Cognitive and functional outcomes of terror victims who suffered from traumatic brain injury

Primary objective: To describe the outcomes of terror victims suffered from traumatic brain injury (TBI).

Research design: Retrospective chart review of 17 terror and 39 non-terror TBI patients treated in a rehabilitation department during the same period.

Methods and procedure: Variables include demographic data, Injury Severity Scale (ISS), length of stay (LOS) and imaging results. ADL was measured using the Functional Independence Measurement (FIM), cognitive and memory functions were measured using the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery and the Rivermead Battery Memory Test (RBMT), respectively.

Main outcome and results: Terror TBI patients were significantly younger, had higher ISS score and higher rates of intracerebral haemorrhage (ICH), brain surgery and penetrating brain injuries than the non-terror TBI group. There was no difference in mean LOS, mean FIM values, mean FIM gain and mean cognitive and memory improvement between groups. Terror victims suffered from a higher percentage of post-traumatic epilepsy (35% vs. 10%, p = 0.05), whereas the rate of PTSD and the rate of return to previous occupation were similar between groups.

Conclusions: Although TBI terror victims had more severe injury, they gained most of ADL functions and their rehabilitation outcomes were similar to non-terror TBI patients. These favourable results were achieved due to a comprehensive interdisciplinary approach to terror victims and also by national support which allowed an adequate period of treatment and sufficient resources as needed.     

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.     

Long-term neuropsychological performance in a cohort of children and adolescents after severe paediatric traumatic brain injury

Objective: The purpose of the present study was to evaluate progress in neuropsychological performance in children and adolescents with severe paediatric traumatic brain injury (TBI), from admission to the rehabilitation centre up to 3-12 years after the trauma.

Methods: Children and adolescents (n = 31, mean age at injury 11.8 years, SD = 3.8; at follow-up 18.8 years; SD = 4.5) who all had suffered a TBI participated. A comprehensive neuropsychological test battery was administered at the start of rehabilitation (T1), around discharge (T2) and in the long-term (at least 3 years after rehabilitation; T3). T1 and T2 were clinical assessments; T3 was executed as a follow-up measurement for this study.

Results: At T1 and T2, most problems were in the domains of attention, memory and executive functioning. At the start of rehabilitation most deficits were with performal intelligence (61%); at discharge (mean length of stay 411 days) considerably less children had severe deficits on the intelligence domain (23%). At long-term follow-up, most problems were in the domains attention, mental speed and memory. From admission to discharge 42% of the children improved on two or more cognitive tests; from discharge to follow-up this percentage was 13%.

Conclusions: In this unique study a clinical cohort of children with severe TBI was followed for many years after injury. Most cognitive deficits were found in the early phase of rehabilitation. Most children did improve on cognitive functioning (40%) during the first year after their injury, whereas at follow-up most children had not changed. At follow-up, more than half of the children (54%) attended a regular school or had a regular job, corresponding to their age and pre-morbid functioning.     

Agitation following traumatic brain injury: an Australian sample

Purpose: Agitation following traumatic brain injury (TBI) is perceived to limit the achievement of rehabilitation goals. The aims of this study were: (1) To examine the nature and incidence of agitation during TBI rehabilitation in an Australian sample; and (2) To explore the relationship between agitation and functional outcomes after TBI.

Method: Retrospective medical record review of 80 participants admitted for rehabilitation following TBI. Outcome data collected at discharge, 6 and 24 months post-discharge, included length of stay, duration of post-traumatic amnesia (PTA), community integration, functional independence and life satisfaction.

Results: Seventy per cent of patients demonstrated agitation during rehabilitation for an average of 32 days. Agitated patients experienced longer PTA duration, increased length of stay and reduced functional independence, specifically cognitive function, at discharge. These differences between agitated and non-agitated participants did not appear to persist and were not evident at follow-up 6 and 24 months post-discharge. Longer duration of agitation was associated with delayed PTA emergence, longer rehabilitation stay and reduced functional independence at discharge and follow-up.

Conclusions: A large proportion of patients with TBI experience agitation. Presence of agitation seems to limit rehabilitation gains at discharge. Longer duration of agitation is associated with persisting limitations to functional independence.     

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.     

Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury

Primary objective: To compare functional physical and cognitive outcome of patients in three age groups with mild, moderate and severe traumatic brain injury (TBI) at discharge from acute care.

Research design: Retrospective database review.

Methods and procedures: Scores on the Extended Glasgow Outcome Scale (GOSE) and on the FIM™ instrument,1 discharge destination and length-of-stay (LOS) were gathered and compared for 2327 patients with TBI admitted to a level 1 trauma hospital from 1997-2003 divided into three age groups; 971 patients between 18-39 years, 672 between 40-59 years and 684 aged 60-99 years.

Main outcomes and results: Relative to younger adults with similar TBI severity, elderly patients showed worse outcome on the GOSE and FIM™ instrument (physical and cognitive ratings) and longer LOS. No difference was observed between the young and middle-aged groups except for cognitive FIM™ ratings and LOS for severe TBI. A higher percentage of elderly patients went to in-patient rehabilitation, to long-term care facilities or died compared to young and middle-aged patients. A higher number of young and middle-aged patients were discharged home.

Conclusions: Further development of services in early rehabilitation as well as post-rehabilitation geared to the specific needs of the elderly patient with TBI is required as the population ages.     

Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial

Objective: To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients with traumatic brain injury (TBI).

Design and methods: Sixty-eight patients (age 12-65 years) with moderate-to-severe TBI were included. They were randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had passed.

Outcome and results: No significant differences were found in the Functional Independence Measure (FIM) (primary outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score at the third month (47% vs. 19%, p = 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second (28% vs. 8%, p = 0.034) and third months (34% vs. 14%, p = 0.044).

Conclusions: Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up recovery rather than changed the final outcome.     

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.     

Clinical progression and outcome of dysphagia following paediatric traumatic brain injury: a prospective study

Objectives: To provide a preliminary clinical profile of the resolution and outcomes of oral-motor impairment and swallowing function in a group of paediatric dysphagia patients post-traumatic brain injury (TBI). To document the level of cognitive impairment parallel to the return to oral intake, and to investigate the correlation between the resolution of impaired swallow function versus the resolution of oral-motor impairment and cognitive impairment.

Participants: Thirteen children admitted to an acute care setting for TBI.

Main outcome measures: A series of oral-motor (Verbal Motor Production Assessment for Children, Frenchay Dysarthria Assessment, Schedule for Oral Motor Assessment) and swallowing (Paramatta Hospital's Assessment for Dysphagia) assessments, an outcome measure for swallowing (Royal Brisbane Hospital's Outcome Measure for Swallowing), and a cognitive rating scale (Rancho Level of Cognitive Functioning Scale).

Results: Across the patient group, oral-motor deficits resolved to normal status between 3 and 11 weeks post-referral (and at an average of 12 weeks post-injury) and swallowing function and resolution to normal diet status were achieved by 3-11 weeks post-referral (and at an average of 12 weeks post-injury). The resolution of dysphagia and the resolution of oral-motor impairment and cognitive impairment were all highly correlated.

Conclusion: The provision of a preliminary profile of oral-motor functioning and dysphagia resolution, and data on the linear relationship between swallowing impairment and cognition, will provide baseline information on the course of rehabilitation of dysphagia in the paediatric population post-TBI. Such data will contribute to more informed service provision and rehabilitation planning for paediatric patients post-TBI.     

Neurocognitive fitness in the sub-acute stage after mild TBI: the effect of age

Objective: Age is assumed to be a negative prognostic factor in recovery from moderate-to-severe traumatic brain injury (TBI). Little is known on cognitive performance after mild TBI in relation to age in the sub-acute stage after injury.

Method: Ninety-nine mild TBI subjects (age 15-75) were compared with 91 healthy control subjects (age 14-74) in a case-control design. Patients were matched on age, sex and level of education, with control subjects. Mean interval between injury and cognitive assessment was 13 days. Neurocognitive test battery contained tests of verbal memory, selective attention, general speed of information processing and verbal fluency.

Results: An overall effect was found of a single mild TBI on neurocognitive performance in the sub-acute stage after injury. Age did not add significantly to the effect of mild TBI on cognitive functioning.

Conclusion: Patients suffering from mild TBI are characterized by subtle neurocognitive deficits in the weeks directly following the trauma. The notion that elderly subjects have a worse outcome in the sub-acute period after mild TBI is at least not in line with the results of this study.     

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.     

Computed tomography findings and early cognitive outcome after traumatic brain injury

Primary objective: To examine the relationship between CT abnormalities and early neuropsychological outcome following traumatic brain injury (TBI) using quantitative CT analyses, data reduction methods for neuropsychological results and specific hypotheses based on literature review.

Research design: Observational, prospective cohort study using acute (emergency) CT data and neuropsychological test data from 89 participants with TBI who were hospitalized for rehabilitation.

Methods and procedures: Principal components analysis with varimax rotation was used to reduce data from a standard battery of eight neuropsychological tests administered after clearance of post-traumatic amnesia (1 month post-TBI on average). Bivariate correlations were used to examine relationships of three factors (verbal memory, cognitive processing speed and verbal working memory) to quantitative volumetric analysis of CT scan abnormalities (size, number and location). Specific hypotheses as to CT predictors of poor performance on each factor were tested using multivariable linear regression that included injury severity and demographic variables.

Main results: Eighty-nine per cent of participants had some pathology on initial CT. Age, education and time to follow commands (TFC), an index of overall injury severity, were significantly associated with the neuropsychological factors. However, none of the specific hypotheses about CT scan variables and cognitive outcome were strongly supported by the data. There was a trend for any CT abnormality to predict slower speed of processing and for higher number of brain lesions to predict worse memory performance.

Conclusions: Despite the precision added by quantitative CT analysis, CT findings did not improve on demographic factors and TFC in predicting early cognitive outcome of TBI. Imaging methods that are more sensitive to white matter integrity may be needed to develop pathophysiologic predictors of TBI outcome.     

Benign paroxysmal positional vertigo as the cause of dizziness in patients after severe traumatic brain injury: diagnosis and treatment

Objectives: To identify patients with benign paroxysmal positional vertigo (BPPV) among patients with severe traumatic brain injury (TBI) and to evaluate the effectiveness of the Particle Repositioning Maneouvre (PRM).

Design and methods: Eighteen months prospective study of 150 consecutive patients with severe TBI referred to an in-patients rehabilitation department.

Interventions: A structured interview emphasizing the possible presence of vertigo followed by a detailed neuro-otological examination. Patients diagnosed with BPPV were immediately treated with the PRM.

Main outcomes and results: BPPV diagnosis was based on a positive Dix-Hallpike positional test. PRM efficacy was determined by repeating the positional test 1 or 2 weeks after treatment. Twenty out of 150 (13.3%) patients complained about positional vertigo. The diagnosis of BPPV was confirmed in 10 patients. Signs and symptoms were completely relieved in six patients after a single PRM, while the other four patients needed repeated treatment for complete resolution of BPPV.

Conclusions: About half of the patients with severe TBI who complain about positional vertigo suffer from BPPV. These patients can be efficiently treated by physical maneouvres improving the rehabilitation outcome.     

The impact of acute care medications on rehabilitation outcome after traumatic brain injury

Objectives: To examine the impact of medications with known central nervous system (CNS) mechanisms of action, given during the acute care stages after traumatic brain injury (TBI), on the extent of cognitive and motor recovery during inpatient rehabilitation.

Design: Retrospective extraction of data utilizing an inception cohort of moderate and severe TBI survivors.

Methods: The records of 182 consecutive moderate and severe TBI survivors admitted to a single, large, Midwestern level I trauma centre and subsequently transferred for acute inpatient rehabilitation were abstracted for the presence of 11 categories of medication, three measures of injury severity (worst 24 hour Glasgow Coma Scale, worst pupillary response, intra-cranial hypertension), three measures of outcome (Function Independence Measure (FIM) Motor and Cognitive scores at both rehabilitation admission and discharge and duration of post-traumatic amnesia (PTA)).

Main outcome and results: The narcotics, benzodiazepines and neuroleptics were the most common categories of CNS active medications (92%, 67% and 43%, respectively). The three categories of medications appeared to have no significant outcome on the FIM outcome variables. The neuroleptics affected cognitive recovery with almost 7 more days required to clear PTA in the neuroleptic treated group. The presence of benzodiazepines did tend to obscure the impact of neuroleptics on PTA duration but the negative impact of neuroleptics on PTA duration remained significant.

Conclusions: The results suggest that the use of neuroleptics during the acute care stage of recovery has a negative impact on recovery of cognitive function at discharge from inpatient rehabilitation. Due to the paucity of subjects with hemiplegia in this cohort, conclusions could not be drawn as to the impact of acute care medications on motor recovery.     

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.     

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.     

Relationship between balance abilities and gait characteristics in children with post-traumatic brain injury

Objectives: To quantify the differences in gait variability and balance performance between typically developed (TD) children and children with post-traumatic brain injury (TBI) and to determine the association between gait variability and functional balance in both groups.

Design: Cross-sectional study.

Setting: Physical therapy department of a paediatric and adolescent rehabilitation hospital.

Participants: A convenience sample of 24 children post-TBI and 24 TD age and sex matched controls.

Intervention: Not applicable.

Main outcome measure: Step length, step time and base width variability measured with an electronic walkway; timed up and go (TUG) test and functional reach test (FRT) as a functional balance test.

Results: Base width and step time variability showed no significant difference between the groups. However, children post-TBI had significantly greater variability in step length in comparison to healthy controls. The functional balance abilities of children post-TBI were significantly limited compared to TD children. A significant linear inverse correlation was found between balance performance and step length variability only among children with a TBI.

Conclusion: Ambulatory children post-severe TBI had decreased balance performance, decreased gait speed and increased step length variability as compared to age-matched healthy controls.     

Dizziness after traumatic brain injury: results from an interview study

Background: Dizziness is a commonly reported sequel to traumatic brain injury (TBI).

Objective: To better define the nature of the symptomatology and the impact that dizziness has on the TBI survivor.

Setting: A community brain injury rehabilitation programme and a community access programme for TBI survivors.

Method: Focus groups with TBI survivors and individual interviews with TBI survivors and some of their carers.

Results: The data confirmed that dizziness is difficult for TBI survivors to define and describe and it consists of multiple symptoms. Dizziness also appears to be associated with significant functional difficulties. Additionally, many of the participants of this study reported falling. Carers reported a number of observable signs of dizziness and indicated that they believed they were able to tell when the person they cared for was dizzy.

Conclusion: The results provide information which will help in the development of more appropriate outcome measurement tools for dizziness after a TBI.     

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.     

Increased inattentional blindness in severe traumatic brain injury: evidence for reduced distractibility?

Primary objective: To examine the role of selective attention and visual perception in medicating inattentional blindness in a severe traumatic brain injured sample.

Research design: Cross-sectional design with age and education matched control sample.

Methods and procedures: Twenty participants with severe traumatic brain injury (n = 10) and matched controls (n = 10) completed a series of tests of focused attention (Stroop test), divided attention (Trail Making Test), visual perception (Visual Object and Space Perception Battery) and two tasks of inattentional blindness.

Main outcomes and results: The group with severe TBI were significantly slower on the Stroop test and TMT and displayed significantly elevated Stroop interference and TMT ratio scores. On the inattentional blindness tasks, fewer TBI participants identified a distracting stimulus.

Conclusion: The results indicate severe TBI is associated with deficits to focused and divided attention with the finding of a potentially more debilitating impairment arising from reduced distractibility following severe TBI.