Incorporating the prosthetic: Traumatic,limb-loss,rehabilitation and refigured military bodies

In this article, I look at the role that context of injury plays in the rehabilitation of military patients who sustained a limb amputation as a result of blast injury trauma in Afghanistan and Iraq. This article contrasts the technologically driven model of rehabilitation produced by the US Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center with a person centered approach building on work in medical anthropology. In this article, two case studies are contrasted illustrating the reasons behind the rejection of an upper extremity prosthetic device in one example and the acceptance of one in another. I argue that even in light of the incredible advances in medical technique and prosthetic technology, a body and functionality focussed rehabilitation must also pay attention to the subjective experiences of individual patients in terms of their present and their past.     

Traumatic brain injury resiliency model: a conceptual model to guide rehabilitation research and practice

Abstract

There is a growing trend in traumatic brain injury (TBI) rehabilitation, and research, to focus on the processes of adaptation following the injury. Resiliency is an umbrella term describing the range of personal protective factors, environmental supports and resources, as well as self-regulatory processes, engaged in response to adversity. An affective, cognitive, and behavioural self-regulatory process model of resiliency in the workplace was adapted to suit the TBI context. Through a narrative review of the literature pertaining to brain injury rehabilitation, participation, and resilience, we substantiated the model, and explained how resiliency can frame research on life experiences following the injury. TBI represents a cascading adversity as the injury and subsequent life experiences (e.g., job loss) shape adaptation. Resiliency is shaped by: personal characteristics (e.g., hope, social functioning, self-awareness, memory, spirituality, coping, and self-efficacy), environmental resources/supports (e.g., services and social support), and self-regulatory processes that lead to the resiliency-related outcomes, which we suggest involve re-engaging in activities, adapting participation, and reconstructing identity. This conceptual model outlines and defines the factors and processes operating and contributing to resiliency following TBI. Recommendations for future research are outlined.

• Implications for rehabilitation

• Investigating resiliency processes can move the traumatic brain injury field beyond examining individual traits and protective factors, to transactional processes that influence participation experiences and opportunities over time.

• The Traumatic Brain Injury Resiliency Model can be used to frame the targets and desired outcomes of rehabilitation interventions, such as self-regulatory processes or environmental supports known to enhance resiliency.

• Studying resiliency will help to shift the paradigms of traumatic brain injury research, and rehabilitation practice, to a focus on life experiences and adaptation, helping individuals, clinicians, and families consider processes of positive change, rather than focusing solely on adversity.

     

Reformulating masculinity: Traumatic brain injury and the gendered nature of care and domestic roles

Purpose.?This article examines the nexus between masculine identity and participation of men living with traumatic brain injury (TBI) in rural New South Wales, Australia. The article considers the impact of adoption of caring and household duties upon identity and participation satisfaction.

Method.?The focus of this paper is on a finding that emerged from the qualitative phase of a larger project examining participation following TBI in rural and regional areas. During semi-structured interviews, participants were invited to discuss aspects of their participation including their daily occupations, supports, experience of country life and rehabilitation services. A grounded theory methodology shaped the analysis of the interviews.

Results.?Results, relating to the reformation of masculinity, centred upon eight men drawn from the cohort who moved from the role of breadwinner pre-injury to primarily domestic and caring roles post-injury. Their narratives illustrated three responses to altered life circumstances that necessitated the revision of gendered roles: non-acceptance of reformulated masculinity, accepting reformulated masculinity for the sake of others and accepting and personally valuing a reformulated masculinity.

Conclusions.?Participation satisfaction for men who take up responsibility for domestic and/or caring duties following TBI is contingent upon successful reformulation of their gendered identity. The research highlights the need for rehabilitation practitioners to adequately support psychosocial adjustment for men following TBI.     

Traumatic brain injury: Association between the Glasgow Coma Scale score and intensive care unit mortality

Background Traumatic brain injury (TBI) prevalence in Botswana is high and this, coupled with a small population, may reduce productivity. There is no previous study in Botswana on the association between mortality from TBI and the Glasgow Coma Scale (GCS) score although global literature supports its existence. Objectives Our primary aim was to determine the association between the initial GCS score and the time to mortality of adults admitted with TBI at the Princess Marina Hospital, Gaborone, Botswana, between 2014 and 2019. Secondary aims were to assess the risk factors associated with time to mortality and to estimate the mortality rate from TBI. Methods This was a retrospective cohort design, medical record census conducted from 1 January 2014 to 31 December 2019. Results In total, 137 participants fulfilled the inclusion criteria, and the majority, 114 (83.2%), were male with a mean age of 34.5 years. The initial GCS score and time to mortality were associated (adjusted hazard ratio (aHR) 0.69; 95% confidence interval (CI) 0.508 - 0.947). Other factors associated with time to mortality included constricted pupil (aHR 0.12; 95% CI 0.044 - 0.344), temperature (aHR 0.82; 95% CI 0.727 - 0.929), and subdural haematoma (aHR 3.41; 95% CI 1.819 - 6.517). Most cases of TBI (74 (54%)) were due to road traffic accidents. The number of deaths was 48 (35% (95% CI 27.1% - 43.6%)), entirely due to severe TBI. Conclusion The study confirmed significant association between GCS and mortality. Males were mainly involved in TBI. These findings lack external validity because of the small sample size, and therefore a larger multicentre study is required for validation. Contributions of the study This study informs the relevant stakeholders in Botswana about sociodemographics, clinical characteristics, management and outcomes of patients admitted to the ICU with severe TBI on the backdrop of scarce ICU resources. It provides a basis for a larger study to inform its external validation.     

Traumatic brain injury among refugees and asylum seekers

Background: Refugees and asylum seekers face many challenges in their pursuit of a safe home. The journey for displaced individuals can be extremely dangerous and many do not survive or go missing. Survivors face significant risks of injury, abuse, and torture. Traumatic brain injury is one of the most common and disabling injuries sustained by these populations. This already complex condition can have profound implications on these groups and their families due to factors related to mental health, cultural perspectives, and their ability to navigate healthcare systems.

Methods: A literature review was performed to investigate the incidence and prevalence of torture and traumatic brain injury in displaced and fleeing populations. Impacts of traumatic brain injury and residency status on outcomes in these individuals were also examined.

Results: The incidence and prevalence of torture and traumatic brain injury among refugees and asylum seekers is significant. These populations may access healthcare systems differently than other groups and as a result may experience a unique health-related outcomes following traumatic brain injury.

Conclusions: This information should sensitize healthcare providers to a potential history of traumatic brain injury sustained by patients/clients who are refugees or asylum seekers and may serve to guide some clinical encounters.

• Implications for rehabilitation

• Traumatic brain injuries are commonly sustained by refugees and asylum seekers.

• Cultural factors may complicate how refugees and asylum seekers understand, report, and manage these injuries.

• The above may be worsened by cognitive, emotional, and behavioral changes following traumatic brain injury.

• Rehabilitation providers should be aware of potential traumatic brain injury history during encounters with refugee and asylum seeker populations, especially if a history of torture is suspected.

     

Traumatic brain injury: An integrated clinical case presentation and literature review: Part I: Assessment and initial management

Holistic nursing care of critically ill patients continues to be a challenge for all levels of critical care clinicians. Patients with multi-system dysfunction in particular, present complicated clinical challenges that demand care based on sound knowledge and understanding of physiological, psychosocial and spiritual needs. Experiential learning through exposure to a range of patient presentations enables incremental development of professional practice and excellence in nursing care. Case study learning enhances understanding through application of theory to practice in complex clinical presentations.

This two-part paper outlines the assessment, interventions and outcome of a person who sustained multiple trauma including severe traumatic brain injury (TBI). Part I explores assessment and initial management from pre-hospital care through to the Emergency Department (ED) and operating theatre. Part II describes the intensive care period as an integral component of the continuum of care. Key issues in the case are presented sequentially with relevant literature integrated and applied to clinical progress, focussing on the complex physiological, psychosocial, spiritual and environmental needs of the patient and his family. The purpose of the paper is to therefore provide a comprehensive learning resource for critical care nurses, particularly for those beginning their practice.     

重型颅脑损伤患者术后行高压氧辅助治疗的疗效观察

目的:评价重型颅脑损伤患者术后行高压氧辅助治疗效果。方法:对于入院时格拉斯哥评分(Glasgow coma scale,GCS)小于8分的228例颅内血肿患者均于24h内行颅内血肿清除术或同时行去骨瓣减压术。术后除常规治疗(108 例对照组)外,应用高压氧治疗(120例高压氧组,HBO组)。4周后进行GCS评分,6 个月进行格拉斯哥愈后评级(Glasgow outcomescale,GOS)。结果:两组治疗后4周的GCS评分,6个月的GOS评级有显著差异(P<0.01)。结论:应用高压氧辅助治疗,对于颅脑外伤术后患者的愈后康复有满意效果。     

外伤后急性弥慢性脑肿胀的CT诊断与临床分析

目的：探讨外伤后急性弥漫性脑肿胀的CT征象及临床表现。材料与方法：回顾性分析52例外伤后弥漫性脑肿胀的CT征象及临床资料,其中46例患者进行了2—5次CT复查。结果：根据CT表现,将52例患者分为24例弥漫型和28例半球型。所有患者CT均表现为基底池（包括鞍上池、环池、四叠体池、大脑大静脉池）及第三脑室受压变窄或闭塞。其中基底池受压变形或部分变小12例,显著变窄25例,大部分或完全闭塞15例;第三脑室变小或显著变窄28例,闭塞15例,正常9例;第四脑室闭塞13例;双侧或单侧外侧裂池变窄或闭塞34例;脑挫裂伤23例,其中迟发性脑血肿6例,硬膜外或硬膜下血肿12例;中线结构移位39例;脑密度升高或减低44例。结论：基底池和第三脑室变小或闭塞可作为CT诊断外伤后弥漫性脑肿胀的可靠征象,基底池的闭塞可作为重型外伤后弥漫性脑肿胀的诊断依据。     

Variation in Pediatric Traumatic Brain Injury Outcomes in the United States

Objective

To ascertain the degree of variation, by state of hospitalization, in outcomes associated with traumatic brain injury (TBI) in a pediatric population.

Design

A retrospective cohort study of pediatric patients admitted to a hospital with a TBI.

Setting

Hospitals from states in the United States that voluntarily participate in the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Participants

Pediatric (age ≤19y) patients hospitalized for TBI (N=71,476) in the United States during 2001, 2004, 2007, and 2010.

Interventions

None.

Main Outcome Measures

Primary outcome was proportion of patients discharged to rehabilitation after an acute care hospitalization among alive discharges. The secondary outcome was inpatient mortality.

Results

The relative risk of discharge to inpatient rehabilitation varied by as much as 3-fold among the states, and the relative risk of inpatient mortality varied by as much as nearly 2-fold. In the United States, approximately 1981 patients could be discharged to inpatient rehabilitation care if the observed variation in outcomes was eliminated.

Conclusions

There was significant variation between states in both rehabilitation discharge and inpatient mortality after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.