Rehabilitation after traumatic brain injury in adults

PURPOSE: Traumatic brain injury (TBI) stands as a major public health problem and one of the most important challenges for neurological rehabilitation. This review discusses advances that have occurred in the past 10 years in rehabilitation after severe TBI in adults. METHOD: First, theoretical concepts, goals of rehabilitation and organization of resources are reviewed. Then specific questions that arise in the rehabilitation of severe TBI patients are considered. RESULTS: Three phases are distinguished in post-traumatic evolution. Acute rehabilitation takes place during coma and arousal states. Specific aims are to prevent orthopaedic and visceral complications, and to provide sensory stimulations with the hope of accelerating arousal. Secondly subacute (generally inpatient) rehabilitation is designed to facilitate and accelerate recovery of impairments, and to compensate for disabilities. Motility, cognition, behaviour, personality and affect should be simultaneously addressed in an holistic approach. Physical as well as psychological independence and self-awareness are the major goals to emphasize. A third, post-acute rehabilitation phase includes outpatient therapy for achieving physical, domestic and social independence, reduction of handicaps and re-entry into the community. CONCLUSIONS: Problems with returning home, obtaining financial independence, driving, returning to work, participating in social relationships and leisure activities, and the importance of psychosocial adjustment and self-acceptance, are outlined. Questions about economic aspects and rehabilitation in the future are addressed.     

Fatigue following traumatic brain injury: Frequency, characteristics, and associated factors.

Objectives: To document the frequency, characteristics, and factors associated with fatigue following traumatic brain injury (TBI). Design: Survey methodology and multivariate statistical design. Setting: Rehabilitation center and community. Participants: 452 participants aged 16 years and over with minor to severe TBI who answered a questionnaire measuring diverse aspects of fatigue as well as different dimensions of psychological distress, pain, and sleep quality. Measures: Proportion of participants reporting being significantly fatigued. Validated measures of fatigue, sleep quality, and psychological distress. Results of a logistic regression analysis. Results: Significant fatigue was reported by 68.5% of participants. Mental fatigue was the most prominent type of fatigue, followed by physical fatigue. Fatigue was present even several years following the accident and had many perceived impacts on day-to-day function. Factors associated with fatigue were a shorter time since injury; being on long-term disability leave; and higher levels of sleep problems, cognitive disturbances, and anxiety. Conclusion: Fatigue is a prevalent problem after TBI that requires more clinical and scientific attention because it probably has important repercussions on the quality of rehabilitation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Misconceptions about traumatic brain injury among educators and rehabilitation staff: A comparative study.

This study compared the responses of 184 educators and 111 rehabilitation specialists on a measure of knowledge about childhood traumatic brain injury (TBI). Educators displayed more misconceptions about TBI overall compared to rehabilitation staff. They underestimated the effect of TBI on cognition, behavior, and continued development. More specifically, educators showed more misconceptions than the rehabilitation staff in the following areas: coma, memory and new learning, anger management, and factors affecting recovery. An important task for rehabilitation staff members is to clarify educator misconceptions about TBI as children transition to school. Information provided should increase the level of teacher preparation and help to maximize children's academic success and adaptation following TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does preinjury alcohol use or blood alcohol level influence cognitive functioning after traumatic brain injury?

Objective: To examine the relations among preinjury alcohol use patterns and admission blood alcohol level (BAL) and postinjury cognitive functioning among individuals with recent TBI. Design: Cohort survey with chart review and follow-up cognitive assessment. Setting: Acute inpatient rehabilitation program in a Level I trauma center. Participants: 124 consecutive initial admissions meeting inclusion criteria. Measures: Admission BAL, preinjury alcohol consumption, consequences, and symptoms of dependence, as well as initial injury severity and subsequent cognitive functioning. Results: Higher BAL at hospital admission was related to greater initial injury severity (lower Glasgow Coma Scale score). Preinjury alcohol consumption and admission BAL were not consistently related to any postinjury assessment of cognition. Conclusion: Alcohol use at the time of injury may exacerbate the initial severity of TBI. Cognitive functioning soon after injury does not appear to be related to any preinjury drinking behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Rehabilitation with brain injury survivors: An empowerment approach.

Reviews the book, Rehabilitation with brain injury survivors: An empowerment approach by Christiane C. O'Hara and Minnie Harrell (see record 1991-97522-000). The authors' goal is stated as being a treatment/evaluation manual for traumatic brain injury (TBI) survivors that corrects the frequent failures of traditional rehabilitation models, and describes an integrated, wholistic approach that can be implemented across settings and used by clients and treatment staff of all disciplines. The manual is published in a loose-leaf notebook format that has been adopted by rehabilitation workshop sponsors and publishers of computer software manuals. It contains five chapters: (1) Introduction; (2) Evaluation; (3) Case Management and Treatment Planning; (4) Cognition; and (5) Emotions/Behavior. Of the 491 pages contained therein, there are 140 pages of text. The remaining pages provide a series of forms and checklists that are to be used for assessment, treatment, and program administration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Construct validity of an attention rating scale for traumatic brain injury.

Attention deficits are nearly ubiquitous after traumatic brain injury (TBI). In the subacute phase of moderate to severe TBI, these deficits may be difficult to measure with the precision needed to predict outcomes, assess degree of recovery, and monitor treatment response. This article reports the findings of four studies, three observational and one a randomized, controlled treatment trial of methylphenidate (MP), designed to provide construct validation of the Moss Attention Rating Scale (MARS), an observational measure of attention dysfunction following TBI. One hundred seven participants with moderate to severe TBI were enrolled during treatment on an inpatient rehabilitation unit. MARS scores were provided independently by four rehabilitation disciplines (Physical, Occupational and Speech Therapies and Nursing). Results indicated that the MARS: (1) is more strongly related to concurrent measures of cognitive versus physical disability, supporting its validity as a measure of cognition, (2) is more strongly related to concurrent psychometric measures of attention versus measures thought to rely less on attention, supporting its validity as a measure of attention; and (3) predicts 1-year outcomes of TBI better than psychometric measures of attention. However, the MARS (4) was not differentially affected by MP versus placebo treatment. Results support the construct validity and utility of the MARS, with further research needed to clarify its role in treatment outcome assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preface.

Introduces this special issue of Rehabilitation Psychology. This special issue was conceptualized as an effort to bring to the journal's readership an understanding of some of the basic concerns in traumatic brain injury (TBI) rehabilitation from the psychologist's perspective. This issue begins with an overview of the various acute and postacute services in TBI rehabilitation, proceeds to discuss the roles and functions of the psychologist within the TBI rehabilitation setting (principally the postacute setting), and then addresses a range of issues related to assessment and intervention. Because of space limitations, we could not fully cover all the issues in these areas. We certainly believe, however, that the selected authors made ambitious and credible efforts with their assigned topics. The reader, seeking to examine better this disability area and current psychosocial treatment interventions, receives a wealth of practical material and references for further review. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality subtypes among driving-while-intoxicated offenders: Follow-up of subsequent driving records.

Investigated the predictive utility of subtypes among males arrested for driving while intoxicated (DWI) with respect to subsequent driving record. Five subtypes had been empirically derived from measures of driving-related attitudes, personality functioning, and hostility. The driving records of 16 Ss (previously described by the 1st author and G. A. Marlatt; see record 1982-21361-001) were evaluated over a 3-yr period beginning with initial assessment. Subtype membership did not predict DWI recidivism or accidents. However, differences were found across clusters with respect to other violations and driving risks. The results are discussed in terms of the clinical utility of differential assessment of non-alcohol-related characteristics in the evaluation and treatment of DWI offenders. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacotherapy for postacute traumatic brain injury: A literature review for guidance in psychological practice.

Objectives: The purpose of this review is to educate and guide the actions of rehabilitation psychologists by providing a summary of the current literature on pharmacotherapies and treatment effectiveness for the chronic sequelae associated with severe traumatic brain injury (TBI). A number of medications are reviewed for use in treating deficits in arousal, cognition, function, and other problems associated with TBI. Findings for their use in this population are summarized. Cautions, limitations, and directions for future research are discussed. Conclusions: Pharmacological management of chronic symptoms of TBI is commonplace in rehabilitation practice. Clear clinical guidelines for the use of pharmacotherapy in TBI are lacking, however, because of the few conclusive findings regarding the effectiveness of any particular agent. Rehabilitation psychologists frequently encounter patients treated with numerous medications and, therefore, need to be aware of potential effects on cognitive and functional abilities. Additionally, rehabilitation psychologists should be aware of available and empirically supported pharmacotherapies as they are in a position to comprehensively assess the patient and provide requested consultation to the treating physician concerning the patient's need for and likelihood of benefiting from various pharmacological agents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Characteristics of drivers and driving record after traumatic and nontraumatic brain injury

OBJECTIVE: To determine whether individuals with a traumatic brain injury (TBI) or stroke (cerebrovascular accident [CVA]) have an increased risk of subsequent motor vehicle crash or moving violation. DESIGN: A retrospective study comparing the driving records of four cohorts hospitalized with TBI, CVA, isolated extremity fractures (FX), and appendicitis (APPY) with the records of four age-matched, gender-matched, and zip code-matched nonhospitalized cohorts. SETTING: Eligible drivers in the state of Washington, 1991 to 1993. PARTICIPANTS/METHODS: Four cohorts hospitalized in 1992 with TBI, CVA, FX, or APPY were identified from Washington state hospital discharge data. The state driver's license database identified patients with drivers' licenses. Each hospitalized cohort was compared with its own age-matched, gender-matched, and zip code-matched nonhospitalized cohort. MAIN OUTCOME MEASURES: Crashes and citations for moving violations 12 months after hospitalization adjusted for age, gender, and prior driving record. RESULTS: The relative risks (RRs) of any subsequent crash or receipt of citation were not greater for those with either CVA or TBI than for nonhospitalized individuals, nor were the risks of experiencing two or more of these events in the 12 months after hospitalization significantly elevated. After adjustment for prior driving record, modest elevations were observed only for the risks of subsequent driving violation among those with TBI (RR=1.3, 1.0-1.7) and among patients with FX (RR=1.2, 1.1-1.4). CONCLUSIONS: The results do not support the hypothesis that individuals who have sustained a brain injury are at increased risk of motor vehicle crashes. Although patients with TBI were more likely to subsequently receive citations than nonhospitalized individuals, a similar increase was observed among patients without brain injury who had FX, suggesting an inability to completely control for driver characteristics that may be related to risk-taking behavior and that are also associated with an increased risk of driving violation.     

Long-term outcome from childhood traumatic brain injury: Intellectual ability, personality, and quality of life.

Objective: Only a handful of studies have attempted to explore very long-term outcomes from childhood traumatic brain injury (TBI). These studies have generally failed to fully consider the impact of injury severity or employ measures sensitive to the survivor's day-to-day function. This study examined outcomes in adulthood, with a focus on functional abilities including education, employment, and quality of life (QOL), and employed predictors including injury severity, age at injury, socioeconomic factors, intelligence, and personality. Method: The study was retrospective and cross-sectional and included 50 adult survivors of child TBI (31 males), aged 19–30 years at evaluation (M = 24.2, SD = 3.6), with injury on average 13.3 years prior to evaluation. Participants were divided according to injury severity—mild (n = 20), moderate (n = 12), and severe (n = 18)—completed an intellectual evaluation and questionnaires regarding educational and employment status, personality, and quality of life. Results: Intellectual and personality measures indicated good outcomes, with mean scores for all groups in the average range and few severity-based findings. In contrast, those with more severe TBI were more likely to have educational and employment problems. QOL was significantly reduced in the context of severe insult, with lower IQ and personality factors most predictive of outcome in this domain. Mild and moderate TBI were generally more benign. Conclusions: Findings suggest that, while TBI is a lifelong problem, its impact is most dramatic in the domain of QOL, where a complex interaction occurs between injury factors, cognition, and personality. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Alcohol abuse and traumatic brain injury: effect on event-related potentials

OBJECTIVE: To examine the individual and combined impact that traumatic brain injury (TBI) and heavy social use of alcohol have on electrophysiologic correlates of working memory and evaluation of task-relevant information. DESIGN: Case-control study. SETTING: University hospital brain injury rehabilitation unit. PARTICIPANTS: Forty male volunteers divided into four groups on the basis of their history of TBI and alcohol intake. Subjects with TBI had experienced a severe closed head injury at least 1 year before testing. MAIN OUTCOME MEASURE: Event-related potentials (ERPs) and neuropsychometric tests. RESULTS: Groups showed no significant differences in average age or neuropsychological tests. TBI groups did not differ in time postinjury or on severity measures. Alcohol use measures were significantly greater in the two alcohol groups. N200 latency and P300 amplitude were impaired in heavy social drinkers and in nondrinking subjects with TBI relative to controls, but were significantly impaired in subjects with TBI who were also heavy social drinkers. CONCLUSION: The results indicate that although alcohol use and TBI independently produce mile alterations in some aspects of late ERP components, the ERP changes are significantly greater when alcohol use and TBI are combined. This study provides evidence that heavy social drinking after TBI has a measurable impact on electrophysiologic correlates of cognition.     

Increased serum levels of macrophage colony-stimulating factor (M-CSF) in alpha- and beta-thalassaemia syndromes: correlation with anaemia and monocyte activation

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.     

Family Caregivers of Stroke Survivors: Characteristics of Caregivers at Risk for Depression.

Objective: To examine characteristics that best predict family caregivers of stroke survivors at risk for depression. Survivor and caregiver demographic variables and caregiver general health, problem-solving skills, social support, satisfaction with rehabilitation health care services, preparedness, and burden were examined. Design: A correlational design. Participants: Seventy-four family caregivers of individuals receiving inpatient stroke rehabilitation were interviewed 1-2 days prior to their relative's discharge. Main Outcome Measure: The Center for Epidemiologic Studies Depression Scale (L. S. Radloff. 1977). Results: Caregivers at risk for depression had a negative orientation toward solving problems, a lack of caregiver preparedness, and impaired social functioning secondary to their own health. Conclusions: Rehabilitation psychologists should be aware that these variables are important in predicting family caregivers of stroke survivors at risk for depression. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The effects of Alzheimer disease on driving-related abilities

Ten Alzheimer disease (AD) patients and 12 healthy elderly controls were evaluated on two tests of driving-related abilities: the Driver Performance Test (DPT) and the Driving Advisement System (DAS). Subjects were administered a battery of neuropsychological tests to determine if severity of dementia in AD correlates with driving performance. On the DPT, the AD patients scored in the average range in two of five skill areas (predicting the effects of a hazard, deciding how to avoid it); below average in two areas (searching for a hazard, executing evasive actions); and poorly in one area (identifying hazards). The elderly controls scored at an average level in all five skill areas. On the DAS, AD patients were significantly slower than the elderly controls on simple, two-choice, and conditional reaction time tests and were much slower than drivers in general. The AD patients' performances on two cognitive tests, the Mini-Mental State Examination (MMSE) and the Category Fluency Test, correlated significantly with aspects of performance on the DPT and the DAS. Although these are preliminary results from a pilot investigation, they suggest that AD patients' driving-related abilities are adversely affected by the disease and that driving-related performance tests and neuropsychological tests may be useful in assessing the impact of AD on driving.     

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.     

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.     

Attribution of blame in accidental and violence-related traumatic brain injury.

Objective: To study reliability and validity of blame attribution following acute moderate to severe traumatic brain injury (TBI) caused by violence versus accident. Study Design: Prospective study with test-retest component, comparing groups with violent versus accidental injuries as determined by self-report and chart review. Participants: Fifty-seven persons in acute rehabilitation for moderate to severe TBI. Measure: Eight-item Blame Attribution Questionnaire. Results: Blame attribution was reliable, even for participants with severe TBI. Violence and accident groups apportioned different amounts of blame to other people; concern with cause of injury and degree of self-blame showed less striking differences. Conclusions: Blame of others, which may increase risk of adverse psychological outcome, is strongest in those with violence-related TBI. Self-blame is not as strongly related to external circumstances and could signal a constructive coping mechanism. (PsycINFO Database Record (c) 2010 APA, all rights reserved)