Predicting the probability of falls in community dwelling persons with brain injury: a pilot study

PRIMARY OBJECTIVES: To determine the usefulness of select balance and functional mobility measures in predicting fall risk in community dwelling persons with brain injury (BI) and to develop a model to quantify fall risk. RESEARCH DESIGN: An exploratory pilot study to predict fall risk in persons with BI. Non-manipulated independent variable was fall status with two levels, non-faller and faller. Dependent variables were scores on the Berg Balance Scale (BBS), the Dynamic Gait Index (DGI) and the Falls Efficacy Scale (FES); age, gender, supervision required and assistive device use. METHODS AND PROCEDURES: Twenty-six participants recruited from support groups and community re-entry programmes were divided into two groups, fallers and non-fallers. The FES, BBS and DGI were administered. MAIN OUTCOMES AND RESULTS: T-tests and chi-square tests revealed between group differences for age, FES, BBS, DGI and assistive device use. Spearman's rho statistic showed moderate relationships among the variables, FES, BBS, DGI and assistive device use. Logistic regression determined the DGI to best predict fall risk. CONCLUSIONS: This study developed a predictive model that could be used by therapists to determine an individual's fall risk in the home or outpatient settings. Assessing risk allows therapists to identify individuals who would benefit from intervention designed to improve balance and gait ability, possibly preventing future falls and a second head injury.     

Use of neuron-specific enolase to predict mild brain injury in motorcycle crash patients with maxillofacial fractures: A pilot study

Purpose

Mild traumatic brain injury (TBI) is common but accurate diagnosis and its clinical consequences have been a problem. Maxillofacial trauma does have an association with TBI. Neuron-specific enolase (NSE) has been developed to evaluate neuronal damage. The objective of this study was to investigate the accuracy of NSE serum levels to detect mild brain injury of patients with sustained maxillofacial fractures during motor vehicle accidents.

A pilot study of factors associated with falls in individuals with incomplete spinal cord injury

BACKGROUND/OBJECTIVE: To determine factors associated with falls among a sample of ambulatory individuals with incomplete spinal cord injury (SCI). STUDY DESIGN: Cross-sectional mail survey. METHODS: A survey instrument of participant characteristics and fall-related variables was developed using relevant items from existing measures and was mailed to 221 individuals with incomplete SCI, who were identified from records of a large specialty hospital in the southeastern United States. Of the 221 prospective participants, 119 completed the questionnaire (54%). Multivariable logistic regression models were used to determine factors that were independently associated with having had a fall in the past year. RESULTS: After adjusting for covariates, having fallen in the past year was significantly (P < 0.05) associated with greater numbers of medical conditions (odds ratio [OR] = 1.3; 95% confidence interval [CI] = 1.0-1.7), having arthritis (OR = 3.4, 95% CI = 1.2-9.6), experiencing dizziness (OR = 5.6, 95% Cl = 1.1-27.7), greater numbers of days with poor physical health (OR = 1.1; 95% Cl = 1.0-1.3), and the restriction of community activities because of fear of falling (OR = 1.5, 95% CI = 1.1-2.1). The multivariable models also showed that the odds of having fallen were significantly lower among those with better current perceived physical health (OR = 0.5; 95% Cl = 0.3-0.9), those with better perceived health compared to a year ago (OR = 0.4; 95% Cl = 0.2-0.8), individuals who exercised more frequently (OR = 0.2; 95% CI = 0.1-0.7), and those who used a walker (OR = 0.3; 95% CI = 0.1-0.9). CONCLUSIONS: Results suggest that interventions that address exercise frequency, walker use, and dizziness have promise for reducing falls for individuals with incomplete SCI.     

Subepidermal moisture surrounding pressure ulcers in persons with a spinal cord injury: A pilot study

Objective

Characterization of a non-invasive method of quantifying subepidermal moisture (SEM) surrounding stages III and IV pressure ulcers (PrUs) in spinal cord injury (SCI).

Design

Prospective, single-visit, single-rater, observational study, using repeated-measures analysis.

Method

Setting-inpatient units of one VA SCI Center.

Participants

Convenience sample of 16 subjects with SCI with stage III or IV PrUs over sacrum or ischium.

Interventions

Measurement with the MoistureMeter-D, a hand-held device using 300 MHz electromagnetic waves.

Outcome measures

Dielectric constant, a dimensionless number which increases with the moisture content. Each subject had a PrU site and a control site. Measurements were made at each site, on intact skin, at four points spaced angularly around the site, in triplicate.

Results

(1) Short-term, single-rater relative error was 2.5%. (2) Order effect: first readings were higher than second readings in 55 of 64 measurement sets. Order effect was significant for control sites (P < 0.0001) but not for PrU sites. (3) Angular effect: SEM varied by angle at the PrU sites (P < 0.01); 12 o''clock position the highest and 6 o''clock the lowest. (4) Ability to differentiate PrUs from intact skin: SEM at PrU sites was greater by 9.0% than control sites (P < 0.05). (5) Site effect: SEM was higher at sacral locations than ischial at control sites by 20% (P < 0.005).

Conclusions

SEM differentiates PrUs from intact skin. Future study designs must take into account order, angular, and site effects on this measure. This information will inform designers of future studies of SEM in healing of PrUs.     

Reading emotions after child brain injury: a comparison between children with brain injury and non-injured controls

Primary objective: Child brain injury can have a lasting, detrimental effect upon socio-emotional behaviour, but little is known about underlying impairments that cause behavioural disturbance. This study explored the possibility that a proportion of difficulties result from compromise to systems in the brain which function in reading emotion in others from eyes, face expression or vocal tone.

Methods and procedures: Measures of ability in reading emotion from faces, voices and eyes were used in conjunction with a battery of tests of cognitive function, in gathering data from 18 children aged between 9-17 with acquired brain injuries (ABI). Performance levels were compared against the normative data from 67 matched 'healthy' children. Questionnaires were used as a measure of socio-emotional behaviour.

Main outcomes and results: The ABI children in the sample were worse than their same age peers at reading emotions. Regression analyses revealed that emotion recognition skills and cognitive abilities were generally unrelated. Some relationships between emotion reading difficulties and behaviour disturbance were found, however there were limitations associated with this particular finding.

Conclusions: Emotion-recognition skills, which are not routinely assessed following child brain injury, can be adversely affected as a consequence of brain injury in childhood.     

A simple protocol for preventing falls and fractures in elderly individuals with musculoskeletal disease

Summary Our protocol resulted in a significant prevention of falls and fractures in addition to marked improvements in the balance function. Intervention comprised a new balance exercise and quadriceps femoris exercise. Subjects were outpatients aged ≥65 years old with musculoskeletal disorders who had a result of ≤15 s for the timed one-leg balance test. Introduction A study on chronological changes in the level of required care revealed that the level of care increases markedly for older patients requiring non-intensive or intensive long-term care. The aim of the present study was to identify frail elderly patients among older patients with chronic pain of the musculoskeletal system and to assess the fracture prevention and fall prevention effects of exercise therapy using stratified analysis. Methods This was a prospective cohort study consisting of 683 outpatients with chronic pain of the musculoskeletal system who were ≥65 years old and had a result of ≤15 s for the timed one-leg balance test with eyes open. Intervention consisted of a new balance exercise and quadriceps femoris exercise regimen. The main outcome was fall rate, while secondary outcomes were the results of the timed one-leg balance test with eyes open and fracture rate. Results Fall rate was decreased by 44% (p < 0.001) and fracture rate by 47% (p < 0.05) by 8 months after the start of the intervention. The results of the timed one-leg balance testing with eyes open improved two- to threefold after intervention (p < 0.01). Conclusions Our protocol has been safely implemented at a large number of clinics in Japan, and the reductions in frequency of falls and fractures suggest that it provides effective preventive care. This investigation was partially supported by Health and Labour Sciences Research Grants (2004, 2005) and a grant for Comprehensive Research on Aging and Health (2005).     

Neuropsychological profile of persons with anoxic brain injury: differences regarding physiopathological mechanism

Primary objective: To determine the neuropsychological profile of persons with anoxic brain injury.

Methods and procedures: A retrospective study on a population of persons with anoxic brain injury admitted to a Brain Injury Unit (Institut Guttmann, Spain) from 1995-2003. The sample was divided according to physiopathological mechanisms in two sub-groups: ischemic anoxia (21 cases) and hypoxemic anoxia (11 cases). Functions assessed included orientation, attention, language, visuo-perceptive and visuo-constructive processing and verbal memory.

Results: Neuropsychological assessment showed diffuse cognitive impairment in all assessed functions. Episodes of ischemic anoxia caused more severe verbal memory and learning problems than episodes of hypoxemic anoxia.

Conclusions: This study shows that memory problems are the most prominent and relevant impairment, although all other cognitive functions are also impaired, affecting both memory itself and general behaviour. Statistical analysis also provides preliminary evidence on the different profile of memory impairment whether cerebral anoxia had hypoxic or ischemic origin.     

Measuring grief in caregivers of persons with acquired brain injury

Primary objective: To investigate the psychometric and validity properties and applicability of a modified version of the Marwit-Meuser Caregiver Grief Inventory (MM-CGI) for use with caregivers of patients with acquired brain injury (ABI).

Research design: Replicate Marwit and Meuser's original psychometric study assessing grief in caregivers of dementia patients.

Methods and procedures: The MM-CGI was administered to 28 ABI caregivers along with standardized measures of caregiver strain, depression, well-being and family support.

Main outcomes and results: Results for ABI caregivers were similar to those for dementia caregivers with the instrument demonstrating excellent internal consistency reliability for total and sub-scale grief scores and strong divergent validity. Results also parallel those of a recent study of cancer caregivers.

Conclusions: The MM-CGI is as useful for diagnosing and treating grief in ABI caregivers as it is for those caring for persons with other serious illnesses.     

Protocolised thromboelastometric-guided haemostatic management in patients with traumatic brain injury: a pilot study

Coagulopathy in patients with traumatic brain injury is associated with an increase in morbidity and mortality. Although timely and aggressive treatment of coagulopathy is of paramount importance, excessive transfusion of blood products has been linked with poor long-term outcomes in patients with traumatic brain injury. A point-of-care thromboelastometric-guided algorithm could assist in creating a more individually tailored approach to each patient. The aim of this study was to evaluate the feasibility of implementing a thromboelastometric-guided algorithm in centres that were formerly naïve to thromboelastometry. Hence, we developed such an algorithm and provided training to four centres across Europe to direct the haemostatic management of patients with severe traumatic brain injury. The primary outcome was adherence to the algorithm and timing of the availability of relevant results. Thirty-two patients were included in the study. Complete adherence to the algorithm was observed in 20 out of 32 cases. The availability of thromboelastometric results after hospital admission was reported significantly earlier than conventional coagulation tests (median (IQR [range]) 33 (20–40 [14–250]) min vs. 71 (51–101 [32–290]) min; p = 0.037). Although only 5 out of 32 patients had abnormalities of conventional coagulation tests, 21 out of 32 patients had a coagulopathic baseline thromboelastometric trace. Implementing a thromboelastometric-guided algorithm for the haemostatic therapy of traumatic brain injury is feasible in centres formerly naïve to this technology and may lead to more rapid and precise coagulation management. Further large-scale studies are warranted to confirm the results of this pilot trial and evaluate clinical outcomes.     

骨折及合并脑外伤患者血清瘦素的变化

目的分析脑外伤、骨折合并脑外伤及单纯骨折的患者血清瘦素水平在不同时期的变化,探讨由脑外伤及合并骨折后所引起的创伤反应对瘦素的影响。方法将54例骨折及合并脑外伤患者分成脑外伤合并骨折组、脑外伤组及单纯骨折组,每组18例;另取健康志愿者正常对照组18例。以上各组再按伤后1—3d、5～7d及10～14d分为3个时间段,予以连续采用放射免疫法检测血清中瘦素水平,分析损伤各组之间瘦素在不同时间段的变化的意义。结果伤后1—3d与对照组相比损伤各组患者血清瘦素浓度增高,差异有显著性（P〈0．05）,但各损伤组之间差异无显著性（P〉0．05）;5～7d时骨折并脑外伤组患者血清瘦素水平开始升高,10～14d时骨折并脑外伤组患者血清瘦素水平达到高峰,以上两个时间段与其它组比较差异有显著性（P〈0．05）。结论血清瘦素水平在骨折合并脑外伤后一定时期内较其他组明显升高,提示瘦素可能在骨折合并脑外伤的创伤反应中起着较强的应答作用。     

Comparison of half-molar sodium lactate and mannitol to treat brain edema in severe traumatic brain injury: A systematic review

PurposeHypertonic fluids such as mannitol and half-molar sodium lactate are given to treat intracranial hypertension in patients with severe traumatic brain injury (TBI). In this study, sodium lactate was compared to mannitol in patients with TBI to investigate the efficacy in reducing intracranial pressure (ICP).MethodsThis study was a systematic review with literature research on articles published in any year in the databases of PubMed, ScienceDirect, Asian Journal of Neurosurgery, and Cochrane Central Register of Controlled Trials. The keywords were “half-molar sodium lactate”, “mannitol”, “cerebral edema or brain swelling”, and “severe traumatic brain injury”. The inclusion criteria were (1) studies published in English, (2) randomized control trials or retrospective/prospective studies on TBI patients, and (3) therapies including half-molar sodium lactate and mannitol and (4) sufficient data such as mean difference (MD) and risk ratio (RR). Data analysis was conducted using Review Manager 5.3.ResultsFrom 1499 studies, a total of 8 studies were eligible. Mannitol group reduced ICP of 0.65 times (MD 0.65; p = 0.64) and improved cerebral perfusion pressure of 0.61 times (MD 0.61; p = 0.88), better than the half-molar group of sodium lactate. But the half-molar group of sodium lactate maintained the mean arterial pressure level of 0.86 times, better than the mannitol group (MD 0.86; p = 0.09).ConclusionHalf-molar sodium lactate is as effective as mannitol in reducing ICP in the early phase of brain injury, superior over mannitol in an extended period. It is able to prevent intracranial hypertension and give better brain tissue perfusion as well as more stable hemodynamics. Blood osmolarity is a concern as it increases serum sodium.     

Social communication skills in persons with post-acute traumatic brain injury: three perspectives

Objective: To describe social communication skills problems identified by individuals with traumatic brain injury (TBI) compared to significant other (SO) and clinician ratings; and associations between these skills and participation outcome measures.

Design: Cohort study.

Methods: Sixty individuals with TBI ≥ 1 year post-injury were administered measures of social communication, societal participation, social integration and life satisfaction. Clinicians and SOs rated the social communication skills of the subjects.

Results: Subjects were able to identify social communication skills problems, associated with lower ratings of community integration and satisfaction with life. Males reported higher scores in social communication and social integration than females. SOs and clinicians identified more social skills problems than subjects.

Conclusions: Persons with TBI experience social communication skills deficits, associated with decreased societal participation and life satisfaction. Further research is needed to determine efficacy of social communication skills treatment and association with improved participation and satisfaction with life.     

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.     

Acquired brain injury self-management programme: A pilot study

Primary objective: Traditional rehabilitation is not well suited to individuals with chronic mild symptoms following an acquired brain injury. To address this, this study adapted a supported self-management programme (SMP) for this population. The aim of this study was to evaluate the potential effectiveness of this novel SMP. Research design: Retrospective case series with repeated measures. Methods and procedures: Fifty-three participants with chronic mild symptoms following an acquired brain injury (primarily mild traumatic brain injury) completed an SMP. The intervention involved eight coaching sessions with each an occupational therapist and psychologist, carried out in the community and based on SMP principles. The Canadian Occupational Performance Measure was administered at baseline, discharge and 3- and 9-month follow-up. This measure yielded scores for performance and satisfaction with daily functioning, covering the domains of self-care, productivity and leisure. Main outcomes and results: A complete case analysis of programme completers revealed that participants' ratings of their occupational performance and satisfaction improved markedly between baseline and discharge from the SMP. This set of outcome measures remained stable between discharge and the two follow-up points. Conclusions: This pilot study suggests that SMPs may improve daily functioning in individuals with chronic mild ABI symptoms. More methodologically robust clinical trials are warranted.     

The effect of Aricept in persons with persistent memory disorder following traumatic brain injury: a pilot study

Primary objective : To investigate the effectiveness of donepezil hydrochloride (Aricept®) in treating persistent memory deficits in people with traumatic brain injury.

Research design : Single subject ABAC design was used so that each participant could serve as their own control.

Methods and procedures : Seven TBI survivors with persistent memory dysfunction, at least 1.5 years post-injury, underwent two 6-month trials of Aricept®. The following tests were used to assess memory and cognition: Brief Visual Memory Test-Revised (BVMT-R), Hopkins Verbal Learning Test, Digit Span and Letter Number Sequence sub-test of the Wechsler Adult Intelligence Scale-III, Controlled Oral Word Association Test and Memory Functioning Questionnaire.

Experimental intervention : During the first treatment phase, participants received 5 mg/day of Aricept® for 1 month, increasing to 10 mg/day of Aricept® for an additional 5 months. During the second treatment phase, participants received 5 mg/day of Aricept® for the entire 6 months.

Main outcomes and results : A repeated measures analysis of variance indicated significant improvement on immediate and delayed memory portions of the BVMT-R when taking 10 mg/day of Aricept®.

Conclusions : Findings contribute to the growing body of research into the use of Aricept® in treating memory deficits in TBI survivors and support the need for further research.     

A pilot study for rehabilitation of central executive deficits after traumatic brain injury

Primary objective: An impairment of the central executive system (CES) of working memory (WM) is a common consequence of traumatic brain injury (TBI), and may also explain deficits in divided attention, long-term memory and executive functions. Here we investigated the efficacy of a rehabilitative program (working memory training: WMT) targeting the CES in improving WM and other cognitive functions dependent on this system.

Methods and procedures: Nine TBI patients with severe WM deficits underwent the WMT (experimental training). The WMT was preceded by a general stimulation training (GST; control training). Patients' cognitive performance was evaluated at the admission, after the GST and at the end of the WMT.

Main outcomes and results: Whereas the GST had no effect on patients' performance, after the WMT patients improved in all the cognitive functions dependent on the CES, but not in those functions not thought to tap this system. Importantly, a beneficial WMT effect was found on patients' everyday life functioning.

Conclusions: The results support the efficacy of the WMT in recovering CES impairments.     

Traumatic brain injury: from model to man

Brain injury is the leading cause of death in trauma patients and produces a large amount of disability. Unfortunately, it is particularly prevalent in young adults, with all the suffering and socio-economic loss this implies. It has a complex neurobiology that has been elucidated largely in animal models, but it has been more difficult to apply the knowledge gained to man, partly due to the heterogeneous nature of human brain injuries.Clinical management consists of trying to prevent and treat ongoing injury processes. This is achieved by early and excellent critical care combining management of intracranial and cerebral perfusion pressure, with drug therapy where needed. New monitoring modalities are arriving and providing new insights, but the majority have yet to prove their worth in terms of improving patient outcome. The knowledge gleaned from experimental work has also begun to have an impact, and new therapies based on control of the elucidated pathophysiology are now in development.     

The incidence of acute kidney injury in patients with traumatic brain injury

There is limited information on the incidence of acute kidney injury (AKI) in patients with traumatic brain injury (TBI) although AKI may contribute to morbidity and mortality. We investigated the incidence of AKI in patients with moderate and severe TBI and the association of AKI with risk factors and outcomes in these patients.

We studied all TBI patients over 16 years of age admitted to the two designated trauma hospitals in the state of Victoria, Australia from 1 January to 31 December 2008. Patients were included if they had head trauma and presented with a Glasgow coma scale (GCS) <13. Prospectively collected data from the hospital trauma registries, ICUs, and pathology databases were analyzed retrospectively. Risk injury failure loss end (RIFLE) criteria were used to categorize renal function.

The incidence of AKI was 9.2% (19/207). Patients who developed AKI were older, had higher severity of illness scores, and a lower GCS. Overall 42.1% of these patients died in hospital compared with 18.1% in patients without AKI. In univariable linear regression analysis, age, severity of illness, and admitting hospital were associated with AKI. After multivariable logistic regression, the occurrence of AKI was associated with age (p < 0.001) and higher APACHE III scores (p = 0.016).

AKI is relatively common even in patients with TBI. Its association with age and APACHE III scores helps identify patients at higher risk of AKI.     

Factors associated with upper extremity contractures after cervical spinal cord injury: A pilot study

Objective: To examine the prevalence of joint contractures in the upper limb and association with voluntary strength, innervation status, functional status, and demographics in a convenience sample of individuals with cervical spinal cord injury to inform future prospective studies.

Design: Cross-sectional convenience sampled pilot study.

Setting: Department of Veterans Affairs Research Laboratory.

Participants: Thirty-eight participants with cervical level spinal cord injury.

Interventions: Not applicable.

Main Outcome Measures: Contractures were measured with goniometric passive range of motion. Every joint in the upper extremity was evaluated bilaterally. Muscle strength was measured with manual muscle testing. Innervation status was determined clinically with surface electrical stimulation. Functional independence was measured with the Spinal Cord Independence Measure III (SCIM-III).

Results: Every participant tested had multiple joints with contractures and, on average, participants were unable to achieve the normative values of passive movement in 52% of the joints tested. Contractures were most common in the shoulder and hand. There was a weak negative relationship between percentage of contractures and time post-injury and a moderate positive relationship between percentage of contractures and age. There was a strong negative correlation between SCIM-III score and percentage of contractures.

Conclusions: Joint contractures were noted in over half of the joints tested. These joint contractures were associated with decreased functional ability as measured by the SCIM-III. This highlights the need the need for detailed evaluation of the arm and hand early after injury as well as continued monitoring of joint characteristics throughout the life course of the individual with tetraplegia.