Psychosocial outcome 5-8 years after severe traumatic brain lesions and the impact of rehabilitation services

Long Term Symptoms and Limitations of Activity of People with Traumatic Brain Injury: A Ten-Year Follow-up

This study examined the effect of Traumatic Brain Injury 10 years post-injury. Frequencies of head injury symptoms and activity limitation by level of severity were measured in a consecutive series of 61 adults who were admitted to a tertiary-care center for traumatic brain injury. Irritability and Anxiety were the most frequently reported symptoms from the Head Injury Symptom Checklist. Bothered by noise and Bothered by light were the least frequently reported. Trouble hearing what is said in a group conversation and Trouble hearing what is said in a one-to-one conversation were the most commonly reported limitations of activity from the Health and Activity Limitations Survey. Overall, this study illustrates that symptoms remain many years following brain injury, irrespective of the injury's severity.

Vocational outcome 6-15 years after a traumatic brain injury

PRIMARY OBJECTIVE

To describe vocational outcome 6-15 years after a traumatic brain injury (TBI) among individuals who were productive by working or studying at the time of their TBI and determine the associations with variables related to the time of injury and at follow-up.

METHODS AND PROCEDURES

Thirty-four individuals with a mild TBI and 45 with a moderate-to-severe TBI were assessed on average 10 years post-injury. Logistic regression was used to determine the association between their current vocational situation and variables related to the time of injury (gender, age, injury severity and educational level) and at follow-up (time since injury, marital status and overall disability).

RESULTS

A total of 67% were productive at follow-up. Age at injury, injury severity and the degree of disability at follow-up were strongly associated with being productive. Younger individuals with milder TBI and less severe disability were significantly more likely to be fully productive. No significant associations were found between productivity and gender, education, time since injury or marital status.

CONCLUSIONS

This study indicates that return to productivity in a long-term perspective after a TBI is possible, in particular when the individual is young, has sustained a mild TBI and has a milder form of overall disability.

Chronic Histopathological and Behavioral Outcomes of Experimental Traumatic Brain Injury in Adult Male Animals

The purpose of this review is to survey the use of experimental animal models for studying the chronic histopathological and behavioral consequences of traumatic brain injury (TBI). The strategies employed to study the long-term consequences of TBI are described, along with a summary of the evidence available to date from common experimental TBI models: fluid percussion injury; controlled cortical impact; blast TBI; and closed-head injury. For each model, evidence is organized according to outcome. Histopathological outcomes included are gross changes in morphology/histology, ventricular enlargement, gray/white matter shrinkage, axonal injury, cerebrovascular histopathology, inflammation, and neurogenesis. Behavioral outcomes included are overall neurological function, motor function, cognitive function, frontal lobe function, and stress-related outcomes. A brief discussion is provided comparing the most common experimental models of TBI and highlighting the utility of each model in understanding specific aspects of TBI pathology. The majority of experimental TBI studies collect data in the acute postinjury period, but few continue into the chronic period. Available evidence from long-term studies suggests that many of the experimental TBI models can lead to progressive changes in histopathology and behavior. The studies described in this review contribute to our understanding of chronic TBI pathology.

Role of hyperbaric oxygen therapy in severe head injury in children

Aim:

A brain injury results in a temporary or permanent impairment of cognitive, emotional, and/or physical function. Predicting the outcome of pediatric brain injury is difficult. Prognostic instruments are not precise enough to reliably predict individual patient's mortality and long-term functional status. The purpose of this article is to provide a guide to the strengths and limitations of the use of hyperbaric oxygen therapy (HBOT) in treating pediatric patients with severe brain injury.

Materials and Methods:

We studied total 56 patients of head injury. Out of them 28 received HBOT. Only cases with severe head injury [Glasgow Coma Scale (GCS) < 8] with no other associated injury were included in the study group. After an initial period of resuscitation and conservative management (10–12 days), all were subjected to three sessions of HBOT at 1-week interval. This study group was compared with a control group of similar severity of head injury (GCS < 8).

Results:

The study and control groups were compared in terms of duration of hospitalization, GCS, disability reduction,and social behavior. Patients who received HBOT were significantly better than the control group on all the parameters with decreased hospital stay, better GCS, and drastic reduction in disability.

Conclusion:

In children with traumatic brain injury, the addition of HBOT significantly improved outcome and quality of life and reduced the risk of complications.

Increasing Leisure Activity Following Severe Traumatic Brain Injury: Does It Make a Difference?

The majority of people with severe traumatic brain injury (TBI) experience long-term disability and are unable to return to their usual activities. Services that offer community social and leisure participation programs are likely to reduce the social burden associated with severe TBI. The aim of this study was to gain an understanding of the personal effects of becoming engaged in community leisure activities. It was hypothesised that adults with severe TBI who participated regularly in leisure activities over a 6-month period would show measurable positive change in the domains of community integration, social support, mental health and quality of life (QOL). Participants numbered 25 adults (mean age 36.95 years) who had been referred to community leisure programs participated in the study. All participants had sustained severe injuries (post-traumatic amnesia > 1 month). A repeated measures design over 6 months was used. Assessment involved a semistructured interview, global subjective QOL rating and administration of standardised measures: SF-12v2, Neurobehavioral Functioning Inventory, Instrumental-Expressive Social Support-Scale, and Community Integration Questionnaire. Adults who participated regularly over 6 months reported positive and statistically significant changes in social integration and mental health. These findings support the use of assisted community participation programs for adults with severe TBI.

Participation in everyday occupations in a late phase of recovery after brain injury

The aim of this study was to describe to what extent individuals of working age, in a late phase after an acquired brain injury, participate in everyday occupations related to home maintenance, work, and leisure. The aim was also to evaluate if participation in different occupations influences their life satisfaction. A sample of 157 people consecutively admitted to a rehabilitation clinic between June 1995 and December 2000 answered a mailed questionnaire. The subjects who were of working age had had a brain injury on average 6 years before this study. The perceived participation was reported using the Reintegration to Normal Living Index (RNL) and life satisfaction according to an expanded version of the LiSat 11. This study showed that in this late phase of recovery after brain injury the subjects still experienced many restrictions in participation in everyday occupations. The area with the lowest reported participation was work activity while most comfort with the situation was reported for self-care. The RNL subscales showed a significant connection with satisfaction with life as a whole. Furthermore an interaction was found between the two subscales "Daily living" and "Perception of self". This study showed restrictions in participation in the community even several years after brain injury, which underlines the need for rehabilitation services long after injury.

Self-concept and quality of life following aquired brain injury: A pilot investigation

OBJECTIVE

To investigate through pilot exploration the relationships between depression, self-concept and perceived quality of life (QoL) in post-acute patients with acquired brain injury (ABI).

METHODS

Nineteen patients with ABI were administered the Beck Depression Inventory-II and the Quality of Life Inventory, along with the Tennessee Self-Concept Scale-2 and the Head Injury Semantic Differential Scale, measures of self-concept. The relationships between these measures were explored using correlational analyses.

RESULTS

Ratings of self-concept were correlated with perceived QoL, suggesting that poorer view of self was associated with lower subjective QoL. Additionally, depressive symptoms were associated with lower QoL ratings, consistent with previous research.

CONCLUSIONS

These results suggest that intra-personal variables, such as self-concept and depression, impact the perceived QoL of the ABI survivor. Future research exploring the mediating effects of these variables on QoL may clarify this relationship and may aid in developing more effective interventions for these individuals.

Demographics, injury characteristics and outcome of traumatic brain injuries in northern Sweden

OBJECTIVES - To describe demographics, injury characteristics and outcome of traumatic brain injury (TBI) in northern Sweden over 10 years. MATERIAL AND METHODS - Data were retrospectively collected on those individuals (n = 332) in Norrbotten, northern Sweden, with a TBI who had been transferred for neurosurgical care from 1992 to 2001. RESULTS - A majority were older men with a mild TBI and an acute or chronic subdural hematoma following a fall. Younger individuals were fewer but had more often a severe TBI from a traffic accident. Most individuals received post-acute care and brain injury rehabilitation. A majority had a moderate or severe disability, but many were discharged back home with no major changes in their physical or social environment. CONCLUSIONS - Our data confirm the relationship between age, cause of injury, injury severity and outcome in relation to TBI and underscore the need for prevention as well as the importance of TBI as a cause of long-term disability.

Le Profil du Loisir, un instrument prometteur en ergothérapie

Description : Les bienfaits du loisir sont bien connus, mais peu d'instruments ont été conçus dans l'optique de mesurer l'engagement d'une personne dans ses loisirs et d'évaluer les facteurs personnels ou environnementaux qui diminuent sa capacité de s'y engager. But : Cet article à pour but de présenter les étapes du développement du Profil du Loisir entre 1990 et 2002. Méthodologie : La planification, la construction et la validation de l'outil ont été faites selon les étapes de Benson et Clark (1982). Les premières versions ont été expérimentées par des ergothérapeutes auprès de personnes ayant eu un traumatisme cranio-cérébral. Résultats : La validation a permis l'élaboration de la version finale (3.0). L'outil présente une fidélité inter-juges allant de acceptable (kappa 0,21–0,4) à très bien (0,61–0,80) et test-retest de acceptable à modérée (0,41–0,60). Conséquences pour la pratique : Le Profil du Loisir s'avère prometteur pour amener les ergothérapeutes à considérer le loisir dans leur pratique et à l'évaluer de façon systématique.

Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

PURPOSE

To examine predictors of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury (TBI).

METHOD

This study involved analysis of data from a retrospective cohort of adults (N = 306) with moderate to severe TBI discharged from a Pennsylvania rehabilitation treatment facility. Extensive pre-injury sociodemographic, injury-severity, post-injury personal (cognitive, physical, affective), post-injury environmental (social, institutional, physical), and post-injury occupational performance (participation in self-care, productivity, leisure activities) data were gathered from hospital records and using in-person interviews. Interviews occurred at a mean time of 14 (range, 7-24) years post-injury. Hierarchical multiple regression analysis was used to investigate determinants of long-term occupational performance outcomes.

RESULTS

Pre-injury behavioural problems, male gender, post-injury cognitive and physical deficits, and lack of access to transportation were significant independent predictors of worse occupational performance outcomes.

CONCLUSIONS

The study supports the use of a comprehensive model for long-term outcomes after TBI where pre-injury characteristics and post-injury cognitive and physical characteristics account for the greatest proportion of explained variance.

Characteristics of residential community integration programs for adults with brain injury

OBJECTIVES

To gather data on some quantifiable characteristics of residential community integration programs available to adults with brain injury.

PARTICIPANTS

Directors, assistant directors, or coordinators of community integration programs for people with brain injury. MEASUREMENT TOOLS: The Community Integration Program Questionnaire (CIPQ).

DESIGN

Nationwide telephone survey of 30 residential community integration programs between June 2002 and June 2003.

RESULTS

There was tremendous variability in the areas of staffing, client, and programmatic characteristics. Staff-to-client ratio varied from 0.77 to 3.3. Lengths of stay ranged from 0.13 to 288 months. Times from injury to admission varied from 0.2 to 180 months.

CONCLUSIONS

The considerable variability in characteristics of residential community integration programs for adults with brain injury presents significant challenges to researchers seeking to identify vital program components and to consumers attempting to compare programs.

Impact of Length of Stay on Functional Outcomes of TBI Patients

The purpose of this study was to compare the functional outcomes of two groups of patients with traumatic brain injury (TBI) with attention to the impact of reduced length of stay (LOS) in the trauma center (TC) and rehabilitation hospital (RH). From 1991 to 1994, 55 patients, Group 1, with serious TBI (Abbreviated Injury Scale score ≥3) were admitted to a level 1 TC and subsequently transferred to a comprehensive inpatient RH. These results have been previously published. From 1996 to 2002, 64 similarly injured patients, Group 2, received inpatient care at the same TC and RH. These patients had a marked decrease in length of stay. Functional Independence Measures (FIM) were obtained at admission (Adm), discharge (D/C), and at 1 year follow-up for both groups. The average length of stay at the TC dropped from 36 days in Group 1 to 26 days in Group 2. In addition, the average length of stay at the RH dropped from 46 days (Group 1) to 25 days (Group 2); overall, an average reduction of 31 days of inpatient care. Group 2 had significantly lower FIM scores at the time of RH discharge for self-care, locomotion, and mobility compared to Group 1. At the 1 year follow-up, however, there were no significant differences between Groups 1 and 2 in these FIM scores. FIM scores at 1 year were higher in Group 2 for communication (90% vs 71%) and social cognition (77% vs 49%) compared to Group 1. Over one-fourth of each group returned to work by the 1 year follow-up. Socially disruptive behavior occurred at least weekly in 28 per cent (Group 1) and 23 per cent (Group 2) of patients. The outcome for serious TBI is better than generally perceived. Reduction of inpatient LOS did not adversely affect the ultimate functional outcome. The decreased LOS placed a greater demand on outpatient rehabilitative services as well as a greater burden on the family of the brain-injured patient

Outcome and Quality of Life 5 Years After Major Trauma

BACKGROUND

This study aimed to determine quality of life after injury and identify factors potentially associated with outcome.

METHODS

Five years after injury from blunt or penetrating trauma, patients received a questionnaire based on the SF-36 Health Survey.

RESULTS

Two hundred five patients (83%) replied. Most were men, median age 39 years, 93% injured by blunt energy, median Injury Severity Score 14 (range 9-57). Mean SF-36 scores were significantly lower than in a matched reference group. Poor outcome was associated with: in-hospital days, intensive care days, surgical procedures, in-hospital major complications, age, recurrent injury, and inadequate information. Subjects reported considerable physical (68%) and psychologic (41%) disabilities. Near half reported need of improved follow-up care. Injury severity did not predict poor health-related quality of life 5 years later.

CONCLUSION

Adequate information, sufficient pain management and follow-up by trauma specialist teams are needed. Certain factors can help identify patients in need of additional help and support.

Lateral fluid percussion brain injury: a 15-year review and evaluation

This article comprehensively reviews the lateral fluid percussion (LFP) model of traumatic brain injury (TBI) in small animal species with particular emphasis on its validity, clinical relevance and reliability. The LFP model, initially described in 1989, has become the most extensively utilized animal model of TBI (to date, 232 PubMed citations), producing both focal and diffuse (mixed) brain injury. Despite subtle variations in injury parameters between laboratories, universal findings are evident across studies, including histological, physiological, metabolic, and behavioral changes that serve to increase the reliability of the model. Moreover, demonstrable histological damage and severity-dependent behavioral deficits, which partially recover over time, validate LFP as a clinically-relevant model of human TBI. The LFP model, also has been used extensively to evaluate potential therapeutic interventions, including resuscitation, pharmacologic therapies, transplantation, and other neuroprotective and neuroregenerative strategies. Although a number of positive studies have identified promising therapies for moderate TBI, the predictive validity of the model may be compromised when findings are translated to severely injured patients. Recently, the clinical relevance of LFP has been enhanced by combining the injury with secondary insults, as well as broadening studies to incorporate issues of gender and age to better approximate the range of human TBI within study design. We conclude that the LFP brain injury model is an appropriate tool to study the cellular and mechanistic aspects of human TBI that cannot be addressed in the clinical setting, as well as for the development and characterization of novel therapeutic interventions. Continued translation of pre-clinical findings to human TBI will enhance the predictive validity of the LFP model, and allow novel neuroprotective and neuroregenerative treatment strategies developed in the laboratory to reach the appropriate TBI patients.

Assessment of motor and process skills reflects brain-injured patients' ability to resume independent living better than neuropsychological tests

OBJECTIVE

To compare recovery of cognitive functions and activities of daily living during the first year of rehabilitation after severe brain trauma.

METHODS

Sixteen patients were evaluated by neuropsychological tests and occupational performance (assessment of motor and process skills, AMPS) on admission to the rehabilitation centre and 3, 6 and 12 months later.

RESULTS

Cognitive functions improved continuously. Motor skills recovered rapidly and were relatively stable after 3 months. For process skills recovery was protracted. Six of 15 patients were still below the cut-off level after 12 months. Eleven of 13 patients deteriorated regarding process skills after leaving the rehabilitation centre.

CONCLUSION

AMPS gives a different view of the patient's restitution than neuropsychological tests and may be a better indicator of the patients' ability to resume independent living. The deterioration of process skills post-rehabilitation suggests that lasting contact in an outpatient setting might facilitate return to social life.

Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated

OBJECTIVE

To evaluate the effectiveness of an intensive cognitive rehabilitation program (ICRP) compared with standard neurorehabilitation (SRP) for persons with traumatic brain injury (TBI).

DESIGN

Nonrandomized controlled intervention trial.

SETTING

Community-based, postacute outpatient brain injury rehabilitation program.

PARTICIPANTS

Fifty-six persons with TBI.

INTERVENTIONS

Participants in ICRP (n=27) received an intensive, highly structured program of integrated cognitive and psychosocial interventions based on principles of holistic neuropsychologic rehabilitation. Participants in SRP (n=29) received comprehensive neurorehabilitation consisting primarily of physical therapy, occupational therapy, speech therapy, and neuropsychologic treatment. Duration of treatment was approximately 4 months for both interventions.

MAIN OUTCOME MEASURES

Community Integration Questionnaire (CIQ); and Quality of Community Integration Questionnaire assessing satisfaction with community functioning and satisfaction with cognitive functioning. Neuropsychologic functioning was evaluated for the ICRP participants.

RESULTS

Both groups showed significant improvement on the CIQ, with the ICRP group exhibiting a significant treatment effect compared with the SRP group. Analysis of clinically significant improvement indicated that ICRP participants were over twice as likely to show clinical benefit on the CIQ (odds ratio=2.41; 95% confidence interval, 0.8-7.2). ICRP participants showed significant improvement in overall neuropsychologic functioning; participants with clinically significant improvement on the CIQ also showed greater improvement of neuropsychologic functioning. Satisfaction with community functioning was not related to community integration after treatment. Satisfaction with cognitive functioning made a significant contribution to posttreatment community integration; this finding may reflect the mediating effects of perceived self-efficacy on functional outcome.

CONCLUSIONS

Intensive, holistic, cognitive rehabilitation is an effective form of rehabilitation, particularly for persons with TBI who have previously been unable to resume community functioning. Perceived self-efficacy may have significant impact on functional outcomes after TBI rehabilitation. Measures of social participation and subjective well-being appear to represent distinct and separable rehabilitation outcomes after TBI.

Traumatic brain injury brief outcome interview

There is much evidence that deficits in physical and psychological functioning persist long after traumatic brain injury occurs. This paper presents a brief outcome interview (BOI) that can be administered in person or over the telephone, with evaluation of change in functioning in three areas: (a). occupational status, (b). mobility/activities of daily living (ADL), and (c). social relationships. Forty-four traumatic brain injury participants were evaluated at an average of 6.2 years postinjury with the present BOI as well as with the Glasgow Outcome Scale and Karnofsky Performance Scale (KPS). The BOI demonstrated strong concurrent validity with both scales, as well as strong test-retest reliability. IQ and memory scores obtained at an average of 4.1 months postinjury suggested that the injury was moderately severe. The average score on the GPS suggested "good recovery" and the average score on the KPS suggested "normal activity with effort, some signs or symptoms." These descriptions matched the BOI for the mobility/ADL dimension, for which all respondents reported some form of independent mobility, and 88.6% of the respondents reported no need for any kind of assistance in daily life functioning. However, significant long-term issues were seen for social and occupational functioning. Fifty-four percent said that they did not socialize as much as before their injury, and half of the participants reported not being involved in a romantic relationship in spite of an average age of 32 years. In terms of occupational status, 40.9% reported not working at all at any kind of job. Compared to before their injury, 47.7% said this was less time, 40.9% said that it was for a lower salary, and 54.5% said that their responsibilities were less. The stability of these social and occupational changes was indicated by high test-test reliabilities for the overall BOI score and the three subscale scores (r's ranged from.97 to 1.0). These stable long-term changes are consistent with some other studies and suggest that the social and occupational needs of this population warrant more attention.

Quality of life and post-concussion symptoms in adults after mild traumatic brain injury: a population-based study in western Sweden

OBJECTIVES

To study quality of life and subjective post-concussion symptoms in adults (16-60 years) with a mild traumatic brain injury (MTBI) 3 months and 1 year after injury.

METHODS

Of a total of 489 patients 173 responded to questionnaires at 3 months and at 1 year, including the SF-36 health-related quality of life survey, which is a standardized measure validated for Swedish conditions. Post-concussion symptoms were rated as either existing or non-existing in a 21-item checklist [a modified version of Comprehensive Psychopathological Rating Scale (CPRS)].

RESULTS

SF-36 showed impaired scores in all dimensions. Existing post-concussion symptoms were reported by 1545%. Significantly, more symptoms were present at 3 months than at 3 weeks after injury. Furthermore, a significant correlation between higher rates of post-concussion symptoms and lower SF-36 scores was found.

CONCLUSIONS

The SF-36 results were significantly impaired compared with an age- and gender-matched normative control group and the rate of post-concussion symptoms was significantly higher at 3 months than at 3 weeks after injury. As a significant correlation between higher rates of symptoms and low SF-36 scores was also found we assume SF-36 to be a sensitive enough measure of MTBI-related effects.

Diagnostic classification of organic psychiatric disorders after aneurysmal subarachnoid hemorrhage: a comparison between ICD-10, DSM-IV and the Lindqvist & Malmgren classification system

OBJECTIVE

There is no universally accepted consensus for organic psychiatric disorders (OPDs) between the two major classifications, ICD-10 and DSM-IV. The aim was to compare the coverage of these systems with the Lindqvist & Malmgren (LM) classification system for organic psychiatry.

METHOD

Organic psychiatric disorders were diagnosed according to ICD-10, DSM-IV, and the LM system in 119 patients 12 months after surgery as a result of aneurysmal subarachnoid hemorrhage.

RESULTS

Among 35 patients with astheno-emotional (AE) disorder (LM system), 83% (95% CI: 67-92%) had mild cognitive disorder (MCD) according to ICD-10 clinical descriptions and diagnostic guidelines (CDDG), 49% (95% CI: 33-64%) had MCD according to ICD-10 diagnostic criteria for research (DCR), and 34% (95% CI: 21-51%) had mild neurocognitive disorder according to DSM-IV. The coverage for other OPDs did not differ between the systems.

CONCLUSION

The coverage for AE disorder (LM system) was significantly higher than the corresponding diagnoses of the ICD-10 and DSM-IV systems. Modifications of the latter systems are suggested.

[Outcome and quality of life after three years in a cohort of patients with severe traumatic brain injury]

OBJECTIVES

The late outcome of patients with severe traumatic brain injury (STBI) has been investigated by measuring deficits, disability and social handicap, but their quality of life (QOL) has been less evaluated, and not by a direct analysis of the subjective patient "and relatives" QOL. The aim of this study was to investigate this outcome and the QOL, with its predictive factors, 3 years after STBI, in a homogeneous cohort of patients.

MATERIAL AND METHODS

We selected all adult patients from the Lille area (north of France) admitted in the CHU in 1995 following STBI. Each was evaluated at home, in the presence of a close relative, using the EBIS document. This one investigates the medical history, initial status and late outcome, as well as the subjective QOL of patients (evaluated by the patient and by a close relative: 0-10 on an analogical visual scale) and close relatives. Relationships between possible explanatory factors and QOL were analysed using correlation tests.

RESULTS

Among the 33 patients, 23 survived at three years. The mean initial GCS score was of 5,6/15 and the mean coma duration of 18.5 days. At three years, physical deficits were usually discrete, intellectual deficits more important and the emotional and behavioural problems even more severe. The GOS was of 6 in one patient, 4-5 in seven, 2-3 in seven and 0-1 in eight. Dependence in advanced activities was more sever than in elementary activities. The subjective QOL of patients was discretely lower (m = 5,48/10) than that estimated by close relatives (m = 5,91). The relatives QOL was similarly reduced (m = 5,45). The factors most influencing the patients QOL were the cognitive and behavioural problems and the dependence in the advanced activities and the GOS for the patients QOL, and the behavioural problem and the dependence in advanced activities for the relatives QOL.

CONCLUSION

The reduction of the patients "and relatives" QOL was parallel at three years. Emotional and behavioural problem as well as the dependence in advanced activities mainly explained these QOL.

[First tier measures in the treatment of intracranial hypertension in the patient with severe craniocerebral trauma. Proposal and justification of a protocol]

The management of severe head injuries in general and that of high intracranial pressure (ICP) in particular are among the most challenging tasks in neurocritical care. One of the difficulties still faced by clinicians is that of reducing variability among centers when implementing management protocols. The purpose of this paper is to propose a standardized protocol for the management of high ICP after severe head injury, consistent with recently published clinical practice guidelines and other clinical evidence such as that provided by the systematic reviews of the Cochrane Collaboration. Despite significant advances in neuromonitoring, deeper insight into the physiopathology of severe brain trauma and the many therapeutic options available, standardized protocols are still lacking. Recently published guidelines provide sketchy recommendations without details on how and when to apply different therapies. Consequently, great variability exists in daily clinical practice even though different centers apply the same evidence-based recommendations. In this paper we suggest a structured protocol in which each step is justified and integrated into an overall strategy for the management of severe head injuries. The most recent data from both the preliminary and definitive results of randomized clinical trials as well as from other sources are discussed. The main goal of this article is to provide neurotraumatology intensive care units with a unified protocol that can be easily modified as new evidence becomes available. This will reduce variation among centers when applying the same therapeutic measures. This goal will facilitate comparisons in outcomes among different centers and will also enable the implementation of more consistent clinical practice in centers involved in multicenter clinical trials.

Astheno-emotional disorder after aneurysmal SAH: reliability, symptomatology and relation to outcome

OBJECTIVES

Neuropsychiatric symptoms commonly found after aneurysmal SAH are covered in the astheno-emotional disorder (AED) of Lindqvist & Malmgrens diagnostic system for organic psychiatry. This study aims to describe the reliability and symptomatology of AED and its relationship with social outcome.

MATERIAL AND METHODS

Patients referred due to aneurysmal SAH (n=78) were assessed after 1-6 months for AED inter-rater reliability (n=36) and after 12 months for AED severity grade, symptomatology and Glasgow Outcome Scale (GOS) (n=63).

RESULTS

There was no systematic error in diagnosing and grading AED, and the agreement was 85% and 67% respectively (kappa=0.65 and 0.52). Fatigability, concentration difficulties and memory difficulties were the most frequent symptoms of AED. The relationship between AED and "moderate disability" of GOS was highly significant (P<0.00006).

CONCLUSIONS

AED affects social outcome, and can be diagnosed with high reliability even without neuropsychological testing. Use of the AED diagnosis for evaluation of organic mental symptoms is encouraged.

Trauma systems--state of the art

Trauma is an inevitable consequence of the lives we lead. There are many approaches to dealing with it but an ideal system, universally applicable, probably does not exist because of the national variations in social, economic, cultural and geographical characteristics. Many countries are beginning to recognise that the 'systems' they have in place for dealing with the burden of trauma are seriously deficient and that this situation cannot be allowed to continue into the new millennium. However, it is highly unlikely that in the near future. governments will suddenly find substantial extra finance for trauma care or the implementation of new systems. Throughout many countries, the individual components of trauma care systems are in place but, for whatever reasons, there is a lack of integration, which results in suboptimal care. The system we all should be aiming for is one of closer communication and greater cooperation. By taking into account community and national needs, available resources, and adapting what is currently in place it should then be possible to create 'a set of things working together as parts of a trauma mechanism'.

Coping strategies and emotional outcome following traumatic brain injury: a comparison with orthopedic patients

OBJECTIVES

To investigate coping strategies in relation to emotional adjustment in individuals with traumatic brain injury (TBI) 1-5 years postinjury and to compare these with a group of 40 participants who sustained serious orthopedic injuries.

DESIGN

Participants completed measures of handicap and coping strategies, and rated their levels of depression, anxiety, and self-esteem on standardized questionnaires.

SETTING

Participants had received inpatient rehabilitation at Bethesda Hospital 1-5 years prior to completing questionnaires. They were recruited from a list of consecutive admissions.

PARTICIPANTS

88 TBI individuals were compared with 40 participants who had sustained serious orthopedic injuries without damage to the central nervous system. They had all been involved in motor vehicle or work-related accidents.

OUTCOME MEASURES

Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI).

RESULTS

Consistent with previous studies; a significant proportion of the current sample displayed high levels of emotional distress. Results showed few differences between the TBI and orthopedic groups. Coping strategies characterized by worry, wishful thinking, and self-blame were associated with higher levels of depression and anxiety in both groups. Strategies focusing on problem solving and having a positive outlook were related to lower anxiety levels, but to a lesser degree.

CONCLUSIONS

This study has provided further evidence that coping strategies are associated with emotional outcome in TBI individuals. There is now a growing empirical basis on which preliminary interventions can be based.

Preliminary outcome analysis of a long-term rehabilitation program for severe acquired brain injury

OBJECTIVES

To describe the general characteristics and functional outcomes of individuals treated in a publicly funded, long-term, acquired brain injury rehabilitation program and investigate variables affecting functional outcomes in this patient population.

DESIGN

Retrospective database review of demographic, descriptive, and functional outcome assessment data.

SETTING

Publicly funded, comprehensive, multidisciplinary, long-term, residential brain injury rehabilitation program in Alberta, Canada (64 beds).

PATIENTS

All rehabilitation patients admitted to and discharged from the brain injury program from February 1991 to March 1999 (n = 349).

INTERVENTIONS

Multidisciplinary rehabilitation program.

MAIN OUTCOME MEASURES

Demographic and descriptive information included sex, age at admission, type and severity of injury, time from injury to long-term program admission, and length of stay (LOS). Functional outcome information included level of care required at admission and discharge, admission and discharge Rappaport disability rating scale scores, and admission and discharge FIM instrument and Functional Assessment Measure scores for a subset of patients.

RESULTS

Fifty-nine percent of the subjects had severe traumatic brain injuries (TBI) and 41% had severe nontraumatic brain injuries (NTBI) of various causes. Mean age at admission was older and LOS was longer for NTBI compared with TBI; there were no other differences between the groups in demographic or descriptive measures. The TBI group had significantly lower admission motor subscale scores than the NTBI group, but the groups did not differ on cognitive scores. All functional assessment measures showed statistically significant improvement from admission to discharge, and 85.6% of patients were discharged to community living after a mean LOS of 359.5 days. Functional status at admission, age at admission, length of time between injury and admission, and LOS in the rehabilitation program significantly correlated with functional improvement.

CONCLUSIONS

Patients with severe TBI and NTBI who were not candidates for other more conventional forms of rehabilitation showed significant improvement in functional outcomes after extended program admissions. Consideration was also given to the potential insensitivity of commonly used outcome assessment measures in this population.

Reliability and validity of the Wisconsin HSS Quality Of Life inventory in traumatic brain injury

The present investigation examined the psychometric properties of the Wisconsin HSS Quality of Life Inventory (WI HSS QOL) when used in the study of traumatic brain injury (TBI). The WI HSS QOL is a theoretically based measure that assesses QOL via level of need satisfaction as conceptualized in Maslow's theory of human needs. Both internal consistency and test-retest reliability were demonstrated in a group of individuals with moderate to severe TBI. The demonstrated consistency of the participants' self-reports indicates that QOL can be reliably assessed from the survivor's perspective. Cluster analytic results generally supported the construct validity of the measure's use in TBI. The cluster solution reflected four of the five theoretical need categories; however, the fifth category, "self-actualization" needs, did not emerge as a single cluster as expected. This deviation from the theoretical model may relate to participants' difficulties in understanding the relatively abstract items designed to assess the concept of self-actualization. Overall, the WI HSS QOL holds significant promise as a measure of QOL in TBI.

Psychological distress and family satisfaction following traumatic brain injury: injured individuals and their primary, secondary, and tertiary carers

OBJECTIVE

To assess family psychosocial outcome following traumatic brain injury (TBI) in all family members, including relatives more peripheral to the person with the injury.

DESIGN

A cross-sectional design was used to gather outcome data from individuals with TBI and primary, secondary, and tertiary carers, 19.3 months posttrauma. Multivariate analyses of variance (ANOVAs) ascertained differences in levels of psychological distress and family satisfaction within families.

SETTING AND PARTICIPANTS

Seventy-nine families (65 individuals with TBI, 72 primary carers, 43 secondary carers, and 22 tertiary carers) were drawn from a sample of outpatients of three metropolitan, acute rehabilitation hospitals over a 12-month period.

OUTCOME MEASURES

In addition to using the Family Satisfaction Scale (FSS), measures of psychological distress included the Beck Depression Inventory (BDI), State Anxiety Inventory (SAI), and Profile of Mood States (POMS).

RESULTS

Although it was noted that a significant proportion of family members were not psychologically distressed and reported good family satisfaction, people with TBI remain at greater risk of poor psychosocial outcome than do their relatives. Of other family members, primary carers-particularly wives-are at greatest risk of poor psychosocial outcome, and a number of secondary and tertiary carers also displayed high levels of psychological distress.

CONCLUSIONS

Male relatives (the majority of whom were secondary or tertiary carers) may report their distress in terms of anger and fatigue, rather than as depression and anxiety. Future research could develop TBI-specific measures of anger and fatigue as screening instruments to identify peripheral family members requiring assistance in adapting to TBI. Many families-despite their initial traumatic experience-eventually cope well, encouraging researchers and clinicians to focus future research efforts on those families who have made good adjustments to TBI.

The rotating pole test: evaluation of its effectiveness in assessing functional motor deficits following experimental head injury in the rat

Neurological motor dysfunction is often an integral component of the neurological sequelae of traumatic brain injury (TBI). In experimental TBI, neurological motor testing is an outcome measure used to monitor severity of injury, and the response to treatment. This study evaluates the effectiveness and sensitivity of the rotating pole test (RP) to characterize and evaluate the temporal course of motor deficits after lateral fluid percussion (FP) injury to the rat brain. The results are compared with the previously characterized and widely used composite neuroscore of motor function (NS). The animals were required to walk across an elevated wooden pole that was either stationary or rotating to left or right directions at different speeds. Male Wistar rats underwent lateral FP injury of moderate severity (mean 2.4 atm, n = 9) or sham surgery (n = 9), and were tested at 48 h and 7 days post-injury using the NS and RP. The results of the NS directly correlated to the results of the RP, showing a significant injury effect at both 48 h and 7 days. This is the first study to show that the RP-test detects neurological motor deficits after lateral FP injury, and suggests that this technique is a reliable behavioral tool for evaluating neurological motor function in the acute period after experimental TBI.

Family Interactions as Targets for Intervention to Improve Social Adjustment After Epilepsy Surgery

PURPOSE

To identify family interactions associated with psychosocial outcome of epilepsy surgery, to design interventions to improve patient outcome.

METHODS

A cross-sectional, case series study of relations among observed family behavior and psychosocial outcome of 43 patients after temporal lobectomy. Videotaped family behavior during family discussion tasks was rated for predominant family affect, affective range, and support of patient autonomy. Multiple regression analyses tested the relation of observed family characteristics to outcomes, controlling for seizure control and other psychological and disease characteristics.

RESULTS

Predominant family affect predicted patients' social adjustment independent of postoperative seizure status and other disease characteristics. The relation between predominant affect and social adjustment was stronger among patients with persisting complex partial seizures (CPSs; r = -0.91), versus patients with auras (r = -0.38) and seizure-free patients (r = -0.28; multiple R = 0.71; p < 0.05). Families with a positive affective climate supported patients' autonomy.

CONCLUSIONS

Two potential targets were identified for family intervention to improve postsurgical social adjustment: (a) family interactions that support a predominantly positive affective climate, and (b) family interactions that support patient autonomy. These findings are consistent with findings in normal and other clinical populations. They identify specific interactions that give rise to positive versus negative affective climate and support versus undermining of autonomy. These results lay the groundwork for intervention studies targeting these specific family interactions. Such intervention studies would clarify the direction of effect of the observed relationships and would test the efficacy of family intervention for improving psychosocial outcomes for patients with epilepsy.

Mild traumatic brain injury from motor vehicle accidents: factors associated with return to work

OBJECTIVES

To describe return to work (RTW) for motor vehicle accident (MVA) survivors with mild traumatic brain injury (MTBI) and to examine relationships between RTW and injury severity, cognitive impairment, social interaction, discharge disposition, and sociodemographics.

DESIGN

Inception cohort assessed within 1 month of injury and at follow-up 6 to 9 months (mean = 7.4) after injury, for comparisons on outcome of RTW.

SETTING

Tertiary care center in Toronto (time 1); at home for follow-up.

PARTICIPANTS

Fifty patients with MTBI resulting from MVA who were consecutively admitted during a 20-month period ending April 1994. Thirteen of 63 eligible patients refused consent or were lost to follow-up. Mean age was 31; 62% were men.

ELIGIBILITY CRITERIA

(1) patients had been working; (2) they had no history of head injury, neurologic disease, or psychiatric illness requiring hospitalization; and (3) they had no catastrophic impairment from accident.

MAIN OUTCOME MEASURE

Return to work (at premorbid or modified level).

RESULTS

Of the 42% who returned to work, 12% resumed their premorbid level of employment and 30% returned to modified work. There were significant differences (p<.05) between the groups in level of social interaction, premorbid occupation, and discharge disposition. On one test of cognitive functioning the difference was at p = .06.

CONCLUSION

Social interaction, jobs with greater decision-making latitude, and discharge home were positively related to RTW for this population. Cognitive impairment within the first month was not a reliable indicator of RTW potential.

Serious traumatic brain injury: an evaluation of functional outcomes

OBJECTIVES

Evaluate independent living, productivity, and social outcomes of patients with serious traumatic brain injury (TBI) after inpatient rehabilitation.

METHODS

Fifty-five adults with serious TBI (Abbreviated Injury Scale score > or = 3) were admitted to a Level I trauma center and subsequently transferred to a comprehensive inpatient rehabilitation hospital (Walton Rehabilitation Hospital). Functional Independence Measures were obtained at admission (Adm), discharge (D/C), and at 3- (n = 52) and 1-year (n = 51) follow-up.

RESULTS

At 1 year, 90% of the patients were living at home. Eight (16%) required full-time supervision, while 41 (82%) were independent of supervision throughout most of the day. Thirteen (25%) patients had returned to work, eight full time and five with reduced responsibility and fewer hours than before injury. Nineteen shared household duties, while eight (16%) had primary responsibility. Fourteen (27%) patients demonstrated socially inappropriate or disruptive behavior at least weekly. [table: see text]

CONCLUSION

Although cognitive skills were diminished for the majority of patients, many achieved a substantial reduction in disability within 18 months after TBI.

Postacute brain injury rehabilitation

This review compares outcomes of adult postacute brain injury rehabilitation (PABIR) with natural recovery after brain injury. Potential outcome predictors and the effectiveness of behavioral, cognitive, pharmacologic, and vocational interventions are also appraised. The importance of standardized outcome assessment is discussed in the context of other research considerations. Although generally uncontrolled, the studies reviewed document benefits for many individuals with brain injury, including increased independence and a rate of return to independent work or training that exceeds 50% and may reach 60% to 80% for intensive comprehensive (holistic) day treatment programs. Available research is sufficiently encouraging to recommend more carefully controlled randomized studies. Future research should emphasize the development of standardized measures of patient characteristics and outcomes, and matching of patient characteristics with optimal rehabilitation approaches.

Economic aspects of capacity for work after severe traumatic brain lesions

During 1981-84,310 patients with severe traumatic brain lesions were treated at the Department of Neurosurgery in Lund, Sweden. A total of 161 patients were treated after the introduction of a more aggressive management protocol in 1983. In this first part of a long-term follow-up study we concentrate on the economic aspects. Two questions were addressed: first, what was the vocational outcome after severe head injuries? and second, what were the long-term effects of the new protocol? Out of 147 patients classified as good recovery/moderate disability (GR/MD) 6-months after injury, 106 patients agreed to participate in the study. Five to 8 years after injury 70 patients were classified as capable of working: 57 of these patients were actually at work, nine were studying and four were unemployed. Twenty-two patients had received disability pension and 14 patients had retired because of old age. In the age groups up to 60 years, 70% of patients had returned to work or school. The number of patients who returned to work was significantly higher after introduction of the more aggressive management protocol: 38 of 57 patients who had returned to work were in the group treated between 1983 and 1984. Mean income for patients who had returned to work was close to the average for the corresponding age groups in Sweden. Mean sick leave 5-8 years after severe head injuries was only slightly higher than average in Sweden. Our data show that a majority of the patients classified as GR/MD 6 months after severe traumatic brain lesions have the capacity to return to work. The improvements in the primary management of patients with severe head injuries introduced in 1983 increased the number of patients who work and thus increased the number of patients who favourably contributed to the economy of the community.