A study of patient-related characteristics and outcome after moderate injury

The purpose of all injury care is to restore patients' pre-injury functioning and to facilitate the return to normal activities. The aim of this prospective study was to describe and analyse psychiatric factors and other patient-related characteristics which influence long-term results after moderate injuries. One hundred and sixty-nine injured patients were randomized to go through a comprehensive psychosocial research protocol and to participate in the 12 month follow up. The 49 patients lost to follow-up differed significantly from all other patients. They were more often single, blue-collar workers with a lower educational level and had a less favourable psychosocial background, including alcohol abuse. The 120 patients who completed the follow-up were divided in two groups: the non-recovered group (NR, N = 58), patients reporting limitations in performing their work and/or limitations in carrying out housework and/or in social life, and the recovered group (R, N = 62), patients reporting full recovery or only minor limitations in exercise or sports 12 months after the injury. The NR patients were older (P < 0.05), had a slightly higher injury Severity Score (P < 0.01) and showed signs of depression both during the acute post-injury period and at 1 year follow up (P < 0.001). The multivariate analysis showed that measurements of pain and depression during the acute post-injury period were associated with the functional outcome after 12 months. Co-operation between injury and psychiatric units should be developed to identify patients needing psychosocial or psychiatric support during the early phase of rehabilitation.     

Patients with traumatic brain injury referred to a rehabilitation and re-employment programme: social and professional outcome for 508 Finnish patients 5 or more years after injury

We studied influence of age and educational level before injury on the social and vocational outcome among a group of traumatic brain injury (TBI) patients with post-injury problems in their education and employment. Patients with TBI, followed up for at least 5 years, and who were admitted to a rehabilitation and re-employment programme, were selected for evaluation of long-term outcome. We used the Glasgow Coma Scale (GCS) scores at the time of emergency admission to the hospital to measure brain injury severity. Age at the time of TBI and educational status before TBI were correlated with the outcome measures at the end of follow-up separately in each category of brain injury severity. The study was carried out at the Kauniala outpatient neurological clinic, which specializes in brain injuries in Finland; it works closely with the Departments of Neurology and Neurosurgery at the Helsinki University Central Hospital. Main outcome measures were functional outcome measured by the Glasgow Outcome Scale (GOS), the educational level reached, and post-injury occupation, as well as the incapacity for work at the end of follow-up. In the severe category of brain injuries, children 7 years or younger at the time of injury suffered severe disability as measured by the GOS scores more often than did the older age groups (p = 0.010, chi 2). They were less often capable of independent employment (p = 0.011, chi 2) than the children injured at the age of 8-16. Patients with a higher education usually had a better outcome. In the category of mild brain injuries the majority of the patients, regardless of age, recovered well according to the GOS, and were capable of independent employment at the end of follow-up. Our patients were selected from the TBI population as survivors with problems in education and re-employment. Those with severe injury sustained early in life (childhood and early teens) coupled with poor educational attainment had relatively worse social and vocational outcome; better outcomes were enjoyed by those severely injured individuals whose injuries were sustained later (late teens or early adulthood). In the groups of patients with moderate and mild brain injuries such a relationship was not found between age or pre-injury education and outcome.     

Effects of a multidisciplinary rehabilitation programme on health-related quality of life in patients with prolonged musculoskeletal disorders: a 6-month follow-up of a prospective controlled study

PURPOSE: The aim of this prospective, controlled, follow-up study (6 months) was to examine the effects of a multidisciplinary rehabilitation programme on perceived health-related quality of life (HRQL) in patients with prolonged musculoskeletal disorders (PMSD). The programme focused on body awareness therapy and cognitive and relaxation treatment. METHOD: The rehabilitation group comprised 122 patients, and there were 114 patients in the matched control group (CG). Both groups of patients had access to primary health care. Baseline data were compared with 6-month follow-up data within and between the groups. The following measurements were employed: HRQL (Nottingham Health Profile), body awareness, postural control, pain (VAS), pain-related medicine consumption, isometric arm muscle endurance, aerobic capacity, psychosomatic symptoms, physical and psychosocial working environment and sick leave. RESULTS: Variables that improved significantly as compared with the CG were: HRQL, anxiety, pain related to movements, psychosomatic symptoms and need for pain-related medicines. CONCLUSIONS: The multidisciplinary rehabilitation programme used here improved HRQL in patients with PMSD to a greater extent than the standard treatment provided within primary heath care (p = 0.01) at least in the short term.     

Educating families and caretakers of traumatically brain injured patients in the new health care environment: a three phase model and bibliography

Shorter inpatient stays for traumatically brain injured patients frequently allow less time for comprehensive education of families and caretakers. What is needed to compensate for the shortened duration of brain injury rehabilitation in many settings is a family educational programme that (1) satisfies the family's acute information needs as they arise, and (2) standardizes the delivery of information so that certain knowledge criteria are met. The following article proposes a three phase model of family and caretaker education with an accompanying bibliographical index.     

Geriatric psycho-social history outline

The outcome o,f marriages contracted after spinal cord injury suffered by males was examined via the questionnaire method. Of those whose first marriage occurred after their injury, the divorce rate was 24.4%. Of those whose were married prior to injury and then remarried following injury, 16.4% were divorced. If all post-injury marriages are considered, the divorce rate is 23.1%. This is close to the divorce rate of the United States as a whole. The outcome of post-injury marriages was also examined with respect to time since injury, level of injury, presence of post-injury children, and post-injury education and employment. Particular attention was given to those males who had never been married prior to their injury.     

Conversational discourse abilities following severe traumatic brain injury: a follow-up study

The major aim of this study was to describe the conversational abilities of a group of severely injured TBI speakers, at a minimum of 2 years post-injury. The association between conversational impairment and (a) selected measures of executive function and (b) psychosocial handicap was also examined. Twenty-four members of the group of 26 severely injured TBI speakers who had initially been assessed between 3 and 6 months post-injury were reviewed at a minimum of 2 years post-injury (mean = 2 years, 10 months). At initial assessment, TBI speakers were compared with non-TBI orthopaedic patients and with a group of university students. At follow-up, however, they were compared only with the orthopaedic patients. Conversational assessment was carried out using a modified form of Damico's Clinical Discourse Analysis. As a group, the TBI speakers' conversational abilities did not improve over time. There was, however, a subgroup (n = 8) of speakers who did improve, and these could be distinguished by greater initial severity of injury and a significantly longer period of speech-language pathology intervention than the speakers who either remained the same or worsened over time. Modest associations between conversational discourse skills and measures of executive function and a measure of psychosocial handicap were identified. These findings indicate that disruptions in conversation persist into the longer term. More assiduous efforts may need to be made to (a) identify subtle discourse changes in the early months after injury and (b) engage TBI speakers in speech-language pathology services. Such services are also required over a longer time frame, in community-based models of service provision.     

Subcellular distribution of GLUT4 in Chinese hamster ovary cells overexpressing mutant dynamin: evidence that dynamin is a regulatory GTPase in GLUT4 endocytosis

Previous studies have suggested that the neurotrophins brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) are neuroprotective or neurotrophic for certain subpopulations of hippocampal neurons following various brain insults. In the present study, the expression of BDNF and NT-3 mRNAs in rat hippocampus was examined after traumatic brain injury. Following lateral fluid percussion (FP) brain injury of moderate severity (2.0-2.1 atm) or sham injury, the hippocampi from adult rats were processed for the in situ hybridization localization of BDNF and NT-3 mRNAs using 35S-labeled cRNA probes at post-injury survival times of 1, 3, 6, 24 and 72 h. Unilateral FP injury markedly increased hybridization for BDNF mRNA in the dentate gyrus bilaterally which peaked at 3 h and remained above control levels for up to 72 h post-injury. A moderate increase in BDNF mRNA expression was also observed bilaterally in the CA3 region of the hippocampus at 1, 3, and 6 h after FP injury, but expression declined to control levels by 24 h. Conversely, NT-3 mRNA was significantly decreased in the dentate gyrus following FP injury at the 6 and 24 h survival times. These results demonstrate that FP brain injury differentially modulates expression of BDNF and NT-3 mRNAs in the hippocampus, and suggest that neurotrophin plasticity is a functional response of hippocampal neurons to brain trauma.     

Long-term outcomes and life satisfaction of adults who had pediatric spinal cord injuries

OBJECTIVE: To determine long-term outcomes and life satisfaction of adults who sustained pediatric spinal cord injury (SCI). DESIGN: Structured interview of adults who were 25 years or older who had pediatric SCI. SETTING: Community. PARTICIPANTS: A convenience sample of 46 patients from a total of 81 patients who received care in an SCI program: 1 refused participation, 4 died, and 30 were lost to follow-up. MAIN OUTCOME MEASURES: A structured questionnaire including physical, psychosocial, and medical information. The Craig Handicap Assessment and Reporting Technique and two measures of life satisfaction were also administered. RESULTS: Participants were 25 to 34 years old, mean 27 years. Thirty-two had tetraplegia and 14 had paraplegia. Thirty-one were men. Mean years of education was 14. Fifty-four percent were employed, 48% lived independently, and 15% were married. Life satisfaction was associated with education, income, satisfaction with employment, and social/recreation opportunities, and was inversely associated with some medical complications. Life satisfaction was not significantly associated with level of injury, age at injury, or duration of injury. CONCLUSIONS: Individuals who had pediatric SCI, much like adult-onset SCI, have the greatest opportunity for a satisfying adult life if rehabilitation emphasizes psychosocial factors such as education, employment, and long-term health management.     

Constitutive and barbital-induced expression of the Cyp6a2 allele of a high producer strain of CYP6A2 in the genetic background of a low producer strain

Expression of immediate early gene (IEG) mRNAs following traumatic brain injury in 3 different models-cryogenic injury, impact injury with craniotomy and impact injury without craniotomy-was investigated using in situ hybridization. Cryogenic brain injury resulted in c-fos and c-jun mRNA expression throughout the ipsilateral cortex, piriform cortex and dentate gyrus on the injured side, with peak at 30 min to 1 h post-injury. Impact injury with craniotomy was associated with hybridization signals in the same areas and also in the subcortical white matter or ependyma underlying the impact site at 30 min post-injury. The expression was rather more prolonged than with cryogenic injury. Impact injury without craniotomy induced the expression of both mRNAs throughout the ipsilateral cortex, piriform cortex and dentate gyrus at 30 min post-injury, but this was promptly attenuated by 1 h post-injury, except for bilateral elevation in the dentate gyrus. The present study, thus, demonstrated that regional and temporal expression of IEG mRNAs is influenced by the intensity, quality and manner of application of the insult. Differences in the expression of IEGs may alter the late response gene expression and affect the succeeding events.     

Depression among acute spinal cord injury patients: A study utilizing the Zung Self-Rating Depression Scale.

Administered the Self-Rating Depression Scale (SRDS) an average of 63 days post-injury to 58 acute spinal cord injury (SCI) patients (aged 18–55 yrs) and 51 age-matched healthy controls (CTLs). Mean SRDS scores were 37.1 for CTLs and 49.0 for SCI Ss. Several factors, including age, yrs of education, level of injury (paraplegic vs quadriplegic), etiology of injury (violent vs nonviolent), presence of acute closed head injury, or recent history of alcohol or substance abuse, had no association with SRDS scores. Since undiagnosed and untreated depression may compromise an SCI patient's adaptation to injury and motivation during rehabilitation, abnormally elevated SRDS scores may help to determine which patients might require more focused psychological assessment and treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interrelationships between crime, substance abuse, and aggressive behaviours among persons with traumatic brain injury

Professionals have suggested that aggressiveness, substance abuse, and criminality contribute to poor outcomes after brain injury. There is considerable research regarding post-injury aggressive behaviour, but limited information concerning criminal behaviour and alcohol use patterns. With a sample of 327 patients varying in severity of traumatic brain injury, the present investigation examined alcohol use patterns, arrest histories, behavioural characteristics, and psychiatric treatment histories. Relative to the uninjured population, analysis revealed relatively high incidence of heavy drinking, both pre- and post-injury, among patients with a history of arrest. Increases in abstinence rates were found regardless of arrest history. In addition, a history of arrest was associated with a greater likelihood of psychiatric treatment. Findings also indicated relatively high levels of aggressive behaviours. Discussion focuses on implications for evaluation, rehabilitation, and future research.     

Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury.

Objective: The long-term consequences of traumatic brain injury affect millions of Americans, many of whom report using religion and spirituality to cope. Little research, however, has investigated how various elements of the religious and spiritual belief systems affect rehabilitation outcomes. The present study sought to assess the use of specifically defined elements of religion and spirituality as psychosocial resources in a sample of traumatically brain injured adults. Participants: The sample included 88 adults with brain injury from 1 to 20 years post injury and their knowledgeable significant others (SOs). The majority of the participants with brain injury were male (76%), African American (75%) and Christian (76%). Measures: Participants subjectively reported on their religious/spiritual beliefs and psychosocial resources as well as their current physical and psychological status. Significant others reported objective rehabilitation outcomes. Analyses: Hierarchical multiple regression analyses were used to determine the proportion of variance in outcomes accounted for by demographic, injury related, psychosocial and religious/spiritual variables. Results: The results indicate that religious well-being (a sense of connection to a higher power) was a unique predictor for life satisfaction, distress and functional ability whereas public religious practice and existential well-being were not. Conclusions: The findings of this project indicate that specific facets of religious and spiritual belief systems do play direct and unique roles in predicting rehabilitation outcomes whereas religious activity does not. Notably, a self-reported individual connection to a higher power was an extremely robust predictor of both subjective and objective outcome. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The cost-effectiveness of the diagnosis of renal artery stenosis

Variables were studied which predict at the acute stage the functional and occupational long-term outcome for patients with traumatic brain injury (TBI). Glasgow Coma Scale (GCS) score on hospital admission, length of coma (LOC) and duration of post-traumatic amnesia (PTA) were studied in a group of 508 TBI rehabilitation patients, age 0.8-71, mean age 19, followed up between five and over 20 years, mean of 12 years. Information from hospital charts and all data available before and after the injury were gathered and reviewed. The study was carried out among a consecutive sample of Finnish patients with TBI referred to a rehabilitation programme at the out-patient neurological clinic of Kauniala Hospital, which specializes in brain injuries in Finland. The patients came from various hospital districts in the country for an evaluation of their educational and vocational problems. Main outcome measures were functional outcome, as measured by the Glasgow Outcome Scale (GOS) at the end of follow-up, and post-injury occupational outcome. The patients' reemployment on the open job marklet, subsidized employment or inability to work was noted. The GCS score on hospital admission correlated clearly with the functional outcome of the patients at the end of follow-up. Length of coma and duration of post-traumatic amnesia correlated specifically with the patient's work history after the brain injury and with functional outcome measured by the GOS. Outcomes varied among age groups and seemed to be affected by age at injury. Accordingly, the extent of recovery and quality of life for rehabilitation patients with TBI can be estimated early on by prognostic factors reflecting injury severity in the acute phase. The results suggest that the GCS score, LOC and duration of PTA all have a strong predictive value in assessing functional or occupational outcome for TBI patients.     

Postural motor programming in paraplegic patients during rehabilitation

One of the basic aims in the rehabilitation of thoracic spinal cord injured (SCI) patients concerns the regaining of sitting posture control. This implies the development of new postural strategies requiring the adjustment of motor programming processes. The aim of this study was to investigate the time course of postural reorganization during active, clinical rehabilitation of thoracic SCI patients with different SCI levels. Thus changes in motor programming in sitting balance control were investigated in two groups of complete low or high thoracic SCI patients. At several stages during the rehabilitation process an experiment was held in which sitting posture was perturbed systematically using submaximal reaching movements over four reaching distances. This bimanual reaching task was presented as a visual precue choice reaction time (RT) task in which reaching distance (i.e. grade of postural perturbation) was precued. Results indicated that in both high and low thoracic SCI patients RTs in movements involving postural perturbation became shorter during the course of the rehabilitation period. However, low thoracic SCI patients were generally slower in the programming of balance perturbing movements than high thoracic SCI patients, a phenomenon that did not change over time. Furthermore, initial differences in RTs as a function of grade of postural perturbation disappeared in both groups in the course of the rehabilitation phase. Precue benefit, equally large for both groups, did not change as a function of rehabilitation time. It is concluded that the observed phenomena signify the gradual development of new central postural control processes in both SCI groups during rehabilitation. Low thoracic SCI patients, having more residual sensorimotor functions, seem to adopt more complex strategies in maintaining and restoring sitting balance that take longer to specify and to programme. High thoracic SCI patients seem to rely on simpler strategies using more passive postural support.     

Controlled trial evaluation of an asthma education programme for adults

BACKGROUND: To improve asthma control and reduce readmission rates through increased knowledge and the development of self management skills, a brief (three hour) adult education programme was developed. METHODS: The course was designed to improve inhaler skills and to teach how to adjust drug doses according to peak flow (PEF) measurements and a treatment plan. It was evaluated in a randomised controlled trial in 76 patients admitted to hospital for asthma by using questionnaires, spirometry, and home monitoring of PEF at entry and at five and 10 months after intervention. The questionnaire provided measures of knowledge about asthma, self management behaviour appropriate to asthma control, asthma symptom frequency and severity, and psychosocial disturbance attributable to asthma. RESULTS: During the 10 months observation period the readmission rate for the educated group was one seventh that of the control group and attendance at accident and emergency departments also decreased. No consistent differential improvements were observed in spirometric results, average PEF, or mean daily variability of PEF. Both groups showed improvements in measures of asthma knowledge, behaviour, symptoms, and psychosocial disturbances. However, the intervention group showed a significantly greater improvement in some measures of asthma knowledge and self management skills. CONCLUSION: Despite minimal effect on measures of airway function, substantial changes in illness behaviour and use of health care facilities can be achieved by a brief asthma education programme.     

Electrical injury and the frequency of cardiac complications

A retrospective review of the patients with electrical injuries admitted over a 5-year period was performed to establish the frequency of cardiac complications. There were 145 admissions during this time. A total of 128 (88 per cent) were low voltage injuries and 17 (12 per cent) were high voltage (> 1000 V) injuries. Of the 145 admissions, 104 (72 per cent) had a 12-lead electrocardiogram (ECG) recorded within 24 h of their injury. Of these patients, 73 (75 per cent) were then observed on a cardiac monitor for at least 24 h post-injury. Cardiac abnormalities were noted in four patients (3 per cent) during this period. Three patients had occasional ectopic beats which settled spontaneously over a 24 h period post-injury. The fourth patient developed atrial fibrillation (AF) after a high voltage injury which resolved following intravenous digoxin. Cardiac complications were more frequent in those who had experienced a loss of consciousness at the time of injury and in those who suffered a high voltage electrical injury. All of the patients with cardiac complications had these at the time of admission to hospital. This suggests that if there is no history of a loss of consciousness and the 12-lead ECG recorded on attendance at the hospital is normal, it is unlikely that the patient will go on to develop cardiac problems.     

Exercise training in COPD patients: the basic questions

Pulmonary rehabilitation programmes aim at improving exercise capacity, activities of daily living, quality of life and perhaps survival in patients with chronic obstructive pulmonary disease (COPD). Recently, well-designed studies investigated and confirmed the efficacy of comprehensive pulmonary rehabilitation programmes, including exercise training, breathing exercises, optimal medical treatment, psychosocial support and health education. In the present overview, the contribution of exercise training in clinical practice to the demonstrated effects of pulmonary rehabilitation is discussed by means of six basic questions. These include: 1) the significance of exercise training; 2) the optimal intensity for exercise training; 3) prescribing training modalities; 4) the effects of exercise training combined with medication, nutrition or oxygen; 5) how training effects should be maintained; and 6) where the rehabilitation programme should be performed: in-patient, out-patient or homecare? First, exercise training has been proven to be an essential component of pulmonary rehabilitation. Training intensity is of key importance. High-intensity training (>70% maximal workload) is feasible even in patients with more advanced COPD. In addition, the effects on peripheral muscle function and ventilatory adaptations are superior to low-intensity training. There is, however, no consensus on the optimal training modalities. Both walking and cycling improved exercise performance. Since peripheral muscle function has been recognized as an important contributor to exercise performance, specific peripheral muscle training recently gained interest. Improved submaximal exercise performance and increased quality of life were found after muscle training. The optimal training regimen (strength or endurance) and the muscle groups to be trained, remain to be determined. Training of respiratory muscles is recommended in patients with ventilatory limitation during exercise. The additional effects of anabolic-androgenic drugs, oxygen and nutrition are not well-established in COPD patients and need further research. In order to maintain training effects, close attention of the rehabilitation team is required. The continuous training frequency necessary to maintain training effects remains to be defined. At this point in time, out-patient-based programmes show the best results and guarantee the best supervision and a multidisciplinary approach. Future research should focus on the role of homecare programmes to maintain improvements.     

Rehabilitation treatment of sexuality issues due to acquired brain injury.

Brain injury can cause myriad deficits that affect an individual's sexuality. Sexuality has not been given much attention in the rehabilitation process. It is important for the rehabilitation team to treat psychosocial and sexual issues before the individual reenters the community. Treatments of psychosocial–sexual issues include sex education groups for survivors and families, social skills groups, individual and group psychotherapy, community skills training, and medication. These approaches can play an important role in helping survivors and their families cope with sexuality issues after brain injury and, thus, can increase self-awareness and decrease disinhibited behaviors. Three case studies describe sexuality issues and highlight the importance of awareness and the relationship between awareness and outcome. Treatment provides the survivor and family with information about how to discuss sexuality issues and teaches the survivor effective interaction skills so as to reduce unwanted sexual behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stable transduction of recombinant adeno-associated virus into hematopoietic stem cells from normal and sickle cell patients

The effectiveness of a health education programme for prevention of alcohol abuse and tobacco smoking among adolescents was assessed by an intervention study with a non-randomized control group. The study was carried out among 7th-9th grade school students in a Local Health Unit of the Brescia province, North Italy. Students were enrolled in either the intervention or the control group, based on the participation of their teachers to the educational programme. A total of 428 students were involved in the programme representing the intervention group, and 658 students not involved in the programme formed the control group. The health education programme included the prevention of alcohol abuse in the first school year (1989-90) and the prevention of tobacco smoking in the second year (1990-91). Each part of the programme included a series of lessons taken by the teachers for about 20 hours. Alcohol use and smoking habits, knowledge about, and attitudes toward alcohol and tobacco use of the students have been assessed by anonymous questionnaires. The questionnaires have been administered during school time at the beginning and the end of each school year, giving a total of 6 questionnaires, from Q1 to Q6. All the questionnaires included the same questions on alcohol and tobacco use, knowledge and attitudes. Of the 1086 students who attended the 7th grade in the year 1989-90, 428 were enrolled as intervention group and 658 as control group. As regards alcohol, the following findings were observed: 1. no difference was found in the percentages of students drinking at least one glass of wine or beer daily between the 2 groups at Q6; 2. no substantial change in the percentage of students aware of the health risks of alcohol abuse from Q1 to Q6 was observed. As regards tobacco smoking, the results of the study showed: 1. no difference between the 2 groups was found at Q6 as regards the proportion of students who smoked one or more cigarettes a month; 2. the percentages of students planning to smoke in the future were similar in the 2 groups in Q6; 3.the percentage of students with a high score on the health consequences of smoking was higher in the intervention than the control group at Q4, but again no difference between the groups was evident at Q6. In conclusion, the health education programme seemed to be unsuccessful in modifying behaviors and attitudes regarding alcohol and tobacco use during the 3-year follow-up.