The use of aesthetic knowledge in the management of brain injury patients.

A patient's recovery from a brain injury (BI) is unpredictable and requires flexible nursing strategies for each stage of recovery. Empirical knowledge provides a framework for delivering nursing care based on scientific principles. Aesthetic knowledge, including intuition, provides a further opportunity to know and understand BI patients and their responses as they progress along the trajectory of recovery. Incorporating both empirical and aesthetic knowledge into the nursing plan of care for this population affords on opportunity for nurses to help patients and their families negotiate the course of recovery with greater success.     

Rehabilitation after traumatic brain injury in adults

Purpose: Traumatic brain injury (TBI) stands as a major public health problem and one of the most important challenges for neurological rehabilitation. This review discusses advances that have occurred in the past 10 years in rehabilitation after severe TBI in adults.

Method: First, theoretical concepts, goals of rehabilitation and organization of resources are reviewed. Then specific questions that arise in the rehabilitation of severe TBI patients are considered.

Results: Three phases are distinguished in post-traumatic evolution. Acute rehabilitation takes place during coma and arousal states. Specific aims are to prevent orthopaedic and visceral complications, and to provide sensory stimulations with the hope of accelerating arousal. Secondly subacute (generally inpatient) rehabilitation is designed to facilitate and accelerate recovery of impairments, and to compensate for disabilities. Motility, cognition, behaviour, personality and affect should be simultaneously addressed in an holistic approach. Physical as well as psychological independence and self-awareness are the major goals to emphasize. A third, post-acute rehabilitation phase includes outpatient therapy for achieving physical, domestic and social independence, reduction of handicaps and re-entry into the community.

Conclusions: Problems with returning home, obtaining financial independence, driving, returning to work, participating in social relationships and leisure activities, and the importance of psychosocial adjustment and self-acceptance, are outlined. Questions about economic aspects and rehabilitation in the future are addressed.     

Serum cardiac troponins as prognostic markers in patients with traumatic and non-traumatic brain injuries: A meta-analysis

Objective

The association between brain injury and elevated serum cardiac troponin (cTn) remains poorly understood. We conducted a systematic review and meta-analysis to evaluate whether elevated cTn increases the risk of mortality in patients with traumatic (TBI) or non-traumatic brain injury (NT-BI).

Predictive Value of a New Brief Cognitive Test for Long-term Functional Outcome in Acute Traumatic Brain Injury

ObjectiveTo determine how results on the EXAmen Cognitif abrégé en Traumatologie (EXACT), a new test specifically designed to briefly assess global cognitive functioning during the acute phase of traumatic brain injury (TBI), can predict long-term functional outcome compared with length of posttraumatic amnesia (PTA), a well-established predictor.DesignInception cohort.SettingsLevel 1 trauma center.ParticipantsA total of 90 patients (N=90) hospitalized for a moderate or severe TBI.InterventionsNot applicable.Main Outcome MeasuresPerformance on the EXACT in the first 3 months after injury and results on the Disability Rating Scale (DRS) at follow-up 1-2 years later.ResultsEXACT scores were all correlated with length of PTA and DRS result. Compared with length of PTA, the EXACT added significantly to the regression and improved prediction of functional outcome. More specifically, a total score ≤80 on the EXACT was associated with a higher rate of long-term disability because of more severe TBI consequences. Behavioral regulation and executive functions were the cognitive domains that showed the most impairment, followed by attention and working memory as well as episodic memory. Except for length of PTA and hospital stay, the DRS score was not correlated with other demographic (age, education) or clinical variables (Glasgow Coma Scale and maximum score on the Therapy Intensity Level Scale).ConclusionsThe EXACT can be administered to most patients early in the acute phase of TBI, and results could be used, along with other predictors such as PTA, to estimate their long-term functional sequelae. The EXACT may be a promising brief cognitive instrument for future studies investigating recovery after TBI.     

Coagulopathy as a predictor of mortality after penetrating traumatic brain injury

Study hypothesis

Traumatic brain injury (TBI) is a leading cause of mortality with penetrating TBI (p-TBI) patients having worse outcomes. These patients are more likely to be coagulopathic than blunt TBI (b-TBI) patients, thus we hypothesize that coagulopathy would be an early predictor of mortality.

脑外伤所致精神障碍40例临床分析

目的探讨脑外伤后所致精神障碍的临床表现类型以及受损部位与精神障碍的关系。方法对40例脑外伤所致精神障碍的临床资料进行分析。结果脑外伤所致精神障碍患者的精神障碍发生率依次为精神病性症状、神经症样综合征、情感障碍、智能障碍、人格改变。同时发现脑挫裂伤和脑震荡都易出现精神问题。结论颅脑外伤是易发生精神障碍的危险因素，临床医生应预以重视。     

颅脑损伤后凝血功能异常与继发性脑损伤

通过对35例急性颅脑损伤患者凝血功能的动态观察，结合跟综的CT扫描检查，探讨了凝血功能异常与继发性脑损伤之间的关系。结果表明：23例患者有不同程度的继发性脑损伤，占66％，该类患者，其凝血功能异常较无继发性脑损伤发生的患者更加显著，且持续较长时间。说明凝血功能的异常可能在继发性脑损伤的发生发展过程中起重要作用。     

The effects of sleep on the relationship between brain injury severity and recovery of cognitive function: A prospective study

Background

Disturbed sleep pattern is a common symptom after head trauma and its prevalence in acute traumatic brain injury (TBI) is less discussed. Sleep has a profound impact on cognitive function recovery and the mediating effect of disturbed sleep on cognitive function recovery has not been examined after acute TBI.

Objectives

To identify the prevalence of disturbed sleep in mild, moderate, and severe acute TBI patients, and to determine the mediating effects of sleep on the relationship between brain injury severity and the recovery of cognitive function.

Design

A prospective study design.

Setting

Neurosurgical wards in a medical center in northern Taiwan.

Participants

Fifty-two acute TBI patients between the ages of 18 and 65 years who had received a diagnosis of TBI for the first time, and were admitted to the neurosurgical ward.

Method

The severity of brain injury was initially determined using the Glasgow Coma Scale. Each patient wore an actigraphy instrument on a non-paralytic or non-dominated limb for 7 consecutive days. A 7-day sleep diary was used to facilitate data analysis. Cognitive function was assessed on the first and seventh day after admission based on the Rancho Los Amigos Levels of Cognitive Functioning.

Results

The mild (n = 35), moderate (n = 7) and severe (n = 10) TBI patients exhibited poorer sleep efficiency, and longer total sleep time (TST) and waking time after sleep onset, compared with the normative values for the sleep-related variables (P < .05 for all). The severe and moderate TBI patients had longer daytime TST than the mild TBI patients (P < .001), and the severe TBI patients had longer 24-h TST than the mild TBI patients (P = .001). The relationship between the severity of brain injury and the recovery of cognition function was mediated by daytime TST (t = −2.65, P = .004).

Conclusions

Poor sleep efficiency, prolonged periods of daytime sleep, and a high prevalence of hypersomnia are common symptoms in acute TBI patients. The duration of daytime sleep mediates the relationship between the severity of brain injury and the recovery of cognition function.     

Factors influencing return to work experienced by people with acquired brain injury: a qualitative research study

Purpose.?To describe the factors experienced by adults with moderate-to-severe acquired brain injury (ABI) as either limiting or facilitating during the process of return to work (RTW) in order to give an advice about the vocational rehabilitation process.

Methods.?A qualitative study was performed. Twelve adults who were working before acquiring traumatic or non-traumatic brain injury (2–3 years earlier) participated. The experiences were gathered by semi-structured interviews. The International Classification of Functioning, Disability and Health was used as a theoretical framework for the interviews and the analysis.

Results.?The most common limiting factor was tiredness. The most common facilitating factors were the will to RTW, the ongoing recovery and the knowledge and support of the employer, colleagues, occupational physician and occupational specialist.

Conclusions.?Different aspects were experienced as being important during the process of RTW after ABI. These aspects should be kept in mind during the process of RTW to make the outcome as successful as possible. It is advised to pay special attention to the recovery opportunities of an individual, to inform the employer, colleagues, occupation physician and the occupational specialist about ABI, and to support people with ABI for long time periods. An important role can be played by the rehabilitation centre.     

Treatment of penetrating brain injury in a rat model using collagen scaffolds incorporating soluble Nogo receptor

Injuries and diseases of the central nervous system (CNS) have the potential to cause permanent loss of brain parenchyma, with severe neurological consequences. Cavitary defects in the brain may afford the possibility of treatment with biomaterials that fill the lesion site while delivering therapeutic agents. This study examined the treatment of penetrating brain injury (PBI) in a rat model with collagen biomaterials and a soluble Nogo receptor (sNgR) molecule. sNgR was aimed at neutralizing myelin proteins that hinder axon regeneration by inducing growth cone collapse. Scaffolds containing sNgR were implanted in the brains of adult rats 1 week after injury and analysed 4 weeks or 8 weeks later. Histological analysis revealed that the scaffolds filled the lesion sites, remained intact with open pores and were infiltrated with cells and extracellular matrix. Immunohistochemical staining demonstrated the composition of the cellular infiltrate to include macrophages, astrocytes and vascular endothelial cells. Isolated regions of the scaffold borders showed integration with surrounding viable brain tissue that included neurons and oligodendrocytes. While axon regeneration was not detected in the scaffolds, the cellular infiltration and vascularization of the lesion site demonstrated a modification of the injury environment with implications for regenerative strategies. Copyright © 2012 John Wiley & Sons, Ltd.     

Evaluation of the implementation of the protocol of an early vocational rehabilitation intervention for people with acquired brain injury

Purpose: The purpose of this study was to evaluate (1) the feasibility of an early vocational rehabilitation (EVR) protocol in the standard rehabilitation process, (2) promoting factors and barriers encountered with the EVR protocol, and (3) perceived effectiveness of the protocol in facilitating return to work (RTW) following acquired brain injury (ABI). Method: A pre- and post-process evaluation was performed in a Dutch rehabilitation center. Dependent variables were feasibility (defined by the usability on process level and fulfillment of usability expectations), promoting factors and barriers, and perceived effectiveness of the protocol. Usability (defined by 13 performance and timing goals) was evaluated with existing forms and registrations. Fulfillment of usability expectations, perceived promoting factors and barriers, and perceived effectiveness were investigated with questionnaires. Data of 23 patients were available for process evaluation. Nine rehabilitation professionals, 10 patients with ABI, nine employers, and six occupational physicians completed the questionnaires. Results: Two-thirds of the performance goals and one-fourth of the timing goals were reached. All respondents cited the structured protocol as a promoting factor. Thirty-two of the thirty-four participants perceived the protocol as being suitable facilitating RTW after ABI. Conclusions: The EVR protocol provides a structured strategy to focus on RTW during standard rehabilitation. It is now possible to implement and test the protocol in other rehabilitation settings.

• Implications for Rehabilitation

• The early vocational rehabilitation (EVR) facilitates an interdisciplinary and systematic focus on return to work during rehabilitation of people with acquired brain injury.

• The feasibility of the EVR protocol has been tested.

• The EVR protocol is ready for implementation and wider testing in other rehabilitation settings.

     

重型颅脑损伤术后顽固性脑蕈的临床分析

目的 探讨重型颅脑损伤术后顽固性脑蕈的形成原因及有效治疗措施。方法 对32例病人进行回顾性分析，总结其形成原因、有效治疗措施。结果 脑水肿、脑积水、颅内感染是重型颅脑损伤术后形成顽固性脑蕈的主要原因，有效运用脱水药物和各种措施降低颅内压、预防感染、保证创口I期愈合是治疗顽固性脑蕈的有效措施。结论 针对不同情况采取相应措施治疗重型颅脑损伤术后顽固性脑蕈，取得较好疗效。     

弥漫性轴索损伤病人的护理

为了探讨弥漫性轴索损伤 (DAI)病人的护理经验 ,对 112例DAI病人的护理过程进行了回顾性分析。体会到急性期保持呼吸道通畅 ,及时纠正低氧血症 ,降低颅内压 ,有效地控制中枢性高热是提高生存率的关键。后期加强基础护理 ,保障足够的热量摄入有利于DAI病人的康复。在尚无特殊治疗方法的今天 ,护理工作是影响DAI病人预后的重要因素。     

Motivation in rehabilitation and acquired brain injury: can theory help us understand it?

Background: In acquired brain injury (ABI) populations, low motivation to engage in rehabilitation is associated with poor rehabilitation outcomes. Motivation in ABI is thought to be influenced by internal and external factors. This is consistent with Self-determination Theory, which posits that motivation is intrinsic and extrinsic. This paper discusses the benefit of using Self-determination Theory to guide measurement of motivation in ABI.

Methods: Using a narrative review of the Self-determination Theory literature and clinical rehabilitation research, this paper discusses the unique role intrinsic and extrinsic motivation has in healthcare settings and the importance of understanding both when providing rehabilitation in ABI.

Results: Based on the extant literature, it is possible that two independently developed measures of motivation for ABI populations, the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self and the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, may assess intrinsic and extrinsic motivation, respectively.

Conclusion: Intrinsic and extrinsic motivation in ABI may be two equally important but independent factors that could provide a comprehensive understanding of motivation in individuals with ABI. This increased understanding could help facilitate behavioural approaches in rehabilitation.

• Implications for Rehabilitation

• Conceptualization of motivation in ABI would benefit from drawing upon Self-determination Theory.

• External factors of motivation such as the therapeutic environment or social support should be carefully considered in rehabilitation in order to increase engagement.

• Assessing motivation as a dual rather than a global construct may provide more precise information about the extent to which a patient is motivated.

     

再发脑肿胀对颅脑损伤术后患者肢体功能恢复影响的临床分析

目的：观察颅脑损伤术后患者再发脑肿胀的发生率及其对患者功能恢复的影响，加强对脑肿胀的预防和治疗。方法：收集2000年1月-2005年1月在我科住院的颅脑损伤术后患者310例，根据患者临床症状，头颅CT（或MRI）检查及临床治疗情况，确诊再发脑肿胀患者16例，计算再发脑肿胀的发生率：选择同期住院的颅脑损伤术后末发生脑肿胀患者并排除其他影响因素的病例150例作为对照组。比较两组患者的平均住院日和平均住院费用：评估两组患者康复治疗前后的Fugl-Meyer评分和Barthel指数。结果：颅脑损伤术后患者再发脑肿胀发生率为5.2％；再发脑肿胀组的患者平均住院日和平均住院费用均较对照组明显增加，两者间差异有显著性意义（P〈0．01）；两组患者康复治疗前Fugl-Meyer评分和Barthel指数比较差异均无显著性意义（P〉0．05），出院时脑肿胀组Fugl-Meyer评分和Barthel指数均低于对照组，两者间差异有显著性意义（P〈0．05）。结论：颅脑损伤术后患者再发脑肿胀会不同程度影响患者的功能恢复．应及时发现和治疗，减少其对功能恢复的影响。     

An evaluation of the use of guidelines in prehospital management of brain injury

Objectives

The Brain Trauma Foundation (BTF) Guidelines for Prehospital Management of Traumatic Brain Injury (TBI) are intended to standardize treatment and improve outcomes in severe TBI patients. The key guideline components focus on airway management, blood pressure support, Glasgow Coma Score assessment, and transport. The purposes of this study were to determine if providers could learn and retain the guidelines (education), assess if providers would use the guidelines in practice (implementation), and evaluate the effect of guideline implementation on patients (outcomes).

Methods

Data were collected prospectively on all trauma patients for five months. Providers were then educated on the TBI guidelines over two months, and five additional months of data were collected. A knowledge test was given before and after the course and three months later to assess education. To assess implementation, data were analyzed to determine whether providers were using the key interventions more consistently after education. The clinical courses of TBI patients before and after guideline implementation were measured to assess outcomes.

Results

Knowledge of TBI care improved significantly after education and remained elevated at three months (62% vs. 82% vs. 79%, p < 0.001). For the 1,044 patients seen, providers demonstrated higher rates of appropriate care, resulting in lower rates of hypoxia (2.8% vs. 1.1%, p = 0.010) and hypotension (4.8% vs. 2.0%, p = 0.018). Mortality was significantly decreased (34.6% vs. 17.0%, p = 0.039), and rates of patients with maximum functional scores at 14 days significantly increased (Glasgow Outcome Score 44.2% vs. 66.0%, p = 0.025; Rancho Los Amigos Scale 55.9% vs. 77.3%, p = 0.045).

Conclusion

Providers were able to learn and implement the BTF guidelines, and outcomes in TBI patients were significantly improved. All emergency medical services providers should be trained in these potentially lifesaving guidelines.     

Four case reports illustrating the contribution of intensive cognitive rehabilitation in patients neuropsychologically handicapped as a result of brain damage

The authors describe the principles and functioning of a 7-week course of interdisciplinary treatment for small groups of patients with cognitive and behavioural difficulties resulting from brain damage. The programme is intended for patients with less severe physical disability. It outlines a programme of individual, practically oriented workshops and of more theoretical group sessions working on cognitive and communications handicaps. The work is based on conceptual explanations, coping strategies and training techniques. The neurological and neuropsychogical consequences of four subjects accepted on such a programme are presented, as well as some of the principles of treatment used for these patients. The efficacy of such programmes is discussed, given the classical post-traumatic picture of brain-injured patients. The programme consists of 1 week of evaluation and 6 weeks of therapeutic sessions.     

创伤性颅脑损伤后神经细胞凋亡的研究

目的：通过对创伤性颅脑损伤后神经细胞凋亡的研究，了解人脑创伤后脑组织中凋亡发生的情况及其所起的作用。方法：采用末端脱氧核苷酸转移酶介导的d-UTP生物素标记法(TUNEL法)检测细胞凋亡。同时显微镜观察病理切片。结果：66．7％出现TUNEL阳性，TUNEL阳性与阴性患者间的GCS评分(t=-2.88，P=O．01)、受伤时间(t=2．14，P=0．049)有显著差异。TUNEL阳性与阴性患者间性别、年龄、预后无显著差异。结论：人脑创伤后脑组织中存在凋亡，且与患者的病情严重程度及病程相关。其在颅脑创伤的病理过程中有一定作用，但只是颅脑损伤后复杂病理过程中的一种表现，即创伤后神经细胞死亡的一种方式。