Mild traumatic brain injury. A primer for understanding its impact on employee return to work

1. Mild head injuries are common occurrences in the United States. 2. If not properly understood and managed, mild head injuries can be unnecessarily costly in terms of lost work days, financial expenditures, and human suffering. 3. If properly understood and treated, most victims of mild head injuries can return to productive lifestyles. 4. Factors that place persons at high risk for more severe symptoms and/or more lengthy recovery periods are easy to conceptualize.     

Family burden following traumatic brain injury.

Investigated burden experienced by 60 spouses and 71 parents who served as primary caregivers to individuals with traumatic brain injury (BI). Burden levels, as assessed by the Questionnaire on Resources and Stress (QRS-SF), were compared for spouses and parents. Both parents and spouses exhibited high levels of burden. Relative to spouses, parents reported significantly greater burden related to lifespan care. Spouses reported significantly less personal reward than did parents. The presence of social aggression and cognitive disability in the individual with BI was found to have a greater association with subjective burden of caregivers than was the presence of physical disability or injury severity. Results of previous studies with QRS-SF scores show that the responsibility assumed by spouses and parents of persons with BI was as great as that experienced by families of people with severe chronic physical disabilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

Personality and functional outcome following traumatic brain injury.

Objective: To investigate pre- to postinjury personality change in relation to outcomes following traumatic brain injury (TBI). Design: Prospective analysis of personality ratings, depression, and outcome using multiple regression analyses. Participants: Cohort of 3 clinical trauma groups (mild TBI, moderate-severe TBI, orthopedic injury) and their significant others (SO). Outcome Measures: Independent Living Scale, Vocational Independence Scale, and Mayo-Portland Adaptability Inventory, 1-2 years postinjury. Predictor Variables: Posttraumatic amnesia (PTA); patient and SO NEO Personality Inventory-Revised ratings of preinjury personality taken at 1-2 months postinjury. Results: Personality function was normal for all groups (regardless of rating source) and stable over time. Neuroticism, and specifically depression, accounted for small proportions of variance in functional outcome, beyond PTA. Conclusions: There is little empirical evidence for significant personality disturbance or change up to 2 years post-TBI. Personality and depression contribute modestly to functional outcomes. Results support a distinction between "personality change" and behavior change following TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive outcome in children and adolescents following severe traumatic brain injury: influence of psychosocial, psychiatric, and injury-related variables

Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than psychiatric or psychosocial factors as correlates of cognitive outcomes. We addressed this concern by recruiting a consecutive series (N = 24) of children age 5 through 14 years who suffered a severe TBI, a matched group who sustained a mild TBI, and a second matched group who sustained an orthopedic injury. Standardized intellectual, memory, psychiatric, family functioning, family psychiatric history, neurological, and neuroimaging assessments were conducted at an average of 2 years following injury. Severe TBI, when compared to mild TBI and orthopedic injury, was associated with significant decrements in intellectual and memory function. A principal components analysis of independent variables that showed significant (p < .05) bivariate correlations with the outcome measures yielded a neuropsychiatric factor encompassing severity of TBI indices and postinjury psychiatric disorders and a psychosocial disadvantage factor. Both factors were independently and significantly related to intellectual and memory function outcome. Postinjury psychiatric disorders added significantly to severity indices and family functioning and family psychiatric history added significantly to socioeconomic status in explaining several specific cognitive outcomes. These results may help to define subgroups of children who will require more intensive services following their injuries.     

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)     

Recovery of time estimation following moderate to severe traumatic brain injury.

Objective: Accurate time estimation abilities are thought to play an important role in efficient performance of many daily activities. This study investigated the role of episodic memory in the recovery of time estimation abilities following moderate to severe traumatic brain injury (TBI). Method: Using a prospective verbal time estimation paradigm, TBI participants were tested in the early phase of recovery from TBI and then again approximately one year later. Verbal time estimations were made for filled intervals both within (i.e., 10 s, 25 s) and beyond (i.e., 45 s 60 s) the time frame of working memory. Results: At baseline, when compared to controls, the TBI group significantly underestimated time durations at the 25 s, 45 s and 60 s intervals, indicating that the TBI group perceived less time as having passed than actually had passed. At follow-up, despite the presence of continued episodic memory impairment and little recovery in episodic memory performance, the TBI group exhibited estimates of time passage that were similar to controls. Conclusion: The pattern of data was interpreted at suggesting that episodic memory performance did not play a noteworthy role in the recovery of temporal perception in TBI participants. (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.     

Neuropsychological issues in litigation following traumatic brain injury.

Provides information about issues confronting neuropsychologists involved in brain injury litigation. Neuropsychologists are often involved as experts in the litigation process because of their unique role in assessment and treatment of brain injury sequelae. Focus is on evaluation, preparation of reports, testimony, professional credibility, ethics, and responsibilities to the patient. Criteria for evaluating the expertise and credentials of psychologists hired by attorneys are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Programming for occupational outcomes following traumatic brain injury.

Examines the occupational outcomes reported from 3 traumatic brain injury (TBI) rehabilitation models: comprehensive neuropsychological rehabilitation, comprehensive neuropsychological rehabilitation and occupational trials, and supported work. It is argued that programming for occupational entry or reentry must include precise specification of barriers to rehabilitation outcome goals and systematic planning for skill generalization and maintenance. The Barriers Profile and the New Medico Barriers to Anticipated Rehabilitation Outcomes Scale are offered as tools to assist interdisciplinary treatment teams in identifying the number and magnitude of personal and environmental barriers to occupational resettlement; their use is illustrated with a case example. Procedures for enhancing generalization and maintenance of treatment goals are discussed. A comment by T. Kay follows. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Material-specific memory in traumatic brain injury: Differential effects during acquisition, recall, and retention.

Material-specific memory refers to the ability to learn and recall new episodic information on the basis of the nature of the stimulus material (e.g., verbal vs. nonverbal-visuospatial). Structural equation modeling was used to analyze data from a sample of patients with traumatic brain injury to compare 3 models of memory functioning: material-specific, material-specific plus general, and general (non-material-specific). The models were examined separately for acquisition, delayed free recall, and retention aspects of memory. Results suggest that, at least in a population with traumatic brain injury, the acquisition of new information takes place in a material-specific memory fashion, delayed free recall involves both material-specific and general (non-material-specific) memory components, but retention relies primarily on general (non-material-specific) memory processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive functioning ten years following traumatic brain injury and rehabilitation.

Many previous studies investigating long-term cognitive impairments following traumatic brain injury (TBI) have focused on extremely severely injured patients, relied on subjective reports of change and failed to use demographically relevant control data. The aim of this study was to investigate cognitive impairments 10 years following TBI and their association with injury severity. Sixty TBI and 43 control participants were assessed on tests of attention, processing speed, memory, and executive function. The TBI group demonstrated significant cognitive impairment on measures of processing speed (Symbol Digit Modalities Test [SDMT], Smith, 1973; Digit Symbol Coding, Wechsler, 1997), memory (Rey Auditory Verbal Learning Test [RAVLT]; Rey, 1958; Lezak, 1976), Doors and People tests; Baddeley, Emslie & Nimmo-Smith, 1994) and executive function (Hayling C [Burgess & Shallice, 1997] and SART errors, Robertson, Manly, Andrade, Baddeley & Yiend, 1997). Logistic Regression analyses indicated that the SDMT, Rey AVLT and Hayling C and SART errors most strongly differentiated the groups in the domains of attention/processing speed, memory and executive function, respectively. Greater injury severity was significantly correlated with poorer test performances across all domains. This study shows that cognitive impairments are present many years following TBI and are associated with injury severity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attention remediation following traumatic brain injury in childhood and adolescence.

Traumatic brain injury (TBI) frequently affects both the basic and the superordinate components of attention; deficits vary according to patient age. This study evaluated the efficacy of a specific remediation intervention for attention. Sixty-five TBI patients (aged 6?18 years) with attention deficit were assessed at baseline and at 1-year follow-up: 40 patients received attention-specific neuropsychological training for 6 months, and the control group comprised 25 patients. Cognitive assessment included a Wechsler Intelligence Scale (e.g., A. Orsini, 1993) and the Continuous Performance Test II (CPT II; C. K. Conners, 2000). The Vineland Adaptive Behavior Scales (VABS; S. Sparrow, D. Balla & D. V. Cicchetti, 1984) was administered to assess the treatment's ecological validity. At baseline, all patients presented with a mild intellectual disability and pathological scores on the CPT II. At follow-up, significant differences were found between the 2 groups on the CPT II and VABS: The clinical group improved more than the control group. Specific remediation training for attention, including a combination of a process-specific approach and metacognitive strategies, significantly improved attention performance. Improvement in attention skills also affected adaptive skills positively. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences in learning and memory after pediatric traumatic brain injury.

Thirty boys and 30 girls who sustained a traumatic brain injury (TBI) were evaluated within 1 year postinjury with the California Verbal Learning Test--Children's Version (CVLT-C; D. C. Delis, J. H. Kramer, E. Kaplan, & B. A. Ober, 1994). Boys had statistically significantly lower performance on the CVLT-C than girls in the absence of statistically significant group differences on various demographic and neurological variables. Although the effect size for this difference was modest (η=.09), gender accounted for a statistically significant amount of the variance (5%) in CVLT-C scores in addition to effects of injury severity and age. It is concluded that male gender is associated with an increased risk for retrieval deficits after pediatric TBI, possibly because of reduced speed or efficiency of information processing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Porteus maze performance following traumatic brain injury in children.

To investigate planning in traumatically brain injured children, the authors gave the Porteus Maze Test (PMT; S. D. Porteus, 1959) to 276 pediatric patients who had sustained a traumatic brain injury (TBI) at least 3 years previously. Sensitivity of the PMT to TBI severity, age at test, and volume of focal brain lesions detected by magnetic resonance imaging was also studied. The Peabody Picture Vocabulary Test-Revised (L. M. Dunn & L. M. Dunn, 1981) was also administered as a control measure. Results indicated that the PMT was highly sensitive to TBI severity and to volume of circumscribed prefrontal lesions. In contrast to the PMT data, receptive vocabulary was related to injury severity but not to discrete prefrontal lesions. Implications for mechanisms of cognitive deficit after TBI in children are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Selective attention deficits and subjective fatigue following traumatic brain injury.

The present study aimed to investigate the relationship between subjective fatigue and selective attention deficits following traumatic brain injury (TBI). Forty-six participants with mild-severe TBI and 46 healthy controls completed fatigue scales (Visual Analogue Scale--Fatigue, Fatigue Severity Scale [FSS] and Causes of Fatigue Questionnaire [COF]), and attentional measures including subtests from the Test of Everyday Attention, and the Complex Selective Attention Task (C-SAT). TBI participants reported greater fatigue on the FSS and COF, performed more slowly on attentional measures, and made more errors on the C-SAT. After controlling for anxiety and depression, fatigue was significantly correlated with performance only on the C-SAT. Findings suggest a relationship between subjective fatigue and impairment on tasks requiring higher order attentional processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Variables associated with employment following severe traumatic brain injury.

Results of a survey of employment outcome and their relationship to psychometric indices indicated that competitive employment following severe traumatic brain injury is an ambitious endeavor. While 98% of the 94 Ss sampled were either employed or in school premorbidly, 43% of them were unemployed postinjury. Psychometric variables were most highly related to employment outcome which suggested a useful role of neuropsychological testing in assisting in vocational rehabilitation planning. Furthermore, the psychometric test results indicated that many Ss who were unemployed may be capable of parttime employment. Future studies are needed to further examine those neuropsychological abilities which subsequently affect employability following severe traumatic brain injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

White matter atrophy, ventricular dilation, and intellectual functioning following traumatic brain injury.

Examined the role in traumatic brain injury (TBI) of injury severity measured by the Glasgow Coma Scale (GCS), white matter atrophy identified by various magnetic resonance imaging (MRI) morphometric techniques, and postinjury intellectual functioning measured with the Wechsler Adult Intelligence Scale—Revised (WAIS—R). MR images of 31 female and 33 male TBI patients were used to calculate corpus callosum (CC) areas, ventricular volumes (estimates of white matter loss), and parenchymal volumes. Results indicated that the men were on the average more severely injured, as indicated by significantly lower GCS scores. CC size correlated significantly with the ventricle-to-brain ratio (VBR), but no significant correlations were found between CC size and WAIS—R scores. Significant correlations were found for men only between VBR and Performance IQ and between VBR and the Digit Symbol subtest of the WAIS—R. Implications for the roles of white matter atrophy and intellectual functioning in TBI are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)