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.     

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.     

Memory outcome at 5 years post-childhood traumatic brain injury

Primary objective: This study seeks to extend previous findings by documenting memory performance in a sample of 70 children at 5 years post-injury. It was anticipated that increasing injury severity would be associated with decreased performance on working and complex memory tasks. It was also expected that injury severity would significantly predict memory, but that the time from insult to subsequent testing would be associated with an increased relationship to non-injury factors.

Research design: Participants were assessed at 5 years post-injury, aged between 6-14 years, using measures of immediate, working and complex memory.

Methods and procedures: The sample comprised 18 children who had sustained a severe TBI, 24 with a moderate TBI, 11 with a mild TBI and 17 healthy controls, matched for age, gender and socio-economic-status.

Results: Results indicated that severe TBI was associated with decreased complex auditory-verbal memory performance, although children with TBI did not display impairment on immediate, working or complex visual-spatial memory. While injury severity significantly predicted complex memory outcome, non-injury factors failed to significantly predict either working or complex memory performance.

Conclusions: Future research should be engineered towards further clarifying what influences recovery from childhood TBI in the elongated post-injury period.     

Management and outcome in patients following head injury admitted to an Irish Regional Hospital

Primary objective: Each year in Ireland, 11 000 patients are admitted to hospital with a traumatic brain injury (TBI) but there are no data on subsequent disability in such patients. The objective of this study was to assess the management and outcome in patients of working age admitted with TBI to the unit.

Methods: Two hundred and sixteen patients admitted with TBI aged 16-65 were identified. Self-reported incidence of disability and access to appropriate services was assessed using the Glasgow outcome scale and a problem-orientated questionnaire.

Results: Eighty-five per cent of patients eligible for review agreed to participate. The majority of injuries (86%) were mild. An intracranial injury was identified on 35% of CT brain scans performed. Patients with an abnormality on CT scanning were more likely to report difficulties with headache, concentration and memory at time of follow-up. When questioned, 34% of patients still perceived difficulties since their injury. Of this group, 60% didn't receive any input from rehabilitation services. One year post-injury, 11% of patients remained unfit for work.

Conclusion: A significant number of patients, even with mild TBI, continue to suffer sequelae from their injury augmented by difficulty in accessing appropriate rehabilitation services.     

Neuropsychological function 23 years after mild traumatic brain injury: a comparison of outcome after paediatric and adult head injuries

Primary objective: To the authors' knowledge no study comparing very long-term neuropsychological outcome after mild paediatric and adult traumatic brain injury (TBI) has been published. The primary objective of this study was to compare neuropsychological outcome 23 years after mainly mild paediatric and adult TBI.

Research design: The study was a neuropsychological follow-up 23 years after a prospective head injury study conducted at a Norwegian public hospital.

Methods and procedures: One hundred and nineteen patients were assessed with a comprehensive neuropsychological test battery. Of these, 45 were paediatric TBI and 74 were adult TBI.

Main outcomes and results: Both the paediatric and adult groups obtained scores in the normal range. In the paediatric group significant relationships were found between head injury severity and current neuropsychological function. The most important predictors of poor outcome were length of post-traumatic amnesia (PTA) and a combination of PTA and EEG pathology within 24 hours of injury. No influence of pre- and post-injury risk factors on current neuropsychological function was evident.

Conclusions: The findings indicate that children sustaining complicated mild TBI may be more vulnerable to development of chronic mild neuropsychological dysfunction than adults sustaining similar head injuries.     

Life satisfaction and distress in family caregivers as related to specific behavioural changes after traumatic brain injury

Primary objective: To predict long-term outcome of those caring for family members who have sustained a traumatic brain injury (TBI).

Methods and procedures: A multivariate approach was used to examine the effectiveness of caregiver coping strategies in the context of TBI-related behavioural change. Self-administered questionnaire packages were collected from 72 adult survivor and family-member pairs who provided information on survivors' altered executive function, behavioural control and emotional sensitivity as well as caregivers' methods of coping, attitudes toward caregiving, indices of distress, mood ratings and quality of life.

Main outcomes and results: Family members generally reported higher levels of satisfaction than dissatisfaction with their caregiving role. The type of neurobehavioural deficit and the approaches taken to cope with stress had specific effects on each dimension of caregiver outcome.

Conclusions: Adequate family support requires finely tuned assessment of factors relevant to successful coping.     

Role of premorbid factors in predicting safe return to driving after severe TBI

Primary objective: The present study explored the possibility of predicting post-injury fitness to safe driving in patients with severe traumatic brain injury (TBI) (n = 66).

Methods and procedure: Sixteen different measures, derived from four domains (demo/biographic, medico-functional, neuropsychological, and psychosocial) were used as predictor variables, whereas driving outcomes were assessed in terms of driving status (post-TBI drivers versus non-drivers) and driving safety (number of post-TBI car accidents and violations).

Main outcomes and results: About 50% of the patients resumed driving after TBI. Compared to post-TBI non-drivers, post-injury drivers had shorter coma duration. With regard to driving safety, the final multiple regression model combined four predictors (years post-injury, accidents and violations before TBI, pre-TBI-risky-personality-index, and pre-TBI-risky-driving-style-index) and explained 72.5% of variance in the outcome measure.

Conclusions: Since the best three predictors of post-injury driving safety addressed patients' premorbid factors, the results suggest that in order to evaluate the actual possibility of safe driving after TBI, it would be advisable to consider carefully patients' pre-TBI histories.     

Alcohol and drug use following traumatic brain injury: A prospective study

Primary objectives: To establish pre-morbid alcohol and drug use in persons with TBI, relative to controls, investigate how patterns of substance use change over time following TBI and identify factors associated with heavy post-injury substance use.

Methods and procedures: The Alcohol Use Disorders Identification test (AUDIT) and Drug Abuse Screening Test (DAST) was completed by 121 hospital inpatients with TBI, documenting pre-injury alcohol and drug use, and 133 demographically similar controls. Participants with TBI completed these measures and the Hospital Anxiety and Depression Scale (HADS) again 1 and 2 years post-injury and 76 also completed them at 3 years.

Results: Participants with TBI showed similar levels of drug and alcohol use to controls pre-injury, with 31.4% of the TBI group and 29.3% of controls drinking at hazardous levels. Alcohol and drug use declined in the first year post-injury, but increased by 2 years post-injury, with only 21.4% of participants with TBI reporting abstinence from alcohol and 25.4% drinking at hazardous levels. Only 9% showed a drug problem, but 24% had returned to some drug use. Those showing heavy alcohol use post-injury were young, male and heavy drinkers pre-injury. Drug and alcohol use was similar at 3 years post-injury.

Conclusions: More active intervention is needed to reduce alcohol and drug use following TBI.     

MRI changes and ApoE genotype, a prospective 1-year follow-up of traumatic brain injury: a pilot study

Primary objective: To examine the association between apolipoprotein E (ApoE) genotype and visibility of traumatic brain lesions during the first year after traumatic brain injury (TBI).

Research design: A prospective 1-year follow-up study in unselected victims of TBI.

Methods: The number and extent of contusions, ventricular size index and semi-quantitative score of other traumatic intraparenchymal lesions were determined with MRI ∼ 1 week and 1 year after TBI and the results were analysed in relation to the ApoE genotype in 33 patients after acute non-trivial TBI.

Results: The ApoE genotype was not associated with the visible changes occurring during this follow-up.

Conclusions: The presence of ApoE4 was not associated with MRI changes during the first year after TBI. This suggests that if the ApoE4 is associated with an unfavourable outcome after TBI, the processes responsible for the repair of visible lesions are not dependent on ApoE genotype.     

Wisconsin Card Sorting Test: factor structure and relationship to productivity and supervision needs following severe traumatic brain injury

Primary objective: The Wisconsin Card Sorting Test (WCST) has been demonstrated to have a relatively stable factor structure in traumatic brain injury (TBI) samples. What is less clear is whether the scores derived from WCST factors are related to functional outcomes. The purpose of the current study was to replicate the WCST factor structure in a sample with severe TBI, and to evaluate the relationship between the factor scores and outcome.

Research design: Retrospective correlational study.

Methods and procedures: Participants (n = 143) who had suffered severe TBI were administered a battery of neuropsychological tests including the WCST within one month of admission to a brain injury rehabilitation program. In addition, participants were administered supervision (Supervision Rating Scale; SRS) and productivity measures (Community Integration Questionnaire- Productivity subscale; CIQ-P) at admission and following discharge.

Experimental intervention: None.

Main outcomes and results: For individuals who were more than one year post injury, more failure to maintain set errors were associated with better occupational outcomes, while more nonperseverative errors were associated with increased supervision needs.

Conclusions: The WCST factor scales are related to functional outcomes in severe TBI. Specifically, the inability to establish a series of correct responses is associated with poorer outcome.     

Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial

Objective: To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients with traumatic brain injury (TBI).

Design and methods: Sixty-eight patients (age 12-65 years) with moderate-to-severe TBI were included. They were randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had passed.

Outcome and results: No significant differences were found in the Functional Independence Measure (FIM) (primary outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score at the third month (47% vs. 19%, p = 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second (28% vs. 8%, p = 0.034) and third months (34% vs. 14%, p = 0.044).

Conclusions: Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up recovery rather than changed the final outcome.     

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.     

Confirmatory factor structure of the Center for Epidemiologic Studies-Depression scale (CES-D) in mild-to-moderate traumatic brain injury

Primary objective: The Center for Epidemiologic Studies Depression scale (CES-D) is a frequently-used self-report measure of depressive symptom severity. Brief depression screening measures can be important in the identification and prediction of depression following traumatic brain injury. The objective of this study was to investigate the validity of the CES-D in measuring depressive symptoms in patients with mild-to-moderate TBI as it has been rarely used in neurologically compromised populations.

Research design: Inception cohort.

Methods and procedures: The CES-D was administered to 340 participants with mild-to-moderate TBI at 3-months post-injury.

Main outcomes and results: Confirmatory factor analysis of the CES-D indicated that the data are a reasonable fit similar to that of Radloff 's original 4-factor model.

Conclusions: These findings suggest that the CES-D may be appropriate for use in patients with mild-to-moderate TBI.     

Dizziness after traumatic brain injury: results from an interview study

Background: Dizziness is a commonly reported sequel to traumatic brain injury (TBI).

Objective: To better define the nature of the symptomatology and the impact that dizziness has on the TBI survivor.

Setting: A community brain injury rehabilitation programme and a community access programme for TBI survivors.

Method: Focus groups with TBI survivors and individual interviews with TBI survivors and some of their carers.

Results: The data confirmed that dizziness is difficult for TBI survivors to define and describe and it consists of multiple symptoms. Dizziness also appears to be associated with significant functional difficulties. Additionally, many of the participants of this study reported falling. Carers reported a number of observable signs of dizziness and indicated that they believed they were able to tell when the person they cared for was dizzy.

Conclusion: The results provide information which will help in the development of more appropriate outcome measurement tools for dizziness after a TBI.     

Post-traumatic growth after head injury: a long-term follow-up

Primary objective: To investigate the time course of any positive psychological changes after traumatic brain injury (TBI) by comparing questionnaire responses in two groups of TBI survivors, early, 1-3 years post-injury and late, 10-12 years post-injury.

Research design: A cross-sectional, between-group design.

Method and Procedure: TBI survivors were selected from the Reading Head Injury out-patient records by date of registration, early survivors from 2002-2004 and late survivors from 1993-1996 and sent a battery of postal questionnaires. These included The Post-traumatic Growth Inventory, The Life Satisfaction Checklist and The Hospital Anxiety and Depression Scale. Individuals were also given the opportunity to answer questions about their perception of their condition and to provide free text responses to reflect best and worst advice received, to describe positive and negative changes in themselves and to identify their most useful coping strategies.

Results: 61 'early' and 65 'late' people were contacted with study details and 52 consented to the study, receiving questionnaires which provided 23 'early' and 25 'late' responses. There was a significantly greater degree of post-traumatic growth, as measured on 'The Post-traumatic Growth Inventory', reported by the later group (*p = 0.000), but no other significant differences between the groups in terms of all the other variables. Both groups reported greater life satisfaction pre-injury.

Conclusion: Measures of Post-traumatic Growth (Relating to Others, Personal Strength, New Possibilities, Appreciation of Life and Spirituality) appear to increase over time after head injury. This is a positive message that clinicians should note and reinforce and could help to shape future adjustment.     

Therapeutic alliance in post-acute brain injury rehabilitation: predictors of strength of alliance and impact of alliance on outcome

Primary objective: To determine factors that influence the strength of therapeutic alliance for patients with traumatic brain injury (TBI) attending post-acute brain injury rehabilitation (PABIR) and to examine the association of therapeutic alliance with outcome after PABIR.

Research design: Prospective cohort study.

Methods and procedures: The study sample consisted of 69 of 95 patients with TBI admitted to the PABIR programme during the study period. Demographic and injury severity data were abstracted from medical records or obtained through interview. Study questionnaires (the modified California Psychotherapy Alliance Scales-patient, family and clinician forms; the Prigatano Alliance Scale; the Awareness Questionnaire; the Center for Epidemiologic Studies-Depression scale; and the Family Assessment Device-General Functioning Scale) were obtained within 2 weeks of patient admission to the PABIR programme.

Main outcomes and results: Study outcomes were functional status (Disability Rating Scale), programme completion and employment status at discharge from PABIR. Higher levels of family discord were associated with poorer therapeutic alliance. Greater discrepancies between family and clinician ratings of patient functioning were associated with poorer therapeutic alliance and poorer effort in therapies. Poor participation was predictive of programme dropout. Productivity status at discharge was predicted by functional status at admission and degree of therapeutic alliance.

Conclusions: Findings indicate that family perceptions and family functioning are important determinants of therapeutic alliance for patients in PABIR. These results indicate that therapists in PABIR programmes should address family perceptions and functioning to facilitate patient bonding with the programme.     

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.     

Gender and traumatic brain injury: do the sexes fare differently?

Objective: To examine the relationship between gender and cognitive recovery 1 year following traumatic brain injury (TBI).

Methods: Patients with blunt TBI were identified from the TBI Model Systems of Care National Database, multi-centre cohort study. The included patients (n = 325) were 16-45 years at injury, admitted to an acute care facility within 24 hours, received inpatient rehabilitation, had documented admission Glasgow Coma Scale (GCS) scores, completed neuropsychological follow-up 1 year post-injury and did not report pre-morbid learning problems. Multivariate analyses of variance examined the unadjusted association between gender and six cognitive domains examining attention/working memory, verbal memory, language, visual analytic skills, problem-solving and motor functioning. Analyses of covariance models were constructed to determine if confounding factors biased the observed associations.

Results: Females performed significantly better than males on tests of attention/working memory and language. Males outperformed females in visual analytic skills. Gender remained significantly associated with performance in these areas when controlling for confounding variables.

Conclusions: These results suggest a better cognitive recovery of females than males following TBI. However, future studies need to include non-TBI patients to control for possible pre-injury gender-related differences, as well as to conduct extended follow-ups to determine the stability of the observed differences.