The National Traumatic Brain Injury Study: Assessing Outcomes across Settings

Acupuncture for Central Pain Affecting the Ribcage following Traumatic Brain Injury and Rib Fractures – a Case Report

This case report describes the use of acupuncture in the management of chronic central pain in a 51 year old man following severe traumatic brain injury and multiple injuries including rib fractures. The patient reported rapid and significant improvements in pain and mood during a course of acupuncture treatment. Chronic pain following traumatic brain injury is a significant problem. Chronic pain after rib fractures is also commonly reported. Acupuncture is widely used in the management of pain but its use has been reported rarely in the traumatic brain injury literature. This case report suggests that acupuncture may be a useful option to consider in these patients. Outcome was assessed formally using a 0 10 verbal numerical rating scale for pain, and the Hospital Anxiety and Depression Scale (HADS) for psychological status before and after the course of treatment. These scales are widely used in clinical practice as well as in research involving patients with traumatic brain injury, although they have not been validated in this population. The changes in this patient's outcome scores were not consistent with the benefits he reported. Treatment of this patient highlighted the difficulties of using standardised self rating scales for patients with cognitive impairment. The report also discusses the effects of acupuncture on this patient's mood.

Outcome Rating Scales for Pediatric Head Injury

Intensivists, surgeons, neurologists, and others involved in pediatric intensive care units (PICUs) have an important investment in both short-and long-term outcomes of children and adolescents with head injury who are treated under their care. Outcomes are most often documented by either single-or multiple-item rating scales and are implemented both during and after hospital care. For this review, the authors have organized the content of rating scales into 6 general classes: (1) mortality prediction, (2) severity, (3) global recovery, (4) activity restrictions, (5) secondary adverse conditions, and (6) limitations in participation, quality of life, and health status. Rating scales that describe the outcomes of children and adolescents after head injury are used to monitor medical and functional recovery, guide clinical management, drive quality assurance initiatives, and conduct clinical research. The authors restrict their selective review to rating scales that describe child outcomes (vs family) and that have been reported and applied in the outcome literature. Although head injury is a major cause of mortality and short-and long-term morbidity in children and adolescents, there is no consensus on which rating scales are optimal for hospital care or community follow-up. Major considerations for clinical use are feasibility, type of outcome information needed, content breadth across multiple ages and levels of recovery, and utility in determining the short-term impact of PICU care on long-term outcome.

Self-rated competency in activities predicts functioning and participation one year after traumatic brain injury

Objective: To investigate whether the Patient Competency Rating Scale at three months predicts global functioning and participation one year after traumatic brain injury.

Design: Prospective cohort study with follow-up at 3 and 12 months post injury. The Patient Competency Rating Scale was analysed in a logistic regression model with the outcomes Community Integration Questionnaire, Glasgow Outcome Scale Extended and return to work/study.

Setting: The neurosurgical department of a trauma referral centre in a metropolitan hospital.

Subjects: A cohort of 70 patients with acute traumatic brain injury, ranging from mild to severe injury.

Main measures: The Patient Competency Rating Scale, assessing competency in activities, was applied as a predictor. Outcomes describing community participation at 12 months were the Community Integration Questionnaire and return to work/study. Global functioning was evaluated by the Glasgow Outcome Scale Extended.

Results: Factor analysis of the Patient Competency Rating Scale items yielded three domains: activities demanding cognition, interpersonal/emotional skills, and activities of daily living (ADL) competency. The first two of these domains significantly predicted return to work/study and community integration, whilst global functioning at one year was predicted by interpersonal/emotional competency.

Conclusions: The Patient Competency Rating Scale at three months predicted functioning and participation one year after traumatic brain injury. This indicates that rehabilitation interventions should focus on cognitive and interpersonal competency in order to enhance participation after traumatic brain injury.

Measuring psychosocial recovery after brain injury: change versus competency

OBJECTIVES

To determine the psychometric properties of an alternative form of the Sydney Psychosocial Reintegration Scale (SPRS) that focuses on competency of functioning (Form B) as opposed to the original form that examines change from the premorbid level (Form A).

DESIGN

Descriptive correlational study. Ratings were made by 2 treating clinicians on patients at discharge and 1 week later by using Forms A and B of the SPRS. A subset of 25 close relatives of the patients also completed the 2 SPRS forms and the London Handicap Scale at patient discharge.

SETTING

Inpatient brain injury rehabilitation unit.

PARTICIPANTS

Sixty-six people with brain injury.

INTERVENTIONS

Not applicable. Main outcome measure The SPRS is a 12-item questionnaire, rated on a 7-point scale, that measures function in occupational, interpersonal, and living skills domains.

RESULTS

The internal consistency of Form B was high (alpha=.90), as was stability (intraclass correlation coefficient [ICC]=.90) and interrater agreement (ICC=.84). Similarly, good psychometric properties were found for Form A for internal consistency (alpha=.90), stability (ICC=.90) and interrater agreement (ICC=.82), which replicated previous findings with this form. Comparability between forms was excellent (ICC=.97), and correspondence between ratings of the clinician and close relatives on Forms A and B was fair to good (ICC=.57, ICC=.67, respectively).

CONCLUSIONS

Form B of the SPRS has psychometric properties equally sound to those of Form A. It is anticipated that there will be many advantages in having alternative forms of the same instrument, thus enabling measurement of psychosocial integration from different perspectives.

Parental stress and burden following traumatic brain injury amongst children and adolescents

PRIMARY OBJECTIVES

To assess parental stress following paediatric traumatic brain injury (TBI), and examine the relationship between self-reported problems, parental stress and general health.

RESEARCH DESIGN

Parents of 97 children admitted with a TBI (49 mild, 19 moderate, 29 severe) to North Staffordshire National Health Service Trust, and parents of 31 uninjured children were interviewed and assessed.

METHODS AND PROCEDURES

Structured interviews were carried out with families, and parents assessed on the Parenting Stress Index (PSI/SF) and General Health Questionnaire (GHQ-12) at recruitment, and repeated 12 months later.

MAIN OUTCOMES AND RESULTS

Forty parents (41.2%) of children with TBI exhibited clinically significant stress. Regardless of injury severity, parents of injured children suffered greater stress than control parents as measured by the PSI/SF (p = 0.001). There was a highly significant relationship between number of problems reported and level of parental stress (p = 0.001). Financial burden was related to severity of TBI. At follow-up, one third of parents of children with severe TBI scored > or =18 on the GHQ-12, signifying poor psychological health.

CONCLUSIONS

The parents of a child with serious TBI should be screened for abnormal levels of stress. Parental stress and family burden may be alleviated by improved information, follow-up and support.