Early rehabilitation of comatose patients after traumatic brain injury

Background and purposeAs a result of improvements in the rescue system and progress in intensive care therapy, an increasing number of patients have survived severe traumatic brain injury in recent years. Early and consistent administration of the correct rehabilitation programme is of crucial importance for the restoration and improvement of cerebral function, as well as social reintegration. This prospective study was conducted at the neurosurgical department of a university hospital to assess the one-year outcome of comatose patients after severe traumatic brain injury.Material and methodsTwenty-seven patients were included. Patients received multimodal early-onset stimulation and continuous inpatient and outpatient rehabilitation therapy. One-year outcome was assessed by means of the Glasgow Outcome Scale, Barthel Index, Functional Independence Measure (FIM) and need of care.ResultsSeven patients died, 4 remained in a vegetative state, 7 were severely disabled, 6 were moderately disabled, and 3 achieved a good recovery 12 months after injury. Median Barthel Index was 65 and median FIM score was 84. The majority of patients were still at least intermittently dependent on care.ConclusionsDespite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity.     

Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology

Vestibular complaints are the most frequent sequelae of mTBI. Vestibular physical therapy has been established as the most important treatment modality for this group of patients. Nevertheless there is little work objectively documenting the impact of vestibular physical therapy on this group of patients. Studies have been completed in the past examining clinical measures like the GCS on overall recovery pattern after TBI. But outcomes measures specifically aimed at examining the adequacy of vestibular tests to track vestibular recoveryhave remained lacking. Scherer and Schubert reinforced the need for best practice vestibular assessment for formulation of appropriate vestibular physical therapy treatment strategies. Now the application of vestibular testing and rehabilitation in this patient population is needed to provide information on objective outcome measures. Vestibular physical therapy is most effective when applied in a customized fashion. While we and others have developed vestibular physical therapy procedures that are applied in best practices for mTBI vestibular patients, these therapies must be customized for the patient entry level of function and expectation level of recovery. Knowledge of the patient's disability and diagnosis is critical to build the foundation for return to activity, work, or sport.     

Clock-drawing performance predicts inpatient rehabilitation outcomes after traumatic brain injury

The authors used clock-drawing performance to assess cognition and predict inpatient rehabilitation outcomes among persons with traumatic brain injury. Clock-drawing performance, as assessed with the Clock Drawing Interpretation Scale, predicts rehabilitation length of stay as well as Functional Independence Measure scores at the time of neurobehavioral assessment and rehabilitation discharge.     

Community based rehabilitation after severe traumatic brain injury: a randomised controlled trial

OBJECTIVE: Evaluation of multidisciplinary community based outreach rehabilitation after severe traumatic brain injury (TBI). METHODS: A randomised controlled trial compared outreach treatment (mean of two sessions a week for 27.3 (SD 19.1) weeks) in community settings such as participants' homes, day centres, or workplaces, with provision of written information detailing alternative resources. Follow up for an average of 24.8 months after initial allocation was by a blinded independent assessor. Participants were aged 16-65, had sustained severe TBI between 3 months and 20 years previously, and had no other neurological conditions. Of 110 initially allocated, 48 outreach and 46 information participants were successfully followed up. Primary outcome measures (Barthel index (BI) and the brain injury community rehabilitation outcome-39 (BICRO-39)) focused on levels of activity and participation. Secondary measures were the functional independence measure and the functional assessment measure (FIM+FAM) and, in a subgroup of 46 participants, the hospital anxiety and depression scale. Analyses were non-parametric. RESULTS: outreach participants were significantly more likely to show gains on the BI and the BICRO-39 total score and self organisation and psychological wellbeing subscales. There were likewise strong trends (p<0.10) for BICRO personal care and mobility, and on the FIM+FAM for personal care and cognitive functions. Differential improvements were not seen for indices of socializing, productive employment, anxiety, or depression. Median changes on individual subscales were small, reflecting the diversity of the clinical population; however, 40% of outreach but only 20% of information participants made a clinically significant improvement of 2+ points on at least one BICRO-39 scale. Time since injury was unrelated to the magnitude of gains. CONCLUSIONS: This is the first RCT of multidisciplinary community rehabilitation after severe TBI, and suggests that even years after injury it can yield benefits which outlive the active treatment period.     

Addressing neuropsychiatric disturbances during rehabilitation after traumatic brain injury: current and future methods

Cognitive, emotional, behavioral, and sensorimotor disturbances are the principal clinical manifestations of traumatic brain injury (TBI) throughout the early postinjury period. These post-traumatic neuropsychiatric disturbances present substantial challenges to patients, their families, and clinicians providing their rehabilitative care, the optimal approaches to which remain incompletely developed. In this article, a neuropsychiatrically informed, neurobiologically anchored approach to understanding and meeting challenges is described. The foundation for that approach is laid, with a review of clinical case definitions of TBI and clarification of their intended referents. The differential diagnosis of event-related neuropsychiatric disturbances is considered next, after which the clinical and neurobiological heterogeneity within the diagnostic category of TBI are discussed. The clinical manifestations of biomechanical force-induced brain dysfunction are described as a state of post-traumatic encephalopathy (PTE) comprising several phenomenologically distinct stages. PTE is then used as a framework for understanding and clinically evaluating the neuropsychiatric sequelae of TBI encountered commonly during the early post-injury rehabilitation period, and for considering the types and timings of neurorehabilitative interventions. Finally, directions for future research that may address productively the challenges to TBI rehabilitation presented by neuropsychiatric disturbances are considered.     

SMARTER goal setting in aphasia rehabilitation

Background: There have been numerous calls for rehabilitation professionals to involve patients or clients in decisions about the goals of therapy. And yet collaborative goal setting in rehabilitation remains uncommon and is particularly difficult to achieve for people with aphasia.

Aims: This discussion paper describes a new framework for conceptualising and structuring collaborative goal setting in aphasia rehabilitation. The framework has been developed based on the results of a large, multi-centred Australian study, the Goals in Aphasia Project, which explored client, family, and speech pathology experiences of rehabilitation goal setting. This framework, called SMARTER Goal Setting, describes a process of goal setting that is Shared, Monitored, Accessible, Relevant, Transparent, Evolving and Relationship-centred.

Methods & Procedures: The methods and results from the Goals in Aphasia Project have already been published elsewhere but involved in-depth interviews with 50 people with aphasia, 48 family members, and 34 treating speech pathologists. This paper reviews the broader literature and summarises relevant findings from the Goals in Aphasia Project as a basis for discussion of each category of SMARTER.

Outcomes & Results: Our new SMARTER framework both challenges and complements elements of the pervasive SMART goal paradigm (that goals should be Specific, Measurable, Achievable, Realistic and Time-bound), which currently dominates rehabilitation goal setting. SMARTER offers an easy way to summarise much of the collaborative work that already takes place in clinical practice but also emphasises aspects that could be improved. SMARTER does not replace SMART, but we suggest that SMART goals can be negotiated in a SMARTER way.

Conclusions: While this paper discusses SMARTER goal setting within aphasia rehabilitation, a particularly challenging context for the implementation of collaborative practice, it may be applicable to rehabilitation more broadly. Given that person-centred goal setting within stroke rehabilitation remains infrequent, we suggest that there is an urgent need to raise awareness of its importance and challenge current practice. The SMARTER framework provides a useful structure to support collaborative goal setting.     

Motor rehabilitation after traumatic brain injury and stroke - Advances in assessment and therapy

A long-term goal in motor rehabilitation is that treatment is not selected on the basis of 'schools of thought', but rather, based on knowledge about efficacy and effectiveness of specific interventions for specific situations (e.g. functional syndromes). Motor dysfunction after stroke or TBI can be caused by many different functional syndromes such as paresis, ataxia, deafferentaion, visuo-perceptual deficits, or apraxia. Examples are provided showing that theory-based analysis of motor behavior makes it possible to describe 'syndrome-specific motor deficits'. Its potential implications for motor rehabilitation are that our understanding of altered motor behavior as well as specific therapeutic approaches might be promoted. A methodological prerequisite for clinical trials in rehabilitation is knowledge about test properties of assessment tools in follow-up situations such as test-retest reliability and responsiveness to change. Test-retest reliability assesses whether a test can produce stable measures with test repetition, while sensitivity to change reflects whether a test detects changes that occur over time. Exemplifying these considerations, a reliability and validity study of a kinematic arm movement analysis is summarized. In terms of new therapeutic developments, two examples of clinical therapeutic studies are provided assessing the efficacy of specific inter-ventions for specific situations in arm and gait rehabilitation: the Arm Ability Training for high functioning hemiparetic stroke and TBI patients, and the treadmill training for non-ambulatory hemiparetic patients. In addition, a new technical development, a machine-controlled gait trainer ist introduced.     

Motor rehabilitation after traumatic brain injury and stroke - Advances in assessment and therapy

A long-term goal in motor rehabilitation is that treatment is not selected on the basis of 'schools of thought', but rather, based on knowledge about efficacy and effectiveness of specific interventions for specific situations (e.g. functional syndromes). Motor dysfunction after stroke or TBI can be caused by many different functional syndromes such as paresis, ataxia, deafferentaion, visuo-perceptual deficits, or apraxia. Examples are provided showing that theory-based analysis of motor behavior makes it possible to describe 'syndrome-specific motor deficits'. Its potential implications for motor rehabilitation are that our understanding of altered motor behavior as well as specific therapeutic approaches might be promoted. A methodological prerequisite for clinical trials in rehabilitation is knowledge about test properties of assessment tools in follow-up situations such as test-retest reliability and responsiveness to change. Test-retest reliability assesses whether a test can produce stable measures with test repetition, while sensitivity to change reflects whether a test detects changes that occur over time. Exemplifying these considerations, a reliability and validity study of a kinematic arm movement analysis is summarized. In terms of new therapeutic developments, two examples of clinical therapeutic studies are provided assessing the efficacy of specific inter-ventions for specific situations in arm and gait rehabilitation: the Arm Ability Training for high functioning hemiparetic stroke and TBI patients, and the treadmill training for non-ambulatory hemiparetic patients. In addition, a new technical development, a machine-controlled gait trainer ist introduced.     

Dementia after traumatic brain injury

Early retrospective studies suggested that individuals with a history of a traumatic brain injury (TBI) had a higher risk for dementia than those without a history of TBI. Two meta-analyses demonstrated that the risk for dementia is higher among men, but not women, with a history of TBI. More recent prospective studies, however, are providing discrepant findings, probably due to important methodological differences. TBI is usually associated with significant neuropsychological deficits, primarily in the domains of attention, executive functioning and memory. These deficits may not improve with time. TBI may also lower the threshold for the clinical expression of dementia among predisposed individuals, and the onset of Alzheimer's disease (AD)-like neuropathological and biochemical changes immediately after severe TBI may play an important role in this mechanism.     

Dose-dependent neuronal injury after traumatic brain injury

The Fluoro-Jade (FJ) stain reliably identifies degenerating neurons after multiple mechanisms of brain injury. We modified the FJ staining protocol to quickly stain frozen hippocampal rat brain sections and to permit systematic counts of stained, injured neurons at 4 and 24 h after mild, moderate or severe fluid percussion traumatic brain injury (TBI). In adjacent sections, laser capture microdissection was used to collect uninjured (FJ negative) CA3 hippocampal neurons to assess the effect of injury severity on mRNA levels of selected genes. Rats were anesthetized, intubated, mechanically ventilated and randomized to sham, mild (1.2 atm), moderate (2.0 atm) or severe (2.3 atm) TBI. Four or 24 h post-TBI, ten frozen sections (10 microm thick, every 15th section) were collected from the hippocampus of each rat, stained with FJ and counterstained with cresyl violet. Fluoro-Jade-positive neurons were counted in hippocampal subfields CA1, CA3 and the dentate gyrus/dentate hilus. At both 4 and 24 h post-TBI, numbers of FJ-positive neurons in all hippocampal regions increased dose-dependently in mildly and moderately injured rats but were not significantly more numerous after severe injury. Although analysis of variance demonstrated no overall difference in expression of mRNA levels for heat shock protein 70, bcl-2, caspase 3, caspase 9 and interleukin-1beta in uninjured CA3 neurons at all injury levels, post hoc analysis suggested that TBI induces increases in neuroprotective gene expression that offset concomitant increases in deleterious gene expression.     

fMRI of the sensorimotor cortex in patients with traumatic brain injury after intensive rehabilitation

For evaluating the patterns of brain activation in sensorimotor areas following motor rehabilitation, seven male patients diagnosed with TBI underwent an fMRI study before and after being subjected to motor rehabilitation. Six patients showed a reduction in the BOLD signal of their motor cortical areas during the second fMRI evaluation. A decrease in cerebellum activation was also observed in two patients. Newly activated areas, were observed in four patients after treatment. In addition, an increase in the activation of the supplementary motor area (SMA) following rehabilitation was observed in only one test subject. The findings show that motor rehabilitation in TBI patients produces a decrease in the BOLD signal for the sensorimotor areas that were activated prior to treatment. In addition, we observed the recruitment of different brain areas to compensate for functional loss due to TBI in line with the cortical reorganisation mechanism.     

Self-awareness after acquired and traumatic brain injury

Self-awareness deficits are common after acquired and (traumatic) brain injury (ABI), particularly in social behaviour, yet the underlying cognitive and neuroanatomical structures supporting social self-awareness are not fully understood. This paper reviews the current literature on prevalence, type and severity of self-awareness deficits in ABI. Neuropsychological and neuroanatomical models are reviewed and theoretical frameworks are examined. We summarise results of a case-control comparison of 20 ABI patients with and 20 ABI patients without behavioural disturbance. Our research found that lack of social self-awareness predicts behavioural disturbance in acquired and traumatic brain injury independent of cognitive and executive function. Theory of mind ability was related to self-awareness and a possible role for metacognition and affective processes in self-awareness is discussed to account for social self-awareness deficits.     

Obsessive-compulsive disorder after traumatic brain injury

Traumatic brain injury ( TBI) neuropsychiatric sequelae are a significant cause of morbidity in TBI victims. Among the recognized sequelae are anxiety, obsessions, compulsions and obsessive-compulsive disorder (OCD). This review addresses the emergence of OCD and OCD symptoms after TBI with an emphasis on neural circuits that underlie OCD symptom expression that may be affected by the injury. Current studies suggest that post-TBI emergent psychopathology, including OCD, is influenced by underlying sub-clinical diathesis, brain injury lesions sites, environmental stressors and the rehabilitation process. Pre-morbid status can be obtained by structured psychiatric interviews, and TBI brain lesions can be defined with advanced neuroimaging techniques. This information along with the management of family and environmental stressors and the enhanced clinical identification of symptoms of anxiety and OCD can be used in the rehabilitation process to improve prognosis after TBI.     

Dysautonomia after severe traumatic brain injury

Background: Dysautonomia after traumatic brain injury (TBI) is characterized by episodes of increased heart rate, respiratory rate, temperature, blood pressure, muscle tone, decorticate or decerebrate posturing, and profuse sweating. This study addresses the incidence of dysautonomia after severe TBI, the clinical variables that are associated with dysautonomia, and the functional outcome of patients with dysautonomia. Methods: A historic cohort study in patients with severe TBI [Glasgow Coma Scale (GCS) ≤ 8 on admission]. Results: Seventy‐six of 119 patients survived and were eligible for follow‐up. The incidence of dysautonomia was 11.8%. Episodes of dysautonomia were prevalent during a mean period of 20.1 days (range 3–68) and were often initiated by discomfort. Patients with dysautonomia showed significant longer periods of coma (24.78 vs. 7.99 days) and mechanical ventilation (22.67 vs. 7.21 days). Dysautonomia was associated with diffuse axonal injury (DAI) [relative risk (RR) 20.83, CI 4.92–83.33] and the development of spasticity (RR 16.94, CI 3.96–71.42). Patients with dysautonomia experienced more secondary complications. They tended to have poorer outcome. Conclusions: Dysautonomia occurs in approximately 10% of patients surviving severe TBI and is associated with DAI and the development of spasticity at follow‐up. The initiation of dysautonomia by discomfort supports the Excitatory: Inhibitory Ratio model as pathophysiological mechanism.     

Obsessive-compulsive disorder after traumatic brain injury

Traumatic brain injury (?TBI) neuropsychiatric sequelae are a significant cause of morbidity in TBI victims. Among the recognized sequelae are anxiety, obsessions, compulsions and obsessive-compulsive disorder (OCD). This review addresses the emergence of OCD and OCD symptoms after TBI with an emphasis on neural circuits that underlie OCD symptom expression that may be affected by the injury. Current studies suggest that post-TBI emergent psychopathology, including OCD, is influenced by underlying sub-clinical diathesis, brain injury lesions sites, environmental stressors and the rehabilitation process. Pre-morbid status can be obtained by structured psychiatric interviews, and TBI brain lesions can be defined with advanced neuroimaging techniques. This information along with the management of family and environmental stressors and the enhanced clinical identification of symptoms of anxiety and OCD can be used in the rehabilitation process to improve prognosis after TBI.