Functional level during the first 2 years after moderate and severe traumatic brain injury

Improvement in Functional Outcome from 6 to 12 Months After Moderate and Severe Traumatic Brain Injury Is Frequent, But May Not Be Detected With the Glasgow Outcome Scale Extended

The aims of this study were (1) to report outcome and change in outcome in patients with moderate and severe traumatic brain injury (mo/sTBI) between 6 and 12 months post-injury as measured by the Glasgow Outcome Scale Extended (GOSE), (2) to explore if demographic/injury-related variables can predict improvement in GOSE score, and (3) to investigate rate of improvement in Disability Rating Scale (DRS) score, in patients with a stable GOSE. All surviving patients ≥16 years of age who were admitted with mo/sTBI (Glasgow Coma Scale [GCS] score ≤13) to the regional trauma center in Central Norway between 2004 and 2019 were prospectively included (n = 439 out of 503 eligible). GOSE and DRS were used to assess outcome. Twelve-months post-injury, 13% with moTBI had severe disability (GOSE 2-4) versus 27% in sTBI, 26% had moderate disability (GOSE 5-6) versus 41% in sTBI and 62% had good recovery (GOSE 7-8) versus 31% in sTBI. From 6 to 12 months post-injury, 27% with moTBI and 32% with sTBI had an improvement, whereas 6% with moTBI and 6% with sTBI had a deterioration in GOSE score. Younger age and higher GCS score were associated with improved GOSE score. Improvement was least frequent for patients with a GOSE score of 3 at 6 months. In patients with a stable GOSE score of 3, an improvement in DRS score was observed in 22 (46%) patients. In conclusion, two thirds and one third of patients with mo/sTBI, respectively, had a good recovery. Importantly, change, mostly improvement, in GOSE score between 6 and 12 months was frequent and argues against the use of 6 months outcome as a time end-point in research. The GOSE does, however, not seem to be sensitive to actual change in function in the lower categories and a combination of outcome measures may be needed to describe the consequences after TBI.

Chronic motor performance following different traumatic brain injury severity-A systematic review

Introduction

Traumatic brain injury (TBI) is now known to be a chronic disease, causing ongoing neurodegeneration and linked to increased risk of neurodegenerative motor diseases, such as Parkinson's disease and amyotrophic lateral sclerosis. While the presentation of motor deficits acutely following traumatic brain injury is well-documented, however, less is known about how these evolve in the long-term post-injury, or how the initial severity of injury affects these outcomes. The purpose of this review, therefore, was to examine objective assessment of chronic motor impairment across the spectrum of TBI in both preclinical and clinical models.

Methods

PubMed, Embase, Scopus, and PsycINFO databases were searched with a search strategy containing key search terms for TBI and motor function. Original research articles reporting chronic motor outcomes with a clearly defined TBI severity (mild, repeated mild, moderate, moderate-severe, and severe) in an adult population were included.

Results

A total of 97 studies met the inclusion criteria, incorporating 62 preclinical and 35 clinical studies. Motor domains examined included neuroscore, gait, fine-motor, balance, and locomotion for preclinical studies and neuroscore, fine-motor, posture, and gait for clinical studies. There was little consensus among the articles presented, with extensive differences both in assessment methodology of the tests and parameters reported. In general, an effect of severity was seen, with more severe injury leading to persistent motor deficits, although subtle fine motor deficits were also seen clinically following repeated injury. Only six clinical studies investigated motor outcomes beyond 10 years post-injury and two preclinical studies to 18-24 months post-injury, and, as such, the interaction between a previous TBI and aging on motor performance is yet to be comprehensively examined.

Conclusion

Further research is required to establish standardized motor assessment procedures to fully characterize chronic motor impairment across the spectrum of TBI with comprehensive outcomes and consistent protocols. Longitudinal studies investigating the same cohort over time are also a key for understanding the interaction between TBI and aging. This is particularly critical, given the risk of neurodegenerative motor disease development following TBI.

Predictors of 10-year functional independence trajectories in older adults with traumatic brain injury: A Model Systems study

BACKGROUND

Older adults have the highest traumatic brain injury (TBI)-related morbidity and mortality, and rates in older adults are increasing, chiefly due to falls.

OBJECTIVE

This study used hierarchical linear modeling (HLM) to examine baseline predictors of functional independence trajectories across 1, 2, 5, and 10 years after TBI in older adults.

METHODS

Participants comprised 2,459 individuals aged 60 or older at the time of TBI, enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure Motor and Cognitive subscale scores and Glasgow Outcome Scale-Extended scores during at least 1 time point.

RESULTS

Functional independence trajectories generally declined over the 10 years after TBI. Individuals who were older, male, underrepresented minorities, had lower education, were unemployed at time of injury, had no history of substance use disorder, or had difficulties with learning, dressing, and going out of the home prior to the TBI, or longer time in posttraumatic amnesia had lower functional independence trajectories across at least one of the functional independence outcomes.

CONCLUSION

These predictors of functional independence in older adults with TBI may heighten awareness of these factors in treatment planning and long-term health monitoring and ultimately as a way to decrease morbidity and mortality.

Return to School Outcomes among Adults with TBI One Year After Rehabilitation Discharge: A TBIMS Study

OBJECTIVE

To examine return to school outcomes 1 year after traumatic brain injury (TBI) rehabilitation discharge.

DESIGN

Longitudinal observational study using Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) data at 1-year post-TBI.

SETTING

Inpatient rehabilitation centers using follow-up telephone calls.

INDIVIDUALS

Individuals (n = 237) enrolled in the TBIMS-NDB since 2001 between the ages of 18 and 59 years who were engaged in postsecondary education (full or part-time) before recorded TBI.

MAIN MEASURES

Return to school, categorized as in a postsecondary setting at first follow-up (reported hours in school greater than zero at one-year follow-up).

RESULTS

Using an alpha level of 0.05 binary logistic regression analysis identified four predictive variables. Significant predictors of return to school include being of lower age, possessing a higher level of functioning at discharge, reporting lower ratings of disability at discharge, and being able to use a vehicle independently for transportation.

CONCLUSION

Pursuit of higher education is a viable means of community reintegration after TBI. Some individuals with TBI face a myriad of barriers and challenges when returning to school. Study findings may facilitate understanding of how TBI affects return to school and community reintegration outcomes.

Long-term outcome after severe traumatic brain injury: a systematic literature review

BACKGROUND

Expectation of long-term outcome is an important factor in treatment decision-making after severe traumatic brain injury (sTBI). Conclusive long-term outcome data substantiating these decisions is nowadays lacking. This systematic review aimed to provide an overview of the scientific literature on long-term outcome after sTBI.

METHODS

A systematic search was conducted using PubMed from 2008 to 2020. Studies were included when reporting long-term outcome ≥ 2 years after sTBI (GCS 3-8 or AIS head score ≥ 4), using standardized outcome measures. Study quality and risk of bias were assessed using the QUIPS tool.

RESULTS

Twenty observational studies were included. Studies showed substantial variation in study objectives and study methodology. GOS-E (n = 12) and GOS (n = 8) were the most frequently used outcome measures. Mortality was reported in 46% of patients (range 18-75%). Unfavourable outcome rates ranged from 29 to 100% and full recovery was seen in 21-27% of patients. Most surviving patients reported SF-36 scores lower than the general population.

CONCLUSION

Literature on long-term outcome after sTBI was limited and heterogeneous. Mortality and unfavourable outcome rates were high and persisting sequelae on multiple domains common. Nonetheless, a considerable proportion of survivors achieved favourable outcome. Future studies should incorporate standardized multidimensional and temporal long-term outcome measures to strengthen the evidence-base for acute and subacute decision-making.

HIGHLIGHTS

1. Expectation of long-term outcome is an important factor in treatment decision-making for patients with severe traumatic brain injury (sTBI). 2. Favourable outcome and full recovery after sTBI are possible, but mortality and unfavourable outcome rates are high. 3. sTBI survivors are likely to suffer from a wide range of long-term consequences, underscoring the need for long-term and multi-modality outcome assessment in future studies. 4. The quality of the scientific literature on long-term outcome after sTBI can and should be improved to advance treatment decision-making.

Neural alterations in working memory of mild-moderate TBI: An fMRI study in Malaysia

Working memory (WM) encompasses crucial cognitive processes or abilities to retain and manipulate temporary information for immediate execution of complex cognitive tasks in daily functioning such as reasoning and decision-making. The WM of individuals sustaining traumatic brain injury (TBI) was commonly compromised, especially in the domain of WM. The current study investigated the brain responses of WM in a group of participants with mild-moderate TBI compared to their healthy counterparts employing functional magnetic resonance imaging. All consented participants (healthy: n = 26 and TBI: n = 15) performed two variations of the n-back WM task with four load conditions (0-, 1-, 2-, and 3-back). The respective within-group effects showed a right hemisphere-dominance activation and slower reaction in performance for the TBI group. Random-effects analysis revealed activation difference between the two groups in the right occipital lobe in the guided n-back with cues, and in the bilateral occipital lobe, superior parietal region, and cingulate cortices in the n-back without cues. The left middle frontal gyrus was implicated in the load-dependent processing of WM in both groups. Further group analysis identified that the notable activation changes in the frontal gyri and anterior cingulate cortex are according to low and high loads. Though relatively smaller in scale, this study was eminent as it clarified the neural alterations in WM in the mild-moderate TBI group compared to healthy controls. It confirmed the robustness of the phenomenon in TBI with the reproducibility of the results in a heterogeneous non-Western sample.

What are the functional consequences after TBI? The SHEFBIT cohort experience

OBJECTIVES

To investigate functional outcome after TBI and identify variables that predict outcome in a multiordinal regression model.

BACKGROUND

The results of global outcome studies after Traumatic Brain Injury(TBI) differ widely due to differences in outcome measure, attrition to follow-up and selection bias. Outcome information would inform patients/families, guide service development and target high-risk individuals.

SUBJECTS/SETTING

prospective cohort of 1322 admissions with TBI, assessed by face to face interviews at 1 yr.

MEASURES

Extended Glasgow Outcome Scale (GOSE) by structured questionnaire.

RESULTS

At 1 year, outcome was determined in 1207(91.3%). Mean age was 46.9(SD17.3); Almost half(49.2%) had mild injury. At one year, 42.9% achieved Good Recovery but GOSE declined in 11.4% of the cohort compared to 10 weeks including 60(4.9%) deaths. In an ordinal logistic regression, increasing TBI severity, etiology (assault), more prominent CT abnormality, past psychiatric history and alcohol intoxication were independent predictors of worse GOSE. A pseudo-R² of 0.38 suggested that many unmeasured factors also contribute to TBI outcome. Future work needs to identify other variables that may influence outcome.

CONCLUSIONS

In a large TBI cohort, there is still considerable functional disability at 1 year. It may be possible to target high-risk groups for rehabilitation.

Association of Lifetime TBI and Military Employment with Late-Life ADL Functioning: A Population-Based Prospective Cohort Study

OBJECTIVE

To determine associations of traumatic brain injury (TBI) and military employment with activities of daily living (ADL) in late life.

SETTING

Community-based integrated healthcare delivery system.

PARTICIPANTS

Male (n=2066) and female (n=2887), aged 65+ and dementia-free.

DESIGN

Population-based prospective cohort study with biennial follow-up and censoring at time of dementia diagnosis.

MAIN OUTCOME MEASURES

ADL difficulties at baseline and accumulation during follow-up.

RESULTS

TBI with loss of consciousness (LOC) before age 40 was associated with slightly higher ADL difficulty at baseline for females (RR=1.44, 95% CI: 1.08-1.93, p=0.01). For males, TBI with LOC at any age was associated with greater ADL difficulty at baseline (age <40: RR=1.58, 95% CI: 1.20 - 2.08, p = 0.001; age 40+: RR=2.14, 95% CI: 1.24 - 3.68, p = 0.006). TBI with LOC was not associated with the rate of accumulation of ADL difficulties over time in males or females. There was no evidence of an association between military employment and either outcome, nor of an interaction between military employment and TBI with LOC. Findings were consistent across a variety of sensitivity analyses.

CONCLUSION

Further investigation into factors underlying greater late-life functional impairment among TBI survivors is warranted.

Factors affecting functional outcomes of traumatic brain injury rehabilitation at a rehabilitation facility in Saudi Arabia

Objectives:

To identify the factors that affect disability after inpatient rehabilitation (IPR) in persons with traumatic brain injury (TBI).

Methods:

This retrospective study identified 140 patients aged ≥16 years who were admitted to the TBI rehabilitation unit at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia between 2015 and 2017. The collected data included demographic variables, TBI cause, coma duration, time from injury to IPR, LOS, and Functional Independence Measure (FIM) scores at IPR admission and discharge.

Results:

Majority of the patients were young males. The TBI was caused by motor vehicle accidents (MVA) in 95% of patients. The mean coma duration, time from injury to IPR admission, and LOS were 47±38, 264±357, and 75±52 days, respectively. The factors that were found to have an association with FIM change were time from injury to IPR admission (p=0.003, r=-0.250), admission FIM score (p=0.003, r=-0.253), and discharge FIM score (p<0.001, r=0.390). Employed patients had high FIM scores at admission (p=0.029, r=0.184) and discharge (p=0.003, r=0.252).

Conclusion:

Reduction in disability at discharge was positively associated with the severity of disability at admission and negatively with the time duration from injury to IPR admission, indicating a need to reduce time before admittance to an IPR setup. The high incidence of MVA causing TBI in a young male population strongly points to a need for appropriate measures of prevention.

Community Integration After Traumatic Brain Injury and Related Factors: A Study in the Nepalese Context

Introduction

Community integration is an essential component for rehabilitation among traumatic brain injury (TBI) survivors, which yields positive outcomes in terms of social activities, community participation, and productive work. A factor that usually facilitates community integration among TBI survivors is social support, whereas physical environment and fatigue are most often found as barriers.

Objectives

This study aimed to (1) describe the level of community integration, fatigue, physical environment, and social support of persons after TBI, and (2) examine the relationship between community integration and these three factors.

Methods

This is a descriptive correlational study. One hundred and twenty TBI survivors living in the communities of Province Number Three, Nepal were enrolled using the stratified sampling technique. The data were collected using the Community Integration Questionnaire, Modified Fatigue Impact Scale, Craig Hospital Inventory of Environmental Factors, and the Multidimensional Scale of Perceived Social Support. Descriptive statistics and Pearson's correlation were used to analyze the data.

Results

Community integration, fatigue, and physical environment showed a moderate level, while social support revealed a high level. Fatigue was significantly correlated with overall community integration, whereas physical environment was found to correlate with two subscales of community integration, home integration and productive activities.

Conclusion

To enhance the level of community integration among TBI survivors, health care providers, in particular rehabilitation nurses and community nurses, should plan and implement strategies such as follow-up appointments or continued rehabilitation at home.

Subjective Cognitive Decline and Related Cognitive Deficits

Since late stage dementia, including Alzheimer's disease (AD), cannot be reversed by any available drugs, there is increasing research interest in the preclinical stage of AD, i.e., subjective cognitive decline (SCD). SCD is characterized by self-perceptive cognitive decline but is difficult to detect using objective tests. At SCD stage, the cognitive deficits can be more easily reversed compared to that of mild cognitive impairment (MCI) and AD only if accurate diagnosis of SCD and early intervention can be developed. In this paper, we review the recent progress of SCD research including current assessment tools, biomarkers, neuroimaging, intervention and expected prognosis, and the potential relevance to traumatic brain injury (TBI)-induced cognitive deficits.

Time between acquired brain injury and admission to community-based rehabilitation: differences in cognitive and functional gains

OBJECTIVE

To determine differences in rehabilitation gains made by people with an acquired brain injury undergoing staged community-based brain injury rehabilitation (SCBIR) at different times between injury and admission.

METHOD

Retrospective cohort analysis of routinely collected demographic and rehabilitation data from clients admitted to SCBIR service 2011-2017 (n=92). Outcome measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4) and UK Functional Assessment Measure (UK FIM+FAM) collected on admission and annually thereafter until discharge. Analysis was stratified by time since injury on admission: 'Early' (<1 year (n=36)), 'Middle' (1-2 years (n=34)) and 'Late' (>2 years (n=22)). Between-group differences were tested using bootstrapped one-way ANOVA. Within-group differences were tested using paired T tests.

RESULTS

Total cohort made significant gains in MPAI-4 and UK FIM+FAM total and all subscales (p = .001). Early group made greatest change in all subscales of both outcome measures (p < .01). Middle cohort improved significantly in all subscales (p < .02) excluding MPAI-4 Adjustment. Late cohort still made statistically significant gains in all UK FIM+FAM subscales (p < .05) and MPAI-4 Participation (p < .01). Item level changes are presented.

CONCLUSION

More than 2 years after injury, people are able to make improvements in participation and functional independence following SCBIR.

Trajectories of self-reported competency up to 10 years following moderate-to-severe traumatic brain injury

Objectives: To describe trajectories of self-reported functional competency up to 10 years following traumatic brain injury (TBI) and identify their predictors from baseline socio-demographic and injury severity characteristics.Design and methods: Data from 94 participants from a longitudinal cohort of patients with moderate-to-severe TBI were analyzed. Socio-demographic and injury severity data were recorded at baseline. Participants completed the Patient Competency Rating Scale (PCRS) at 1, 2, 5, and 10 years. Hierarchical linear modeling was used to examine PCRS trajectories over time and assess baseline predictors.Results: There was no significant change in average PCRS scores across the follow-up time points in the full sample. Emotional and cognitive competencies had the lowest mean scores. Gender, employment, and the interaction term between gender and time were significant predictors of PCRS trajectories. Females and those who were unemployed at the time of injury showed lower trajectories of self-reported competency.Conclusion: Self-reported competency remained stable from one-year post-injury for men only. Lower mean scores in the domains of emotional and cognitive competencies suggest a need for continued rehabilitation focus in the chronic phase after TBI. Special attention to women and individuals who are unemployed at the time of injury may be warranted.

Global outcome after traumatic brain injury in a prospective cohort

OBJECTIVES

Traumatic Brain Injury(TBI) is one of the most common neurosurgical emergencies but the long-term outcome remains unclear. This study investigated the global outcome and return to work after TBI and tried to identify any relationships that exist with injury and demographic features.

PATIENTS & METHODS

1322 consecutive TBI admissions over 4 years, assessed at a specialist neurorehabilitation clinic at 10weeks and 1 yr. The outcomes were Extended Glasgow Outcome Scale(GOSE), return to work, Rivermead Head Injury Follow-up Questionnaire, Rivermead Post-Concussion Symptoms and the Hospital Anxiety and Depression Score.

RESULTS

1 year follow-up was achieved in 1207(91.3%). Mean age was 46.9(SD17.3) and 49.2% had mild TBI. The proportion attaining Good Recovery increased from 25.1% to 42.9% by 1 year. However 11.4% deteriorated in GOSE. Only 28.1% of individuals returned to the same pre-morbid level of work by 10 weeks, improving to 45.9% at 1 year. Over a quarter (25.6%) at 1 year were unable to make any return to work or study. Several demographic and injury variables were associated with these outcomes including TBI severity, social class, past psychiatric history and alcohol intoxication. These may allow targeting of vulnerable individuals.

CONCLUSIONS

In a largely representative TBI population including predominantly mild injury, there is still considerable functional disability at 1 year and many individuals are unable to make any return to pre-morbid vocation.

Factors affecting functional outcome in patients with traumatic brain injury sequelae: Our single-center experiences on brain injury rehabilitation

Objectives

This study aims to investigate the effect of rehabilitation on functional level of traumatic brain injury (TBI) patients and to examine the associated factors on functional gain in this patient population.

Patients and methods

Between October 2010 and November 2015, a total of 71 patients (63 males, 8 females; mean age 26.6±8.1 years; range, 18 to 56 years) who were admitted to our rehabilitation clinic with moderate-to-severe TBI were retrospectively analyzed. Functional recovery was assessed using the Functional Independence Measure (FIM) and Functional Ambulation Classification (FAC) scales. The patients were divided into two groups according to time from TBI to the initiation of rehabilitation: early (<6 months) and late (≥6 months). Possible predictive factors associated with FIM gain were evaluated.

Results

There was a significant improvement in the FIM scores from admission to discharge (p<0.001). There was a statistically significant difference in the FIM gain and FIM efficiency between the patient groups according to the initiation of rehabilitation (p<0.001). The FAC scores increased from admission to discharge, showing statistical significance (p<0.001). Duration of rehabilitation, early rehabilitation, heterotopic ossification, and deep venous thrombosis were found to be significant factors associated with FIM gain (p<0.001).

Conclusion

Our study results suggest that rehabilitation is effective for functional gain, particularly in the early period in patients with moderate- to-severe TBI and duration of rehabilitation, early rehabilitation, heterotopic ossification, and deep venous thrombosis are also predictors of functional improvement.

Long-Term Follow-Up of Disability, Cognitive, and Emotional Impairments after Severe Traumatic Brain Injury

Aim

To assess the clinical course of disability, cognitive, and emotional impairments in patients with severe TBI (s-TBI) from 3 months to up to 7 years post trauma.

Methods

A prospective cohort study of s-TBI in northern Sweden was conducted. Patients aged 18-65 years with acute Glasgow Coma Scale 3-8 were assessed with the Glasgow Outcome Scale Extended (GOSE), the Hospital Anxiety and Depression Scale (HADS), and the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) at 3 months, 1 year, and 7 years after the injury.

Results

The scores on both GOSE and BNIS improved significantly from 3 months (GOSE mean: 4.4 ± 2.3, BNIS mean: 31.5 ± 7.0) to 1 year (GOSE mean: 5.5 ± 2.7, p = 0.003, BNIS mean: 33.2 ± 6.3, p = 0.04), but no significant improvement was found from 1 year to 7 years (GOSE mean: 4.7 ± 2.8, p = 0.13, BNIS mean: 33.5 ± 3.9, p = 0.424) after the injury. The BNIS subscale “speech/language” at 1 year was significantly associated with favourable outcomes on the GOSE at 7 years (OR = 2.115, CI: 1.004-4.456, p = 0.049).

Conclusions

These findings indicate that disability and cognition seem to improve over time after s-TBI and appear to be relatively stable from 1 year to 7 years. Since cognitive function on some of the BNIS subscales was associated with outcome on the GOSE, these results indicate that both screening and follow-up of cognitive function could be of importance for the rehabilitation of persons with s-TBI.

Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes

OBJECTIVE

Among the elderly, use of antithrombotics (ATs), antiplatelets (APs; aspirin, clopidogrel), and/or anticoagulants (ACs; warfarin, direct oral ACs [DOACs; dabigatran, rivaroxaban, apixaban]) to prevent thromboembolic events must be carefully weighed against the risk of intracranial hemorrhage (ICH) with trauma. The goal of this study was to assess the risk of sustaining a traumatic brain injury (TBI), ICH, and poorer outcomes in relation to AT use among all patients 65 years or older presenting to a single institution with head trauma.

METHODS

Data were collected from all head trauma patients 65 years or older presenting to the authors' supraregional tertiary trauma center over a 24-month period and included age, sex, injury mechanism, medical history, international normalized ratio, Glasgow Coma Scale (GCS) score, ICH presence and type, hospital admission, reversal therapy, surgery, discharge destination, Extended Glasgow Outcome Scale (GOSE) score at discharge, and mortality.

RESULTS

A total of 1365 head trauma patients 65 years or older were included; 724 were on AT therapy (413 on APs, 151 on ACs, 59 on DOACs, 48 on 2 APs, 38 on AP+AC, and 15 on AP+DOAC) and 641 were not. Among all head trauma patients, the risk of sustaining a TBI was associated with AP use after adjusting for covariates. Of the 731 TBI patients, those using ATs had higher rates of ICH (p <0.0001), functional dependency at discharge (GOSE score ≤ 4; p < 0.0001), and mortality (p < 0.0001). Elevated rates of ICH progression on follow-up CT scanning were observed in patients in the warfarin monotherapy (OR 5.30, p < 0.0001) and warfarin + AP (OR 6.15, p = 0.0011). Risk of mortality was not associated with single antiplatelet use but was notably high with 2 APs (OR 4.66, p = 0.0056), warfarin (OR 5.18, p = 0.0003), and DOAC use (OR 5.09, p = 0.0149).

CONCLUSIONS

Elderly trauma patients on ATs, especially combination therapy, are at elevated risk of ICH and poor outcomes compared with those not on AT therapy. While both AP and warfarin use alone and in combination were associated with significantly elevated odds of sustaining an ICH among TBI patients, only warfarin use was a predictor of hemorrhage progression on follow-up scans. The use of a single AP was not associated with mortality; however, the combination of both aspirin and clopidogrel was. Warfarin and DOAC users had comparable mortality rates; however, DOAC users had lower rates of ICH progression, and fewer survivors were functionally dependent at discharge than were warfarin users. DOACs are an overall safer alternative to warfarin for patients at high risk of falls.

Measuring Change Over Time: A Systematic Review of Evaluative Measures of Cognitive Functioning in Traumatic Brain Injury

Objectives: The purpose of evaluative instruments is to measure the magnitude of change in a construct of interest over time. The measurement properties of these instruments, as they relate to the instrument's ability to fulfill its purpose, determine the degree of certainty with which the results yielded can be viewed. This work systematically reviews all instruments that have been used to evaluate cognitive functioning in persons with traumatic brain injury (TBI), and critically assesses their evaluative measurement properties: construct validity, test-retest reliability, and responsiveness. Data Sources: MEDLINE, Central, EMBASE, Scopus, PsycINFO were searched from inception to December 2016 to identify longitudinal studies focused on cognitive evaluation of persons with TBI, from which instruments used for measuring cognitive functioning were abstracted. MEDLINE, instrument manuals, and citations of articles identified in the primary search were then screened for studies on measurement properties of instruments utilized at least twice within the longitudinal studies. Study Selection: All English-language, peer-reviewed studies of longitudinal design that measured cognition in adults with a TBI diagnosis over any period of time, identified in the primary search, were used to identify instruments. A secondary search was carried out to identify all studies that assessed the evaluative measurement properties of the instruments abstracted in the primary search. Data Extraction: Data on psychometric properties, cognitive domains covered and clinical utility were extracted for all instruments. Results: In total, 38 longitudinal studies from the primary search, utilizing 15 instruments, met inclusion and quality criteria. Following review of studies identified in the secondary search, it was determined that none of the instruments utilized had been assessed for all the relevant measurement properties in the TBI population. The most frequently assessed property was construct validity. Conclusions: There is insufficient evidence for the validity and reliability of instruments measuring cognitive functioning, longitudinally, in persons with TBI. Several instruments with well-defined construct validity in TBI samples warrant further assessment for test-retest reliability and responsiveness. Registration Number: www.crd.york.ac.uk/PROSPERO/, identifier CRD42017055309.

The course and prognostic factors of cognitive outcomes after traumatic brain injury: A systematic review and meta-analysis

Despite indications that TBI may be a precursor of cognitive decline and subsequent development of Alzheimer's disease, little is known about the time course of this relationship and the factors involved. This systematic review summarizes the evidence pertinent to this subject matter. All English language studies of longitudinal design, and works cited within them, found in six literature databases, were considered, and their quality assessed. Of 65 articles appraised, 44 studies were selected. Results were organized by timing of assessments, injury severity, and cognitive domains assessed. Differences in the course of cognitive performance were observed across injury severity groups and cognitive domains, with differential proportions of reports of improvement, decline, or no change over time. The evidence for genetic, sex-, age-, and injury-related factors as determinants of cognitive outcome was inconsistent. The non-uniform trajectory of cognitive performance post-TBI supports the notion that this construct is non-homogeneous, and that different factors influence its course. Agreement on a core set of predictors and consideration of psychometric properties of outcome measures is needed.

Employment Probability Trajectories Up To 10 Years After Moderate-To-Severe Traumatic Brain Injury

Aims: To examine trajectories of employment probability up to 10 years following moderate-to-severe traumatic brain injury (TBI) and identify significant predictors from baseline socio-demographic and injury characteristics. Methods: A longitudinal observational study followed 97 individuals with moderate-to-severe TBI for their employment status up to 10 years post injury. Participants were enrolled at the Trauma Referral Center in South-Eastern Norway between 2005 and 2007. Socio-demographic and injury characteristics were recorded at baseline. Employment outcomes were assessed at 1, 2, 5, and 10 years. Hierarchical linear modeling (HLM) was used to examine employment status over time and assess the predictors of time, gender, age, relationship status, education, employment pre-injury, occupation, cause of injury, acute Glasgow Coma Scale (GCS) score, duration of post-traumatic amnesia (PTA), CT findings, and injury severity score, as well as the interaction terms between significant predictors and time. Results: The linear trajectory of employment probabilities for the full sample remained at ~50% across 1, 2, 5, and 10-years post-injury. Gender (p = 0.016), relationship status (p = 0.002), employment (p < 0.001) and occupational status at injury (p = 0.005), and GCS (p = 0.006) yielded statistically significant effects on employment probability trajectories. Male gender, those in a partnered relationship at the time of injury, individuals who had been employed at the time of injury, those in a white-collar profession, and participants with a higher acute GCS score had significantly higher overall employment probability trajectories across the four time points. The time*gender interaction term was statistically significant (p = 0.002), suggesting that employment probabilities remained fairly stable over time for men, but showed a downward trend for women. The time*employment at injury interaction term was statistically significant (p = 0.003), suggesting that employment probabilities were fairly level over time for those who were employed at injury, but showed an upward trend over time for those who had been unemployed at injury. Conclusion: Overall employment probability trajectories remained relatively stable between 1 and 10 years. Baseline socio-demographic and injury characteristics were predictive of employment trajectories. Regular follow-up is recommended for patients at risk of long-term unemployment.

Protocol for the mixed-methods development of a concussion-specific health-related quality of life outcome measure based on the international classification of functioning, disability and health

INTRODUCTION

Recovery from concussion has traditionally been evaluated by patient-reported symptoms, objective measures such as loss of consciousness, specific dimensions such as depression or fatigue, cognitive status, employment status, level of physical activity and the more complex construct of disability. Increasingly, patient-reported outcome measures of health-related quality of life (HRQOL) are being emphasised as an important end point in patient care, clinical trial and health policy decisions. Currently, no standardised concussion-specific HRQOL outcome measure exists. The process for developing a concussion-specific HRQOL outcome measure based on the international classification of functioning, disability and health is outlined.

METHODS AND ANALYSIS

A multistage, patient-centred approach to developing the outcome measure will integrate evidence from systematic reviews, qualitative research and cognitive interviewing into a self-report questionnaire to guide clinical decision-making. The psychometric properties of the questionnaire will be evaluated to assess the inter-rater reliability and construct validity of the measure in individuals with persistent post-concussion symptoms. To date, the systematic review and the clinical expert interviews within the preparatory phase have been completed and work is progressing on the subsequent phases. It is anticipated that the outcome measure will be ready for psychometric testing in September 2018.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ottawa Health Science Network Research Ethics Board (Protocol #20170720-01H) on 31 October 2017 to conduct the patient and clinical expert interviews. Ethical approval for psychometric testing of the outcome measure will be sought by the Ottawa Health Science Network Research Ethics Board in Phase II, after the development of the final HRQOL questionnaire. Results will be disseminated through peer-reviewed journals and professional conferences.

PROSPERO REGISTRATION

Phase I systematic review registration number CRD42017075588 (15 June 2017). Phase II systematic review registration number CRD42017075588 (27 September 2017).

Trajectory of Functional Independent Measurements during First Five Years after Moderate and Severe Traumatic Brain Injury

A better understanding of long-term functional recovery process for patients with traumatic brain injury (TBI) facilitates effective rehabilitations. The aim of this study was to classify and characterize patients with moderate-to-severe TBI based on their functional trajectories up to 5 years post-injury. The study included 121 patients with moderate-to-severe TBIs (International Classification of Diseases, Tenth Revision [ICD-10], S06.0-S06.9), 16-55 years of age, and admitted at Trauma Referral Hospital within 24 h of injury between 2005 and 2007. Demographics and injury characteristics were documented at the admission, and functional status was recorded at 3 months and 1 and 5 years post-injury using Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) subscales. We used group-based trajectory models to classify patients' functional trajectories over a 5-year period. For FIM-M, three trajectories were identified: 8.2% of patients showed stable low recovery (13.6 ± 1.5, 17.9 ± 8.8, and 21.0 ± 17.9), 9.2% elevated good recovery (35.8 ± 14.5, 75.5 ± 12.4, and 85.5 ± 8.1), and 82.6% stable good recovery (89.0 ± 3.6, 90.3 ± 1.9, and 90.8 ± 1.0) at the three follow-up points, respectively. For FIM-C, four trajectories were revealed: 4.1% of patients showed stable low recovery (5.0 ± 0, 5.0 ± 0, and 5.0 ± 0), 12.6% delayed moderate recovery (8.9 ± 3.5, 20.6 ± 4.6, and 28.3 ± 3.8), 28.7% elevated good recovery (27.0 ± 3.8, 30.4 ± 7.3, and 31.1 ± 2.3), and 54.6% stable good recovery (32.8 ± 2.3, 34.6 ± 1.0, and 34.7 ± 1.0). The results suggest that three FIM-M and four FIM-C trajectories described various patterns of functional recovery 5 years after moderate-to-severe TBI, with stable good recovery being the most common trajectory. Identifying and characterizing the trajectory memberships should enable targeted rehabilitation programs, inform patient-centered care, and improve long-term outcomes.

Feasibility and Preliminary Validation of an Online Version of the Ohio State University Traumatic Brain Injury Identification Method

OBJECTIVE

To test the feasibility and validity of an online version of an established interview designed to determine a lifetime history of traumatic brain injury (TBI).

DESIGN

Cross-sectional.

SETTING

General community.

PARTICIPANTS

A volunteer sample of individuals (N= 265) from the general population across the United States.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Online version of the Ohio State University Traumatic Brain Injury Identification Method, Rivermead Postconcussion Symptoms Questionnaire (RPQ), Patient-Reported Outcomes Measurement Information System Cognitive Concerns Scale.

RESULTS

The measure was completed by 89.4% of the sample with most participants completing the measure in <8 minutes. After controlling for age, sex, psychiatric history, drug or alcohol history, and history of developmental disability, worst TBI severity was significantly associated with scores on the RPQ, F(2,230)=4.56, P=.011, and having a TBI within the past 2 years was associated with higher scores on the cognitive factor subscale of the RPQ, F(1,75)=7.7, P=.007.

CONCLUSIONS

The online administration of the Ohio State University Traumatic Brain Injury Identification Method appears to be feasible in the general population. Preliminary validity was demonstrated for the indices of worst TBI severity and time since most recent TBI.

Exploring self-concept, wellbeing and distress in therapeutic songwriting participants following acquired brain injury: A case series analysis

Acquired brain injury (ABI) presents a significant threat to sense of self and necessitates a complex process of psychosocial adjustment. Self-concept changes remain understudied in the early stages of inpatient rehabilitation. The aim of the current study was to examine changes in self-concept, distress, wellbeing and functional skills for five inpatients undertaking a music therapy intervention within a subacute rehabilitation centre in Victoria, Australia. Participants completed a six-week, 12-session therapeutic songwriting programme to produce past-, current- and future-self-focused songs. A range of self-concept, subjective wellbeing and distress measures were completed pre-, mid- and post-intervention. A descriptive case series approach was applied to determine trends in pre-post scores for five individual cases. Participants showing the greatest gains across self-concept and subjective wellbeing indices also showed the greatest functional gains on the Functional Independence Measure (FIM) from admission to discharge. The current study highlights the importance of examining early changes in self-concept, wellbeing and distress in subacute rehabilitation, and suggests that individualised songwriting programmes warrant further research attention in neurological populations.

Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis

Background

Optimal glycaemic targets in traumatic brain injury (TBI) remain unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing intensive with conventional glycaemic control in TBI requiring admission to an intensive care unit (ICU).

Methods

We systematically searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to November 2016. Outcomes of interest included ICU and in-hospital mortality, poor neurological outcome, the incidence of hypoglycaemia and infective complications. Data were analysed by pairwise random effects models with secondary analysis of differing levels of conventional glycaemic control.

Results

Ten RCTs, involving 1066 TBI patients were included. Three studies were conducted exclusively in a TBI population, whereas in seven trials, the TBI population was a sub-cohort of a mixed neurocritical or general ICU population. Glycaemic targets with intensive control ranged from 4.4 to 6.7 mmol/L, while conventional targets aimed to keep glucose levels below thresholds of 8.4–12 mmol/L. Conventional versus intensive control showed no association with ICU or hospital mortality (relative risk (RR) (95% CI) 0.93 (0.68–1.27), P = 0.64 and 1.07 (0.84–1.36), P = 0.62, respectively). The risk of a poor neurological outcome was higher with conventional control (RR (95% CI) = 1.10 (1.001–1.24), P = 0.047). However, severe hypoglycaemia occurred less frequently with conventional control (RR (95% CI) = 0.22 (0.09–0.52), P = 0.001).

Conclusions

This meta-analysis of intensive glycaemic control shows no association with reduced mortality in TBI. Intensive glucose control showed a borderline significant reduction in the risk of poor neurological outcome, but markedly increased the risk of hypoglycaemia. These contradictory findings should motivate further research.

Electronic supplementary material

The online version of this article (10.1186/s13054-017-1883-y) contains supplementary material, which is available to authorized users.

COBI (COntinuous hyperosmolar therapy for traumatic Brain-Injured patients) trial protocol: a multicentre randomised open-label trial with blinded adjudication of primary outcome

INTRODUCTION

Traumatic brain injury (TBI) is a major cause of death and severe prolonged disability. Intracranial hypertension (ICH) is a critical risk factor of bad outcomes after TBI. Continuous infusion of hyperosmolar therapy has been proposed for the prevention and the treatment of ICH. Whether an early administration of continuous hyperosmolar therapy improves long-term outcomes of patients with TBI is uncertain. The aim of the COBI study (number clinicaltrial.gov 03143751, pre-results stage) is to assess the efficiency and the safety of continuous hyperosmolar therapy in patients with TBI.

METHODS AND ANALYSIS

The COBI (COntinuous hyperosmolar therapy in traumatic Brain-Injured patients) trial is a multicentre, randomised, controlled, open-label, two-arms study with blinded adjudication of primary outcome. Three hundred and seventy patients hospitalised in intensive care unit with a TBI (Glasgow Coma Scale ≤12 and abnormal brain CT scan) are randomised in the first 24 hours following trauma to standard care or continuous hyperosmolar therapy (20% NaCl) plus standard care. Continuous hyperosmolar therapy is maintained for at least 48 hours in the treatment group and continued for as long as is necessary to prevent ICH. The primary outcome is the score on the Extended Glasgow Outcome Scale at 6 months. The treatment effect is estimated with ordinal logistic regression adjusted for prespecified prognostic factors and expressed as a common OR.

ETHICS AND DISSEMINATION

The COBI trial protocol has been approved by the ethics committee of Paris Ile de France VIII and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The COBI trial is the first randomised controlled trial powered to investigate whether continuous hyperosmolar therapy in patients with TBI improve long-term recovery.

TRIAL REGISTRATION NUMBER

Trial registration number is NCT03143751.

Traumatic brain injury rehabilitation in Riyadh, Saudi Arabia: Time to rehabilitation admission, length of stay and functional outcome

OBJECTIVES

(1) Describe trends in time to rehabilitation admission and rehabilitation length of stay (LOS), (2) compare functional independence at discharge from rehabilitation between patients who arrived directly from acute care versus those from elsewhere and (3) identify independent predictors of functional outcomes following rehabilitation.

SETTING

Traumatic brain injuries rehabilitation unit of King Fahad Medical City, Riyadh, Saudi Arabia.

METHODS

We collected information on time from injury to rehabilitation admission, rehabilitation LOS, functional independence measure (FIM) score (admission and discharge) and demographic variables for 66 patients who arrived to rehabilitation from acute care and 142 patients who arrived from elsewhere. A mixed model analysis of variance measured change in FIM score between groups. Hierarchical regression was employed to investigate variables associated with FIM score at rehabilitation discharge.

RESULTS

Patients arriving directly from acute care had a time from injury to rehabilitation admission 1/3 that of, and a higher discharge FIM score than, patients arriving from elsewhere. For the latter group, increasing time from injury to rehabilitation admission was associated with lower rehabilitation discharge FIM score.

CONCLUSIONS

Reducing time from injury to rehabilitation admission and promoting enrolment to inpatient traumatic brain injury rehabilitation directly from acute care may improve functional outcome at discharge from rehabilitation.

The trajectories of overall disability in the first 5 years after moderate and severe traumatic brain injury

PRIMARY OBJECTIVES

To assess longitudinal trajectories of overall disability after moderate-to-severe traumatic brain injury (TBI) and to examine whether those trajectories could be predicted by socio-demographic and injury characteristics.

METHODS

Demographics and injury characteristics of 105 individuals with moderate-to-severe TBI were extracted from medical records. At the 1-, 2-, and 5-year follow-ups, TBI-related disability was assessed by the GOSE. A hierarchical linear model (HLM) was used to examine functional outcomes up to 5 years following injury and whether those outcomes could be predicted by: time, gender, age, relationship, education, employment pre-injury, occupation, GCS, cause of injury, length of post-traumatic amnesia (PTA), CT findings and injury severity score, as well as the interactions between each of these predictors and time.

RESULTS

Higher GOSE trajectories (lower disability) were predicted by younger age at injury and shorter PTA, as well as by the interaction terms of time*PTA and time*employment. Those who had been employed at injury decreased in disability over time, while those who had been unemployed increased in disability.

CONCLUSION

The study results support the view that individual factors generally outweigh injury-related factors as predictors of disability after TBI, except for PTA.

Prevalence, recovery patterns and predictors of quality of life and costs after non-fatal injury: the Brabant Injury Outcome Surveillance (BIOS) study

INTRODUCTION

Trauma is a major public health problem worldwide that leads to high medical and societal costs. Overall, improved understanding of the full spectrum of the societal impact and burden of injury is needed. The main purpose of the Brabant Injury Outcome Surveillance (BIOS) study is to provide insight into prevalence, predictors and recovery patterns of short-term and long-term health-related quality of life (HRQoL) and costs after injury.

MATERIALS AND METHODS

This is a prospective, observational, follow-up cohort study in which HRQoL, psychological, social and functional outcome, and costs after trauma will be assessed during 24 months follow-up within injured patients admitted in 1 of 10 hospitals in the county Noord-Brabant, the Netherlands. Data will be collected by self-reported questionnaires at 1 week (including preinjury assessment), and 1, 3, 6, 12 and 24 months after injury. If patients are not capable of filling out the questionnaires, proxies will be asked to participate. Also, information about mechanism and severity of injury, comorbidity and indirect and direct costs will be collected. Mixed models will be used to examine the course of HRQoL, functional and psychological outcome, costs over time and between different groups, and to identify predictors for poor or good outcome.

RELEVANCE

This study should make a substantial contribution to the international collaborative effort to assess the societal impact and burden of injuries more accurately. The BIOS results will also be used to develop an outcome prediction model for outcome evaluation including, besides the classic fatal, non-fatal outcome.

TRIAL REGISTRATION NUMBER

NCT02508675.