A Preliminary Model for Posttraumatic Brain Injury Depression

Malec JF, Brown AW, Moessner AM, Stump TE, Monahan P. A preliminary model for posttraumatic brain injury depression.

Objective

To develop, based on previous research, and evaluate a model for depression after traumatic brain injury (TBI).

Design

Cross-sectional structural equation modeling (SEM) of data from consecutively recruited patients.

Setting

Acute hospital and inpatient rehabilitation units.

Participants

Adult patients (N=158) after hospital admission for moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measures

External appraisal of ability in participants was measured by the Mayo-Portland Adaptability Inventory (MPAI-4) Ability Index completed by a TBI clinical nurse specialist. Patient self-appraisal of post-TBI ability and depression were measured by the Awareness Questionnaire and Beck Depression Inventory-II. Functional outcome 1 year after injury was assessed with the MPAI-4 Participation Index.

Results

Successive SEM resulted in a parsimonious model with excellent fit. Consistent with prior research, a moderately strong association between self-appraisal of post-TBI ability and depression was found. Injury severity, as measured by the duration of posttraumatic amnesia (PTA), was not significantly associated with post-TBI depression. The 1-year functional outcome was associated with depression and TBI severity.

Conclusions

The strong association between self-appraisal of post-TBI ability and depression is consistent with the cognitive-behavioral model of depression and recommends consideration and further study of cognitive-behavioral therapy for post-TBI depression. The lack of association between TBI severity and depression may represent the indirect and proxy nature of current measures of TBI severity such as PTA. Emerging neuroimaging techniques (eg, diffusion tensor imaging, magnetic resonance imaging spectroscopy) may provide the more direct measures of disruption of brain function after TBI that are needed to advance this line of research.     

Functional limitations and depression after traumatic brain injury: examination of the temporal relationship

Pagulayan KF, Hoffman JM, Temkin NR, Machamer JE, Dikmen SS. Functional limitations and depression after traumatic brain injury: examination of the temporal relationship.

Objective

To examine the temporal relationship between self-reported injury-related functional limitations and depressive symptomatology after traumatic brain injury (TBI).

Design

A longitudinal cohort study with 3 evaluation points.

Setting

A level I trauma center.

Participants

Adolescents and adults (N=135) with complicated mild to severe TBI (72% had complicated mild injuries) who were recruited within 24 hours of injury and then completed the measure at all 3 time points.

Interventions

Not applicable.

Main Outcome Measures

Sickness Impact Profile and Center for Epidemiological Studies−Depression Scale.

Results

Individuals who reported more depressive symptomatology consistently endorsed more injury-related difficulties, showing the strong relationship between depression and perceived psychosocial functioning. Examination of these relationships over time revealed that increased depressive symptomatology follows higher levels of perceived injury-related changes but that reports of injury-related changes are not associated with earlier depression. These findings suggest a unidirectional temporal relationship between these variables.

Conclusions

Perceived changes in daily functioning appear to influence emotional well-being over time after TBI. However, depressive symptoms do not appear to negatively impact individuals' perception of later functioning. These results further our understanding of the complicated relationship between these variables and may have important implications for treatment of depression after TBI.     

Poor sleep quality and changes in objectively recorded sleep after traumatic brain injury: a preliminary study

Parcell DL, Ponsford JL, Redman JR, Rajaratnam SM. Poor sleep quality and changes in objectively recorded sleep after traumatic brain injury: a preliminary study.

Objectives

To evaluate changes in sleep quality and objectively assessed sleep parameters after traumatic brain injury (TBI) and to investigate the relationship between such changes and mood state and injury characteristics.

Design

Survey and laboratory-based nocturnal polysomnography.

Setting

Sleep laboratory.

Participants

Ten community-based subjects with moderate to very severe TBI and 10 age- and sex-matched controls from the general community.

Interventions

Not applicable.

Main Outcome Measures

Pittsburgh Sleep Quality Index for self-report sleep quality, nocturnal polysomnography for objective sleep recording, and Hospital Anxiety and Depression Scales.

Results

Compared with controls, TBI patients reported significantly poorer sleep quality and higher levels of anxiety and depression. Objective sleep recording showed that TBI patients showed an increase in deep (slow wave) sleep, a reduction in rapid eye movement sleep, and more frequent nighttime awakenings. No significant relationship was observed between these changes in sleep and injury severity or time since injury. Anxiety and depression covaried with the observed changes in sleep.

Conclusions

The findings contribute to the growing body of evidence that sleep is involved in the physiologic processes underlying neural recovery. The association between anxiety and depression and the observed changes in sleep in TBI patients warrants further examination to determine whether a causative relationship exists.     

Psychosocial factors and maternal wellbeing: an exploratory path analysis

Background

Developing a sense of well-being and achieving competence and satisfaction in the maternal role have a tremendous impact on the quality of parenting behaviour and the child's psychosocial development. Little is known about the mechanisms through which learned resourcefulness, social support and stress affect postnatal depression and women's sense of competence and satisfaction in the maternal role.

Objectives

To test a conceptual model that examines the relationships between learned resourcefulness, social support, stress, maternal role competence and satisfaction, and postnatal depression in first-time Chinese mothers.

Design

A predictive correlational study using secondary analysis of data from an intervention study.

Settings

The study was conducted in two regional public hospitals in Hong Kong.

Participants

A total of 181 first-time Chinese mothers were followed at six weeks post-partum.

Methods

Participants completed five instruments at six weeks post-partum: the Self-Control Schedule, Medical Outcomes Study Social Support Survey, Social Readjustment Rating Scale, Parenting Sense of Competence Scale and Edinburgh Postnatal Depression Scale. Path analysis was employed.

Results

The findings indicate that learned resourcefulness and social support have a direct impact on maternal role competence and satisfaction and on postnatal depression. Stress affected postnatal depression directly and maternal role competence and satisfaction indirectly, via learned resourcefulness and social support. Both learned resourcefulness and social support mediated the effects of stress on maternal role competence and satisfaction and postnatal depression.

Conclusions

This study establishes potential mechanisms through which learned resourcefulness, social support and stress contribute to maternal role competence and satisfaction and postnatal depression during early motherhood. Culturally competent healthcare should be developed to provide support and equip women with learned resourcefulness skills to combat the stress of early motherhood, thereby enhancing maternal role competence and satisfaction and minimizing the risk of postnatal depression.     

Mortality Over Four Decades After Traumatic Brain Injury Rehabilitation: A Retrospective Cohort Study

Harrison-Felix CL, Whiteneck GG, Jha A, DeVivo MJ, Hammond FM, Hart DM. Mortality over four decades after traumatic brain injury rehabilitation: a retrospective cohort study.

Objective

To investigate mortality, life expectancy, risk factors for death, and causes of death in persons with traumatic brain injury (TBI).

Design

Retrospective cohort study.

Setting

Used data from an inpatient rehabilitation facility, the Social Security Death Index, death certificates, and the U.S. population age-race-sex-specific and cause-specific mortality rates.

Participants

Persons with TBI (N=1678) surviving to their first anniversary of injury admitted to rehabilitation from an acute care hospital within 1 year of injury between 1961 and 2002.

Interventions

Not applicable.

Main Outcome Measures

Vital status, standardized mortality ratio, life expectancy, cause of death.

Results

Persons with TBI were 1.5 times more likely to die than persons in the general population of similar age, sex, and race, resulting in an estimated average life expectancy reduction of 4 years. Within the TBI population, the strongest independent risk factors for death after 1 year postinjury were being older, being male, having less education, having a longer hospitalization, having an earlier year of injury, and being in a vegetative state at rehabilitation discharge. After 1 year postinjury, persons with TBI were 49 times more likely to die of aspiration pneumonia, 22 times more likely to die of seizures, 4 times more likely to die of pneumonia, 3 times more likely to commit suicide, and 2.5 times more likely to die of digestive conditions than persons in the general population of similar age, sex, and race.

Conclusions

This study demonstrated life expectancy after TBI rehabilitation is reduced and associated with specific risk factors and causes of death.     

Environmental barriers to and availability of healthy foods for people with mobility disabilities living in urban and suburban neighborhoods

Mojtahedi MC, Boblick P, Rimmer JH, Rowland JL, Jones RA, Braunschweig CL. Environmental barriers to and availability of healthy foods for people with mobility disabilities living in urban and suburban neighborhoods.

Objective

To assess the impact of the built environment on access to healthy foods for people with mobility disabilities by measuring wheelchair accessibility of grocery stores and availability of healthy affordable foods.

Design

A survey consisting of 87 questions.

Setting

A low-income, multiracial urban Chicago neighborhood with a 3-mile radius was compared with a suburban neighborhood of the same size in which the population is similar in income level and racial distribution.

Participants

Not applicable.

Interventions

Not applicable.

Main Outcome Measures

Accessibility issues outside and within grocery stores and the availability of healthy affordable food items in these grocery stores.

Results

The urban area had more stores (n=48) than the suburban area (n=34); however, only 46% of urban stores had an entrance that would allow an individual requiring a ramp or level entrance to gain access compared with 88% of suburban stores (P<.001). Wheelchair accessibility characteristics of grocery and convenience stores did not differ between the urban and suburban areas. The availability of healthy affordable foods in urban and suburban stores was relatively low, with only 33% to 40% of the 18 items available, and did not differ between urban and suburban stores.

Conclusions

People with mobility impairments are at a disadvantage in maintaining healthy food choices because of limited access to stores and healthy foods.     

Patient-centredness in physiotherapy from the perspective of the chronic low back pain patient

Objective

To define patient-centredness from the patient's perspective in the context of physiotherapy for chronic low back pain (CLBP).

Design

Qualitative study using semi-structured interviews to explore perceptions of various aspects of physiotherapy management of CLBP.

Setting

Physiotherapy departments in one geographical area of the UK National Health Service.

Participants

Twenty-five individuals who had received physiotherapy for CLBP within the previous 6 months.

Results

Six key themes emerged as the dimensions that the participants perceived to be important for patient-centred physiotherapy: communication; individual care; decision-making; information; the physiotherapist; and organisation of care. Communication was the most important dimension, underpinning the five other dimensions as well as being a distinct dimension of patient-centred physiotherapy.

Conclusions

Physiotherapists should have an understanding of the six dimensions of patient-centred physiotherapy for CLBP. Improving physiotherapists’ communication skills may better facilitate patient-centred physiotherapy, and therefore enhance the experience of physiotherapy for this client group.     

Characterizing wandering behaviors in persons with traumatic brain injury residing in veterans health administration nursing homes

Belanger HG, King-Kallimanis B, Nelson AL, Schonfeld L, Scott SG, Vanderploeg RD. Characterizing wandering behaviors in persons with traumatic brain injury residing in Veterans Health Administration nursing homes.

Objective

To examine the prevalence and correlates of wandering in persons with traumatic brain injury (TBI) in nursing homes (NHs).

Design

Using a cross-sectional design, logistic regression modeling was used to analyze a national database.

Setting

One hundred thirty-four NH facilities operated by the Veterans Health Administration.

Participants

NH residents (N=625) with TBI as well as a sample (n=164) drawn from a larger dataset of NH residents without TBI using 1:K matching on age.

Interventions

Not applicable.

Main Outcome Measure

Wandering.

Results

Wanderers with and without TBI did not differ significantly overall. The prevalence of wandering among patients with TBI was 14%, compared with 6.5% of the general nursing home population. The results of the multivariate logistic regression suggested that wandering was associated with poor memory, poor decision making, behavior problems, independence in locomotion and ambulation, and dependence in activities of daily living related to basic hygiene.

Conclusions

Wandering is relatively common in NH residents with TBI. As expected, it is associated with cognitive, social, and physical impairments. Further research with a larger sample should examine those with comorbid dementia and/or psychiatric diagnoses.     

Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence

Macciocchi S, Seel RT, Thompson N, Byams R, Bowman B. Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence.

Objectives

To examine prospectively the incidence and severity of co-occurring traumatic brain injury (TBI) in persons with traumatic spinal cord injury (SCI) and to describe a TBI assessment process for SCI rehabilitation professionals.

Design

A prospective, cohort design to collect and analyze clinical variables relevant for diagnosing co-occurring TBI.

Setting

An urban, single-center National Institute of Disability and Rehabilitation Research Model Spinal Cord Injury System in the Southeastern United States.

Participants

People (N=198) who met inclusion criteria and provided consent within an 18-month recruitment window.

Interventions

Not applicable.

Main Outcome Measure

FIM cognitive scale.

Results

Based on participants' presence and duration of posttraumatic amnesia, initial Glasgow Coma Scale total score, and presence of cerebral lesion documented by neuroimaging, 60% of our traumatic SCI sample also sustained a TBI (n=118). Most co-occurring TBIs were mild (34%). Co-occurring mild complicated (10%), moderate (6%), and severe TBI (10%) were less common but still occurred in a significant percentage (26%) of persons with traumatic SCI. Persons with traumatic SCI who were injured in motor vehicle collisions and falls were more likely to sustain a co-occurring TBI. Cervical level traumatic SCI was associated with greater rates of TBI but not more severe injuries. Tree analyses established a practical algorithm for classifying TBI severity associated with traumatic SCI. Analysis of variance established criterion validity for the algorithm's TBI severity classifications.

Conclusions

Findings from our prospective study provide strong support that TBI is a common co-occurring injury with traumatic SCI. Incomplete acute care medical record documentation of TBI in the traumatic SCI population remains a considerable issue, and there is a significant need to educate emergency department and acute care personnel on the TBI clinical data needs of acute rehabilitation providers. A systematic algorithm for reviewing acute care medical records can yield valid estimates of TBI severity in the traumatic SCI population.     

Neuropsychologic and functional outcome after complicated mild traumatic brain injury

Kashluba S, Hanks RA, Casey JE, Millis SR. Neuropsychologic and functional outcome after complicated mild traumatic brain injury.

Objective

To investigate the extent to which neuropsychologic and functional outcome after complicated mild traumatic brain injury (TBI) parallels that of moderate TBI recovery.

Design

A longitudinal study comparing neuropsychologic and functional status of persons with complicated mild TBI and moderate TBI at discharge from inpatient rehabilitation and at 1 year postinjury.

Setting

Rehabilitation hospital with a Traumatic Brain Injury Model System.

Participants

Persons with complicated mild TBI (n=102), each with an intracranial brain lesion documented through neuroimaging and a highest Glasgow Coma Scale (GCS) score in the emergency department between 13 and 15, and 127 persons with moderate TBI.

Interventions

Not applicable.

Main Outcome Measures

FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Wechsler Memory Scale logical memory I and II, Rey Auditory Verbal Learning Test, Trail-Making Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Wisconsin Card Sorting Test, and block design.

Results

Few differences in neuropsychologic performance existed between the TBI groups. Less severely impaired information processing speed and verbal learning were seen in the complicated mild TBI group at rehabilitation discharge and 1 year postinjury. Despite overall improvement across cognitive domains within the complicated mild TBI group, some degree of impairment remained at 1 year postinjury on those measures that had identified participants as impaired soon after injury. No differences on functional ability measures were found between the TBI groups at either time period postinjury, with both groups exhibiting incomplete recovery of functional status at the 1-year follow-up.

Conclusions

When classifying severity of TBI based on GCS scores, consideration of a moderate injury designation should be given to persons with an intracranial bleed and a GCS score between 13 and 15.     

Personal Bankruptcy After Traumatic Brain or Spinal Cord Injury: The Role of Medical Debt

Relyea-Chew A, Hollingworth W, Chan L, Comstock BA, Overstreet KA, Jarvik JG. Personal bankruptcy after traumatic brain or spinal cord injury: the role of medical debt.

Objective

To estimate the prevalence of medical debt among traumatic brain injury (TBI) and spinal cord injury (SCI) patients who discharged their debts through bankruptcy.

Design

A cross-sectional comparison of bankruptcy filings of injured versus randomly selected bankruptcy petitioners.

Setting

Patients hospitalized with SCI or TBI (1996-2002) and personal bankruptcy petitioners (2001-2004) in western Washington State.

Participants

Subjects (N=186) who filed for bankruptcy, comprised of 93 patients with previous SCI or TBI and 93 randomly selected bankruptcy petitioners.

Interventions

Not applicable.

Main Outcome Measures

Medical and nonmedical debt, assets, income, expenses, and employment recorded in the bankruptcy petition.

Results

Five percent of randomly selected petitioners and 26% of petitioners with TBI or SCI had substantial medical debt (debt that accounted for more than 20% of all unsecured debts). SCI and TBI petitioners had fewer assets and were more likely to be receiving government income assistance at the time of bankruptcy than controls. SCI and TBI patients with a higher blood alcohol content at injury were more likely to have substantial medical debts (odds ratio=2.70; 95% confidence interval, 1.04-7.00).

Conclusions

Medical debt plays an important role in some bankruptcies after TBI or SCI. We discuss policy options for reducing financial distress after serious injury.     

Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury

Vickery CD, Sherer M, Nick TG, Nakase-Richardson R, Corrigan JD, Hammond F, Macciocchi S, Ripley DL, Sander A. Relationships among premorbid alcohol use, acute intoxication, and early functional status after traumatic brain injury.

Objective

To investigate the relationships among intoxication at time of injury, preinjury history of problem drinking, and early functional status in patients with traumatic brain injury (TBI).

Design

Prospective cohort study.

Setting

Acute inpatient TBI rehabilitation.

Participants

Participants were 1748 persons with TBI.

Interventions

Not applicable.

Main Outcome Measures

Blood alcohol levels (BALs) were obtained at admission to the emergency department, and a history of problem drinking was obtained through interview. Study outcomes, Disability Rating Scale (DRS), and FIM instrument scores were gathered at admission to inpatient rehabilitation.

Results

Multivariate regression analysis revealed that BAL and a history of binge drinking were predictive of DRS, but not FIM, scores. A higher BAL was associated with poorer functional status on the DRS. Paradoxically, a history of binge drinking was associated with more intact functional status on the DRS.

Conclusions

The relationships among intoxication at time of injury, history of problem drinking, and early outcome after TBI were modest. Injury severity had a more significant association with TBI functional status.     

Family Functioning Is Associated With Depressive Symptoms in Caregivers of Acute Stroke Survivors

Epstein-Lubow GP, Beevers CG, Bishop DS, Miller IW. Family functioning is associated with depressive symptoms in caregivers of acute stroke survivors.

Objective

To determine whether family functioning is uniquely associated with caregiver depressive symptoms in the immediate aftermath of stroke.

Design

Cross-sectional data from the baseline assessment of an intervention study for stroke survivors and their families.

Setting

Neurology inpatient service of a large urban hospital.

Participants

Stroke survivors (n=192), each with a primary caregiver. The mean age of stroke survivors was 66 years, and most, 57%, were men (n=110). The mean age of caregivers was 57 years, and 73% (n=140) of the caregivers were women. Eighty-five percent of caregivers were white.

Interventions

Not applicable.

Main Outcome Measures

Measures were chosen to assess caregivers' depressive symptoms (Centers for Epidemiologic Studies Depression Scale), family functioning (Family Assessment Device), and additional factors such as health status (Medical Outcomes Study 36-Item Short-Form Health Survey) and stroke survivors' cognitive abilities (modified Mini-Mental State Examination) and functional impairments (FIM and Frenchay Activities Index).

Results

Depressive symptoms were mild to moderate in 14% and severe in 27% of caregivers. Family functioning was assessed as unhealthy in 34% of caregiver-patient dyads. In statistical regression models, caregiver depression was associated with patients' sex, caregivers' general health, and family functioning.

Conclusions

Forty-one percent of caregivers experienced prominent depressive symptoms after their family member's stroke. Higher depression severity in caregivers was associated with caring for a man, and having worse health and poor family functioning. After stroke, the assessment of caregivers' health and family functioning may help determine which caregivers are most at risk for a depressive syndrome.     

Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection

Weil L, Frauwirth NH, Amirdelfan K, Grant D, Rosenberg JA. Fluoroscopic analysis of lumbar epidural contrast spread after lumbar interlaminar injection.

Objective

To describe and answer questions concerning the spread of contrast in patients receiving correctly placed lumbar epidural steroid injections (ESIs) under fluoroscopy.

Design

Prospective observational study.

Setting

An outpatient surgery center.

Participants

Consecutive patients (N=114) receiving ESIs under fluoroscopy who met inclusion criteria.

Interventions

Not applicable.

Main Outcome Measures

Spread of contrast in relation to variables, including unilateral versus bilateral, anterior versus posterior, and spread more than 1 level caudally versus less than 1 level. Variables were examined in relation to needle tip placement, level of injection, and male versus female patients. All data were collected with fluoroscopy images in lateral and anteroposterior views after injection of 5mL of fluid.

Results

Spread was greater than 1 segment caudally more than 75% of the time under all variables. Anterior versus posterior epidural spread on the lateral view was approximately even over all cases and anterior spread was found more often when the needle was within the width of the distal spinous process tip. Needle placement medial or lateral to the spinous process width also significantly affected whether the spread was unilateral versus bilateral. If the needle tip was lateral to the width of the spinous process, spread was unilateral 75% of the time, versus 45% of the time if the needle tip was medial.

Conclusions

Contrast spread is affected by needle placement, with other variables kept equal, in the performance of an interlaminar lumbar ESI. These data support the performance of interlaminar lumbar ESIs with fluoroscopic guidance and provide some parameters with which to guide the injectionist.     

Determinants of utilization of physical rehabilitation services for persons with chronic and disabling conditions: an exploratory study

Elrod CS, DeJong G. Determinants of utilization of physical rehabilitation services for persons with chronic and disabling conditions: an exploratory study.

Objective

To determine which variables influence the receipt of physical rehabilitation services (ie, physical, occupational, speech therapy) for a population of people with chronic and disabling conditions.

Design

A convenience sample of 502 adults with cerebral palsy (CP), multiple sclerosis (MS), and spinal cord injury (SCI), drawn from diverse parts of the United States.

Setting

Respondents were surveyed in the general community.

Participants

Persons (91% under the age of 65y) with CP, MS, or SCI who responded to the 1999 component of a national longitudinal survey.

Interventions

Not applicable.

Main Outcome Measures

Self-reported need for physical rehabilitation services. Bivariate and multivariate analyses were used to examine variables that influenced utilization of services.

Results

Some 53% of respondents did not receive self-reported needed physical rehabilitation services. Respondents who had Medicaid were more likely than those with Medicare or private insurance to receive physical rehabilitation services. Respondents having a lower household income and poorer health were less likely to receive services.

Conclusions

Our findings indicate that health care funding sources provide widely disparate coverage for physical rehabilitation services to persons with 3 specific chronic and disabling conditions. Policy-makers and health plan administrators should re-evaluate their coverage of physical rehabilitation services designed to enhance quality of life and reduce the burden of lost independence.     

The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: A cluster randomised trial

Background

Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy.

Objectives

The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses.

Design

A cluster randomised trial was conducted between September 2006 and July 2008.

Settings

Ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward.

Participants

All nurses from participating wards.

Methods

A knowledge test measured nurses’ knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately.

Results

After correction for baseline, the mean difference between the intervention and the control group on hospital nurses’ knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: −0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10-0.81). For the other two topics there was no statistically significant effect. Nursing home nurses’ knowledge did neither improve (0 points, CI: −0.35 to 0.35) overall, nor for the separate subjects.

Conclusion

The educational intervention improved hospital nurses’ knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is needed.

Trial registration

ClinicalTrials.gov ID [NCT00365430].     

Relationship of Preinjury Caregiver and Family Functioning to Community Integration in Adults With Traumatic Brain Injury

Sady MD, Sander AM, Clark AN, Sherer M, Nakase-Richardson R, Malec JF. Relationship of preinjury caregiver and family functioning to community integration in adults with traumatic brain injury.

Objective

To investigate the relationship of preinjury caregiver and family functioning to community integration outcomes in persons with traumatic brain injury (TBI).

Design

Inception cohort.

Setting

Three TBI Model Systems inpatient rehabilitation facilities.

Participants

Persons with TBI (N=141) and their caregivers admitted to inpatient rehabilitation and followed up at 1 to 2 years after injury.

Interventions

Not applicable.

Main Outcome Measures

Community Integration Questionnaire and the Social and Occupation scales of the Craig Handicap Assessment and Reporting Technique.

Results

There were significant interactions of several preinjury caregiver and family variables with injury severity. For persons with complicated mild/moderate injury, better family functioning was associated with greater home integration, and less caregiver distress was associated with better social integration. For persons with severe injuries, greater caregiver perceived social support was associated with better outcomes in productivity and social integration.

Conclusions

Preinjury caregiver and family characteristics interact with injury severity to affect outcomes in persons with injury. Research on outcomes should include measures of caregiver and family functioning. Early interventions targeted toward decreasing caregiver distress, increasing support, and improving family functioning may have a positive impact on later outcomes.     

Age-related differences in Tai Chi gait kinematics and leg muscle electromyography: a pilot study

Wu G. Age-related differences in Tai Chi gait kinematics and leg muscle electromyography: a pilot study.

Objective

To compare the biomechanic features of Tai Chi gait by elders with those by young adults, and with those of normative gait.

Design

Cross-sectional study.

Setting

Laboratory-based testing.

Participants

Young (n=6; 3 women) and old (n=6; 5 women) Tai Chi practitioners.

Intervention

All subjects had practiced Tai Chi for at least 4 months.

Main Outcome Measures

Spatial, temporal, and leg muscle electromyography during Tai Chi gait and normative gait.

Results

The primary age-related differences in Tai Chi gait were during single stance, with elders having significantly shorter single-stance time (−50%), less lateral displacement (-30%), knee flexion (-42%), hip flexion (-39%), activation time in the tibialis anterior (-13%), soleus (-39%), and tensor fascia lata (TFL) (-21%), activation magnitude in the tibialis anterior (-39%), and coactivation time of the tibialis anterior and soleus (-47%). Compared with normative gait, elders during Tai Chi gait had significantly larger knee (139%) and hip (66%) flexions, longer duration (90%-170%) and higher magnitude (200%-400%) of the tibialis anterior, rectus femoris, and TFL muscle activities, and longer duration of coactivation of most leg muscle pairs (130%-380%).

Conclusions

The elders practice Tai Chi gait in higher posture than younger subjects. The Tai Chi gait poses significantly higher challenges to elder’s balance and muscular system than does their normative gait.     

Pre-existing Health Conditions and Repeat Traumatic Brain Injury

Saunders LL, Selassie AW, Hill EG, Horner MD, Nicholas JS, Lackland DT, Corrigan JD. Pre-existing health conditions and repeat traumatic brain injury.

Objective

To assess and compare the effect of Pre-existing epilepsy/seizure disorder and drug/alcohol problem on the hazard of repeat traumatic brain injury (TBI) in persons with TBI who participated in a follow-up study.

Design

Retrospective cohort.

Setting

Acute care hospitals in South Carolina.

Participants

Participants were from the South Carolina Traumatic Brain Injury Follow-up Registry cohort of persons (N=2118) who were discharged from an acute care hospital in South Carolina and who participated in a year-1 follow-up interview.

Interventions

Not applicable.

Main Outcome Measures

Repeat TBI was defined by 2 isolated events of TBI in the same person at least 72 hours apart and recorded in hospital discharge or emergency department records from 1999 through 2005.

Results

A Cox proportional hazards model was used to assess the associations of Pre-existing epilepsy/seizure disorder and drug/alcohol problem with time to repeat TBI, controlling for other confounding factors. There were 2099 persons with information on both Pre-existing conditions. There were 147 (7%) persons who sustained repeat TBI after recruitment to the follow-up study, and 82 (3.9%) had a previous TBI before recruitment for which they were seen in the hospital discharge or emergency department since 1996. The hazard of repeat TBI for persons with Pre-existing epilepsy/seizure disorder was 2.3 times the hazard for those without (hazard ratio, 2.3; 95% confidence interval, 1.2-4.4; P=.011). Pre-existing drug/alcohol problem was not associated with repeat TBI. Other variables significantly associated with repeat TBI were having a prior TBI, being insured under Medicaid, and having no insurance.

Conclusions

Pre-existing epilepsy/seizure disorder predisposes to repeat TBI. Appropriate management of seizure control may be an important strategy to allay the occurrence of repeat TBI.