Defining outcome

The effectiveness of traumatic brain injury rehabilitation: a review

The rehabilitation of traumatic brain injury (TBI) has undergone tremendous development over the past 20 years. A much more aggressive, extended and comprehensive approach is now common and clinically accepted. Multiple new forms and sites of treatment are utilized such as cognitive, behavioural, sub-acute and post-acute rehabilitation programmes. While there has been widespread clinical acceptance of these treatments the appearance of well-designed experimental or quasi-experimental studies actually evaluating the results of such treatment have been, until recently, generally lacking. This review article selects, analyses, and critiques the most salient of recent studies published regarding the overall clinical benefit, and to some extent the cost benefit, of TBI treatment programmes in their multiple forms. A conclusion which is reached following this survey is that while truly randomized controlled studies still have not been achieved, an impressive variety of studies of quasi-experimental design have been completed. The overall conclusion from these studies is that the efficacy (and cost-effectiveness) of TBI rehabilitation is strongly supported.

The post-concussional syndrome: physiogenesis, psychogenesis and malingering. An integrative model

Current models of post-concussional symptoms after mild head injury rest on the dichotomy between organic and psychogenic factors, which underpins Lishman's formulation; organic genesis and psychologically-driven persistence (Br J Psychiatry 1988; 153: 460-469). Recent prospective neuropsychological and bio-social studies of mild head injury, and perspectives from cognitive behavioural and health psychology, are reviewed. It is argued that the organic-psychogenic conceptualization inadequately explains chronic post-concussional symptoms. Psychosocial and cognitive-behavioural factors and the coping process may influence post-concussional symptoms over their entire time course, in particular the late phase. A multifactorial model of chronic post-concussional symptoms is proposed which integrates biological processes with these factors. It is through the recognition and identification of separate processes that questions about outcome, the limits of the impact of organic and psychosocial factors, the nature of exaggeration, and appropriate therapy, may be resolved.

Clinical neurological trauma parameters as predictors for neuropsychological recovery and long-term outcome in paediatric closed head injury: a review of the literature

We present a review of recent prospective studies of long-term outcome in paediatric closed head injury. Special attention is given to the relationship between the neurological trauma parameters and neuropsychological outcome. First we discuss the most important methods of assessing the severity of the injury. We review the most prominent neurobehavioural and cognitive sequelae. Subsequently we address the question of prediction of residual sequelae in view of the early trauma parameters. The main problem when comparing different studies is the lack of procedural uniformity both in assessment of the severity of the injury as well as in measurement of neuropsychological outcome. Inconsistencies and discrepancies among various studies are pointed out. We summarise those results which are supported by many studies and hence are less controversial. In addition we present some recommendations for future investigations.

Post-coma disturbance and post-traumatic amnesia as nonlinear predictors of cognitive outcome following severe closed head injury: findings from the Westmead Head Injury Project

This study sought to identify combinations of early neurological variables which best predict cognitive outcome 12 months after severe head injury. At the time of admission patients were assessed on seven neurological indices. Twelve months later a battery of neuropsychological tests examining recent memory functioning and speed of information processing was administered. Recent memory functioning was best predicted by a combination of post-coma disturbance (PCD; i.e. the duration of post-traumatic amnesia, PTA, minus the duration of coma) and presence of subarachnoid haemorrhage (multiple r = 0.54, p < 0.001). Speed of information processing was best predicted by the duration of PTA (r = 0.35, p < 0.01). However, these conclusions were based on square root transformation of PCD and PTA variables. The success of this transformation in assisting prediction confirms suggestions that the relationship between PTA and cognitive outcome is nonlinear.

Prediction of motor status 3 and 6 months post severe traumatic brain injury: a preliminary study

The prediction of outcome following severe traumatic brain injury has received considerable attention in recent years. Previous prediction studies have focused on a long-term follow-up or prediction period. The reported outcome measures generally adopted a global approach (e.g. independent living) in terms of the prediction of physical function. The objective of the present study was to construct clinically useful predictive equations of motor system status, as represented by selected postural reactions (indicators of central nervous system function). Specifically, these equations would serve to predict the recovery of equilibrium and protective reactions both at 3 and 6 months post-injury, respectively. A stepwise multiple logistic regression analysis was performed, where nine predictive variables were considered using a multivariate approach. The results indicate that coma duration followed by age contribute significantly to the predictive capability of the models at both 3 and 6 months post-injury. Specifically, at 3 months, the predictive variables 'coma duration' and 'age' enabled an 84.62% correct prediction rate, whereas, at 6 months, 'coma duration' and 'age' enabled a 79.49% correct prediction rate. In addition, the exact probabilities (for given sample ages and coma durations) and associated 95% confidence intervals were calculated based on the predictive models obtained. The theoretical framework underlying these predictive models can form the basis for further studies. Furthermore, these preliminary predictive models have potential implications for early treatment planning and patient management.

Functional outcome of low-level traumatically brain-injured admitted to an acute rehabilitation programme

A retrospective analysis of functional status at discharge, disposition, Glasgow Outcome Scale (GOS) score at 6 months and 1 year was undertaken for 23 consecutive 'low-level' traumatic brain injury victims admitted in a state of complete dependency to an acute rehabilitation programme. All patients met criteria for extremely severe traumatic brain injury, with an average Glasgow Coma Scale score of 8.7 at admission to the rehabilitation facility (an average of 44 days post-injury). All but three patients made significant functional gains during the acute rehabilitation stay. Almost half of the study patients (48%) were discharged at home while the rest went to sub-acute rehabilitation programmes. At 6 months post-injury eight (35%) met GOS criteria for 'good' outcome or 'moderate disability'. A review of clinical features, categories of functional progress, and relationships of outcome and disposition to variables known to have predictive value in such a patient population is described. Analysis of variables related to admission selection criteria that have been used in this rehabilitation programme is presented and the basis and implications of selection criteria discussed.

Acceptance of disability, work involvement and subjective rehabilitation status of traumatic brain-injured (TBI) patients

A follow-up of 78 TBI patients one to two years after discharge from rehabilitation hospital supported hypothesized correspondence between work involvement and subjective rehabilitation status (SRS). Subjective rehabilitation was defined as the gratification of basic needs: physical well-being, emotional security, and family, social, economic, and vocational needs. Highest SRS was found among patients employed in the open market. Lower SRS was found in patients employed under protected conditions who also reported their work to be much less congruent with their expectations. Unemployed patients living active lives reported higher SRS than unemployed patients living passive lives, but both showed lower SRS than employed patients. Both work involvement and SRS were found to be related to acceptance of disability (AD). However, longitudinal data are needed to ascertain whether AD precedes or follows the other two variables. Both possibilities may be correct.

Severe traumatic brain injury--epidemiology and outcome after 3 years

In 1987 80 patients living in the region of St Gallen, Switzerland, suffered from head injury with neuroradiologically visible intracranial lesions (annual incidence 20/100,000). One-quarter died during the first month after injury, and six others during the following 3 years. All except three of the 45 survivors interviewed and examined after 3 years had symptoms and functional impairment related to injury: neuropsychological (78%), behavioural (58%), neurological (53%), and related to bone or soft tissue trauma (36%). Half of the patients suffered from headache. Although these impairments caused little disability--only 5% of the patients had a Glasgow Outcome Score of 2 or 3--handicap in social life was reported in half of them and only 13 of 29 working before the accident were able to resume their former work. The consequences for long-term management of these patients are discussed.

Brain injury: analysis of outcome in a post-acute rehabilitation system. Part 1: General analysis

During the past decade the rehabilitation field has developed new, non-hospital based programmes of cognitive, behavioural, social, educational and vocational treatments to address the higher order cognitive, behavioural and social deficits following brain injury. These new arrays of programmes are referred to under the term 'post-acute' rehabilitation. No comprehensive, methodologically sound study of the effects of these new treatments has been made to date. This paper reports data from brain-injured patients who underwent treatment within a co-ordinated system of post-acute brain-injury rehabilitation programmes. This system consists of a continuum of neurobehavioural, residential, day treatment and community and home programmes, and provides overt components of medical and rehabilitation care: behavioural management; activities of daily living, self-management, substance-abuse, social, academic and vocational skills training; counselling; and family education. The changes in function during the course of treatment by this post-acute sequence of rehabilitation have been obtained and are reported here. A defined total population of N = 192 is examined, with exclusions for appropriate causes (e.g. patients seen only for evaluation) producing a study population of N = 173; of these, follow-up was achieved in 145 cases, a follow-up rate of 83.8%. Time from date of injury to data of admission, severity of deficit at time of admission to programme, and other appropriate independent variables are used to characterize the population. A single-blind interview methodology was employed in obtaining dependent measures of outcome at 6, 12, or 24 month periods post-discharge. Measures of outcome included residential status, level of productivity activity and hours per day of attendant care or supervision required. Dependent variables were analysed for the total study population and a subgroup greater than 1 year from date of injury at entry to treatment and not from a treatment facility. Results are presented in terms of the percentage change in dependent measures from the point of admission to follow-up. Appropriate parametric and non-parametric statistical analyses of significance have been carried out. The results document substantial improvements in function during the post-acute rehabilitation of this population and such improvements are unlikely to be the result of spontaneous improvement alone.