Recovery of arm function in patients with paresis after traumatic brain injury

OBJECTIVE

To characterize the frequency of recovery of arm paresis in patients with traumatic brain injury (TBI) admitted to rehabilitation.

DESIGN

Retrospective review identifying a cohort of patients with moderate or severe arm paresis after TBI followed at least 6 months postinjury.

SETTING

Freestanding acute rehabilitation hospital TBI unit.

PATIENTS AND METHODS

Forty-four patients with moderate to severe arm paresis were selected from 264 consecutive admissions and characterized by injury pathology subtype, injury severity (duration of unconsciousness [loss of consciousness, LOC] and posttraumatic amnesia [PTA]), age, and level of paresis according to Brunnstrom Stages of Recovery (BS 1 to 6). Patient groups with and without arm paresis were compared according to these variables (t tests and chi(2)).

MAIN OUTCOME MEASURES

Recovery of arm paresis to isolated motor function (BS 5 or 6) and time to achieve recovery. Recovered and nonrecovered patients were compared (Mann-Whitney, t tests, and chi(2)) on injury severity, initial level of paresis, age, time to rehabilitation admission, and pathology subtype. Time to recovery was compared for patients at different levels of initial paresis, ranges of LOC, and pathology subtypes (Mann-Whitney and Kruskal-Wallis tests).

RESULTS

Forty-four patients (17%) had moderate (BS 3 to 4) or severe (BS 1 to 2) paresis at rehabilitation admission. They were more severely injured than nonparetic patients based on longer LOC (p < .002) and PTA (p < .009). Thirty-six patients (82%) recovered by 6 months; 72% of these recovered by 2 months. If still paretic at 2 months, only 56% recovered. Mean recovery time was 6.9 weeks (SD, 6.1) from injury. Time to recovery was best predicted by initial level of paresis and injury severity (r2 = .48), but not age. Patients with diffuse injury tended towards a more protracted recovery (7.9 weeks, SD 6.5) than patients with focal injury (4.2 weeks, SD 3.9) (p = .08) and only those with diffuse injury showed further recovery after 3 months.

CONCLUSIONS

Arm paresis after TBI is relatively infrequent. Most patients recover by 2 months but later recovery is possible, especially in patients with primarily diffuse brain damage. Recovery is highly related to initial impairment, injury severity, and distribution of brain injury.

Time course of changes in bilateral arm power of swimmers during recovery from injury using a swim bench

OBJECTIVES

There has been little research on the time course of recovery from injury in athletes. This is especially the case for recovery in arm power in injured swimmers. The purpose of this study was to compare the power output of the injured and non-injured arms of swimmers during recovery from injury by use of a maximal exercise test on a computer interfaced isokinetic swim bench.

METHODS

Thirteen swimmers (five men and eight women; age 18.8 (3.2) years; stature 1.76 (0.05) m; body mass 61.7 (5.9) kg; mean (SD)) gave written informed consent and were recruited to this study throughout a three year period. All subjects had experienced non-aquatic soft tissue injury to their dominant-side shoulder or upper arm in the three months before participation, but had been allowed to return to swimming training. All of the subjects had injured their dominant arm and the mean time for absence from training was 3.7 (1.1) weeks. At return to training and at four, eight, and twelve weeks thereafter, subjects performed two all-out 30 second tests on the swim bench by simulating the swimming arm action. From these tests, peak power output (PPO), mean power output (MPO), and power decay (PD) for each arm during the 30 seconds of exercise could be determined by averaging the two tests. The differences between return to training and the four, eight, and twelve week periods were analysed using repeated measures analysis of variance with Tukey b post hoc test.

RESULTS

The repeated testing showed 95% confidence intervals of +/- 11.4 W for PPO, +/- 9.5 W for MPO and +/- 0.5 for PD. When the swimmers returned to training the results showed that PPO was 179 (21.9) v 111 (18.1) W (P = 0.02), MPO was 122 (9.8) v 101 (8.8) W (P = 0.01), and PD was 2.5 (0.6) v 5.2 (1.9) (P = 0.001) for non-injured and injured arms respectively (all values mean (SEM)). There were similar differences at four weeks which disappeared after eight weeks, except for that of PPO which was still evident (187.3 (21.9) v 156.8 (18.1) W; P = 0.01). At 12 weeks there were no differences between the non-injured and injured arm on any of the indices of arm power (P > 0.05).

CONCLUSIONS

These results suggest that, using the swim bench power test, differences in bilateral arm power output after injury persist for at least eight weeks after return to swimming training. These findings support the need for prolonged rehabilitation after such injury. This would best include physiotherapy and a training programme within which special consideration is given to the recuperation process.

Functional outcome after violence related traumatic brain injury

Violent injuries have become an increasingly prevalent cause of traumatic brain injury (TBI). These injuries can be classified as either penetrating or non-penetrating in nature. While much of the research on violence has been within a military population, there exists a marked difference between military and civilian injuries. Prior work has reported relatively poor outcomes for those individuals who have suffered penetrating TBIs, but little has been done to assess specific functional outcome parameters in survivors. We examined 25 subjects that had sustained blunt injuries and 25 cases with penetrating injuries as a result of a violent act. Cases were matched by initial Glasgow Coma Scale (GCS), age and educational level. Mean GCS for this study sample was 8.8. The following outcome variables were assessed at rehabilitation admission and discharge and at 1 year post injury: Disability Rating Scale (DRS), Rancho Los Amigos Scale (LCFS), Functional Independence Measure (FIM) (ambulation, expression items), length of stay, and cost of care. Student's t-tests were performed to assess for differences between the two groups. No significant differences were noted between the groups for any of the outcome variables. Although penetrating injuries may have a higher initial mortality, those who survive to come to rehabilitation appear to have similar outcomes to those patients with non-penetrating violence related injuries.

Functional outcomes of older adults with traumatic brain injury: a prospective, multicenter analysis

OBJECTIVE

To investigate improvement rates and medical services costs in older brain injured adults relative to younger patients.

DESIGN

Descriptive statistics were computed in a prospective comparative study of 50 patients 55 years and older and 50 patients 18 to 54 years old matched for gender and injury severity (number of days in coma, admission Glasgow Coma Score, intracranial pressure). Independent t tests were performed to examine differences between the two samples on specific variables.

SETTING

Five medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services.

PARTICIPANTS

Patients were selected from a national database of 531 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury between 1989 and 1994.

MAIN OUTCOME MEASURES

Disability Rating Scale, Functional Independence Measure, Rancho Los Amigos Levels of Cognitive Functioning Scale, length of stay, acute care and rehabilitation charges, and discharge disposition.

RESULTS

Older persons averaged a significantly longer rehabilitation length of stay, higher total rehabilitation charges, and a lower rate of change on functional measures. No significant differences between groups were found for acute care length of stay, daily rehabilitation charges, acute care charges (daily or total), or discharge disposition.

CONCLUSIONS

Although older persons demonstrated functional changes, the cost of change was substantially higher than for younger patients, coincident with longer lengths of stay. These higher overall charges and slower rates of change may effect changes in referral and management patterns.

Rehabilitation and follow-up of children with severe traumatic brain injury

We studied the outcome of 25 patients [12 girls and 13 boys; mean age 13.7 (SD 3.9 years)] with severe traumatic brain injury (TBI). The Glasgow Coma Scale (GCS) score 6 h after the injury was (mean) 4.5 (SD 2.7), and the mean duration of unconsciousness was 15.8 (SD 10.6) days. Being the most severely brain-injured children in the health care region, they were all referred to its only regional pediatric rehabilitation center during 1986-1990. At discharge, 1 patient was healthy, 1 was in a vegetative state and 18 had multiple impairments. Motor problems were present in 22, epilepsy in 7 and speech impairment in 14. It was not possible to assess cognition in 3 of the children, and 15 of the remaining 22 fell in the normal range. At follow up 2-6 years after trauma, all 23 survivors reported at least one sequela, and 21 had multiple sequelae. As many as two-thirds had normal I.Q. and only 3 were non-ambulatory, but behavioral and personality disturbances were so disabling that none of the patients in this group had been able to readjust to a normal life in society after the trauma.

[The use of physical factors in the combined treatment of traumatic damages to the nerve trunks of the extremities]

Traumatic impairment of peripheral nerves in the limbs requires multimodality treatment including physiotherapy, chemotherapy, orthopedic methods, massage, manual therapy. The above complex produced responses in the majority of patients treated.

Magnetic resonance imaging of acute tendon injury in the finger

Accurate assessment of flexor tendon function in a digit with an acute, non-penetrating injury is difficult. MR imaging can negate the need for surgical exploration and the associated morbidity.

Resuscitation of the injured child

Unintentional injury is the leading cause of death for children less than 14 years of age. Optimal injury control includes prevention, acute care, and rehabilitation. When prevention efforts fail, a dedicated well-trained team must be prepared to resuscitate and treat the injured child. This article presents an approach to resuscitation that emphasizes the primary and secondary survey. Early and aggressive airway control with cervical spine protection is stressed, followed by a rapid assessment of ventilatory mechanics and circulatory status. Clinical indicators of inadequate tissue perfusion are described, with priorities concerning intravenous access highlighted. Initial resuscitation steps, complemented by laboratory and radiological assessment, occur before the secondary survey. The secondary survey completes the early resuscitation phase and consists of a systematic and complete physical examination. Resuscitation priorities specific to the multiply-injured child are also discussed. Finally, the importance of rehabilitation and prevention efforts are included.

Second toe-to-finger transfer in hand mutilations

A series of 68 second toe-to-long finger transfers in 55 patients, including 52 transfers in 41 patients with mutilating injuries and 16 transfers in 14 patients with congenital deformities, was reviewed. Mean followup was 6.7 years. The failure rate was 6%, and secondary procedures were done in 18% of the patients. In the group with traumatic injuries, mean flexion was 36 degrees, with a mean extension lag of 33 degrees. Two-point discrimination was an average of 11 mm. Grasp was 47% of that for the normal contralateral side, and pinch was 38%. Of the manual workers, 62.5% returned to the same job. Analysis of the congenital series was more difficult. Although mobility was not significantly better in these patients, discrimination was a mean 5 mm (10 patients were tested). Growth plates remained open in 86% of the patients. All patients were able to use their finger to pinch.

Non-penetrating corneal foreign body injuries: factors affecting delay in rehabilitation of patients

A review of 783 patients with non-penetrating, superficial corneal foreign bodies (FBs), indicated that delay in rehabilitation was related to two factors: (1) the size of the abrasion following removal of the FB, larger abrasions requiring longer duration of antibiotic ointment, and (2) inadequate removal of corneal rust. Allergy to chloramphenicol 1% ointment (5.5 in 1000), commonly used in the management of corneal abrasions, is unpredictable and can also impair rapid rehabilitation.

Functional outcome in children with traumatic brain injury. Agreement between clinical judgment and the functional independence measure

As improvements in the delivery of trauma care have increased survival from injury, it has become essential to assess the resulting morbidity to plan for medical and psychosocial services, particularly for children whose needs may be wide and long term. This paper focuses on the assessment of disability of 598 children, age 8 to 19 yr, hospitalized for traumatic brain injury with or without injury to other body regions, exclusive of spinal cord injury. The disability was measured at discharge from acute care in nine areas of functional activities and a recovery time assigned by a clinician. For the study, children were divided into three groups: those whose recovery was expected in less than 7 months (Group A: n = 463), in 7 to 24 months (Group B: n = 66) and in greater than 2 yr (Group C: n = 69). The clinician's expectation of recovery time significantly (P less than 0.01) reflected the injury severity as measured by the Glasgow Coma Scale and the Injury Severity Score. By the Glasgow Coma Scale, 16.4% were comatose on admission in Group A, 51.5% in Group B and 58% in Group C. The Injury Severity Score was significantly different with 25.5% severely injured in Group A, 68.2% in Group B and 84% in Group C. At discharge, 15% in Group A had four or more areas of impairments, 61% in Group B and 84% in Group C. The Functional Independence Measure confirmed the clinician's assessment of compromise with significantly (P less than 0.01) different average values of 110, 80 and 58 for Groups A, B and C, respectively.

Effect of associated injuries and blood volume replacement on death, rehabilitation needs, and disability in blunt traumatic brain injury

OBJECTIVE

To examine the effects of associated injuries on death, disability, rehabilitation needs, and cost in patients with blunt traumatic brain injury.

DESIGN

A retrospective case series analysis of 1,709 patients with blunt traumatic brain injury, or 37.2% of 4,590 consecutive blunt trauma patients, was combined with a prospective study of a subset of 202 of the 1,709 brain-injured patients obtained during the same time period with regard to need for rehabilitation services, residual disability, and costs at 1 yr after discharge from the acute trauma center.

SETTING

A level I regional trauma center that is also the statewide neurotrauma and multiple trauma unit serving a population of more than 3 million persons.

RESULTS

Contingency table analysis showed the Glasgow Coma Scale to be highly predictive (p less than .0001) of likelihood of mortality, need for postacute inpatient rehabilitation, or discharge home. Of the blunt traumatic brain injury patients, 40.4% (691) had an isolated brain injury and 59.6% (1,018) had brain plus at least one other systemic injury. The mortality rate of the isolated brain injury group was 11.1% compared with 21.8% in all brain plus systemic injury groups (p less than .0001). Spine, lung, visceral, pelvis, or extremity injuries in blunt traumatic brain injury all increased mortality rate to greater than 25% (all simultaneously significant, p less than .0001). Analysis of the interaction of brain injury (quantified by Glasgow Coma Scale) with blood replacement in the initial 24 hrs showed that at any Glasgow Coma Scale range, percent mortality increased as the volume of blood increased. Hypovolemic shock increased the mortality rate from 12.8% to 62.1% (p less than .0001). The need for postacute inpatient rehabilitation in survivors also increased as blood replacement increased, and shock increased the percent of patients requiring post-acute inpatient rehabilitation from 39.7% to 60.3%. In 202 consecutive surviving brain trauma patients followed for 1 yr, isolated brain-injured patients with moderate brain injuries had a 4% need for posttrauma, postacute inpatient rehabilitation with a total cost per case of $12,489 compared with the brain plus extremity injury group, who had a 23% postacute inpatient rehabilitation rate and a total cost per case of $36,177 at 1 yr. With severe brain injury, isolated brain injury increased postacute inpatient rehabilitation to 29% and 1-yr cost to $59,274, but with the brain plus extremity injury group, postacute inpatient rehabilitation increased to 49% and cost to $84,950.

CONCLUSIONS

In blunt traumatic brain injury, the addition of major visceral or extremity injuries, with need for blood replacement or shock, increases the risk of death, the need for rehabilitation, and the costs of disability.

Severely injured geriatric patients return to independent living: a study of factors influencing function and independence

Our previous work demonstrated that geriatric trauma patients (age greater than 65 years) consume disproportionate amounts of health care resources. In the past we hypothesized that late mortality is high, long-term outcome is poor, and return to independence is low in a severely injured geriatric population. Of 6,480 trauma admissions over 5 years, geriatric patients (n = 495) with blunt trauma injury (n = 421) and an ISS greater than 16 (n = 105) who survived until discharge (n = 61) underwent long-term follow-up (mean = 2.82 years). We surveyed 20 measures of functional ability; 10 measures of independence; availability and use of rehabilitation resources; employment history; alcohol use; support systems; and nursing home requirements. Of the 105 patients, 7 were subsequently lost to follow-up. Among the remaining 98, 44 (44.9%) died in hospital and 54 (55.1%) were discharged and interviewed. The mean age of the contacted patients was 72.6; their mean ISS was 23.3. Forty eight of 54 (88.9%) were alive at the time of interview, while 6/54 (11.1%) had died. Although only 8/48 patients regained their preinjury level of function, 32/48 (67%) returned to independent living. The 32 independent patients, those with "acceptable" outcome, were compared with an "unacceptable" outcome group composed of the 44 in-hospital deaths, the 6 late deaths, and the 16 dependent patients. Factors associated with poor outcome include a GCS score less than or equal to (p = 0.001), age greater than or equal to 75 (p = 0.004), shock upon admission (p = 0.014), presence of head injury (p = 0.03), and sepsis (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Differential reading recovery in patients with severe to moderate closed head injury

A differential recovery was seen when alternate forms of a nationally standardized test of Reading Vocabulary, Literal Reading Comprehension and Inferential Reading Comprehension was administered serially to 10 consecutive closed head injury admissions to a university rehabilitation hospital. Inferential Reading Comprehension was the most impaired and had the fastest recovery rate. Subtle cognitive deficits in Inferential Reading Comprehension were detected when Reading Vocabulary was at or better than a twelfth grade level. Maximal recovery of all three reading functions occurred within 4 months after trauma, with most occurring in the first 3 months. The reading recovery pattern parallels the recovery of intelligence scores in the literature.

Bilateral femoral nerve neuropathy following blunt trauma. Case report

A unique case of bilateral compressive injury of the femoral nerves is reported in a 19-year-old man. Traumatic femoral nerve neuropathy following operative injury, penetrating injury, anticoagulant therapy with hemorrhage, and stretch injury has been described previously, and the literature concerning this unusual clinical problem is reviewed. Bilateral traumatic femoral nerve neuropathy resulting from compressive injury has not been previously reported.

A model of orthopaedic dysfunction for clinical decision making in physical therapy practice

This model serves as a framework for the critical analysis of current practice concepts. The analysis obtained from using this model should be integrated with other physiological systems of the body during examination and treatment processes. Currently used as a basis for graduate study in orthopaedic physical therapy, the model helps students identify fundamental research questions, compare various examination and treatment philosophies, and comprehend generic treatment goals and strategies.

Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion

We reviewed 144 consecutive patients with flail chest and/or pulmonary contusion between 1979 and 1984. The purpose was to analyze the factors adversely affecting morbidity and mortality. There were 97 males and 47 females, with an average age of 40 years +/- 18 S.D. (range, 2-83). Seventy-five per cent of the injuries were caused by motor vehicle accidents, with the remainder due to falls (17%), cardiopulmonary resuscitation (4%), altercations (2%), or falling objects (2%). The Injury Severity Score (ISS) averaged 32 +/- 14 S.D. in all survivors versus 60 +/- 14 S.D. in those who died. Eighty-three patients (58%) required mechanical ventilation. Thirty-six patients died (25%). Isolated pulmonary contusion or flail chest had a mortality of 16% each. However, the mortality more than doubled when there was a combined pulmonary contusion and flail chest (42%). More than half of all deaths were directly attributed to central nervous system injuries with another third due to massive hemorrhage. Factors that were associated with a higher morbidity and mortality included severe associated thoracic injuries, a high ISS, the presence of shock, falls from heights, and the combination of pulmonary contusion and flail chest.

Aggressive trauma care benefits the elderly

Few past studies have examined the long-term functional outcome of geriatric patients who survive trauma. To evaluate factors that determine the long-term potential for recovery in this population, we studied 63 survivors of blunt trauma over age 65 years between 9 and 38 months after hospital discharge. The overall level of injury was moderate, with a mean Injury Severity Score of 15.8 +/- 1.1. Thirty-nine patients (62%) had two or more body regions injured. Forty-five patients (71%) had pre-existing cardiopulmonary disease. Surgery was required in half of the patients, one third experienced complications, and nine (14%) required ventilatory support for 5 or more days. Only two patients did not live independently before trauma. Immediately after discharge, 21 patients (33%) were independent, 23 (37%) were dependent but living at home, and 19 (30%) required nursing-home care (NH). NH patients were older, more severely injured, had more severe head and neck trauma, and required surgery more frequently after trauma than patients discharged directly home. Twelve of the 19 NH patients (63%) returned home 3.1 +/- 0.9 months after discharge, and 13 of the 23 dependent patients (57%) became independent. Ultimately, 56 patients (89%) returned home after trauma. These patients were younger, had a shorter hospital stay, and experienced fewer complications than patients who required permanent NH care. Among 12 patients 80 years old and over, eight patients eventually returned home. Overall, 38 patients (57%) returned to independent living after trauma. Aggressive support of the elderly trauma victim appears justified, since few patients require permanent NH care and the majority return to independent living after trauma.

Successful vascular reconstruction. Determinants of disability

Improvements in limb salvage during the last decade are a reflection of advances in angiography, antibiotics and technique. We report a 100 per cent success rate with vascular repair and a 100 per cent disability outcome in extremity injuries. Ten male patients, with a mean age of 27.3 (range 18 to 41) years, sustained trauma to the extremity with vascular injury. The etiology of injury was gunshot wounds (5), blunt trauma (4), and stab wounds (1). Time from injury to vascular repair was a mean of 186 (range 60 to 360) min. Vessels injured included popliteal artery and vein (4), tibial artery and vein (2), subclavian artery and vein (2), and axillary artery (1). Six of the injuries were associated with fracture of the adjacent bone and treated with external skeletal fixation. All patients had an associated nerve injury. Five patients underwent fasciotomy; nine were treated with 500 ml Dextran-40 for 48 hr (each day for 2 days). All patients received cephalosporin antibiotics pre-, intra-, and post-operatively. All patients had successful vascular repair, as identified by Doppler ultrasound (10 patients) and intra-/post-operative arteriography (5 patients). The median follow-up period was 22 (range 18 to 30) months. There were no primary amputations (within 30 days); there were four late amputations (2, no function and foot ulcer; 2, causalgia). The five popliteal/tibial injuries had no dorsiflexion and foot drop, two had no function and leg ulcers; two patients had femoral and sciatic nerve injury at the thigh; and three patients had injuries to the brachial plexus.(ABSTRACT TRUNCATED AT 250 WORDS)

Late outcome of very severe blunt head trauma: a 10-15 year second follow-up

Forty patients with very severe blunt head trauma (post-traumatic amnesia greater than or equal to 1 month) were initially examined at an average of 4.5 months after the injury. The patients were visited in their homes 2.5 years and 10-15 years after the accident and questionnaires were presented to patients, relatives and/or staff. Though physical impairment, dysarthria and defects of memory remained severe in many cases, the psychosocial sequelae presented the most serious problems. Permanent changes in personality and emotion were reported in two thirds and were especially frequent among the youngest patients. The worse overall outcome was seen in cases with severe brainstem involvement or anterior lesions or both. In spite of the great frequency of deficits long-term improvement of functional state was common and several regained at least some work capacity.

Computerized tomography head scans as predictors of rehabilitation outcome

This study explored the relationship between rehabilitation functional outcome, demographic characteristics, and predicted goal achievement for 30 patients with closed head injury according to characteristics of their computerized tomography (CT) head scans performed within 10 days of injury. Goals and outcome were measured according to levels of independent/dependent function at discharge from an interdisciplinary inpatient rehabilitation program by means of the Patient Evaluation Conference System (PECS). Patients were classified into the three following major subgroups according to CT findings: (1) normal; (2) 1 hemisphere lesion; and (3) bilateral lesion. Marked differences in patient outcome and in the team's ability to accurately predict outcome were found to match the subgroups so classified. The need to incorporate CT scan data into early team planning and goal setting is stressed.