Clinician influences on use of portable electronic memory devices in traumatic brain injury rehabilitation

Primary objective: To explore the relationship between a group of clinicians' own experience, training and confidence with portable electronic memory devices and their use of the same in traumatic brain injury (TBI) rehabilitation.

Research design: Survey study.

Methods and procedures: Eighty-one TBI clinicians from various disciplines and work settings completed a survey distributed in person or by mail.

Main outcomes and results: Twenty-nine respondents (36%) reported using portable electronic memory devices with patients with TBI. Using regression analysis, respondent device training and confidence teaching patients device use were statistically associated with respondents' use of such devices in TBI rehabilitation.

Conclusions: Portable electronic memory device use with persons following TBI may be under-utilized. The importance of ongoing clinician training and of maximizing clinician confidence utilizing these devices in TBI rehabilitation is emphasized. The representativeness of the respondent sample is discussed. Specific training strategies and continued research needs are presented.     

Recognition of emotion from facial expression following traumatic brain injury

Primary Objective: To assess three domains of emotion recognition in people with traumatic brain injury (TBI).

Research design: A between group comparison.

Procedures: Twenty-four participants with severe TBI and 15 matched participants without brain damage were asked to label and match facial expressions with and without context. The participants with TBI were also interviewed regarding changes in subjective experience of emotion.

Main outcomes and results: Participants with TBI were found to be significantly impaired on expression labelling and matching, but experienced some improvement when provided with context. Negative emotions were particularly affected. Affective semantic knowledge and face perception appeared to be relatively intact in this group. The majority of participants with TBI reported some change in the post-injury experience of everyday emotion, although the pattern of changes differed greatly between individuals. Reduced subjective experience, especially of sadness and fear, was associated with poor emotion matching but not emotion labelling.     

Theory of mind in children with traumatic brain injury

Objective: This study was designed to examine the existence of deficits in mentalizing or theory of mind (ToM) in children with traumatic brain injury (TBI).

Research design: ToM functioning was assessed in 12 children aged 6-12 years with TBI and documented frontal lobe damage and compared to 12 controls matched for age, sex and verbal ability. Brief measures of attention and memory were also included.

Main outcome and results: The TBI group was significantly impaired relative to controls on the advanced ToM measure and a measure of basic emotion recognition. No difference was found in a basic measure of ToM.

Conclusion: Traumatic brain damage in childhood may disrupt the developmental acquisition of emotion recognition and advanced ToM skills. The clinical and theoretical importance of these findings is discussed and the implications for the assessment and treatment of children who have experienced TBI are outlined.     

Sex differences in mortality after traumatic brain injury, Colorado 1994-1998

Primary objective: The purpose of this study was to assess the relationship between sex and traumatic brain injury (TBI) mortality.

Methods and procedures: A total of 20 465 persons with TBI were identified from a Colorado population-based surveillance system for 1994-1998. Case fatality ratios were calculated to identify sex differences for selected risk factors. Unconditional logistic regression was used to determine the relationship between TBI mortality and sex controlling for risk factors.

Main outcomes and results: Adjusting for age, race, metropolitan residence and penetrating injury, the estimated odds of TBI mortality for males compared to females was 1.21 (95% CI 1.10, 1.34) for pre-hospital fatalities and 1.19 (95% CI 1.05, 1.37) for hospital fatalities.

Conclusion: Results indicate differences in TBI mortality comparing males and females. Future studies are warranted to identify if behaviour and physiological responses are associated with TBI outcomes among males and females.     

Assessing emotion recognition in 9-15-years olds: preliminary analysis of abilities in reading emotion from faces, voices and eyes

Primary objective: Little is known about how emotion recognition abilities develop during childhood and adolescence, although adolescence is a time marked by significant changes in socio-emotional behaviour. The first aim of this study was to explore the range of emotion recognition skills that 9-15-year olds would normally display and whether emotion-reading skills are reliably measurable. Secondly, one wanted to determine whether adolescence is a period during which skills in recognizing emotions improve.

Methods and procedures: Novel and adapted measures of emotion processing were used in tasks that required 67 9-15-year olds to read emotion from voices, eyes and faces.

Main outcomes and results: Findings indicate that emotion recognition abilities are reliably measurable skills. A stage of improvement in facial expression recognition and reading emotion from eyes was found to occur at ∼11 years of age.

Conclusions: The findings show that these skills can be measured and that it is possible to devise assessment tests which are sensitive to developmental improvements in emotion recognition skills in early adolescence, when screening for the effects of child brain injury.     

Development and evaluation of a pictorial-based analogical problem-solving programme for people with traumatic brain injury

Background: People with traumatic brain injury (TBI) must often deal with cognitive problems, including social problem-solving. The study reported herein evaluated the effectiveness of a newly developed pictorial-based analogical problem-solving skills training programme. It is hypothesized that the programme can help people with TBI to learn better problem-solving skills through systematic, theoretically driven learning strategies.

Method: Based on the instrumental enrichment model and the hierarchy of daily problem-solving as suggested by Holloran and Bressler, analogical problem-solving training software was developed. Thirty subjects with TBI then attended a 20-session interactive analogical problem-solving skills training programme. Another 20 subjects with TBI and of similar demographics formed the control group. The outcome measures included session-based quizzes on analogical problem-solving, the Category Test of the Halstead Reitan Test Battery (HRTB) and the Lawton IADL Scale.

Findings: The analogical problem-solving training strategies were found to be effective in improving problem-solving skills. The subjects generally demonstrated a selective improvement in their functional and overall problem-solving skills, but not in their basic problem-solving skills. The subjects in the control group showed stable problem-solving skills over a 4-week interval (no statistically significant changes). The findings indicated the therapeutic significance of the training programme.

Conclusions: The results of the study suggested that innovative cognitive rehabilitation programmes can be customized to match the needs of clients with TBI. The applicability and implications of the interactive pictorial-based analogical problem-solving skill-training programme that was used in the study and possibilities for future study in this research area are also discussed.     

Functional outcomes following anoxic brain injury: a comparison with traumatic brain injury

Primary objective: To compare the functional outcomes of patients with anoxic brain injury (ABI) and patients with traumatic brain injury (TBI) following inpatient rehabilitation.

Research design: Retrospective chart review.

Methods and procedures: Data on 68 patients with brain injury (34 with ABI and 34 with TBI) were collected.

Main outcomes and results: The ABI and TBI groups were demographically similar, except that patients with ABI were more likely to be married. Both groups significantly improved their function and were similar upon discharge. For the ABI group, there were trends toward a shorter length of stay, increased total FIM efficiency and decreased cost of stay when compared with the TBI group. The patients with ABI tended to be discharged to a sub-acute rehabilitation facility more than those in the TBI group.

Conclusions: This study is important because it shows that patients with ABI benefit from inpatient rehabilitation and made significant functional gains comparable to the gains of patients with TBI.     

The use of video self-modelling and feedback to teach cooking skills to individuals with traumatic brain injury: a pilot study

Objective: To evaluate the effectiveness of video self-modelling plus prompting and feedback to teach a cooking skill to people with traumatic brain injury (TBI) and to examine skill generalization to a novel food item.

Research design: Multiple probe across participants.

Methods and procedures: Four individuals with TBI received instruction in cooking. They watched videotapes of themselves cooking and practiced that skill while receiving prompts and feedback. Treatment effects were evaluated by comparing performance before, during and after training and at a 2 and 4 week follow-up. Additionally, cooking performance on a novel food item was examined.

Main outcomes and results: Three of the four individuals achieved criterion performance within four training sessions. Those individuals also substantially maintained their skills 2 and 4 weeks following training and generalized their skills to a novel food item.

Conclusions: Video self-modelling plus prompting and feedback appears to be an effective treatment for teaching simple cooking skills to individuals with TBI. Further research should examine whether the video alone is sufficient for skill acquisition and evaluate the effectiveness of video self-modelling to teach other skills.     

Email-facilitated qualitative interviews with traumatic brain injury survivors: a new and accessible method

Primary objective: To trial the method of email-facilitated qualitative interviewing with people with traumatic brain injury (TBI).

Research design: Qualitative semi-structured email-facilitated interviews.

Procedures: Nineteen people (17 severe diagnosis) with a TBI participated in email interviews.

Main outcomes and results: Findings indicate that this method facilitates the participation of people with TBI in qualitative interviews. Advantages include increased time for reflection, composing answers and greater control of the interview setting. In addition, the data indicates that people with a TBI are capable of greater insight, reflection and humour than indicated by previous research.

Conclusion: Findings indicate that new technologies may advance data collection methods for people with cognitive-linguistic impairments who face participation barriers in face-to-face interviews.     

Cognitive appraisal accuracy moderates the relationship between injury severity and psychosocial outcomes in traumatic brain injury

Objective:Traumatic brain injury (TBI) frequently results in significant changes in physical, cognitive and emotional status. Outcomes after TBI may be related to accurate appraisal of these changes. This study examined the relationship between cognitive appraisal accuracy and psychosocial outcomes in TBI survivors.

Methods: Participants were male and female TBI survivors (n = 103) who were at least 6 months post-injury and a family member of each survivor. Appraisal accuracy was assessed using self- and observer-report measures of perceived cognitive difficulties. Family members also completed a measure of psychosocial function. Hierarchical regression techniques were used to determine whether cognitive appraisal accuracy accounted for a significant proportion of variance in psychosocial outcomes.

Results:Study findingsindicated cognitive appraisal accuracy moderated the relationship between injury severity and aspects of psychosocial function.

Conclusions:The results suggest that brain injury outcomes may be improved when an individual is able to accurately assess limitations.     

Wisconsin Card Sorting Test: factor structure and relationship to productivity and supervision needs following severe traumatic brain injury

Primary objective: The Wisconsin Card Sorting Test (WCST) has been demonstrated to have a relatively stable factor structure in traumatic brain injury (TBI) samples. What is less clear is whether the scores derived from WCST factors are related to functional outcomes. The purpose of the current study was to replicate the WCST factor structure in a sample with severe TBI, and to evaluate the relationship between the factor scores and outcome.

Research design: Retrospective correlational study.

Methods and procedures: Participants (n = 143) who had suffered severe TBI were administered a battery of neuropsychological tests including the WCST within one month of admission to a brain injury rehabilitation program. In addition, participants were administered supervision (Supervision Rating Scale; SRS) and productivity measures (Community Integration Questionnaire- Productivity subscale; CIQ-P) at admission and following discharge.

Experimental intervention: None.

Main outcomes and results: For individuals who were more than one year post injury, more failure to maintain set errors were associated with better occupational outcomes, while more nonperseverative errors were associated with increased supervision needs.

Conclusions: The WCST factor scales are related to functional outcomes in severe TBI. Specifically, the inability to establish a series of correct responses is associated with poorer outcome.     

Psychological adjustment and marital satisfaction following head injury. Which critical personal characteristics should both partners develop?

Primary objective and research design: Using a correlational design, this study verifies the relationships between personal characteristics of individuals with TBI and their spouses and their level of psychological and marital adjustment.

Methods and procedure: Seventy individuals with TBI and their spouses in the post-acute rehabilitation phase completed self-report questionnaires assessing the predictive variables (coping and social problem-solving strategies; perceived communication skills) and the criteria variables of psychological and marital adjustment.

Main outcomes and results: In the target group, the characteristics most strongly related to adjustment variables were an effective attitude towards problems, infrequent use of avoidance coping strategies, and a positive perception of one's spouse's communication skills. Individuals with TBI and their spouses report significantly lower scores on some of these personal characteristics, compared to those of a matched control group of 70 couples from the general population.

Conclusions: Specific personal characteristics are critical for psychological and marital adjustment following TBI. This knowledge may be of relevance for detecting couples at risk for developing difficulties in the post-acute rehabilitation phase. Rehabilitation interventions targeting the personal characteristics identified as critical for the adjustment process could help to prevent these difficulties.     

The incidence of visual perceptual impairment in patients with severe traumatic brain injury

Primary objectives: To investigate the incidence of visual perceptual impairments in a sample of patients with traumatic brain injury (TBI) using the Occupational Therapy Adult Perceptual Screening Test (OT-APST), compare incidence rates to a normative sample and explore the relationship between the presence of visual perceptual impairment and the severity of cognitive and functional impairment following TBI.

Research design: Cohort study using a convenience sample of patients with TBI and a normative sample.

Methods and procedures: Thirty-one patients with severe TBI and 195 healthy people were compared on the OT-APST and measures of cognition and function.

Main outcomes and results: The most common impairments in the TBI sample were unilateral neglect (45.2%) and impairments of body scheme (25.8%) and constructional skills (25.8%). Significantly higher incidences of agnosia, apraxia, unilateral neglect and impairments in body scheme and constructional skills were found in the TBI sample compared to the normative sample. No significant relationship was found between the presence of visual perceptual impairments and the level of cognitive and functional impairment after TBI.

Conclusions: Visual perceptual changes are evident in patients with severe TBI when compared to a normative sample. Routine use of a screening tool such as the OT-APST may help identify visual perceptual impairments in these patients and the need for more detailed assessment.     

Parental coping following childhood acquired brain injury

Primary objective: To examine parental coping following an acquired brain injury of their child, the relationship between maternal and paternal coping, and the extent to which social support and family environment affect parental coping.

Research design: A cross-sectional design was used.

Methods and procedures: Parents (n = 30) of children with acquired brain injury provided relevant demographic data and completed questionnaires investigating coping, social support and perceptions of family environment.

Main outcomes and results: Perception-focused coping strategies were used most often by parents. Mothers had a more extensive repertoire than fathers, and the relationship between maternal and paternal coping appeared to be complementary. Relationships were found between emotion-focused coping and instrumental support (r = 0.39) and perception-focused coping and family cohesion (r = 0.37).

Conclusions: Recognizing parental coping styles, enhancing the development of positive strategies, and underscoring the importance of social support and the family environment will assist parents to cope positively with their child's acquired brain injury.     

Recovery in memory function in the first year following TBI in children

Primary objective : To examine memory skills, at acute, 6- and 12-monthly stages, following childhood traumatic brain injury (TBI).

Research design : Prospective, longitudinal, between-group design, comparing pre-injury and postinjury intellectual and memory measures, across three levels of injury severity.

Methods and procedures : Investigation of memory skills in a group of 76 children who had sustained a mild, moderate or severe TBI. Specific tests were used to measure immediate and short-term memory, and more complex multi-trial learning.

Main outcomes and results : The severe TBI group exhibited greater deficits on memory tasks, irrespective of modality, in the acute, 6- and 12-month post-injury stages, in comparison to mild and moderate TBI groups. Performance was dependent on both injury severity and task demands.

Conclusions : Memory difficulties are present during the acute, 6- and 12-months following childhood TBI. With a clearer understanding of the memory deficits following TBI, appropriate strategies can be taught and interventions implemented for these children.     

The ineffectiveness of the Hospital Anxiety and Depression Scale for diagnosis in an Omani traumatic brain injured population

Background: The rehabilitation of the traumatic brain injury (TBI) patient is especially challenging in non-western populations as the phenotypic indicators as well as the neurobehavioral assessments for the survivors of brain injury are limited.

Objective: The study screened for the prevalence of anxiety and depressive states among patients with TBI and examined the validity of the Hospital Anxiety and Depression Scale (HADS) to identify TBI patients with comorbid affective dysfunctions, specifically anxiety and depressive disorders, in an Omani population.

Methods: Sixty-eight survivors of TBI were screened with the semi-structured, Composite International Diagnostic Interview (CIDI) and the HADS. A receiver operating characteristics (ROC) curve was calculated to discriminate the power of the HADS for every possible threshold score.

Results: The semi-structured interview revealed the prevalence rate of 57.4% for depressive disorder and 50% for anxiety disorder. The sensitivity (53.8%) and specificity 75.9%, gave the best compromise using the cut-off score of 4, suggesting HADS is not a useful screening tool for this particular population.

Conclusions: Phenotypic indicators as detected by CIDI revealed that prevalence of affective dysfunctionality is common among this TBI population. Although the HADS is the most widely used screening instrument in other clinical populations, it does not appear to be a reliable resource in identifying depression and anxiety in people with traumatic brain injury in Oman.     

Masculine role adherence and outcomes among men with traumatic brain injury

Primary objective: Traumatic brain injury (TBI) is a significant health problem disproportionately affecting men and is often associated with changes in masculine role functioning in life domains such as vocational functioning, sexual and inter-personal functioning and personal independence. These changes could have serious implications for men's adjustment following injury. The aim of this study was to examine the relations among traditional masculine role adherence, psychosocial adjustment and rehabilitation outcomes in men with TBI.

Research design: A correlational design was chosen to examine the relations among variables. Spearman correlations and Wilcoxon Rank Sum tests were used to examine relationships between masculine role variables and outcome variables.

Methods and procedures: The study included 33 men with TBI who had been discharged from inpatient rehabilitation within 5 years. Participants completed surveys on traditional masculine gender role adherence and gender role conflict and additional data, including measures of functional outcome, life satisfaction, psychosocial outcomes and earnings, were obtained through the TBI Model System longitudinal data collection system.

Main outcomes and results: The results revealed significant associations between masculine role adherence and satisfaction with life, follow-up earnings and FIM change from admission to discharge.

Conclusions: In the current study, particular masculine role variables corresponded to different functional and psychological outcomes. Understanding these differences provides new directions for treatment and offers important information about aspects of traditional masculine roles that may enhance or hinder adjustment to injury.     

Do men and women differ in their course following traumatic brain injury? A preliminary prospective investigation of early outcome

Primary objective: To examine the effect of a patient's sex on measures of outcome in a matched sample of patients admitted for acute traumatic brain injury (TBI).

Research design: A prospective multi-centred group comparison study based in metropolitan Sydney, Australia.

Methods and procedures: Data was collected on 25 women admitted for treatment following non-penetrating TBI. Forty-five men were then matched with regards to age and injury severity. All subjects met the study criteria of having a moderate-to-severe TBI and aged 50 years old or younger. Exclusion criteria included history of previous head injury, psychiatric disturbance and significant alcohol and/or substance abuse. Data included injury details and physiological and psychometric measures of outcome.

Main outcomes and results: Women demonstrated better outcomes as indicated by their Glasgow Outcome Scale scores (adjusted for initial injury severity and age at injury odds ratio [OR] 4.2, 95% CI 1.4-12.7) and having shorter Length of Stay (adjusted OR 9.03, 95% CI 3.13-26.08).

Conclusions: Understanding the presence of sex differences in outcome following TBI is an emerging area of research. This study indicated that, after matching for initial injury severity and age at injury, women with severe TBI demonstrate a better early outcome than men.     

Confirmatory factor structure of the Center for Epidemiologic Studies-Depression scale (CES-D) in mild-to-moderate traumatic brain injury

Primary objective: The Center for Epidemiologic Studies Depression scale (CES-D) is a frequently-used self-report measure of depressive symptom severity. Brief depression screening measures can be important in the identification and prediction of depression following traumatic brain injury. The objective of this study was to investigate the validity of the CES-D in measuring depressive symptoms in patients with mild-to-moderate TBI as it has been rarely used in neurologically compromised populations.

Research design: Inception cohort.

Methods and procedures: The CES-D was administered to 340 participants with mild-to-moderate TBI at 3-months post-injury.

Main outcomes and results: Confirmatory factor analysis of the CES-D indicated that the data are a reasonable fit similar to that of Radloff 's original 4-factor model.

Conclusions: These findings suggest that the CES-D may be appropriate for use in patients with mild-to-moderate TBI.