Cognitive deficits in spinal cord injury: epidemiology and outcome.

Cognitive deficits are common among patients with acute spinal cord injury (SCI), but reported prevalence figures vary because of different methods of study. Factors associated with cognitive deficits in patients with SCI include age, educational background, history of learning disability, chronic alcohol and substance abuse, and concomitant or recurrent traumatic brain injury. Psychologic testing of patients with and without cognitive deficits indicates that impaired psychosocial adjustment and adaptation are more frequent in SCI patients who have evidence of cognitive deficits. Various associations have been found between neuropsychologic test performance and major depression. Cognitive functioning and premorbid educational level appear to be associated with medical stability, the patient's ability to assimilate the necessary skills for survival and adaptation after SCI, and readmission patterns after discharge for initial inpatient rehabilitation.     

综合康复治疗重度脑损伤青壮年患者的临床观察

目的　观察重度脑损伤青壮年患者在康复治疗时间延迟的情况下经综合康复治疗的临床疗效。方法　对 11例青壮年重度脑损伤患者进行以神经发育技术为主的综合康复治疗 ,采用功能独立性评测(FIM)及Berg平衡量表进行疗效评定 ,采用单因素方差分析对患者入院时或清醒后、治疗 6个月和 12个月时的评定结果进行统计学分析。结果　 11例患者在治疗 6个月及 12个月后 ,FIM运动分、认知分和总分及Berg评分均较首次评定显著增加 (P <0 .0 1)。结论　虽然重度脑损伤青壮年患者开始康复治疗的延搁时间长 ,但采用综合康复治疗仍能获得满意的疗效     

Les troubles cognitifs des traumatismes crâniens sévères

Severe traumatic brain injury is associated with complex cognitive deficits including memory problems, attention deficits, slowed information processing, dysexecutive syndrome, and behavioural modifications. These deficits may be difficult to detect. Theymay have a harmful impact on social and vocational reintegration. However, recently there have been advances in the rehabilitation of these cognitive impairments and in social and vocational reintegration programmes.     

Answering the call: the influence of neuroimaging and electrophysiological evidence on rehabilitation

Functional recovery after brain damage or disease is dependent on the neuroplastic capability of the cortex and the nonaffected brain. Following cortical injury in the motor and sensory regions, the adjacent spared neural tissues and related areas undergo modifications that are required in order to drive more normal motor control. Current rehabilitation models seek to stimulate functional recovery by capitalizing on the inherent potential of the brain for positive reorganization after neurological injury or disease. This article discusses how neuroimaging and electrophysiological data can inform clinical practice; representative data from the modalities of functional magnetic resonance imaging, diffusion tensor imaging, magnetoencephalography, electroencephalography, and positron emission tomography are cited. Data from a variety of central nervous system disease and damage models are presented to illustrate how rehabilitation practices are beginning to be shaped and informed by neuroimaging and electrophysiological data.     

Cognitive outcome in traumatic brain injury survivors

PURPOSE OF REVIEW: This review discusses recent studies investigating the cognitive and psychiatric outcome of posttraumatic brain injury. In addition, it aims to highlight key areas for future research. RECENT FINDINGS: Detailed cognitive assessments have revealed particular deficits in processing speed in the visual domain and the detrimental impact of interference on attentional performance. A pilot functional imaging study revealed neural changes in survivors performing a response inhibition task, even when matched to controls on behavioural indices. Recent psychiatric studies highlight the incidence of these disorders in the survivors and attempt to characterize distinct psychiatric profiles. Adult and child survivors appear to show differential difficulties. Successful rehabilitation strategies addressing these psychiatric and cognitive deficits include holistic intensive neuropsychological interventions and the introduction of electronic devices. Systematic randomized trials are needed to provide an adequate evidence base for clinical practice. The potential for cognitive enhancement using psychopharmacological agents has yet to be exploited. These treatments may lead to improved quality of life for traumatic brain injury survivors and their families. SUMMARY: Survivors of head injury show a diverse pattern of cognitive and psychiatric profiles. Recent research highlights the nature of some of these deficits and possible ways to enhance functioning. However, the area is well poised for rapid progress in the understanding of cognitive and emotional dysfunction following traumatic brain injury (TBI) and its rehabilitation through neuropsychological and psychopharmacological means.     

Traumatic brain injury in children: issues in community function.

The pathology and sequelae of pediatric traumatic brain injury (TBI) differ from those of the adult TBI population. In childhood TBI, cognitive impairment and secondary delays are often overlooked in the referral and intervention process. Although TBI is the leading cause of acquired disability in childhood, most children with TBI are discharged from acute care to home with little or no rehabilitation. This literature review provides current information germane to the occupational therapist on sequelae and functional limitations that may exist or develop after TBI in children. Further, methods by which these deficits can be addressed within the context of Individuals With Disabilities Education Act guidelines are described. Children with a history of TBI should be screened regularly because some cognitive problems emerge years after the injury as developmental demands on the child increase. In this article, school-based therapists are urged to look beyond a child's motor limitations to address the cognitive and neuropsychological problems typical of this population.     

Outcome after traumatic brain injury: pathway analysis of contributions from premorbid, injury severity, and recovery variables

OBJECTIVE: To examine the relationship of premorbid variables, injury severity, and cognitive and functional status to outcome 1 year after traumatic brain injury (TBI) and to assess the feasibility of multivariate path analysis as a way to discover those relationships. DESIGN: Prospective, longitudinal. SETTINGS: Level I trauma center, acute inpatient rehabilitation hospital. PATIENTS: One hundred seven subjects (87 men, 20 women; mean age, 33.91 +/- 14.2 yr) who had experienced severe TBI, typically from motor vehicle crashes. INTERVENTIONS: Acute medical and rehabilitation care. MAIN OUTCOME MEASURES: Disability Rating Scale, Community Integration Questionnaire, and return to employment. Evaluated in acute rehabilitation, and at 6 and 12 months' postinjury. RESULTS: Path analyses revealed that premorbid factors had significant relationships with injury severity, functional skills, cognitive status, and outcome; injury severity affected cognitive and functional skills; and cognitive status influenced outcome. No significant relationships were found between injury severity and emotional status, injury severity and outcome, emotional status and outcome, and functional skills and outcome. CONCLUSIONS: Multivariate analysis is important to understanding outcome after TBI. Injury severity, as measured in this study, is less important to 12-month outcome than the premorbid status of the person and the difficulties (particularly cognitive deficits) exhibited at follow-up 6 months after the trauma.     

Role of agitation in prediction of outcomes after traumatic brain injury

OBJECTIVE: To determine the role of agitation in the prediction of traumatic brain injury rehabilitation outcomes. DESIGN: A longitudinal study of 340 consecutive patients admitted to an acute traumatic brain injury rehabilitation unit was conducted. Outcomes under study included rehabilitation length of stay, discharge destination, functional independence at discharge (FIM instrument), productivity at 1-yr follow-up, and life satisfaction at 1-yr follow-up (Satisfaction with Life Scale). RESULTS: Univariate analyses suggested that the presence of agitation in rehabilitation is predictive of a longer length of stay and decreased functional independence in the cognitive realm at discharge. In addition, individuals who exhibit agitation at any time during rehabilitation are less likely to be discharged to a private residence. However, multivariate analyses indicated that cognitive functioning at admission to rehabilitation (FIM cognitive) mediates the relationship between the presence of agitation and length of rehabilitation, as well as between agitation and FIM cognitive at discharge. Similar results were found when discharge residence was the dependent variable; however, agitation also contributed some unique variance to the prediction. Lower cognitive functioning at admission to rehabilitation was associated with the occurrence of agitation during rehabilitation, longer length of stay, lower cognitive functioning at discharge, and a decreased likelihood that an individual would be discharged to a private residence. CONCLUSIONS: The results of the multivariate analyses support the contention that agitation and cognition are intimately related, with the long-term effects of the former being at least partially driven by the latter. These findings support the importance of systematically monitoring both agitation and cognition when applying interventions to reduce agitation.     

Simulation-based executive cognitive assessment and rehabilitation after traumatic frontal lobe injury: a case report

Purpose. To investigate whether identifying specific deficits after brain injury can lead to a more focused and potentially effective cognitive rehabilitation technology.

Method. Cognitive simulation assessment was undertaken in a 47-year-old man with trauma-related prefrontal damage and persisting occupational and cognitive-behavioral difficulties at 15 months post brain injury.

Results. Results revealed significant difficulties in measured levels of activity, initiative, information utilization, response flexibility, and effective decision-making strategies which accorded well with his real-life complaints despite normal neuropsychological test scores. This profile of findings was then used to design a two-stage intervention program. The first stage focused on participant education and awareness about his simulation-based problem solving difficulties. In the second stage specific goals were formulated to improve problem solving impairments that were then the target of weekly training sessions using pertinent decision-making and problem-solving vignettes. A parallel version of the cognitive simulation assessment was undertaken post-cognitive training (3 months after initial assessment) and revealed significant improvements in targeted executive cognitive-behavioral areas.

Conclusion. Results of this cognitive rehabilitation probe supported the feasibility and validity of undertaking a cognitive simulation approach to identify residual executive function deficits after traumatic brain injury, even with a normal neuropsychological test profile. Further studies are needed to establish the reliability, generalizability and maintenance of such gains.     

Simulation-based executive cognitive assessment and rehabilitation after traumatic frontal lobe injury: A case report

Purpose.?To investigate whether identifying specific deficits after brain injury can lead to a more focused and potentially effective cognitive rehabilitation technology.

Method.?Cognitive simulation assessment was undertaken in a 47-year-old man with trauma-related prefrontal damage and persisting occupational and cognitive-behavioral difficulties at 15 months post brain injury.

Results.?Results revealed significant difficulties in measured levels of activity, initiative, information utilization, response flexibility, and effective decision-making strategies which accorded well with his real-life complaints despite normal neuropsychological test scores. This profile of findings was then used to design a two-stage intervention program. The first stage focused on participant education and awareness about his simulation-based problem solving difficulties. In the second stage specific goals were formulated to improve problem solving impairments that were then the target of weekly training sessions using pertinent decision-making and problem-solving vignettes. A parallel version of the cognitive simulation assessment was undertaken post-cognitive training (3 months after initial assessment) and revealed significant improvements in targeted executive cognitive-behavioral areas.

Conclusion.?Results of this cognitive rehabilitation probe supported the feasibility and validity of undertaking a cognitive simulation approach to identify residual executive function deficits after traumatic brain injury, even with a normal neuropsychological test profile. Further studies are needed to establish the reliability, generalizability and maintenance of such gains.     

Use of the Barthel Index and the Functional Independence Measure during early inpatient rehabilitation after single incident brain injury

OBJECTIVE: To compare the appropriateness and responsiveness of the Barthel Index and the Functional Independence Measure (FIM) during early inpatient rehabilitation after single incident brain injury. DESIGN: Cohort study. SETTING: A regional neurological rehabilitation unit. PATIENTS: Two hundred and fifty-nine consecutive patients undergoing inpatient comprehensive neurological rehabilitation following a vascular brain injury due to single cerebral infarction (n = 75), spontaneous intracerebral haemorrhage (n = 34) and subarachnoid haemorrhage (n = 43), and 107 patients who had sustained traumatic brain injury. MEASUREMENTS: Admission and discharge FIM total, physical and cognitive scores and the Barthel Index were recorded. Appropriateness and responsiveness in the study samples were determined by examining score distributions and floor and ceiling effects, and by an effect size calculation respectively. Non-parametric statistical analysis was used to calculate the significance of the change in scores. RESULTS: In all patient groups there was a significant improvement (Wilcoxon's rank sum, P<0.0001) in the Barthel Index (mean change score: vascular 3.9, traumatic 3.95) and FIM (mean change score: vascular 17.3, traumatic 17.4) scores during rehabilitation, and similar effect sizes were found for the Barthel Index (effect size: vascular 0.65, traumatic 0.55) and FIM total (effect size: vascular 0.59, traumatic 0.48) and physical scores in all patient groups. In each patient group the cognitive component of the FIM had the smallest effect size (0.35-0.43). CONCLUSIONS: All measures were appropriate for younger (less than 65 years of age) patients undergoing early inpatient rehabilitation after single incident vascular or traumatic brain injury. The Barthel Index and the total and physical FIM scores showed similar responsiveness, whilst the cognitive FIM score was least responsive. These findings suggest that none of the FIM scores have any advantage over the Barthel Index in evaluating change in these circumstances.     

Family Involvement in Traumatic Brain Injury Inpatient Rehabilitation: A Propensity Score Analysis of Effects on Outcomes During the First Year After Discharge

ObjectiveTo evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge.DesignPropensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data.SettingNine inpatient rehabilitation centers in the United States.ParticipantsPatients (N=1835) admitted for first inpatient rehabilitation after an index TBI.InterventionFamily attendance during therapy sessions.Main Outcome MeasuresParticipation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9.ResultsParticipants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance.ConclusionsFamily involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients’ families in the rehabilitation process to maximize outcomes.     

Comparison of rehabilitation outcome in patients with aphasic and non-aphasic traumatic brain injury.

OBJECTIVE: To compare the functional, cognitive and disability status of aphasic and non-aphasic traumatic brain injury patients. DESIGN: A prospective comparative study in which 103 patients with traumatic brain injury participated. SUBJECTS: Fifty-one aphasic and 52 non-aphasic patients with traumatic brain injury. METHODS: Functional Independence Measure and Disability Rating Scale were used to determine functional status and disability. Cognitive status was evaluated by the Mini-Mental Status Examination. Aphasic patients were evaluated using the Gülhane Aphasia Test for language disorders. RESULTS: The most frequent type of aphasia was Broca aphasia at 26.49% followed by anomic at 19.6% and trans-cortical motor at 15.6%. Functional Independence Measure, Disability Rating Scale and Mini-Mental Status Examination scores at admission and at discharge showed significant differences in aphasic patients (p<0.001). There were no significant differences in the Functional Independence Measure, Disability Rating Scale and Mini-Mental Status Examination gains between the aphasic and non-aphasic patients (p>0.01). CONCLUSION: Although aphasia could be accepted as a negative prognostic indicator in patients with traumatic brain injury, we could not detect any difference in functional and cognitive gains between the aphasic and non-aphasic patients.     

Changes in event-related potential functional networks predict traumatic brain injury in piglets

BackgroundTraumatic brain injury is a leading cause of cognitive and behavioral deficits in children in the US each year. None of the current diagnostic tools, such as quantitative cognitive and balance tests, have been validated to identify mild traumatic brain injury in infants, adults and animals. In this preliminary study, we report a novel, quantitative tool that has the potential to quickly and reliably diagnose traumatic brain injury and which can track the state of the brain during recovery across multiple ages and species.MethodsUsing 32 scalp electrodes, we recorded involuntary auditory event-related potentials from 22 awake four-week-old piglets one day before and one, four, and seven days after two different injury types (diffuse and focal) or sham. From these recordings, we generated event-related potential functional networks and assessed whether the patterns of the observed changes in these networks could distinguish brain-injured piglets from non-injured.FindingsPiglet brains exhibited significant changes after injury, as evaluated by five network metrics. The injury prediction algorithm developed from our analysis of the changes in the event-related potentials functional networks ultimately produced a tool with 82% predictive accuracy.InterpretationThis novel approach is the first application of auditory event-related potential functional networks to the prediction of traumatic brain injury. The resulting tool is a robust, objective and predictive method that offers promise for detecting mild traumatic brain injury, in particular because collecting event-related potentials data is noninvasive and inexpensive.     

Haloperidol, but not olanzapine, impairs cognitive performance after traumatic brain injury in rats

OBJECTIVE: Traumatic brain injury can cause a variety of impairments, including persistent alterations in personality, mood, and cognition. Antipsychotic agents are frequently used to treat pathologic behaviors in traumatic brain injury patients, but the influence of prolonged administration of such drugs on cognition after injury is unknown. The effects of two antipsychotic drugs on cognitive recovery after traumatic brain injury were assessed using the fluid percussion model in rats. DESIGN: The typical antipsychotic, haloperidol, and the third-generation antipsychotic, olanzapine, were administered via intraperitoneal injection beginning 24 hr after injury and continuing daily for the duration of the study. Morris water maze performance was assessed on days 11-15 postinjury. RESULTS: Haloperidol, an antagonist acting on D2-like dopamine receptors, exacerbated the cognitive deficits induced by injury, as injured rats treated with 0.30 mg/kg haloperidol performed worse in the Morris water maze than injured rats treated with vehicle. CONCLUSIONS: Our results demonstrate the importance of the D2 receptor in cognitive recovery after traumatic brain injury. Also, the data illustrate that some classes of antipsychotic drugs may influence cognitive recovery, and further research is needed to determine the optimal pharmacologic treatment of aggression, agitation, and other pathologic behaviors in patients with traumatic brain injury.     

Normative database of judgment of complexity task with functional near infrared spectroscopy--application for TBI

The ability to assess frontal lobe function in a rapid, objective, and standardized way, without the need for expertise in cognitive test administration might be particularly helpful in mild traumatic brain injury (TBI), where objective measures are needed. Functional near infrared spectroscopy (fNIRS) is a reliable technique to noninvasively measure local hemodynamic changes in brain areas near the head surface. In this paper, we are combining fNIRS and frameless stereotaxy which allowed us to co-register the functional images with previously acquired anatomical MRI volumes. In our experiment, the subjects were asked to perform a task, evaluating the complexity of daily life activities, previously shown with fMRI to activate areas of the anterior frontal cortex. We reconstructed averaged oxyhemoglobin and deoxyhemoglobin data from 20 healthy subjects in a spherical coordinate. The spherical coordinate is a natural representation of surface brain activation projection. Our results show surface activation projected from the medial frontopolar cortex which is consistent with previous fMRI results. With this original technique, we will construct a normative database for a simple cognitive test which can be useful in evaluating cognitive disability such as mild traumatic brain injury.     

Objectively assessing balance deficits after TBI: Role of computerized posturography

Balance impairment, or postural instability, is a common source of residual physical disability after severe traumatic brain injury (TBI). Standardized functional measures such as the Functional Independence Measure (FIM) do not specifically assess balance. Furthermore, no agreement exists as to the optimal way to objectively measure balance problems in the TBI population. Technological advances have led to force-plate balance measurement known as computerized posturography testing (CPT). Published CPT data for severe TBI are lacking, and the feasibility of using CPT during rehabilitation has not been described. This study described CPT findings in 21 ambulatory patients with severe TBI who were undergoing inpatient rehabilitation at a Defense and Veterans Brain Injury Center. Results demonstrated the utility of CPT in detecting and quantifying postural instability. Comparisons with the normative database indicate that the sample had a high degree of balance impairment despite some participants having reached the ceiling of the FIM ambulation scale at discharge from the acute rehabilitation setting. The quantitative CPT measures are a promising way to characterize postural instability in severe TBI populations.     

Long-term medical care utilization and costs among traumatic brain injury survivors

OBJECTIVE: To examine billing patterns and predictors of healthcare utilization and costs associated with traumatic brain injury. DESIGN: Retrospective cohort study of healthcare billings for 63 survivors of traumatic brain injury, over a 19-mo period, using a state-sponsored Medicaid program. The relationship of indicators of injury severity and disability to billings and payments was investigated. Mean age at time of injury was 33 yrs. Mean highest Glasgow Coma Scale rating immediately after brain injury was 8. RESULTS: A total of 795,635 US dollars was billed to Medicaid for 3,950 services and medications used. A total of 281,897 US dollars was paid for these billings out of the Medicaid account studied. Billings were used for statistical analyses, as they were considered the most stable indicator of cost. Motor deficits at discharge from inpatient rehabilitation (FIM motor score) showed inverse relationships to total billings (rho = -0.42, P < 0.001), subcategories of billings reflecting equipment and supplies (rho = -.26, P = 0.020), and outpatient billings (rho = -0.27, P = 0.015). Change in FIM motor scores during inpatient rehabilitation was inversely associated with billings (rho = -0.40). Change in FIM motor scores provided unique information in predicting utilization after accounting for demographic characteristics and severity of injury. CONCLUSIONS: Motor disability and improvement during inpatient rehabilitation were significant predictors of billings after traumatic brain injury. Initial severity of brain injury was not a significant factor in utilization.