Insomnia screening in postacute traumatic brain injury: utility and validity of the Pittsburgh Sleep Quality Index

OBJECTIVE

To assess insomnia in a rehabilitation population, the authors examined the utility and validity of the Pittsburgh Sleep Quality Index (PSQI). The assessment of insomnia is relevant to the treatment of traumatic brain injury at the postacute level and routine screening for insomnia may be enhanced by the availability of a standardized, conveniently used, self-report sleep questionnaire.

DESIGN

The authors prospectively studied 91 consecutive patients with traumatic brain injury who were admitted to an outpatient neurorehabilitation program. Besides administering the PSQI, Beck Depression Inventory, Epworth Sleepiness Scale, and Multidimensional Pain Inventory, sleep diary and interview data were obtained and used to divide subjects into insomnia and noninsomnia groups according to the criteria established by the Diagnostic and Statistical Manual of Mental Disorders, ed 4.

RESULTS

Sensitivity and specificity rates to the clinical diagnosis of insomnia were 93% and 100%, respectively, for a PSQI Global Score of >8, and 83% and 100% for a diagnosis of insomnia based exclusively on PSQI-derived sleep variable data. Sleep diary data provided concurrent validity for PSQI estimates of sleep-onset latency, sleep duration, and sleep efficiency. The Beck Depression Inventory, Epworth Sleepiness Scale, and Multidimensional Pain Inventory established concurrent validity for individual PSQI items pertaining to mood, hypersomnia, and pain disturbance.

CONCLUSION

The PSQI was demonstrated to be a valid and useful screening tool for assessing insomnia among postacute patients with traumatic brain injury.

Factors associated with insomnia among post-acute traumatic brain injury survivors

This study investigated the relationships between insomnia and select demographic, injury and psychosocial variables in post-acute, traumatic brain injury. Clinical assessment of sleep and mood was undertaken via objective measures and a diagnostic interview among 91 consecutive brain injury admissions to an outpatient neurorehabilitation clinic. No associations between insomnia and gender, education, age, and time since injury were found. A logistic regression model of insomnia prediction based upon the Beck Depression Inventory (BDI), self-reported pain disturbance, litigation and Glasgow Coma Score (GCS) correctly classified 87% of the sample with respect to the presence or absence of insomnia; however, depression and injury severity were the only variables that made a significant unique contribution to the prediction of insomnia. It is concluded that among post-acute traumatic brain injury patients, insomnia is linked with both the presence of depression and a history of milder brain injuries. This suggests that the determinants of insomnia may differ from the acute to the post-acute phase, with neurological factors playing a primary role early in the recovery process and psychosocial factors ascending later. Therefore, assessment and treatment of insomnia must give careful attention to the larger psychosocial context in which the sleep disorder emerges, particularly to role of emotional disturbance.

Moving bullet syndrome: a complication of penetrating head injury

Penetrating injuries, by definition, result in retained bullets or fragments. Usually, these fragments are removed surgically during wound debridement. Occasionally, the position of the bullet may preclude removal if it is thought that surgery could exacerbate neurologic damage. Complications from retained fragments are uncommon. One rare complication is the spontaneous migration of the fragment. Two cases of spontaneous migration of retained bullets are presented. In both cases neurologic deterioration was noted and computed tomographic imaging was diagnostic. In one case, this complication delayed transfer from the acute care hospital to rehabilitation. In the other case, the migrating bullet was removed during the inpatient rehabilitation stay. Each person improved neurologically after the migrating bullet fragment was removed. Additionally, functional progress was marked in both persons and symptomatic relief noted. Rehabilitation physicians caring for survivors of penetrating brain injuries need to be aware of this potentially devastating phenomenon.

Amantadine: a potential treatment for the minimally conscious state

Pharmacologic strategies have been advocated to enhance the neurorehabilitation of persons with severe traumatic brain injury. Dopaminergic pathways have been felt to play a significant role in arousal. Employing single case design methodology we present the case of a survivor of severe traumatic brain injury who appeared to have a dose dependent response to the pro-dopaminergic medication amantadine. Further research is necessary to clarify the role of pharmacotherapy in the improvement of functional outcome.

Do calendars enhance posttraumatic temporal orientation?: a pilot study

The purpose of this study was to determine the effectiveness of an in-room calendar to correct temporal disorientation in a brain-injured population. Thirty consecutive brain injured patients (16 traumatic, 14 non-traumatic) admitted to a brain injury rehabilitation unit were randomly assigned to either a group with in-room calendars (n = 14) or a group without calendars (n = 16). A baseline Temporal Orientation Test (TOT) score was obtained. Daily TOT scores were obtained for patients throughout their rehabilitation stay or until two consecutive normal scores were obtained. When orientation errors were made, they were corrected and the attention of the patient was drawn to the calendar. There were no statistically significant associations between group and age, gender or mean GCS (for patients with traumatic etiology). Only baseline length of post-traumatic amnesia (PTA) had a significant association with eventual emergence from PTA (as defined by a normal score on the TOT). Age and presence of calendar were not significant. In-room calendars have been espoused as orientation aides. The data from this pilot study suggest that calendars do not hasten re-orientation. This finding suggests that other widely held but not rigorously tested beliefs regarding cognitive rehabilitation may need to be examined.

Posttraumatic amnesia: its relation to functional outcome

OBJECTIVE

To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population.

PATIENTS

Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation.

MEASURES

Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation.

RESULTS

Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge.

CONCLUSION

Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.

Functional outcome after violence related traumatic brain injury

Violent injuries have become an increasingly prevalent cause of traumatic brain injury (TBI). These injuries can be classified as either penetrating or non-penetrating in nature. While much of the research on violence has been within a military population, there exists a marked difference between military and civilian injuries. Prior work has reported relatively poor outcomes for those individuals who have suffered penetrating TBIs, but little has been done to assess specific functional outcome parameters in survivors. We examined 25 subjects that had sustained blunt injuries and 25 cases with penetrating injuries as a result of a violent act. Cases were matched by initial Glasgow Coma Scale (GCS), age and educational level. Mean GCS for this study sample was 8.8. The following outcome variables were assessed at rehabilitation admission and discharge and at 1 year post injury: Disability Rating Scale (DRS), Rancho Los Amigos Scale (LCFS), Functional Independence Measure (FIM) (ambulation, expression items), length of stay, and cost of care. Student's t-tests were performed to assess for differences between the two groups. No significant differences were noted between the groups for any of the outcome variables. Although penetrating injuries may have a higher initial mortality, those who survive to come to rehabilitation appear to have similar outcomes to those patients with non-penetrating violence related injuries.

Psychogenic polydipsia after traumatic brain injury. A case report

Electrolyte abnormalities are common medical complications of traumatic brain injury (TBI). Hyponatremia is the most common of these disorders. The syndrome of inappropriate antidiuretic hormone and cerebral salt-wasting are the most well known causes of hyponatremia following TBI. In the presence of polydipsia and polyuria, psychogenic polydipsia should be included in the differential diagnosis. It is important to distinguish among these entities because treatment differs to such an extent that improper diagnosis may lead to a worsening of the patient's condition. We present a patient who presented with a new onset of polyuria and polydipsia after sustaining a TBI. Evaluation, including monitoring of fluid intake and output, serum and urine sodium and osmolarity, as well as a fluid deprivation test revealed the cause to be psychogenic polydipsia. The patient's symptoms improved after institution of a behavioral program and fluid restriction. Various models of drinking behavior have been used to identify the site of dysregulation. Dopaminergic, cholinergic, and hippocampal etiologies have been implicated in this abnormality of fluid homeostasis. If disorders of these systems can lead to psychogenic polydipsia, it is reasonable to believe that a person who has sustained a TBI would be at higher risk of developing psychogenic polydipsia.

Cerebral salt wasting syndrome in brain injury patients: a potential cause of hyponatremia

Hyponatremia is a common neuromedical problem seen in survivors of central nervous system injury. The etiology of this hyponatremia is often diagnosed as syndrome of inappropriate diuretic hormone (SIADH). Fluid restriction is usually the first line of treatment. However, this can exacerbate vasospasm and produce resultant ischemia. Cerebral salt wasting is a syndrome of renal sodium loss that may occur commonly after central nervous system injury, yet remains unrecognized. Treatment of cerebral salt wasting consists of hydration and salt replacement. This article uses a case report to discuss the importance of recognition of this syndrome, and treatment concerns are reviewed.

Revised trauma score: an additive predictor of disability following traumatic brain injury?

Recent studies have clarified the role of hypoxic-ischemic damage as a secondary factor in traumatic brain injury (TBI). Many trauma centers are now consistently using the Revised Trauma Score (Glasgow Coma Scale, systolic blood pressure, and respiratory rate) to assist with triage of multitrauma patients. This study investigated the predictive power of the Revised Trauma Score (RTS) instead of the Glasgow Coma Scale (GCS) in determination of disability as measured by the Disability Rating Scale (DRS). Data were obtained as part of the National Institute for Disability and Rehabilitation Research TBI Model Systems database on 501 patients receiving acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial RTS and GCS were obtained on admission to the emergency department, along with the lowest GCS measured in the first 24 h. Analysis of initial RTS and GCS demonstrated modest, but statistically significant Pearson's correlations with DRS at rehabilitation admission (-0.18 and -0.25, respectively) and discharge (-0.22 and -0.24, respectively). Lowest GCS within the first 24 h postinjury also failed to show a strong relationship with DRS at rehabilitation admission (-0.28) and discharge (-0.24). Multiple regression analysis performed on RTS subsets for systolic blood pressure and respiratory rate did not reveal an added predictive value. Although RTS may be important in emergency triage for its ability to predict mortality, this study indicates its limited usefulness in prediction of disability.

Relationship between Glasgow coma scale and functional outcome

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.

Sleep disturbance in traumatic brain injury: pharmacologic options

The role of sleep disturbance in the behavioral and functional sequelae following Traumatic Brain Injury is becoming increasingly well understood. Sleep disturbances occurs commonly in Traumatic Brain injury patients. Survivors of Traumatic Brain Injury may experience sleep dysfunction during all stages of recovery. An effective understanding of the pathophysiology of sleep disturbance and the role medications play in both causation and treatment is essential for facilitation of rehabilitation management and functional recovery.

Occipital status epilepticus: an unusual case of post-traumatic blindness

Post-traumatic seizures can be a cause of multiple clinical and behavioral abnormalities. We present an unusual case of post-traumatic epilepsy resulting in blindness. The patient was a 35-year-old female with a past history of toxemia of pregnancy who was assaulted, sustaining a traumatic brain injury (TBI). Glasgow Coma Score upon presentation to the emergency department was 10. Initial CAT scan was negative. Subsequent MRI revealed occipital edema. On examination, she was found to be blind in both eyes. Consistent with cortical blindness, extra-ocular movements, pupillary reflexes and fundoscopic examination were normal. Unusual scanning eye movements were noted. Electroencephalography (EEG) revealed epileptiform discharges in both occipital regions consistent with occipital status epilepticus. Seizures were eventually controlled with Phenytoin and Phenobarbital, with subsequent conversion to Carbamazepine. Central vision returned, but peripheral sight was never regained. Follow up EEG revealed no evidence of epileptiform activity. Post-traumatic occipital status epilepticus is rare. Cortical blindness in TBI patients with minimal occipital pathology on imaging is generally transient. This case points out the need for the treating rehabilitation professional to be vigilant in assessing for post-traumatic seizures in patients with persisting visual deficits.

Delivery of primary care to the physically challenged

The specialty of physical medicine and rehabilitation evolved beyond conventional medical views to include consideration of the needs of the physically disabled person's function and quality of life. A care delivery system of medical rehabilitation programs and services then evolved. Recently, the United States' health care system has been recognized as being deficient in meeting the on-going health care needs of the physically disabled after they have completed medical rehabilitation needs. We discuss the history of the health care needs of the physically challenged and we examine current issues of need and delivery of services. We also describe an innovative model program designed to meet those needs.

A diagnostic tool with important implications for treatment of addiction: identification of factors underlying relapse and remission time distributions

The results of analysis of successive relapse and remission times of many opiate addicts were examined. It is discovered that motivation is the preeminent factor that governs the distribution of lengths of remission times (periods of abstinence), differences in types of motivation leading to an underlying mixture of three or fewer Weibull distributions. On the other hand, two distinct factors-namely wear-out (dysfunction resulting from exhaustion or tiring out brought on by the addict's enforced life-style) and precipitation of events that may not be beyond the control of the addict-govern the distribution of lengths of relapse times (periods of using opiates), leading, typically, to an underlying competing-risk distribution. Methods for using this information to aid in treatment and in research are described.