Response to "Care continuum in traumatic brain injury rehabilitation".

Comments on the original article "Care continuum in traumatic brain injury rehabilitation," by J. M. Uomoto and A. McLean (see record 1990-02670-001). As someone working within the insurance industry with the responsibility for purchasing services for TBI patients, I think that the TBI care continuum, as presented by Uomoto and McLean, represents a sensible response to a critical need. It does not offer, however, any specific information on what is effective and simply restates what has already been recognized by many in the insurance industry: head trauma rehabilitation is long, complex, multidisciplinary, intensely individualistic, and enormously expensive. The insurance industry is aware that a continuum care approach is necessary. Clearly, no one can dispute that treatment has to be ongoing and multifaceted to address a disability that has such a colossal medical, social, vocational, and psychological impact. In addition, the need for acute hospitalization, acute rehabilitation, and a protective environment to provide care and address basic needs is readily accepted. The problem for the insurance industry is what constitutes effective treatment beyond the acute phase of trauma stabilization and maintenance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Incidence of chronic pain following traumatic brain injury

OBJECTIVE: To index the frequency of reported chronic pain in patients with traumatic brain injury (TBI). DESIGN: A case series study was conducted on consecutive patients with TBI. SETTING: TBI patients were recruited from an adult tertiary care center brain injury clinic. PATIENTS: A consecutive sample of 132 patients who attended a brain injury rehabilitation center after TBI. The sample included 53 mild and 79 moderate/severe TBI patients. OUTCOME MEASURES: Patients were administered a protocol that indexed pain site, frequency, severity, and duration. RESULTS: Chronic pain was reported by 58% of mild TBI and 52% of moderate/severe TBI patients. Headaches were the most commonly reported pain problem. Chronic headaches were reported by 47% of mild TBI patients and 34% of moderate/ severe TBI patients. Neck/shoulder, back, upper limb, and lower limb pain were reported similarly by mild and moderate/severe TBI patients. CONCLUSIONS: Findings indicate that chronic pain is a significant problem in mild and moderate/severe TBI patients. More effective diagnosis of TBI patients with chronic pain may facilitate rehabilitation of these patients.     

Serious traumatic brain injury: an evaluation of functional outcomes

OBJECTIVES: Evaluate independent living, productivity, and social outcomes of patients with serious traumatic brain injury (TBI) after inpatient rehabilitation. METHODS: Fifty-five adults with serious TBI (Abbreviated Injury Scale score > or = 3) were admitted to a Level I trauma center and subsequently transferred to a comprehensive inpatient rehabilitation hospital (Walton Rehabilitation Hospital). Functional Independence Measures were obtained at admission (Adm), discharge (D/C), and at 3- (n = 52) and 1-year (n = 51) follow-up. RESULTS: At 1 year, 90% of the patients were living at home. Eight (16%) required full-time supervision, while 41 (82%) were independent of supervision throughout most of the day. Thirteen (25%) patients had returned to work, eight full time and five with reduced responsibility and fewer hours than before injury. Nineteen shared household duties, while eight (16%) had primary responsibility. Fourteen (27%) patients demonstrated socially inappropriate or disruptive behavior at least weekly. [table: see text] CONCLUSION: Although cognitive skills were diminished for the majority of patients, many achieved a substantial reduction in disability within 18 months after TBI.     

Small area study of mortality among people living near multiple sources of air pollution

The Pacific Conference scheduled for October 1-3, 1988, is a critical event in the development of an integrated community-based plan for a comprehensive continuum of services to address the "silent epidemic," Traumatic Brain Injured (TBI). This paper provides insights of the complex nature and the special problems faced by the TBI survivors; their families, natural supports and caregivers, as well as the health, social and educational care providers in Hawaii. Process for the development of the community plan is presented.     

Epidemiology of traumatic brain injury in South Australia

Reviews of statewide hospital separations' summaries and medical record data from a major teaching hospital, were conducted to describe the epidemiology of traumatic brain injury (TBI) in South Australia (SA), and to document the demographics of the population affected and the nature of their injuries. The groups most at risk were defined for targeting preventive programmes, and predictions were made regarding their ongoing service needs, for more appropriate provision of care. The results indicate that SA experiences a high incidence of TBI. At 322 per 100,000 head of population annually, it exceeds studies (with comparable methodologies) in communities in the United States and Europe. The causes; nature and severity of the injuries were similar to those found in the international literature, as were the profiles of the population most at risk. Specifically, young males living in the country and working in manual trades showed the highest incidence, and were most likely to have sustained their TBI whilst driving a motor vehicle. When a formula to predict service needs was adapted using the SA data, it was apparent that hospitals in this state care for more than 4000 new cases of TBI each year and that, on discharge, over 1000 of these will have some degree of residual impairment and will therefore require some form of post-injury services.     

The Impact of Patient-Centered Information on Patients' Treatment Satisfaction and Outcomes in Traumatic Brain Injury Rehabilitation.

Objective: To evaluate the effects on patients with traumatic brain injury (TBI) of detailed, personalized information about their injuries, acute care treatment, and rehabilitation progress. Participants: Twenty-eight former or present military personnel (mean age = 30 years) with moderate to severe TBI (mean of 29 days spent in intensive care before admission to TBI unit). Design: Two (personalized information vs. general information) × 2 (high- vs. low-patient preference for health care information) factorial design. Interpersonal behavior of patients, information providers, and health care staff were measured by the Impact Message Inventory. Outcome Measures: Rehabilitation Intensity of Therapy Scale, Functional Independence Measure, Treatment Satisfaction Questionnaire. Results: Patients given personalized information exerted greater effort in physical therapy, made greater improvement in functional independence, and were more satisfied with rehabilitation treatment. Patient preference for information and ratings of interpersonal behavior were largely unrelated to patient outcomes. Conclusion: Cognitively impaired TBI patients can benefit from interventions designed to enhance their sense of control and personal involvement in their own care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic amnesia: its relation to functional outcome

OBJECTIVE: To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS: Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES: Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS: Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION: Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.     

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)     

Suicidality and veterans with a history of traumatic brain injury: Precipitating events, protective factors, and prevention strategies.

Objectives: To increase understanding regarding precipitating and preventative factors of suicidal behavior and to highlight past experiences and recommendations regarding services aimed at suicide prevention among Veterans with a history of traumatic brain injury (TBI). Study Design: Qualitative. Participants: Sample of 13 Veterans with a history of TBI, and a history of clinically significant suicidal ideation or behavior. Method: In-person interviews were conducted and data were analyzed using a hermeneutic approach. Results: Shared precipitants noted included loss-of-self post-TBI, cognitive sequelae, and psychiatric and emotional disturbances. Common protective factors noted included social supports, a sense of purpose regarding the future, religion and spirituality, and mental health care. Means of improving care were also identified (e.g., increasing the availability of services and mental health professionals’ knowledge regarding TBI, providing more structured treatment). Conclusions: Findings highlight potential areas of importance in the assessment and treatment of suicidal Veterans with a history of TBI. Recommendations regarding means of improving care are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Potential of and problems with new measures of psychometric intelligence after traumatic brain injury.

Objective: Examination of the concurrent and criterion validities of the General Ability Measure for Adults (GAMA) and the Wechsler Adult Intelligence Scale–Third Edition (WAIS–III) in patients with traumatic brain injury (TBI). Study Design: Correlational methods and multivariate analyses of variance. Setting: Regional rehabilitation center. Participants: Prospective series of consecutive rehabilitation referrals, including 60 adults with TBI and no confounding premorbid histories. Main Outcome Measures: GAMA and WAIS–III IQ and factor index scores were obtained within 1 year after injury and were compared with each other and with measures of injury severity. Results: GAMA and WAIS–III summary IQ scores demonstrated substantial covariance (supporting concurrent validity), but neither was sufficiently sensitive to injury severity. The WAIS–III Processing Speed (PS) index was the only measure that clearly demonstrated criterion validity. Conclusions: GAMA and WAIS–III summary IQ scores measure similar abilities but may not be sensitive to degree of injury severity in individuals with TBI. In contrast, the WAIS–III PS index appears to have promise in the evaluation of sequelae of TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Response to "Programming for occupational outcomes following traumatic brain injury".

Responds to an article Programming for occupational outcomes following traumatic brain injury by William J. Haffey and Frank D. Lewis (see record 1990-02644-001). The dramatic upsurge in attention paid in the past 10 years to the rehabilitation of persons with traumatic brain injury (TBI) has resulted in an accelerating proliferation of treatment programs purporting to apply specialized techniques that will "remediate" the cognitive and behavioral deficits of this population, with implicit or explicit promises of functional gain. Specifically, given the epidemiologic realities of the TBI population, returning to work is a major goal of the rehabilitation process. With the movement of TBI rehabilitation programs out of academic medical centers and into the private sector, increasing numbers of zealous professionals are ready to apply a variety of treatment approaches, thousands of families are eager to find the "best" program, and more and more nervous insurers are both mandated and requested to pay for expensive treatments that hold out the promise of return to work. Unfortunately, the field of TBI rehabilitation has been more eager to provide services than critically evaluate the effectiveness of those services. The first major contribution of the Haffey and Lewis article is to call attention both to the paucity of posttreatment vocational outcome studies, and to emphasize the need to evaluate the success of various models of vocational rehabilitation. The second major contribution of the Haffey and Lewis article is their offering of a concrete example of one approach to systematic programming for vocational outcomes. Our experience is that vocational potential—and therefore reasonable goals—only emerge as the product of a process that involves testing the client's capacities not just cognitively and behaviorally, but also his or her capacity to conform to a series of messages and procedures that will determine the viability of any given vocational plan. Readers should take from the concrete programming suggestions in this article the laudable objective of making vocational goals, obstacles, and critical events specific and public, but beware of mechanically applying the approach without appreciating the complex subtleties in enabling a brain-injured person to become a productive worker. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethnicity and age issues: Attitudes affecting rehabilitation of individuals with spinal cord injury.

The individual with spinal cord injury, family, staff, and significant others bring attitudes regarding age and ethnicity into the rehabilitation team dynamic. Such preconceived attitudes may direct one's ability to be open to change and incorporate new information. The authors present 3 cases that highlight the bidirectional nature of bias challenges and the potential impact of bias issues on the hospital setting, staff, individual, family, and significant others. The bidirectional nature of bias challenges is illustrated with 2 cases of bias issues presented by individuals with spinal cord injury during hospitalization and with I case of bias impact on an individual health care provider. Interventions and strategies to maximize information sharing, education, and adjustment during hospitalization, discharge planning, and community living are discussed. Individuals may face increasing challenges in maximizing the derived benefit from both health care delivery and community services if personal bias plays a role in excluding qualified personnel from consideration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Task performance in virtual environments used for cognitive rehabilitation after traumatic brain injury

OBJECTIVE: This report describes a reliability study using a prototype computer-simulated virtual environment to assess basic daily living skills in a sample of persons with traumatic brain injury (TBI). The benefits of using virtual reality in training for situations where safety is a factor have been established in defense and industry, but have not been demonstrated in rehabilitation. SUBJECTS: Thirty subjects with TBI receiving comprehensive rehabilitation services at a residential facility. METHODS: An immersive virtual kitchen was developed in which a meal preparation task involving multiple steps could be performed. The prototype was tested using subjects who completed the task twice within 7 days. RESULTS: The stability of performance was estimated using intraclass correlation coefficients (ICCs). The ICC value for total performance based on all steps involved in the meal preparation task was .73. When three items with low variance were removed the ICC improved to .81. Little evidence of vestibular optical side-effects was noted in the subjects tested. CONCLUSION: Adequate initial reliability exists to continue development of the environment as an assessment and training prototype for persons with brain injury.     

Deep venous thrombosis: incidence on admission to a brain injury rehabilitation program

OBJECTIVE: To determine the incidence of deep venous thrombosis (DVT) in brain injured individuals at time of admission to a brain injury (BI) rehabilitation program. DESIGN: Prospective study, sequential case series. SETTING: University tertiary care BI rehabilitation center. DATA SET: Eighty-two traumatic brain injury (TBI) and 71 atraumatic brain injury (ABI) patients were consecutively admitted to our BI unit over a 12-month period and screened within 24 hours of admission for a lower extremity DVT with color flow duplex Doppler ultrasonography. All patients had been prophylaxed with either subcutaneous heparin anticoagulation therapy or intermittent compression devices, and all patients were within 2 months of the original BI. MAIN OUTCOME MEASURES: Evidence of intrinsic venous occlusion by duplex Doppler. RESULTS: DVTs were detected and treated prior to rehabilitation admission in three patients (2%), and these persisted at rehabilitation admission. New DVTs were detected at time of rehabilitation admission in 17 patients (11%). All were occult DVTs; none of the 17 patients had clinical findings indicative of acute DVT. No significant differences were noted in the TBI group when age, highest 24-hour Glasgow Coma Scale score, length of acute hospitalization, type of DVT prophylaxis, or presence of an extremity fracture were compared for individuals with and without DVT. No significant differences were noted in the ABI group when age, length of acute hospitalization, and type of DVT prophylaxis were compared for individuals with and without DVT. CONCLUSION: The overall incidence of DVTs was 13% and the incidence of occult DVT was 11%. Individuals with TBI had an overall incidence of DVTs of 20% and an occult DVT incidence of 18%. Individuals with ABI had an overall incidence of DVT's of 6% and an occult DVT incidence of 4%. These findings indicate the importance of baseline screening for DVT in this patient population.     

Comparison of functional outcomes and treatment cost between a computer-based cognitive rehabilitation teletherapy program and a face-to-face rehabilitation program.

The authors compared outcomes of 19 participants who received computer-based cognitive teletherapy rehabilitation with 20 participants who received face-to-face speech-language rehabilitation. The study compared outcomes from 2 "real-word" treatment programs provided by an outpatient rehabilitation center. A total of 39 participants with moderate to severe closed head traumatic brain injuries and a minimum of 1 year following injury were analyzed. Outcome measures included clinical indicators of independent living status, return to work or school, and independent driving. Cost measures included the total cost of the treatment and a measure of service costs per hour. Time since injury was a covariate, and an analysis of covariance revealed no differences between groups in independent living, driving status, return to work or school, or total treatment costs. The computer-based teletherapy cognitive rehabilitation program provided similar functional outcomes as face-to-face speech-language therapy at a similar total cost. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Symptomatic Helicobacter pylori infection in a neurorehabilitation population

Helicobacter pylori infection has been associated with acute and chronic gastritis, peptic ulcer disease, hypertension, and possibly gastric carcinoma and coronary artery disease. The prevalence of H pylori infection is more than 50% in people older than 60 years; however, the prevalence is not known in patients with traumatic brain injury (TBI) or cerebrovascular accidents who are treated in inpatient rehabilitation services. This report describes 10 symptomatic patients with TBI and strokes who were diagnosed with and treated for H pylori infection after transfer to a neurorehabilitation unit during a 12-month period. Physicians who treat patients with TBI and stroke need to be aware of the possible high prevalence of H pylori infection in their patients. The authors recommend H pylori screening for symptomatic patients in neurorehabilitation units and providing definitive treatment to prevent recurrent gastrointestinal bleeding, peptic ulcer disease, and gastritis.     

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.     

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)     

Blame attribution in intentional and unintentional traumatic brain injury: Longitudinal changes and impact on subjective well-being.

Objective: Examine longitudinal changes in attribution of blame to self and others, and concern over cause of injury, in both intentional (violence-related) and unintentional (accidental) traumatic brain injury (TBI); investigate the relation of these factors to subjective well-being outcomes at 1 year post-TBI. Study Design: Prospective, multicenter, observational study with longitudinal component. Participants: 99 men with unintentional TBI and 25 men with intentional TBI who sustained moderate to severe injuries, received inpatient rehabilitation, and provided data in both acute rehabilitation and 1-year follow-up. Measures: Blame Attribution Questionnaire, General Health Questionnaire-30, Neurobehavioral Functioning Inventory-Revised Depression Scale, Satisfaction With Life Scale, community participation measures. Results: At both time points, participants with intentional TBI blamed others more while those with unintentional TBI blamed themselves more (trend). Other-blame at 1 year predicted depression but not life satisfaction. Self-blame was not a significant predictor of depression or life satisfaction. Increasing concern over cause/blame for injury from acute rehabilitation to follow-up was associated with high levels of emotional distress. Conclusion: Blame attribution issues may be markers of TBI-related emotional distress regardless of injury etiology, particularly when others are blamed for the injury and/or concerns over cause of injury do not resolve over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)