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.     

Diabetes Prevalence and Influence on Resource Use in Washington State Inpatient Rehabilitation Facilities, 2001 to 2007

Weeks DL, Daratha KB, Towle LA. Diabetes prevalence and influence on resource use in Washington State inpatient rehabilitation facilities, 2001 to 2007.

Objective

To determine the prevalence of diabetes in inpatient rehabilitation facilities in Washington State from 2001 to 2007, and to determine the impact of diabetes on length of stay (LOS) and charges per day.

Design

Longitudinal retrospective cohort analysis of inpatient rehabilitation discharge data from the Washington State Department of Health Comprehensive Hospital Abstract Reporting System.

Setting

Inpatient rehabilitation.

Participants

Adults (N=56,382) who were discharged from inpatient rehabilitation in Washington State between 2001 and 2007.

Interventions

Not applicable.

Main Outcome Measures

Evidence of an established diagnosis of diabetes from International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes; comorbid conditions reported in ICD-9-CM codes; LOS; and charges per stay.

Results

For all discharges from 2001 to 2007, diabetes prevalence was 17.8%; prevalence within specific impairment groups was 21.3% for the stroke subgroup, 14.2% for the orthopedic disorders subgroup, and 25% for the medically complex conditions subgroup. For all discharges, and within each impairment subgroup, prevalence did not change significantly from year to year. When adjusted for burden of nondiabetes comorbidities, LOS was significantly shorter for all discharges with diabetes younger than 65 years. The association between a diabetes codiagnosis and LOS in specific impairment groups was complex, ranging from a significantly shorter LOS for discharges with diabetes in the stroke subgroup to a finding of no significant difference in LOS among discharges with or without diabetes in the orthopedic impairments subgroup. Across all discharges, charges per day from 2003 to 2007 were significantly greater in discharges with diabetes. Within each specific impairment subgroup, charges per day across the entire study period were significantly greater for discharges with diabetes.

Conclusions

The high prevalence of diabetes, coupled with its impact on resource use, suggests that substantial pressures may be placed on the inpatient rehabilitation care system to respond to the needs of those with diabetes.     

Impact of age on long-term recovery from traumatic brain injury

Marquez de la Plata CD, Hart T, Hammond FM, Frol AB, Hudak A, Harper CR, O'Neil-Pirozzi TM, Whyte J, Carlile M, Diaz-Arrastia R. Impact of age on long-term recovery from traumatic brain injury.

Objective

To determine whether older persons are at increased risk for progressive functional decline after traumatic brain injury (TBI).

Design

Longitudinal cohort study.

Setting

Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers.

Participants

Subjects enrolled in the TBIMS national dataset.

Interventions

Not applicable.

Main Outcome Measures

Disability Rating Scale (DRS), FIM instrument cognitive items, and the Glasgow Outcome Scale-Extended.

Results

Participants were separated into 3 age tertiles: youngest (16-26y), intermediate (27-39y), and oldest (≥40y). DRS scores were comparable across age groups at admission to a rehabilitation center. The oldest group was slightly more disabled at discharge from rehabilitation despite having less severe acute injury severity than the younger groups. Although DRS scores for the 2 younger groups improved significantly from year 1 to year 5, the greatest magnitude of improvement in disability was seen among the youngest group. In addition, after dividing patients into groups according to whether their DRS scores improved (13%), declined (10%), or remained stable (77%) over time, the likelihood of decline was found to be greater for the 2 older groups than for the youngest group. A multiple regression model showed that age has a significant negative influence on DRS score 5 years post-TBI after accounting for the effects of covariates.

Conclusions

This study supported our primary hypothesis that older patients show greater decline over the first 5 years after TBI than younger patients. In addition, the greatest amount of improvement in disability was observed among the youngest group of survivors. These results suggest that TBI survivors, especially older patients, may be candidates for neuroprotective therapies after TBI.     

Modality-Specific, Multitask Locomotor Deficits Persist Despite Good Recovery After a Traumatic Brain Injury

McFadyen BJ, Cantin J-F, Swaine B, Duchesneau G, Doyon J, Dumas D, Fait P. Modality-specific, multitask locomotor deficits persist despite good recovery after a traumatic brain injury.

Objective

To study the effects of sensory modality of simultaneous tasks during walking with and without obstacles after moderate to severe traumatic brain injury (TBI).

Design

Group comparison study.

Setting

Gait analysis laboratory within a postacute rehabilitation facility.

Participants

Volunteer sample (N=18). Persons with moderate to severe TBI (n=11) (9 men, 3 women; age, 37.56±13.79y) and a comparison group (n=7) of subjects without neurologic problems matched on average for body mass index and age (4 men, 3 women; age, 39.19±17.35y).

Interventions

Not applicable.

Main Outcome Measures

Magnitudes and variability for walking speeds, foot clearance margins (ratio of foot clearance distance to obstacle height), and response reaction times (both direct and as a relative cost because of obstacle avoidance).

Results

The TBI group had well-recovered walking speeds and a general ability to avoid obstacles. However, these subjects did show lower trail limb toe clearances (P=.003) across all conditions. Response reaction times to the Stroop tasks were longer in general for the TBI group (P=.017), and this group showed significant increases in response reaction times for the visual modality within the more challenging obstacle avoidance task that was not observed for control subjects. A measure of multitask costs related to differences in response reaction times between obstructed and unobstructed trials also only showed increased attention costs for the visual over the auditory stimuli for the TBI group (P=.002).

Conclusions

Mobility is a complex construct, and the present results provide preliminary findings that, even after good locomotor recovery, subjects with moderate to severe TBI show residual locomotor deficits in multitasking. Furthermore, our results suggest that sensory modality is important, and greater multitask costs occur during sensory competition (ie, visual interference).     

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.     

Ethnic differences in discharge destination among older patients with traumatic brain injury

Chang P-F, Ostir GV, Kuo Y-F, Granger CV, Ottenbacher KJ. Ethnic differences in discharge destination among older patients with traumatic brain injury.

Objective

To estimate the association between ethnicity and discharge destination in older patients with traumatic brain injury (TBI).

Design

A retrospective analysis.

Setting

Nationally representative sample of older patients from the Uniform Data System for Medical Rehabilitation in 2002 and 2003.

Participants

Patients (N=9240) aged 65 years or older who received inpatient rehabilitation services for TBI.

Interventions

Not applicable.

Main Outcome Measures

Discharge destination (home, assisted living facility, institution) and ethnicity (white, black, Hispanic).

Results

Multinomial logit models showed that older Hispanics (odds ratio [OR]=2.24; 95% confidence interval [CI], 1.66-3.02) and older blacks (OR=2; 95% CI, 1.55-2.59) with TBI were significantly more likely to be discharged home than older whites with TBI, after adjusting for relevant risk factors. Older blacks were also 78% less likely (OR=.22; 95% CI, .08-.60) to be discharged to an assisted living facility than whites after adjusting for relevant risk factors.

Conclusions

Our findings indicate that older minority patients with TBI were significantly more likely to be discharged home than white patients with TBI. Studies are needed to investigate underlying factors associated with this ethnic difference.     

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.     

Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation

Yokoyama O, Sakuma F, Itoh R, Sashika H. Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation.

Objective

To compare outcomes, complications, and therapy intensity of inpatient rehabilitation in patients with paraplegia caused by spinal cord injury associated with aortic aneurysm repair (SCI-AA) versus patients with traumatic spinal cord injury (SCI).

Design

Case-controlled study.

Setting

SCI unit in a rehabilitation center.

Participants

Seventeen patients with SCI-AA and 17 patients with traumatic SCI.

Intervention

Standard rehabilitation therapy for SCI.

Main Outcome Measures

Length of stay (LOS) in acute and rehabilitation hospitals; FIM instrument scores; FIM change; FIM efficiency; complications; therapy intensity; and ambulatory state and return to community at discharge.

Results

No significant differences were noted in acute and rehabilitation LOS and admission FIM scores. Discharge FIM scores, FIM change, and FIM efficiencies were significantly lower in the SCI-AA group, which had many complications related to AA and SCI. Intensity of rehabilitation sports therapy in the SCI-AA group was significantly lower than that of the traumatic SCI group, but total therapy intensity did not differ significantly. Both had similar rates of return to ambulatory state and discharge to the community.

Conclusions

SCI-AA patients had many complications that interfered with rehabilitation therapy, and could not achieve functional gains comparable to those with traumatic SCI. However, both groups achieved comparable success with return to ambulatory state and discharge to the community.     

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.     

Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome

Mazzini L, Campini R, Angelino E, Rognone F, Pastore I, Oliveri G. Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil 2003;84:1637-41.

Objectives

To detect the clinical and radiologic characteristics of posttraumatic hydrocephalus (PTH), to define its prognostic value, and to assess the effects of shunt surgery.

Design

Correlational study on a prospective cohort.

Setting

Brain injury rehabilitation center.

Participants

One hundred forty patients with severe traumatic brain injury (TBI) referred to an inpatient intensive rehabilitation unit of primary care in a university-based system.

Interventions

Not applicable.

Main outcome measures

The Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), FIM™ instrument, and Neurobehavioural Rating Scale (NRS), as well as single-photon emission computed tomography (SPECT) and magnetic resonance imaging.

Results

PTH was found in 45% of patients. Risk factors for PTH were as follows: age (P<.04), duration of coma (P<.0001), and decompressive craniectomy (P<.0001). PTH correlated with the degree of hypoperfusion in the temporal lobes (P<.001). Patients who showed clinical deterioration improved after surgery. PTH correlated significantly with GOS, DRS, FIM, and NRS (P<.0001) 1 year after the trauma, and it influenced the appearance of posttraumatic epilepsy (P<.02).

Conclusions

PTH concerns about 50% of patients with severe TBI. It influences functional and behavioral outcome and the appearance of posttraumatic epilepsy. The selection of patients for surgery can be defined principally on a clinical basis. SPECT may be helpful for differentiating ventricular enlargement due to cortical atrophy and hydrocephalus.     

Factors Predicting Inpatient Rehabilitation Length of Stay of Acute Stroke Patients in Singapore

Tan WS, Heng BH, Chua KS, Chan KF. Factors predicting inpatient rehabilitation length of stay of acute stroke patients in Singapore.

Objective

To determine the predictors of hospital length of stay (LOS) of stroke patients at the point of admission.

Design

A retrospective cohort study.

Setting

An acute hospital rehabilitation center in Singapore.

Participants

Stroke patients (N=491) admitted between March 2005 and December 2006.

Interventions

None.

Main Outcome Measures

Rehabilitation LOS was calculated as the total number of rehabilitation days before discharge. We measured the functional status of patients by using the Functional Independence Measure (FIM).

Results

The median LOS was 29 days (mean = 30.8d). Independent clinical and sociodemographic characteristics found to significantly predict rehabilitation LOS were FIM motor score at admission, the presence of more than 3 comorbid conditions at admission, living with nonimmediate relatives before admission, and the hospital subsidy status of the patient. In particular, the admission FIM motor score explained 43% of the variation in LOS and decreased the LOS by approximately 1.1 days for each 1-point increase in score.

Conclusion

Patients' socioeconomic status and family structure was found to influence LOS and should be considered in allocating resources and determining treatment need. The extent of motor function of patients at admission is an important factor influencing rehabilitation LOS and is a useful tool for facilitating rehabilitation resource planning for stroke patients.     

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.     

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.     

Effect of severity of post-traumatic confusion and its constituent symptoms on outcome after traumatic brain injury

Sherer M, Yablon SA, Nakase-Richardson R, Nick TG. Effect of severity of post-traumatic confusion and its constituent symptoms on outcome after traumatic brain injury.

Objective

To investigate the prognostic significance of severity of post-traumatic confusion (PTC) and its constituent symptoms for early and late outcome after traumatic brain injury (TBI).

Design

Prospective cohort study.

Setting

Inpatient brain injury rehabilitation program.

Participants

A total of 168 patients meeting study criteria from 195 consecutive Traumatic Brain Injury Model Systems neurorehabilitation admissions.

Interventions

Not applicable.

Main Outcome Measures

Employability at neurorehabilitation discharge and productivity status at 1 year postinjury.

Results

More severely confused patients had poorer outcomes for both employability and productivity. Multivariable logistic regression revealed that after adjustment for all other predictors, time to follow commands, and confusion severity predicted employability at discharge and age and confusion severity predicted productivity status at 1 year. Each symptom showed an unadjusted effect on discharge employability. All symptoms except nighttime sleep disturbance or daytime decreased arousal had effects on productivity at 1 year. Presence of psychotic-type symptoms was associated with especially poor productivity outcomes.

Conclusions

PTC constituent symptoms and severity predict outcome after TBI. Presence or absence of psychotic-type symptoms on a single evaluation at approximately 21 days postinjury may have particular prognostic significance for productivity outcome.     

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.     

Feasibility of a brief neuropsychologic test battery during acute inpatient rehabilitation after traumatic brain injury

Kalmar K, Novack TA, Nakase-Richardson R, Sherer M, Frol AB, Gordon WA, Hanks RA, Giacino JT, Ricker JH. Feasibility of a brief neuropsychologic test battery during acute inpatient rehabilitation after traumatic brain injury.

Objectives

To determine (1) if more than 50% of patients with moderate to severe traumatic brain injury (TBI) who met study criteria can complete a battery of neuropsychologic tests in less than 75 minutes 2 to 6 weeks after injury regardless of posttraumatic amnesia (PTA) status; (2) which tests are most likely to be completed; and (3) range of scores obtained.

Design

Prospective multicenter observational study.

Setting

Acute inpatient neurorehabilitation hospitals.

Participants

Screened 543 Traumatic Brain Injury Model System patients with moderate to severe TBI; 354 were tested at 2 to 6 weeks postinjury.

Interventions

Not applicable.

Main Outcome Measure

Percentage of patients able to complete the neuropsychologic tests in less than 75 minutes.

Results

Two hundred eighteen (62%) patients completed the battery in 66 minutes on average. Mean interval from injury to testing was 28.3±7.1 days. Tests completed with the highest frequency were California Verbal Learning Test−II, FAS, and animal naming. Performance was less impaired (P<.001) on all measures for patients who had emerged from PTA.

Conclusions

Approximately two thirds of screened patients were able to complete a brief neuropsychologic test battery at 2 to 6 weeks postinjury, regardless of PTA status. Although patients out of PTA were less impaired on all test measures, confusion did not preclude participation in the test battery or prohibit assignment of test scores. Early neuropsychologic assessment after TBI is feasible even for many patients who are still in PTA.     

The impact of female reproductive function on outcomes after traumatic brain injury

Ripley DL, Harrison-Felix C, Sendroy-Terrill M, Cusick CP, Dannels-McClure A, Morey C. The impact of female reproductive function on outcomes after traumatic brain injury.

Objectives

To determine the impact of traumatic brain injury (TBI) on female menstrual and reproductive functioning and to examine the relationships between severity of injury, duration of amenorrhea, and TBI outcomes.

Design

Retrospective cohort survey.

Setting

Telephone interview.

Participants

Women (N=30; age range, 18-45y), between 1 and 3 years postinjury, who had completed inpatient rehabilitation for TBI.

Interventions

Not applicable.

Main Outcome Measures

Data collected included menstrual and reproductive functioning pre- and postinjury, demographic, and injury characteristics. Outcome measures included the Glasgow Outcome Scale-Extended (GOS-E), the Mayo-Portland Adaptability Inventory-4 (MPAI-4), and the Medical Outcome Study 12-Item Short-Form Health Survey, Version 2 (SF-12v2).

Results

The median duration of amenorrhea was 61 days (range, 20-344d). Many subjects' menstrual function changed after TBI, reporting a significant increase in skipped menses postinjury (P<.001) and a trend toward more painful menses (P=.061). More severe TBI, as measured by the duration of posttraumatic amnesia, was significantly predictive of a longer duration of amenorrhea (P=.004). Subjects with a shorter duration of amenorrhea scored significantly better on the SF-12 physical component subscale (P=.004), the GOS-E (P=.05), and the MPAI-4 participation subscale (P=.05) after controlling for age, injury severity, and time postinjury.

Conclusions

The severity of TBI was predictive of duration of amenorrhea and a shorter duration of amenorrhea was predictive of better ratings of global outcome, community participation, and health-related quality of life postinjury.     

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.     

The association of functional oral intake and pneumonia in patients with severe traumatic brain injury

Hansen TS, Larsen K, Engberg AW. The association of functional oral intake and pneumonia in patients with severe traumatic brain injury.

Objectives

To investigate the incidence and onset time of pneumonia for patients with severe traumatic brain injury (TBI) in the early phase of rehabilitation and to identify parameters associated with the risk of pneumonia.

Design

Observational retrospective cohort study.

Setting

Subacute rehabilitation department in a university hospital in Denmark.

Participants

Patients (N=173) aged 16 to 65 years with severe TBI who were admitted during a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously.

Interventions

Not applicable.

Main Outcome Measure

Pneumonia.

Results

Twenty-seven percent of the patients admitted to the brain injury unit were in treatment for pneumonia; pneumonia developed in 12% of the patients during rehabilitation; the condition occurred within 19 days of admission in all but 1 patient. Of these patients, 81% received nothing by mouth. Three factors identified patients at highest risk of pneumonia: Glasgow Coma Scale score less than 9 (1 day after cessation of sedation); Rancho Los Amigos Scale score less than 3 (on admission); and no oral intake on admission. Having a tracheotomy tube and/or feeding tube was also associated with a higher occurrence of pneumonia.

Conclusions

Among patients with severe TBI, 27% had pneumonia at transfer from the intensive care unit. Pneumonia developed in only 12% of the participants during rehabilitation. Patients with a low level of consciousness and patients with a tracheotomy tube or feeding tube had a higher likelihood of pneumonia.     

Prediction of memory rehabilitation outcomes in traumatic brain injury by using functional magnetic resonance imaging

Strangman GE, O'Neil-Pirozzi TM, Goldstein R, Kelkar K, Katz DI, Burke D, Rauch SL, Savage CR, Glenn MB. Prediction of memory rehabilitation outcomes in traumatic brain injury by using functional magnetic resonance imaging.

Objective

To evaluate the ability of functional magnetic resonance imaging (fMRI) measures collected from people with traumatic brain injury (TBI) to provide predictive value for rehabilitation outcomes over and above standard predictors.

Design

Prospective study.

Setting

Academic medical center.

Participants

Persons (N=54) with TBI greater than 1 year postinjury.

Intervention

A novel 12-session group rehabilitation program focusing on internal strategies to improve memory.

Main Outcome Measure

The Hopkins Verbal Learning Test−Revised (HVLT-R) delayed recall score.

Results

fMRI measures were collected while participants performed a strategically directed word memorization task. Prediction models were multiple linear regressions with the following primary predictors of outcome: age, education, injury severity, preintervention HVLT-R, and task-related fMRI activation of the left dorsolateral and left ventrolateral prefrontal cortex (VLPFC). Baseline HVLT-R was a significant predictor of outcome (P=.007), as was injury severity (for severe vs mild, P=.049). We also found a significant quadratic (inverted-U) effect of fMRI in the VLPFC (P=.007).

Conclusions

This study supports previous evidence that left prefrontal activity is related to strategic verbal learning, and the magnitude of this activation predicted success in response to cognitive memory rehabilitation strategies. Extreme under- or overactivation of VLPFC was associated with less successful learning after rehabilitation. Further study is necessary to clarify this relationship and to expand and optimize the possible uses of functional imaging to guide rehabilitation therapies.