Recovery and rehabilitation following traumatic brain injury

Although most patients are discharged following traumatic brain injury TBI with good recovery , recent reports indicate that many have persistent neuropsychological deficits. The purposes of this study were to 1 determine if functional, neuropsychological and social outcome at 3 and 6 months in patients hospitalized following TBI could be ascertained via telephone follow up, and 2 assess use of rehabilitation services in this population. Patients were identified through acute hospital admissions. A trained nurse practitioner abstracted data from acute charts. Using the Functional Independence Measure FIM , Neurobehavioral Rating Scale NRS , Telephone Interview for Cognitive Status TICS , and a social questionnaire she obtained follow up information at 3 and 6 months post injury. Of 74 patients initially identified, 51 and 48 were available at 3 and 6 months, respectively. Most experienced mild to moderate TBI. Physical disability was minimal at follow up as indicated by the FIM. Approximately half of the patients were rated cognitively impaired on the TICS at 3 months and over one third remained impaired at 6 months. At 6 months 60.5% remained unemployed. Only eight of the 67 discharged survivors received any rehabilitation services. A brief telephone follow up appears to be a cost effective way to ascertain functional and neuropsychological outcome in TBI survivors. Since few of these patients received rehabilitation, a telephone follow up may identify those who would potentially benefit from additional rehabilitation services.     

胰腺钝性损伤急诊CT诊断与外科治疗

【摘要】〓目的〓探讨胰腺损伤的诊断及外科治疗。方法〓回顾分析经临床诊疗和手术证实为钝性胰腺损伤(13例)患者CT表现和治疗结果。结果〓13例患者中,胰腺挫伤4例,挫裂伤9例,其中胰腺横断伤1例;均伴有胰周被膜、肾前筋膜增厚,胰腺周围脂肪间隙模糊及积液;2例伴假囊肿形成。合并伤包括脾挫裂伤5例,肝挫裂伤6例,肾挫裂伤3例。12例痊愈,1例死亡,3例术后6月假性囊肿形成。结论〓腹部CT检查对胰腺损伤的早期诊断及治疗具有非常重要的价值。     

Everyday memory following traumatic brain injury

Residual memory deficits may represent a problem to the everyday functioning of a large number of people, including those who have sustained traumatic brain injury (TBI). The present exploratory study sought to investigate the interrelationships between subjective memory reports, performance on traditional memory tests, and performance on tests of prospective memory. These interrelationships were contrasted between a group of 24 adults who had sustained TBI and a group of 24 matched control subjects. Prospective memory was hypothesized to be indicative of everyday memory functioning. The results provided preliminary evidence that prospective memory tests are sensitive to TBIrelated neurological impairment and, in comparison to traditional tests, may be better indicators of functional memory capacity. This pattern was particularly true for control subjects, possibly because TBI subjects had difficulties in evaluating their memory functioning.     

Perceived needs following traumatic brain injury

OBJECTIVES: (1) Provide population-based estimates of perceived needs following traumatic brain injury (TBI) and the prevalence of unmet needs 1 year postinjury; (2) identify relations among needs that define unique clusters of individuals; and (3) identify risk factors for experiencing selected needs. DESIGN: Telephone survey 1 year after injury of a prospective cohort of all people hospitalized with TBI in the state of Colorado during 2000. MEASURES: Self-reported need for assistance in 13 areas of functioning. RESULTS: A total of 58.8% of persons hospitalized with TBI experienced at least 1 need during the year following injury; 40.2% will experience at least 1 unmet need 1 year after injury. Most frequently experienced needs were "improving your memory, solving problems better" (34.1%), "managing stress, emotional upsets" (27.9%), and "managing your money, paying bills" (23.3%). Cluster analysis revealed 8 distinctive groupings of subjects. If a need existed, those least likely to be met involved cognitive abilities, employment, and alcohol and/or drug use. CONCLUSIONS: Results were consistent with findings from previous assessments of need for services based on surveys of convenience samples; however, the prevalence of unmet needs 1 year after injury may be higher than previously suspected. More post-hospital services addressing cognitive and emotional problems appear needed. Risk factors for experiencing needs suggest potential avenues for clinical intervention.     

Neuroplasticity following non-penetrating traumatic brain injury

The primary objective of this review is to examine the methodology and evidence for neuroplasticity operating in recovery from traumatic brain injury (TBI), as compared with previous findings in patients sustaining perinatal and infantile focal vascular lesions. The evidence to date indicates that the traditional view of enhanced reorganization of function after early focal brain lesions might apply to early focal brain lesions, but does not conform with studies of early severe diffuse brain injury. In contrast to early focal vascular lesions, young age confers no advantage in the outcome of severe diffuse brain injury. Disruption of myelination could potentially alter connectivity, a suggestion which could be confirmed through diffusion tensor imaging (DTI). Initial reports of DTI in TBI patients support the possibility that this technique can demonstrate alterations in white matter connections which are not seen on conventional magnetic resonance imaging (MRI) and might change over time or with interventions. Preliminary functional MRI studies of TBI patients indicate alterations in the pattern of brain activation, suggesting recruitment of more extensive cortical regions to perform tasks which stress computational resources. Functional MRI, coupled with DTI and possibly other imaging modalities holds the promise of elucidating mechanisms of neuroplasticity and repair following TBI.     

Sexual functioning following traumatic brain injury

In this study we investigated sexual functioning in 52 outpatients with a history of traumatic brain injury to determine: (1) the prevalence of reported sexual dysfunction; and (2) the relationship between sexual functioning and age, severity and locus of injury, time since injury, and physical and cognitive function. Reports of sexual functioning indicated a reduction below levels within non-injured populations, but only to statistically significant levels on two scales of the Derogatis Interview of Sexual Function (DISF): Orgasm and Drive/Desire. Location of injury was related to sexuality in that patients with frontal lobe lesions reported an overall higher level of sexual satisfaction and functioning than those individuals without frontal lobe lesions. Time since injury was inversely related to reports of levels of sexual arousal; that is, patients with more recent injuries reported greater levels of arousal than those not recently injured. Right hemisphere injuries also correlated with higher scores on reports of sexual arousal and sexual experiences.     

Psychiatric comorbidity following traumatic brain injury

PRIMARY OBJECTIVE: Survivors of traumatic brain injury (TBI) are at increased risk for development of severe, long-term psychiatric disorders. However, the aetiology of these disorders remains unclear. This article systematically reviews the most current prevalence rates and evidence for causality, in terms of established criteria. MAIN OUTCOME AND RESULTS: Psychiatric syndromes are consistently present at an elevated rate following TBI. Survivors of TBI are particularly susceptible to major depression, generalized anxiety disorder and post-traumatic stress disorder. Evidence for a biological gradient is generally lacking, although this criterion may not be appropriate in the case of TBI. The temporal pattern of onset is variable and reliable critical periods for the post-injury development of a psychiatric disorder remain to be identified; however, individuals appear to remain at risk for years following injury. CONCLUSIONS: Non-organic factors, including pre-morbid personality traits and post-injury psychological reactions to disability and trauma, are implicated in the generation and maintenance of post-TBI psychiatric disorder. There remains insufficient evidence to conclude what role the neuropathological consequences of TBI play in the development of post-TBI psychiatric disorder.     

Acute confusion following traumatic brain injury

Primary objective: To determine the incidence, duration and symptoms associated with acute confusion/delirium among traumatic brain injury (TBI) neuro-rehabilitation admissions.

Research design: Prospective evaluation of neurobehavioural impairments following TBI among inpatient neurorehabilitation admissions.

Methods and procedures: Eighty-five consecutive TBI model system patients were evaluated using measures of orientation, cognition, motor restlessness and delirium.

Main outcomes and results: Fifty-nine individuals met Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition Delirium Diagnostic Criteria (DDC) on initial evaluation and 42 of these resolved delirium during inpatient rehabilitation. Multivariable logistic regression analyses revealed significant unique associations of the Galveston Orientation and Amnesia Test (GOAT), Delirium Rating Scale, Cognitive Test for Delirium and time elapsed since injury with DDC status.

Conclusions: Findings indicate that delirium is common among neuro-rehabilitation admissions with TBI. Use of a single measure (e.g. GOAT) will result in poor characterization of the multi-faceted symptom complex shown by patients with post-traumatic confusion.     

Vital capacity following traumatic brain injury

This study was designed to describe lung volume subdivisions in individuals with traumatic brain injury. Records were reviewed for 114 consecutive referrals for motor speech evaluations in a community re-entry residential rehabilitation programme. Obtained measures were vital capacity, inspiratory capacity, and expiratory reserve volume at the time of evaluation. Seventy-nine per cent of subjects evidenced at least moderate deficits in expiratory reserve volume, with 60% evidencing severe deficits. Inspiratory capacity was the least affected, with 61% of subjects evidencing values within normal limits. Possible contributors to reduced expiratory reserve volumes include expiratory muscle weakness due to physical inactivity, inability to voluntarily perform the task, or perceived effort.     

Outcome following moderate traumatic brain injury

BACKGROUND: Little is known about the outcome following moderate traumatic brain injury (TBI) (GCS 9-12). Most patients regain consciousness; however, the full magnitude of long-term cognitive and functional deficits is unknown. METHODS: We conducted a prospective observational study evaluating the outcome of patients suffering moderate TBI between October 1995 and March 1998. Long-term outcome was assessed by telephone interviews. RESULTS: A total of 79 consecutive patients were included. Average length of ICU and total hospital stay was 9.1 and 15.8 days respectively. The median GCS at 24 hours was 10 with 67% improving to GCS 15 by time of discharge. The presence of multisystem trauma did not affect outcome; however, age >/=45, initiation of enteral feeding after postinjury day 4 and the presence of pneumonia were all associated with longer lengths of stay and increased complication rates. Fifty-six (71%) patients were contacted for follow-up at an average of 27.5 months. GOS scores were 5 in 44%, 4 in 41%, 3 in 9%, 1 in 6%. Seventy-four percent of patients employed premorbidly returned to full-time work. Questions regarding cognitive and functional status revealed significant problems in the majority of patients. CONCLUSIONS: Pneumonia, age >/=45 years and a delay in initiation of enteral feeding all increased the duration of acute care hospital stay following moderate TBI. In addition, cognitive, emotional, and functional problems following such injuries are extensive and long lasting. Physicians must be knowledgeable of these long-term sequela so they can provide the appropriate support and treatment to these patients.     

Psychiatric comorbidity following traumatic brain injury

Primary objective: Survivors of traumatic brain injury (TBI) are at increased risk for development of severe, long-term psychiatric disorders. However, the aetiology of these disorders remains unclear. This article systematically reviews the most current prevalence rates and evidence for causality, in terms of established criteria.

Main outcome and results: Psychiatric syndromes are consistently present at an elevated rate following TBI. Survivors of TBI are particularly susceptible to major depression, generalized anxiety disorder and post-traumatic stress disorder. Evidence for a biological gradient is generally lacking, although this criterion may not be appropriate in the case of TBI. The temporal pattern of onset is variable and reliable critical periods for the post-injury development of a psychiatric disorder remain to be identified; however, individuals appear to remain at risk for years following injury.

Conclusions: Non-organic factors, including pre-morbid personality traits and post-injury psychological reactions to disability and trauma, are implicated in the generation and maintenance of post-TBI psychiatric disorder. There remains insufficient evidence to conclude what role the neuropathological consequences of TBI play in the development of post-TBI psychiatric disorder.     

Sexual dysfunction following traumatic hand injury

The purpose of this study was to examine the frequency and nature of sexual dysfunction present in a population with traumatic hand injuries. One hundred twenty patients were seen for psychological evaluation during the first two months postinjury. Forty-nine percent (59) reported sexual dysfunction during the initial two months. Six months postinjury 19% (23) continued to have sexual dysfunction. At that time a more extensive sexual history was obtained. Three categories of sexual dysfunction were identified following interviews: (1) impotence (35% or 8 patients), (2) reduced sexual desire (65% or 15), and (3) rejection of sexual contact by the partner (39% or 9). Four major causes of impaired sexual functioning were reported: (1) pain (22% or 5 patients), (2) deformity anxiety (52% or 12), (3) replant anxiety (9% or 2), and (4) contagious anxiety (39% or 9). The results of this study indicate that persistent sexual dysfunction may be a major difficulty following hand trauma. The type of dysfunction as well as the perceived cause of dysfunction are not the same for each case. Consideration of each is necessary to design efficacious intervention strategies.     

Anterior hypopituitarism following traumatic brain injury

PRIMARY OBJECTIVES: To review evidence that there exists a substantial sub-population of patients with endocrine disorders as a result of traumatic brain injury (TBI) and to underscore the importance of screening patients with TBI considered most at risk for hypopituitarism with the goal of attaining beneficial effects in terms of morbidity and quality of life. DESIGN AND METHODS: Reviewed recent literature regarding the frequency of TBI-induced hypopituitarism. MAIN OUTCOMES AND RESULTS: Studies by Kelly DF, Gaw Gonzalo IT, Cohan P, et al. Hypopituitarism following traumatic brain injury and aneurysmal subarachnoid hemorrhage: A preliminary report. Journal of Neurosurgery 2000;93:743-751, Lieberman SA, Oberoi AL, Gilkison CR, et al. Prevalence of neuroendocrine dysfunction in patients recovering from traumatic brain injury. Journal of Clinical Endocrinology and Metabolism 2001;86:2752-2756 and Aimaretti G, Ambrosio MR, Di Somma C, et al. Traumatic brain injury and subarachnoid haemorrhage are conditions at high risk for hypopituitarism. Screening study at 3 months after the brain injury, In press., found that about one-half to one-third of patients with TBI had anterior pituitary hormone deficiencies, including growth hormone (GH) deficiency in 15-21%, and subtle deficiencies in thyroid, adrenal and gonadal axes. One or more hormonal deficiencies produce diverse physical and psychological symptoms that may mimic symptoms attributed to brain trauma and may impair rehabilitation. A more general concern is the fact that hypopituitarism increases the risk of significant morbidity (e.g. ischaemic heart disease) and mortality (shortened life span). CONCLUSIONS: To attain maximal improvement in mental and physical functioning as well as in quality of life for victims of TBI, it is crucial that anterior pituitary hormonal function be assessed. Appropriate hormone replacement therapy for those patients with both TBI and TBI-induced pituitary function impairment could, for the first time, allow treatment and correction of underlying causes of TBI sequelae rather than merely symptomatic treatment.     

Service utilization following traumatic brain injury

OBJECTIVES: To document service utilization by people with a traumatic brain injury at different times postinjury and to identify factors that predict service use. DESIGN: Cross-sectional study design. Four groups of subjects were randomly selected from a regional database, according to their time postinjury: 6-18 months; 2-4 years; 6-9 years; and 10-17 years. SUBJECTS: A total of 119 adults with a traumatic brain injury (TBI). SETTING: Hospital and community-based clients in Sydney, Australia. OUTCOME MEASURES: Glasgow Outcome Scale, Disability Rating Scale; Functional Independence Measure; Lidcombe Psychosocial Disability Scale; number, type, and frequency of services used in the previous 12 months. RESULTS: Subjects in all four groups used a variety of services. The mean number of services used was 4.2, and there was only a moderate decline in service use over time. The use of medical and allied health services remained high in all four groups. Severity of injury, physical and cognitive disability, and psychosocial disability were all predictors of service utilization. Psychosocial disability was strongly associated with ongoing service utilization. CONCLUSION: In this study, people with TBI used services well beyond the early stage of recovery. Psychosocial disability may be a better predictor of service use than physical and cognitive disability alone.     

Sleep disturbances following traumatic brain injury

Opinion statement  

Rehabilitation and outcome following pediatric traumatic brain injury

The long-term outcome for a child who has sustained a traumatic brain injury must be viewed in the context of ongoing development and maturation. Although neuronal plasticity provides the potential for neuronal reorganization in a child's brain, it is the behavioral demands of the environment that allow the child to take advantage of this potential and to maximize recovery. Pediatric rehabilitation is the setting that provides the necessary experiences for stimulating neuronal reorganization following TBI. However, neuronal reorganization has a cost to long-term development. The ultimate long-term impact of a TBI sustained in childhood depends on the child's ability to achieve developmental milestones following injury. Although injury-related and treatment-related factors are critical during the early stages of recovery, patient-related factors such as age-at-injury, developmental achievement at time of injury, maturation, and family involvement and resources impact the later stages of recovery. The process of pediatric rehabilitation following TBI is to provide an enriched, stimulating environment tailored to the needs of the child and based on real-word experiences. Early in the recovery process, pediatric rehabilitation is the setting that maximizes the potential for neuronal reorganization. Early rehabilitation also prepares the family for the child's long-term recovery and developmental needs. Involvement and training of family members early in the recovery process is critical for successful long-term outcome. Family members are the individuals best equipped to ensure treatment compliance and follow through with treatment recommendations, in maintaining treatment gains, and in generalizing treatment effects beyond the medical settings. Despite the life-long ramifications of childhood TBI, pediatric rehabilitation is the necessary step in promoting recovery and successful long-term outcome.