high 10 years after the injury although it had decreased over the years. The neurobehavioral and emotional disturbances had the most significant effect on the quality of life of the injured and strain felt by the relative. The relationship between the quality of life of the injured and strain felt by the relative was not linear. The implications of the findings for developing different forms of rehabilitation and support systems is discussed.     

Group psychotherapy for persons with traumatic brain injury: management of frustration and substance abuse

Residual emotional and behavioral difficulties in individuals who have sustained a traumatic brain injury (TBI) have been well documented in the literature. The issues are complex, interdependent, and often include substance abuse, depression, anxiety, chronic suicidal or homicidal ideation, poor impulse control, and significant degrees of frustration and anger. Often, preexisting psychological conditions and poor coping strategies are exacerbated by the trauma. Emotional and behavioral difficulties can interfere with the neurorehabilitation process at all levels. In acute rehabilitation, these issues have traditionally been addressed on an individual basis. However, in postacute settings, an interpersonal group format can be effectively implemented. The majority of individuals with TBI have minimal funding for long-term cognitive and behavioral remediation; often the only avenue available is support groups. This article will describe group psychotherapy models used with individuals with acute or postacute TBI within a comprehensive rehabilitation center. Interdisciplinary treatment of frustration and substance abuse and a continuum of care will be emphasized. Education, social support, skills development, interpersonal process, and cognitive-behavioral approaches will also be discussed. The psychotherapy groups focus on treatment of substance abuse and frustration management through education, social support, and development of interpersonal skills. Practical considerations of running such groups are presented.     

Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation

OBJECTIVE: To assess the new "Lund therapy" of posttraumatic brain edema, based on principles for brain-volume regulation and improved microcirculation. DESIGN: A prospective, nonrandomized outcome study over a 5-yr period on severely head-injured patients with increased intracranial pressure, comparing the results with a historical control group with the same selection criteria for patients who were treated according to conventional principles. SETTING: General intensive care unit of a university hospital. PATIENTS: Fifty-three consecutive head-injured patients with a Glasgow Coma Score of <8, and with increased intracranial pressure (>25 mm Hg), despite conventional treatment. INTERVENTIONS: Interstitial fluid resorption was obtained by lowering intracapillary hydrostatic pressure, by preserving normal colloid osmotic pressure, and by maintaining a normovolemic (normal albumin/serum and hemoglobin/serum), not overtransfused patient. Intracapillary pressure was reduced by the combination of precapillary vasoconstriction (low-dose thiopental, dihydroergotamine) and reduction of mean arterial pressure, the latter attained with a beta1-antagonist (metoprolol 0.2 to 0.3 mg/kg/24 hrs iv) and an alpha2-agonist (clonidine 0.4 to 0.8 microg/kg x 4 to 6 iv). Clonidine, in combination with normovolemia, also improves microcirculation by reducing catecholamines in plasma. Intracranial blood volume was reduced by arterial (low-dose thiopental sodium and dihydroergotamine) and large-vein (dihydroergotamine) vasoconstriction. The start dose of dihydroergotamine (maximum 0.9 microg/kg/hr) was successively reduced toward discontinuation within 4 to 5 days. MEASUREMENTS AND MAIN RESULTS: There were 8% of patients who died and the neurologic conditions of 13% remained severely damaged, compared with 47% and 11%, respectively, for the control group. CONCLUSIONS: The low mortality compared with previous outcome studies strongly indicates that this therapy improves outcome for severe head injuries. However, a randomized, controlled study is needed to reach general acceptance of this new therapy.