Treatment to improve self-awareness in persons with acquired brain injury

Aim: To examine the effects of an awareness training protocol embedded within the practice of instrumental activities of daily living (IADLs) in participants with acquired brain injury on levels of self-awareness and functional performance.

Methods: This study used a randomized control trial design: 10 participants with moderate-to-severe brain injury received six sessions of the self-awareness training while they performed IADLs (experimental group) and 10 participants performed the same IADLs but received conventional therapeutic practice (control group). In the experimental group, participants were asked to predict their performance before each task performance and to estimate their performance level after the performance.

Outcome measures: Pre- and post-intervention outcome measures taken from the two groups were compared. Instruments were standardized measures of 'general' self-awareness with collateral reports by informants (e.g. Awareness Questionnaire); 'task-specific' self-awareness (e.g. Assessment of Awareness of Disability) and Self-Regulation Skills Inventory (SRSI). Performance on IADLs was assessed using the Assessment of Motor and Process Skills (AMPS).

Results: Compared to the control group, the intervention significantly improved IADL performances and self-regulation. No significant treatment effect was observed for task-specific self-awareness, general self-awareness or community integration.

Conclusions: The self-awareness intervention significantly but selectively improved self-awareness during IADL task performance as well as functional performance. The need for a larger study with more treatment sessions is discussed.     

Who benefits? Outcome following a coping skills group intervention for traumatically brain injured individuals

Primary objective: To investigate the variables associated with positive psychological outcome following a group intervention for 33 individuals with traumatic brain injury.

Research design: Evaluation study which used multiple regression analysis to examine the variables associated with change in psychological adjustment following a 10-session cognitive behaviour therapy-based group.

Methods and procedures: The predictor variables were age at injury, time since injury, injury severity, self-awareness, pre-morbid intellectual function, memory function, executive function and level of depression and anxiety prior to intervention.

Main outcomes and results: The predictor variables contributed a significant proportion of the variance in percentage change in depression. The major finding was that better outcomes following intervention were associated with greater self-awareness of injury-related deficits.

Conclusions: The present study identified a number of variables that were associated with improvement in depression following psychological intervention and may assist future treatment resources to be directed most effectively.     

The effects of Donepezil on traumatic brain injury acute rehabilitation outcomes

Primary objective: To evaluate the effects of administering Donepezil during inpatient rehabilitation for individuals with TBI.

Research design: Retrospective, age and injury severity matched, mixed between-within subjects analysis.

Methods and procedures: Thirty-six patients with moderate-to-severe TBI admitted to acute rehabilitation within 90 days of injury. Main outcome measures included FIM cognitive total scores and rehabilitation lengths of stay.

Intervention: Initiation of Donepezil administration beginning at 5 mg daily. Dose titration and continuation based on perceived clinical response.

Main outcomes and results: No differences in cognitive improvement were observed between the Donepezil treatment group and the matched control group. Sub-set analyses suggested that administration of Donepezil early in the rehabilitation stay was significantly related to higher rates of cognitive improvement.

Conclusions: Preliminary evidence suggests that Donepezil administration early in the rehabilitation stay may have advantageous treatment effects. A prospective, randomized, placebo-controlled clinical trial with standard timing, dosage and treatment duration is recommended to further evaluate treatment efficacy.     

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.     

How clinicians talk about the application of goal planning to rehabilitation for people with brain injury-variable interpretations of value and purpose

Primary objective: To explore the way clinicians talk about the value and purpose of goal planning in rehabilitation for people with brain injury

Research design: Grounded theory

Methods and procedures: Nine clinicians from a range of professional backgrounds were interviewed. The interview data were analysed using the constant comparative method of grounded theory.

Main outcomes and results: While the clinicians considered goal planning important, the expressed reasons for valuing goal planning were at times unclear. The term 'goal' referred to not one but many concepts within the rehabilitation environment; goal planning was used to serve a range of different purposes. Different reasons for undertaking goal planning were interrelated but at times conflicted, potentially creating tensions within the rehabilitation environment.

Conclusions: Discussions around goal planning terminology should progress from service-level agreements towards more evidenced-based international consensus. Individual services might benefit from discussing and agreeing on the purpose for goal planning in their work.     

Factors related to recovery after mild traumatic brain injury

Primary objectives: To study the variables that relate to outcome after mild traumatic brain injury (TBI).

Methods and procedures: Sixty-seven adults with disappointing recoveries after mild TBI most occurring in a compensation or litigation context were studied with regard to pre-injury, neuro-trauma, physical, emotional and cognitive variables on outcome. Validity of physical, emotional and cognitive symptoms was controlled for.

Main outcomes and results: Except for prior psychological traumatization, neither pre-injury, neuro-trauma or cognitive variables were related to outcome. Variables most consistently related to outcome were depression, pain and symptom invalidity on measures of response bias. These factors accounted for the majority of variance in outcome.

Conclusions: In cases of poor recovery after mild TBI where compensation or litigation may be a factor, most of the variance in recovery seems to be explained by depression, pain and symptom invalidity, rather than by the injury variables themselves.     

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.     

Early prediction of functional outcome after stroke

Objectives: (I) To obtain biomechanical parameters and assessment scores applied at a very early stage after stroke that predict best the functional outcome after rehabilitation. (II) To evaluate the predictive value of changes (i.e. increase or decrease) of these parameters during the first week in relation to the predictive value of their absolute scores.

Design: Prospective outcome study.

Subjects: Forty-one stroke patients, admitted to the stroke unit within 24 hours.

Main outcome measures: Barthel Index, Rivermead Motor Assessment, Motor Club Assessment and Functional movement activities, NIH-Stroke scale (NIH-SS), Grip strength.

Results: Parameters assessed within the first hours after stroke correlated only weakly with the outcome. The best model predicting functional outcome and independence in activities of daily living of stroke patients after 6 months was that including NIH-SS, grip strength, age and previous stroke explaining 79% of the variance. These parameters assessed on day 7 post-stroke are more predictive than the difference between stroke onset and day 7 post-stroke.

Conclusion: Parameters for predicting outcome should not be assessed before day 7 post-stroke.     

Prediction of functional rehabilitation outcomes in clients with stroke

Objectives: To evaluate the validity of the Neurobehavioral Cognitive Status Examination (NCSE or Cognistat) and to determine its effects in order to estimate the functional outcomes of survivors with stroke.

Methods: The present study first studied the factor structure NCSE in 148 Chinese survivors with stroke (aged 45-91 years). They were admitted to hospital consecutively and recruited prospectively. The relationship of NCSE with Functional Independence Measures (FIM), a set of measures commonly adopted as an indicator of the outcome of rehabilitation, was studied.

Results: One hundred and forty-eight patients with stroke (49.3% male, 50.7% female), with a mean age of 70.38 and an average number of years of education of 3.50 years joined the study. A two-factor NCSE structure was obtained, namely verbal-spatial and integrated cognition, accounting for 62.77% of the variance. A significant relationship between NCSE factors and the functional status of clients with stroke on admission and upon discharge, as well as age, years of education and length of hospital stay were indicated.

Conclusions: This study supports a systematic relationship between cognitive factors and functional outcome in Chinese patients with stroke. Similarities and differences in the NCSE factor structure between the population with stroke and general neurological populations were discussed and the utility of NCSE in stroke rehabilitation, such as its predictive validity in functional independence is suggested.     

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.     

Management of impaired self-awareness in persons with traumatic brain injury

Aim: To develop and evaluate a systematic intervention programme for the management of impaired self-awareness (ISD) in people with traumatic brain injury.

Methods: This study adopted a pre-test-post-test control group design. Twenty-one patients with traumatic brain injury were randomly assigned to an experimental group and a control group according to their admission sequence. The groups joined a newly developed Awareness Intervention Programme (AIP) and a conventional rehabilitation programme respectively for 4 weeks. Pre- and post-intervention outcome measures taken from the two groups were compared. Wilcoxon Signed-Ranks Tests were conducted to compare the within-group changes of the outcome measures of the Self-Awareness of Deficits Interview (SADI), the Functional Independence Measure (FIM) and the Lawton Instrumental Activities of Daily Living Score (Lawton IADL) in the control and experimental groups. Mann Whitney U-tests were conducted to compare the across-group differences of improvements of outcome measures between the participants in the two groups.

Results: After AIP training, the participants in the experimental group demonstrated significant improvement in their level of awareness as compared to the control group. However, the functional outcomes of the participants in experimental group did not show significant differences.

Conclusion: The AIP can promote improvement in the level of self-awareness of people with traumatic brain injury. This new programme can be further developed to extend a better carryover treatment effect to functional improvement in daily activities.     

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.     

Mental imagery for relearning of people after brain injury

Objective: This paper reported on the application of mental imagery to the relearning of daily task performance in people with brain injury.

Method: The changes in two subjects who had suffered from cerebral infarction shown throughout a 3-week mental imagery programme were described. The subjects' improvement in task performance and other clinical outcomes illustrated the programme's therapeutic effects on skill relearning, maintenance and generalization.

Results: After completing the programme, the subjects showed improvements in performance at both the trained and untrained tasks. Feedback from the patients also suggested its ability to enhance their day-to-day functioning. Clinical assessment results indicated that the subjects experienced an increase in the attention and sequential processing functions but not in the motor and other cognitive functions.

Conclusion: Mental imagery appears to be effective at enhancing the task relearning of subjects after brain injury. The skills acquired under this treatment regime can be retained and then generalized to other tasks. Its therapeutic effect is probably mediated by the improved attention and planning and execution functions associated with the rehearsal. Further research should conduct clinical controlled trials to gather evidence on its efficacy at promoting functional regain in people suffering from neurological disorders.     

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.     

Cerebral anoxia and disability

Objectives: To describe the sequelae of cerebral anoxia following out-of-hospital cardiac arrest, to study the functional outcome and to seek a link between the acute stage and the disability.

Method: A retrospective study was performed. The initial findings and the neurological and neuropsychological status are recorded of 12 patients admitted to the rehabilitation unit for after-effects of cerebral anoxia following out-of-hospital cardiac arrest.

Results: After clinical and neuropsychological assessment, all patients displayed cognitive impairment. Two groups of patients appeared: seven patients were severely disabled with a dysexecutive and behavioural frontal lobe syndrome and memory deficit; five out of the seven also presented an extra-pyramidal syndrome; the other five patients presented behavioural dysfunction related to frontal lobe disorder but were independent in daily life activities. No correlation was found between the acute stage data and the outcome.

Conclusion: Neurological and neuropsychological impairment after cerebral anoxia may be severe but seems difficult to predict. A dysexecutive syndrome was noted in all 12 patients.     

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.     

Traumatic brain injury and functional outcomes: does minority status matter?

Objectives: (1) to determine differences between minorities vs. non-minorities on demographic, injury and rehabilitation characteristics and functional outcomes at admission, discharge and 1-year post-injury and (2) to examine differences in functional outcome at 1-year post-injury among (African-Americans, Hispanics and Whites).

Design: Retrospective study.

Setting: Longitudinal data were extracted from the TBI Model Systems database.

Participants: 4929 individuals with moderate-to-severe TBI (3354 Whites vs. 1575 Minorities: 1207 African-Americans and 368 Hispanics) hospitalized between 1989-2004.

Main outcome measures: Functional outcomes at 1-year post-injury (Disability Rating Scale, Functional Independence Measure, Glasgow Outcome Scale-Extended and Community Integration Questionnaire).

Results: At discharge and 1-year post-injury, minorities had poorer functional outcomes compared with Caucasians on all measures. After controlling for sociodemographic, injury and functional characteristics at admission, Hispanics and African-Americans still showed worse functional outcomes at 1-year post-injury compared with Whites on the DRS, FIM and CIQ. There were no significant differences between African Americans and Hispanics.

Conclusions: Minorities had significantly reduced long-term functional outcome after rehabilitation relative to Whites. It is imperative that rehabilitation professionals' consider factors related to poorer long-term functional outcome and work to improve the quality of life of minorities with TBI.     

Cognitive training in home environment

Primary objective: To examine the efficacy of cognitive rehabilitation in the patient's home or vocational environment.

Research design: Pre-post-follow-up design.

Methods and procedures: Ten outpatients with acquired attention and memory problems received cognitive training three times weekly, for 3 weeks. They received individual attention training with Attention Process Training, training for generalization for everyday activities and education in compensatory strategies for self-selected cognitive problems. Treatment effects were evaluated with neuropsychological and occupational therapy instruments before and after the training and after 3 months on impairment, activity and participation levels.

Main outcomes and results: The results indicated a positive effect on some measures on impairment level, but no differences on activity or participation levels at follow-up.

Conclusions: The study indicates that home-based cognitive training improves some attentional and memory functions and facilitates learning of strategies. Future controlled studies are needed to confirm the results and analyse the efficacy of different aspects of home-based training.     

Comparability of Mayo-Portland Adaptability Inventory ratings by staff, significant others and people with acquired brain injury

Objectives: To determine the internal consistency, reliability and comparability of the Mayo-Portland Adaptability Inventory (MPAI-4) and sub-scales completed by people with acquired brain injury (ABI), family and significant others (SO) and rehabilitation staff.

Subjects: 134 people with ABI consecutively seen for outpatient rehabilitation evaluation.

Method: MPAI-4 protocols based on independent ratings by the people with ABI undergoing evaluation, SO and rehabilitation staff were submitted to Rasch Facets analysis to determine the internal consistency of the overall measure and sub-scales (Ability, Adjustment and Participation indices) for each rater group and for a composite measure based on all rater groups. Rater agreement for individual items was also examined.

Results: Rasch indicators of internal consistency were entirely within acceptable limits for 3-rater composite full scale and sub-scale measures; these indicators were generally within acceptable limits for measures based on a single rater group. Item agreement was generally acceptable; disagreements suggested various sources of bias for specific rater groups.

Conclusions: The MPAI-4 possesses satisfactory internal consistency regardless of rating source. A composite measure based on ratings made independently by people with ABI, SO and staff may serve as a 'gold standard' for research purposes. In the clinical setting, assessment of varying perspectives and biases may not only best represent outcome as evaluated by all parties involved but be essential to developing effective rehabilitation plans.