Assessment of health-related quality of life in persons after traumatic brain injury — development of the Qolibri, a specific measure

Trajectories and associated factors of quality of life, global outcome, and post-concussion symptoms in the first year following mild traumatic brain injury

PURPOSE

To investigate the associated factors and change trajectories of quality of life (QoL), global outcome, and post-concussion symptoms (PCS) over the first year following mild traumatic brain injury (mTBI).

METHODS

This was a prospective longitudinal study of 100 participants with mTBI from neurosurgical outpatient departments in Chiayi County District Hospitals in Taiwan. The checklist of post-concussion syndromes (CPCS) was used to assess PCS at enrollment and at 1, 3, and 12 months after mTBI; the glasgow outcome scale extended (GOSE), the quality of life after brain injured (QOLIBRI), Chinese version, and the Short Form 36 Health Survey (SF-36), Taiwan version, were used to assess mTBI global outcome and QoL at 1, 3, and 12 months after mTBI.

RESULTS

Latent class growth models (LCGMs) indicated the change trajectories of QOLIBRI, PCS SF-36, MCS SF-36, GOSE, and PCS. Classes of trajectory were associated with age ≥40 years, unemployment at 1 month after injury, and educational level ≤12 years. Univariate analysis revealed that employment status at 1 month post-injury was correlated with the trajectories of QOLIBRI, PCS SF-36, MCS SF-36, and GOSE, but not PCS.

CONCLUSIONS

Employment status was the most crucial associated factor for QoL in individuals with mTBI at the 1-year follow-up. Future studies should explore the benefits of employment on QoL of individuals with mTBI.

Changes in impaired self-awareness after acquired brain injury in patients following intensive neuropsychological rehabilitation

The objective of this study was to investigate changes in self-awareness impairments in outpatients with acquired brain injury (ABI) and the effects these changes have on rehabilitation. Participants were 78 patients with ABI (8.3 years post-injury) who followed an intensive outpatient neuropsychological rehabilitation programme. This longitudinal study comprised pre (T1) and post (T2) measurements and a one-year follow-up (T3). Thirty-eight patients completed the study. The main outcome domains were self-awareness, depressive symptoms, psychological and physical dysfunction, and health-related quality of life (HRQoL). Patients were divided into three awareness groups: underestimation, accurate estimation, and overestimation of competencies. Most patients who underestimated their competencies at the start of treatment accurately estimated their competencies directly after treatment (9 out of 11 patients). These patients also exhibited the largest treatment effects regarding depressive symptoms, psychological and physical dysfunction, and HRQoL. Most patients with impaired self-awareness (i.e., overestimation of competencies) at the start of treatment continued to overestimate their competencies after treatment (10 out of 14 patients). These patients exhibited a significant decrease in depressive symptoms but no other treatment effects. The results indicate that changes in outcome are related to changes in awareness, which underline the importance of taking into account different awareness groups with respect to treatment effects.

Health-related quality of life after mild, moderate and severe traumatic brain injury: patterns and predictors of suboptimal functioning during the first year after injury

BACKGROUND

The Glasgow Outcome Scale Extended (GOSE) is the established functional outcome scale to assess disability following traumatic brain injury (TBI), however does not capture the patient's subjective perspective. Health-related quality of life (HRQL) does capture the individual's perception of disability after TBI, and has therefore been recognized as an important outcome in TBI. In contrast to GOSE, HRQL enables comparison of health outcome across various disease states and with healthy individuals. We aimed to assess functional outcome, HRQL, recovery, and predictors of 6 and 12-month outcome in a comprehensive sample of patients with mild, moderate or severe TBI, and to examine the relationship between functional impairment (GOSE) and HRQL.

METHODS

A prospective cohort study was conducted among a sample of 2066 adult TBI patients who attended the emergency department (ED). GOSE was determined through questionnaires or structured interviews. Questionnaires 6 and 12 months after ED treatment included socio-demographic information and HRQL measured with Short-Form Health Survey (SF-36; reflecting physical, mental and social functioning) and Perceived Quality of Life Scale (PQoL; measuring degree of satisfaction with functioning).

RESULTS

996 TBI survivors with mild, moderate or severe TBI completed the 6-month questionnaire. Functional outcome and HRQL after moderate or severe TBI was significantly lower than after mild TBI. Patients with moderate TBI showed greatest improvement. After one year, the mild TBI group reached outcomes comparable to population norms. TBI of all severities highly affected SF-36 domains physical and social functioning, and physical and emotional role functioning. GOSE scores were highly related to all SF-36 domains and PQoL scores. Female gender, older age, co-morbidity and high ISS were strongest independent predictors of decreased HRQL at 6 and 12 months after TBI.

CONCLUSIONS

HRQL and recovery patterns differ for mild, moderate and severe TBI. This study indicates that GOSE, although clinically relevant, fails to capture the subjective perspective of TBI patients, which endorses the use of HRQL as valuable addition to established instruments in assessing disability following TBI. Influence of TBI severity on recovery, together with female gender, older age, co-morbidity and high ISS should be considered in long-term follow-up and intervention programs.

Health-related quality of life after TBI: a systematic review of study design, instruments, measurement properties, and outcome

Measurement of health-related quality of life (HRQL) is essential to quantify the subjective burden of traumatic brain injury (TBI) in survivors. We performed a systematic review of HRQL studies in TBI to evaluate study design, instruments used, methodological quality, and outcome. Fifty-eight studies were included, showing large variation in HRQL instruments and assessment time points used. The Short Form-36 (SF-36) was most frequently used. A high prevalence of health problems during and after the first year of TBI was a common finding of the studies included. In the long term, patients with a TBI still showed large deficits from full recovery compared to population norms. Positive results for internal consistency and interpretability of the SF-36 were reported in validity studies. The Quality of Life after Brain Injury instrument (QOLIBRI), European Brain Injury Questionnaire (EBIQ), Child Health Questionnaire (CHQ), and the World Health Organization Quality of Life short version (WHOQOL-BREF) showed positive results, but evidence was limited. Meta-analysis of SF-36 showed that TBI outcome is heterogeneous, encompassing a broad spectrum of HRQL, with most problems reported in the physical, emotional, and social functioning domain. The use of SF-36 in combination with a TBI-specific instrument, i.e., QOLIBRI, seems promising. Consensus on preferred methodologies of HRQL measurement in TBI would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of the burden of TBI.

A Rasch Analysis of the QOLIBRI Six-Item Overall Scale

OBJECTIVE

The Quality Of Life after BRain Injury (QOLIBRI) consortium has developed a short six-item scale (QOLIBRI-OS) to screen health-related quality of life after traumatic brain injury. The goal of the current study is to examine further psychometric qualities of the Quality Of Life after BRain Injury-Overall Scale (QOLIBRI-OS) at the item level using Rasch analysis with particular emphasis on the operating characteristics of the items.

METHOD

A total of 921 participants with traumatic brain injury were recruited. The analysis sample was restricted to 795 participants with Glasgow Coma Score and Glasgow Outcome Score-Extended available in order to ensure a well-characterized sample.

RESULTS

Overall fit statistics indicate sufficient reliability of the QOLIBRI-OS. The assumption of unidimensionality could be confirmed with reservation. The range of item locations is small, whereas item thresholds cover a wide range of the latent trait. The majority of parameter estimations for all class intervals of the respective test are in accordance with the model assumptions.

CONCLUSION

The results show that, despite marginal misfits to the model, the six items representing the QOLIBRI-OS could establish a Rasch scale.

Rationale and design of the prospective German registry of outcome in patients with severe disorders of consciousness after acute brain injury

OBJECTIVE

To describe the rationale and design of a new patient registry (Koma Outcome von Patienten der Frührehabilitation-Register [KOPF-R; Registry for Coma Outcome in Patients Undergoing Acute Rehabilitation]) that has the scope to examine determinants of long-term outcome and functioning of patients with severe disorders of consciousness (DOC).

DESIGN

Prospective multicenter neurologic rehabilitation registry.

SETTING

Five specialized neurologic rehabilitation facilities.

PARTICIPANTS

Patients (N=42) with DOC in vegetative state or minimally conscious state (MCS) as defined by the Coma Recovery Scale-Revised (CRS-R) after brain injury. Patients are being continuously enrolled. The data presented here cover the enrollment period from August 2011 to January 2012.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

CRS-R, FIM, and emergence from MCS.

RESULTS

The registry was set up in 5 facilities across the state of Bavaria/Germany with a special expertise in the rehabilitation of acquired brain injury. Inclusion of patients started in August 2011. Measures include sociodemographic and clinical characteristics, course of acute therapy, electrophysiologic measures (evoked potentials, electroencephalogram), neuron-specific enolase, current medication, functioning, cognition, participation, quality of life, quantity and characteristics of rehabilitation therapy, caregiver burden, and attitudes toward end-of-life decisions. Main diagnoses were traumatic brain injury (24%), intracerebral or subarachnoid hemorrhage (31%), and anoxic-ischemic encephalopathy (45%). Mean CRS-R score ± SD at admission to rehabilitation was 5.9 ± 3.3, and mean FIM score ± SD at admission was 18 ± 0.4.

CONCLUSIONS

The KOPF-R aspires to contribute prospective data on prognosis in severe DOC.

Factors contributing to chronic fatigue after traumatic brain injury

BACKGROUND

The annual incidence of traumatic brain injury in Europe amounts to 235 per 100 000 persons. About two-thirds will develop posttraumatic brain injury chronic fatigue (pTBI-CF).

AIM

To identify the reversible hormonal and nonhormonal causes of pTBI-CF.

PATIENTS AND METHODS

Ninety patients with varying degrees of pTBI-CF underwent endocrine testing and an evaluation of sleep, attention, coping style, daily activity and dependency, physical performance, emotional well-being, and quality of life.

RESULTS

Vitamin D deficiency was found in 65%, poor sleep quality in 54%, anxiety disorders in 36%, growth hormone deficiency in 16%, and gonadal hormone deficiencies in 9%. Fatigue severity was correlated with poor sleep (R = +0.65, P < .0001), serum 25-hydroxy vitamin D levels (R = -0.50, P < .0001), and anxiety (R = +0.50, P < .0001) but not with growth hormone deficiency or gonadal hormone deficiencies. The first 3 factors together explained 59% of the fatigue score variance.

CONCLUSIONS

Poor sleep, vitamin D deficiency, and anxiety were the most important factors associated with pTBI-CF. Appropriate treatment of these disorders may help to reduce fatigue in these patients.

ICF profiling of patients with traumatic brain injury: an international professional survey

PURPOSE

A worldwide internet survey was conducted (1) to identify problems of individuals with traumatic brain injury (TBI) addressed by health professionals and (2) to summarize these problems using the International Classification of Functioning, Disability and Health (ICF).

METHOD

A pool of professionals involved in the TBI rehabilitation process that included physicians, nurses, physical therapists, occupational therapists, social workers and psychologists were surveyed to identify problems in functioning and contextual factors of individuals with TBI using open-ended questions. All answers were translated ("linked") to the ICF based on established rules. The frequencies of the linked ICF categories were reported stratified based on context.

RESULTS

One-hundred thirty seven professionals from the six World Health Organization regions identified 5656 concepts. 92.66% could be linked to the ICF; 33.03% were related to the domain of body functions, 27.28% to activities and participation, 10.98% to structures and 21.38% to environmental factors.

CONCLUSIONS

The complexity of TBI was described through the identification of a wide variety of ICF categories. ICF language proved to be a neutral framework allowing the comparison of answers between different professionals in different world regions.

IMPLICATIONS FOR REHABILITATION

People that suffered a traumatic brain injury (TBI) may have a variety of sequelae that impair functioning. The International Classification of Functioning, Disability and Health (ICF) can help in providing information regarding the identification of patients problems and needs as well as planning, implementing and coordinating the rehabilitation process. The ICF provides a frame of reference process illustrated as the rehabilitation cycle that can help during the rehabilitation process in goal setting bringing together the clinicians' and patient's perspectives in a patient oriented biopsychosocial approach. In the field of TBI rehabilitation, activity limitations and participation restrictions are broadly affected as reported by the professionals interviewed and highly influenced by cognitive and moreover behavioral problems.

Re-orientation of clinical research in traumatic brain injury: report of an international workshop on comparative effectiveness research

During the National Neurotrauma Symposium 2010, the DG Research of the European Commission and the National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NINDS) organized a workshop on comparative effectiveness research (CER) in traumatic brain injury (TBI). This workshop reviewed existing approaches to improve outcomes of TBI patients. It had two main outcomes: First, it initiated a process of re-orientation of clinical research in TBI. Second, it provided ideas for a potential collaboration between the European Commission and the NIH/NINDS to stimulate research in TBI. Advances in provision of care for TBI patients have resulted from observational studies, guideline development, and meta-analyses of individual patient data. In contrast, randomized controlled trials have not led to any identifiable major advances. Rigorous protocols and tightly selected populations constrain generalizability. The workshop addressed additional research approaches, summarized the greatest unmet needs, and highlighted priorities for future research. The collection of high-quality clinical databases, associated with systems biology and CER, offers substantial opportunities. Systems biology aims to identify multiple factors contributing to a disease and addresses complex interactions. Effectiveness research aims to measure benefits and risks of systems of care and interventions in ordinary settings and broader populations. These approaches have great potential for TBI research. Although not new, they still need to be introduced to and accepted by TBI researchers as instruments for clinical research. As with therapeutic targets in individual patient management, so it is with research tools: one size does not fit all.

Comparison of subjective and objective assessments of outcome after traumatic brain injury using the International Classification of Functioning, Disability and Health (ICF)

PURPOSE

The aim is to examine two aspects of outcome after traumatic brain injury (TBI). Functional outcome was assessed by the Glasgow Outcome Scale - Extended (GOSE) and by clinician ratings, while health-related quality of life (HRQoL) was assessed by the Quality of Life after Brain Injury (QOLIBRI).

METHOD

The GOSE and the QOLIBRI were linked to the International Classification of Functioning, Disability and Health (ICF) to analyse their content. Functional outcome on ICF categories was assessed by rehabilitation clinicians in 55 participants with TBI and was compared to the participants' own judgements of their HRQoL.

RESULTS

The QOLIBRI was linked to 42 and the GOSE to 57 two-level ICF categories covering 78% of the categories on the ICF brief core set for TBI. The closest agreement in the views of the professionals and the participants was found on the Physical Problems and Cognition scales of the QOLIBRI.

CONCLUSIONS

The problems encountered after TBI are well covered by the QOLIBRI and the GOSE. They capture important domains that are not traditionally sufficiently documented, especially in the domains of interpersonal relationships, social and leisure activities, self and the environment. The findings indicate that they are useful and complementary outcome measures for TBI. In rehabilitation, they can serve as tools in assessment, setting meaningful goals and creating therapeutic alliance.

The association between physical health and delusional-like experiences: a general population study

OBJECTIVE

Delusional-like experiences (DLE) are prevalent in the community. Recent community based studies have found that DLE are more common in those with depression and anxiety disorders, and in those with subclinical symptoms of depression and anxiety. Chronic physical disorders are associated with comorbid depression and anxiety; however, there is a lack of evidence about the association of DLE with common physical conditions. The aim of this study was to explore associations between the common physical disorders and DLE using a large population sample.

METHODS

Subjects were drawn from the Australian National Survey of Mental Health and Wellbeing 2007, a national household survey of 8841 residents aged between 16 and 85 years. The presence of DLE, selected common physical disorders and symptoms were assessed using a modified World Mental Health Composite International Diagnostic Interview (CIDI) schedule. We examined the relationship between DLE, and physical health-related variables using logistic regression, with adjustments for potential confounding factors.

RESULTS

Of the 8771, 776 (8.4%) subjects positively endorsed one or more DLE. Of the six physical disorders examined, only diabetes and arthritis were significantly associated with the endorsement of DLE. Of the seven broad physical symptoms explored, only hearing problems were consistently associated with DLE.

CONCLUSION

Delusional-like experiences are common in the Australian community, and are associated with selected chronic physical disorders and with impaired hearing. The direction of causality between these variables warrants closer research scrutiny.

Functioning and disability in traumatic brain injury: the Italian patient perspective in developing ICF Core Sets

OBJECTIVE

The purpose of the study was to explore the aspects of functioning and health relevant to patients with traumatic brain injury (TBI) and to the caregivers of TBI patients explicitly involved in the preliminary study for the Development of the ICF Core Set for TBI using a qualitative research method.

METHOD

The sampling of patients followed the maximum variation strategy. To respect this strategy, we involved patients with different degrees of impairment and so, for some people it was not possible to join the group because of their severe cognitive impairment, in this case we interviewed their caregivers. The focus groups were digitally recorded and transcribed verbatim. The meaning condensation procedure was used for the data analysis. After qualitative data analyses, the resulting concepts were linked to ICF categories according to established linking rules.

RESULTS

Eighteen focus groups and five single interviews were performed. Forty-one patients participated in 10 focus groups. Thirty-three caregivers participated in eight focus group and six caregivers underwent a single interview. Saturation at 10% cutoff was reached. Based on 10 patient focus groups, we linked the concepts to 144 2nd level ICF different categories. In the eight focus group with caregiver we linked the concepts to 129 2nd level categories. In the single interviews, we could link the concepts only to Environmental factors and we linked to 25 ICF different categories.

CONCLUSION

A broad range of aspects of functioning and health as well as several Environmental factors important to patients with TBI were explored and included in the preparatory phase of the development of ICF Core Sets for TBI. Whereas patients focused on problems in mobility, employment and recreation and leisure the caregivers highlighted several issues related to self-care as being important for the patients.

Outcome measures for traumatic brain injury

Traumatic brain injury (TBI) is a major public health problem resulting in death and disabilities of young and productive people. Though the mortality of TBI has decreased substantially in recent years the disability due to TBI has not appreciably reduced. Various outcome scales have been proposed and used to assess disability after TBI. A few, commonly used are Glasgow Outcome Scale (GOS) with or without extended scores, Disability Rating Scale (DRS), Functional Independence Measure (FIM), Community Integration Questionnaire (CIQ), and the Functional Status Examination (FSE). These scales assess disability resulting from physical and cognitive impairments. For patients with good physical recovery a cognitive and neuropsychological outcome measure is required. Such measures include Neurobehavioural Function Inventory and specific neuropsychological tests like Rey Complex Figure for visuoconstruction and memory, Controlled Oral Word Association for verbal fluency, Symbol Digit Modalities (verbal) for sustained attention and Grooved Pegboard for fine motor dexterity. A more holistic and complete outcome measure is Quality of Life (QOL). Disease specific QOL measure for TBI, Quality of Life after Brain Injury (QOLIBRI) has also been recently proposed. The problems with outcome measures include poor operational definitions, lack of sensitivity or low ceiling effects, inability to evaluate patients who cannot report, lack of integration of morbidity and mortality categories, and limited domains of functioning assessed. GOSE-E satisfies most of the criteria of good outcome scale and in combination with neuropsychological tests is a near complete instrument for assessment of outcome after TBI.

Quality of Life after Brain Injury (QOLIBRI): scale validity and correlates of quality of life

The QOLIBRI (Quality of Life after Brain Injury) is a novel health-related quality-of-life (HRQoL) instrument specifically developed for traumatic brain injury (TBI). It provides a profile of HRQoL in six domains together with an overall score. Scale validity and factors associated with HRQoL were investigated in a multi-center international study. A total of 795 adults with brain injury were studied from 3 months to 15 years post-injury. The majority of participants (58%) had severe injuries as assessed by 24-h worst Glasgow Coma Scale (GCS) score. Systematic relationships were observed between the QOLIBRI and the Glasgow Outcome Scale-Extended (GOSE), Hospital Anxiety and Depression Scale (HADS), and SF-36. Within each scale patients with disability reported having low HRQoL in two to three times as many areas as those who had made a good recovery. The main correlates of the total QOLIBRI score were emotional state (HADS depression and anxiety), functional status (amount of help needed and outcome on the GOSE), and comorbid health conditions. Together these five variables accounted for 58% of the variance in total QOLIBRI scores. The QOLIBRI is the first tool developed to assess disease-specific HRQoL in brain injury, and it contains novel information not given by other currently available assessments.

Quality of Life after Brain Injury (QOLIBRI): scale development and metric properties

The consequences of traumatic brain injury (TBI) for health-related quality of life (HRQoL) are poorly investigated, and a TBI-specific instrument has not previously been available. The cross-cultural development of a new measure to assess HRQoL after TBI is described here. An international TBI Task Force derived a conceptual model from previous work, constructed an initial item bank of 148 items, and then reduced the item set through two successive multicenter validation studies. The first study, with eight language versions of the QOLIBRI, recruited 1528 participants with TBI, and the second with six language versions, recruited 921 participants. The data from 795 participants from the second study who had complete Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) data were used to finalize the instrument. The final version of the QOLIBRI consists of 37 items in six scales (see Appendix ). Satisfaction is assessed in the areas of "Cognition," "Self," "Daily Life and Autonomy," and "Social Relationships," and feeling bothered by "Emotions," and "Physical Problems." The QOLIBRI scales meet standard psychometric criteria (internal consistency, alpha = 0.75-0.89, test-retest reliability, r(tt) = 0.78-0.85). Test-retest reliability (r(tt) = 0.68-0.87) as well as internal consistency (alpha = 0.81-0.91) were also good in a subgroup of participants with lower cognitive performance. Although there is one strong HRQoL factor, a six-scale structure explaining additional variance was validated by exploratory and confirmatory factor analyses, and with Rasch modeling. The QOLIBRI is a new cross-culturally developed instrument for assessing HRQoL after TBI that fulfills standard psychometric criteria. It is potentially useful for clinicians and researchers conducting clinical trials, for assessing the impact of rehabilitation or other interventions, and for carrying out epidemiological surveys.

Measuring functional and quality of life outcomes following major head injury: common scales and checklists

Traumatic brain injury (TBI) is a major public health issue, which results in significant mortality and long term disability. The profound impact of TBI is not only felt by the individuals who suffer the injury but also their care-givers and society as a whole. Clinicians and researchers require reliable and valid measures of long term outcome not only to truly quantify the burden of TBI and the scale of functional impairment in survivors, but also to allow early appropriate allocation of rehabilitation supports. In addition, clinical trials which aim to improve outcomes in this devastating condition require high quality measures to accurately assess the impact of the interventions being studied. In this article, we review the properties of an ideal measure of outcome in the TBI population. Then, we describe the key components and performance of the measurement tools most commonly used to quantify outcome in clinical studies in TBI. These measurement tools include: the Glasgow Outcome Scale (GOS) and extended Glasgow Outcome Scale (GOSe); Disability Rating Scale (DRS); Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Functional Status Examination (FSE) and the TBI-specific and generic quality of life measures used in TBI patients (SF-36 and SF-12, WHOQOL-BREF, SIP, EQ-5D, EBIQ, and QOLIBRI).

Recommendations for the use of common outcome measures in traumatic brain injury research

This article summarizes the selection of outcome measures by the interagency Traumatic Brain Injury (TBI) Outcomes Workgroup to address primary clinical research objectives, including documentation of the natural course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements Workgroups, the TBI Outcomes Workgroup adopted the standard 3-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in TBI from each identified domain, including global level of function, neuropsychological impairment, psychological status, TBI-related symptoms, executive functions, cognitive and physical activity limitations, social role participation, and perceived health-related quality of life. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to some older ("legacy") measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Towards systemic sustainable performance of TBI care systems: emergency leadership frontiers

Background

Traumatic brain injuries (TBIs) continue as a twenty-first century subterranean and almost invisible scourge internationally. TBI care systems provide a safety net for survival, recovery, and reintegration into social communities from this scourge, particularly in Canada, the European Union, and the USA.

Aims

This paper examines the underlying issues of systemic performance and sustainability of TBI care systems, in the light of decreasing care resources and increasing demands for services.

Methods

This paper reviews the extant literature on TBI care systems, systems reengineering, and emergency leadership literature.

Results

This paper presents a seven care layer paradigm, which forms the essence of systemic performance in the care of patients with TBIs. It also identifies five key strategic drivers that hold promise for the future systemic sustainability of TBI care systems.

Conclusions

Transformational leadership and engagement from the international emergency medical community is the key to generating positive change. The sustainability/performance care framework is relevant and pertinent for consideration internationally and in the context of other emergency medical populations.

[Health-related quality of life as an outcome criterion in traumatology]

Health-related quality of life is a multidimensional concept which describes relevant aspects of physical, emotional and social well-being as reported by patients. Numerous generic and disease-specific instruments for measuring health-related quality of life have been developed and in addition preference-based instruments are available for use in health economic evaluation. The SF-36 and EQ-5D questionnaires belong to the most frequently used generic measures of quality of life. The Trauma Outcome Profile (TOP) and the Quality of Life after Brain Injury (QOLIBRI) questionnaires are disease-specific measures designed to assess health-related quality of life after trauma. In the context of a brief description of these questionnaires several examples of their use in studies of patients after trauma are given. These examples show that successful conceptual and methodological developments in quality of life research provide a sound basis for patient-oriented outcome assessment after trauma.

Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life

A multicenter randomized control trial (RCT) was conducted to evaluate the effects of a treatment for dysexecutive problems after acquired brain injury (ABI) on daily life functioning. Seventy-five ABI patients were randomly allocated to either the experimental treatment, multifaceted strategy training for executive dysfunction, or a control treatment, computerized cognitive function training. Assessment took place before, directly after, and 6 months post-treatment. The primary outcome measure, the Role Resumption List (RRL), and two other follow-up measures, the Treatment Goal Attainment (TGA) and the Executive Secretarial Task (EST), were indications of daily life executive functioning. The experimental group improved significantly more over time than the controls on the RRL and attained significantly higher scores on the TGA and EST. We conclude that our treatment has resulted in significant improvements of executive functioning in daily life, lasting at least 6 months post-treatment. Although control patients' satisfaction and subjective well-being were at the same level, the experimental group had better abilities to set and accomplish realistic goals, to plan, initiate, and regulate a series of real-life tasks, and to resume previous roles with respect to work, social relations, leisure activities, and mobility.

Developing core sets for persons with traumatic brain injury based on the international classification of functioning, disability, and health

The authors outline the process for developing the International Classification of Functioning, Disability, and Health (ICF) Core Sets for traumatic brain injury (TBI). ICF Core Sets are selections of categories of the ICF that identify relevant categories of patients affected by specific diseases. Comprehensive and brief ICF Core Sets for TBI should become useful for clinical practice and for research. The final definition of the ICF Core Sets for TBI will be determined at an ICF Core Sets Consensus Conference, which will integrate evidence from preliminary studies. The development of ICF Core Sets is an inclusive and open process and rehabilitation professionals are invited to participate.

New approaches to increase statistical power in TBI trials: insights from the IMPACT study

INTRODUCTION

None of the multi-centre phase III randomized controlled trials (RCTs) performed in TBI have convincingly demonstrated efficacy. Problems in clinical trial design and analysis may have contributed to these failures. Clinical trials in the TBI population pose several complicated methodological challenges, related especially to the heterogeneity of the population. In this paper we examine the issue of heterogeneity within the IMPACT (International Mission on Prognosis and Clinical Trial design in TBI) database and investigate the application of conventional and innovative methods for the statistical analysis of trials in TBI.

METHODS AND RESULTS

Simulation studies in the IMPACT database (N = 9205) showed substantial gains in efficiency with covariate adjustment. Adjusting for 7 important predictors yielded up to a 28% potential reduction in trial size. Ongoing analyses on the potential benefit of ordinal analysis, such as proportional odds and sliding dichotomy, gave promising results with even larger potential reductions in trial size.

CONCLUSION

The statistical power of RCTs in TBI can be considerably increased by applying covariate adjustment and by ordinal analysis methods of the GOS. These methods need to be considered for optimizing future TBI trials.

Moderate and severe traumatic brain injury in adults

Traumatic brain injury (TBI) is a major health and socioeconomic problem that affects all societies. In recent years, patterns of injury have been changing, with more injuries, particularly contusions, occurring in older patients. Blast injuries have been identified as a novel entity with specific characteristics. Traditional approaches to the classification of clinical severity are the subject of debate owing to the widespread policy of early sedation and ventilation in more severely injured patients, and are being supplemented with structural and functional neuroimaging. Basic science research has greatly advanced our knowledge of the mechanisms involved in secondary damage, creating opportunities for medical intervention and targeted therapies; however, translating this research into patient benefit remains a challenge. Clinical management has become much more structured and evidence based since the publication of guidelines covering many aspects of care. In this Review, we summarise new developments and current knowledge and controversies, focusing on moderate and severe TBI in adults. Suggestions are provided for the way forward, with an emphasis on epidemiological monitoring, trauma organisation, and approaches to management.

The European Brain Injury Questionnaire (EBIQ) as a reliable outcome measure for use with people with brain injury

PRIMARY PURPOSE

There is a need to develop reliable outcome measures to determine well-being after brain injury. In 1997, Teasdale et al. published the European Brain Injury Questionnaire (EBIQ), a self-report and relative-report measure of the subjective experience of cognitive, emotional and social difficulties experienced by people with brain injury. It is now used in several rehabilitation centres as an outcome measure, but its test-re-test reliability has yet not been determined. The primary purpose of the present study is to establish this degree of reliability.

RESEARCH DESIGN

The EBIQ was administered twice within an approximately 1-month period to 50 people with brain injury, to 20 relatives of people with brain injury and to 51 normal controls.

RESULTS

The results showed significant and satisfactory test-re-test reliabilities for all three groups across all nine EBIQ scales (r = 0.55-0.90).

CONCLUSION

It is concluded that the EBIQ is a clinically reliable measure to determine the subjective well-being of people with brain injury and to assess change of subjective concerns over time.

The QOLIBRI--towards a quality of life tool after traumatic brain injury: current developments in Asia

INTRODUCTION

There is no disease-specific health-related quality of life (HRQoL) tool devoted to traumatic brain injury (TBI).

MATERIAL AND METHODS

Over 1500 TBI patients from 10 countries filled out a preliminary version of the QOLIBRI taking TBI specificities into account. 3 successive versions and consecutive statistical analyses were necessary to get a psychometrically-reliable tool.

RESULTS

The QOLIBRI final version, filled out in 15 min, consists of 2 parts. The first part assesses satisfaction with HRQoL and is composed of 6 overall items and 29 items allocated to 4 subscales: thinking, feelings, autonomy and social aspects. The second part, devoted to "bothered" questions, is composed of 12 items in 2 subscales: negative feelings and restrictions. The 6 subscales meet standard psychometric criteria. In addition, 2 items evaluate medical-oriented aspects. The questionnaire is validated in German, Finnish, Italian, French, English, Dutch.

CONCLUSION

TBI patients may now be assessed, beyond more "objective" measures including handicap and recovery, with a new measure of assessing the TBI patient's own opinion on his/her HRQoL, applicable across different populations and cultures. Validations in China Mainland, Hong-Kong, Taiwan, Japan, Egypt, Poland, Norway, Indonesia, and Malaya are on the way.

Activity and Life After Survival of a Cardiac Arrest (ALASCA) and the effectiveness of an early intervention service: design of a randomised controlled trial

BACKGROUND

Cardiac arrest survivors may experience hypoxic brain injury that results in cognitive impairments which frequently remain unrecognised. This may lead to limitations in daily activities and participation in society, a decreased quality of life for the patient, and a high strain for the caregiver. Publications about interventions directed at improving quality of life after survival of a cardiac arrest are scarce. Therefore, evidence about effective rehabilitation programmes for cardiac arrest survivors is urgently needed. This paper presents the design of the ALASCA (Activity and Life After Survival of a Cardiac Arrest) trial, a randomised, controlled clinical trial to evaluate the effects of a new early intervention service for survivors of a cardiac arrest and their caregivers.

METHODS/DESIGN

The study population comprises all people who survive two weeks after a cardiac arrest and are admitted to one of the participating hospitals in the Southern part of the Netherlands. In a two-group randomised, controlled clinical trial, half of the participants will receive an early intervention service. The early intervention service consists of several consultations with a specialised nurse for the patient and their caregiver during the first three months after the cardiac arrest. The intervention is directed at screening for cognitive problems, provision of informational, emotional and practical support, and stimulating self-management. If necessary, referral to specialised care can take place. Persons in the control group will receive the care as usual. The primary outcome measures are the extent of participation in society and quality of life of the patient one year after a cardiac arrest. Secondary outcome measures are the level of cognitive, emotional and cardiovascular impairment and daily functioning of the patient, as well as the strain for and quality of life of the caregiver. Participants and their caregivers will be followed for twelve months after the cardiac arrest.A process evaluation will be performed to gain insight into factors that might have contributed to the effectiveness of the intervention and to gather information about the feasibility of the programme. Furthermore, an economic evaluation will be carried out to determine the cost-effectiveness and cost-utility of the intervention.

DISCUSSION

The results of this study will provide evidence on the effectiveness of this early intervention service, as well as the cost-effectiveness and its feasibility.

TRIAL REGISTRATION

Current Controlled Trials [ISRCTN74835019].

Life after survival: long-term daily life functioning and quality of life of patients with hypoxic brain injury as a result of a cardiac arrest

OBJECTIVES

To determine the level of daily functioning and quality of life of patients with hypoxic brain injury after a cardiac arrest and to investigate the predictive value of the duration of coma and post-traumatic amnesia in long-term functioning.

DESIGN

A retrospective cohort study.

SETTING

A Dutch rehabilitation centre.

SUBJECTS

Thirty-two patients with hypoxic brain injury caused by a cardiac arrest 2-7 years ago, who were admitted to a brain injury rehabilitation programme.

MAIN OUTCOME MEASURES

Cognitive Failures Questionnaire (CFQ), Frenchay Activities Index (FAI), Impact on Participation and Autonomy Questionnaire (IPAQ) and Quality of Life after Brain Injury questionnaire (QOLIBRI). Data on duration of coma and post-traumatic amnesia were retrieved from medical files.

RESULTS

A significant association was found between duration of coma, complaints of cognitive functioning (r = 0.57, P < 0.05) and quality of life after brain injury (r = -0.70, P < 0.01). Duration of post-traumatic amnesia was associated with both daily functioning (r = -0.70, P < 0.01) and quality of life (r = -0.70, P < 0.01). Furthermore complaints of cognitive functioning were associated with both the level of participation in society (r = 0.76, P < 0.01) and quality of life (r = 0.77, P < 0.01).

CONCLUSIONS

Long-term outcome of patients with hypoxic brain injury after a cardiac arrest shows that this group is limited in cognitive and daily functioning, participation and quality of life. Based on the duration of coma and post-traumatic amnesia, an estimation of daily life functioning and quality of life 2-7 years after a cardiac arrest can be made.

Quality-of-life: child and parent perspectives following severe traumatic brain injury

PURPOSE

Traumatic brain injury (TBI) can produce temporary or permanent impairment. Quality-of-life (QoL) after TBI has been well studied in adults, but less so in children. The aim of this study was to assess the QoL of children with TBI and compare the findings with the evaluations of parents and children without brain injury.

METHODS

Participants were 23 children with TBI, mean age 11 years, who had been treated at the SARAH Network of Rehabilitation Hospitals. Participants were matched by age, sex, parents' socio-cultural level and place of residence with 23 other children who had no history of brain injury. The instruments used were the SARAH QoL Questionnaire for Children and Adolescents, Wechsler Intelligence Scale for Children, the SARAH Physical-Functional Classification of the Child and Adolescent and a structured interview with parents.

RESULTS

The results demonstrated that, in an average 4 years after the accident, all of the children with TBI were attending school and most could walk independently. The parents' reports about post-TBI problems were marginally associated with the children's self-evaluations. The parents showed important concerns regarding their child across all dimensions of life.

CONCLUSIONS

Children with TBI report significantly reduced QoL compared to a control group in the physical, psychological, cognitive and total score dimensions. However, TBI children with average academic performance (65%) obtained the same QoL scores as the control group.

Assessing quality of life in older people: psychometric properties of the WHOQOL-BREF

The World Health Organization has developed a brief generic questionnaire to assess quality of life, the WHOQOL-BREF. It has been studied in diverse groups, but not specifically in older people. The purpose of this study was to analyze the psychometric properties of the French version of the WHOQOL-BREF questionnaire in healthy older people and to compare the mean profiles of participants with the mean profile obtained in the international validation study of the WHOQOL-BREF. Of the total sample of 262 Swiss French speaking older participants, 122 completed a retest after 2 weeks. The WHOQOL-BREF items demonstrated high test-retest reliability and validity. The WHOQOL-BREF items were differentially related to physical and mental health measures (SF-12 components, morbidity, and depression), thereby demonstrating convergent and discriminant validity. Compared to the international validation sample of the WHOQOL-BREF, participants of the present study reported higher QOL on 22 of the 26 items. A comparison of item profiles between male and female participants revealed gender differences for two items only (social support and negative feelings). We conclude that the psychometric properties of the WHOQOL-BREF items in older adults are good. To consider the 24 specific facets that are assessed by the WHOQOL-BREF appropriately, we recommend using item profiles on the individual and the sample level.

Assessment of subjective health and health-related quality of life in persons with acquired or degenerative brain injury

PURPOSE OF REVIEW

Health-related quality of life is a new outcome variable in neurology. Several generic measures aim at assessing this variable in adults with neurological diseases. Disease-specific measures are still rare; however, individuals with neurological diseases frequently suffer from cognitive impairment, yet are often excluded from health-related quality of life investigations. When included in such studies, cognitive functioning is not monitored via neuropsychological evaluation, possibly leading to methodological problems. Papers from May 2004 until July 2005 are reviewed with respect to psychometric quality and information about persons after traumatic brain injury, stroke, Parkinson's disease or dementia.

RECENT FINDINGS

Several new cross-sectional and longitudinal outcome studies are reviewed. The Medical Outcome Study Short Form with 36 items, the Sickness Impact Profile and the Nottingham Health Profile were identified as the most frequently used measures in neurology. For traumatic brain injury, two new generic instrument validations (Life Satisfaction Index-A, Subjective Quality of Life Profile) and one internationally validated disease-specific development (Quality of Life after Brain Injury) were found; for stroke, one disease-specific tool (Burden of Stroke Scale) was identified. In Parkinson's disease, the disease-specific health-related quality of life measure Parkinson's Disease Questionnaire-39 is well validated. In dementia, three dementia-specific instruments (Quality of Life for Dementia, Quality of Life in Late-Stage Dementia Scale and Quality of Life in Alzheimer's Disease Scale) seem to be valid.

SUMMARY

In neurology, only a few measures have been developed and validated for respondents with cognitive impairment, often showing poorer validity results than studies involving healthy persons. Health-related quality of life assessment should therefore be validated in the specific diseases and, if necessary, combined with a neuropsychological evaluation and a disease-specific health-related quality of life measure.

Early rehabilitation of higher cortical brain functioning in neurosurgery, humanizing the restoration of human skills after acute brain lesions

OBJECTIVE

Increasingly more patients after brain damage survive, however, suffering from severe impairments of higher cerebral functioning.

METHODS

Patients after acute brain damage, mainly secondary to TBI, are referred for early neurosurgical rehabilitation. Our concept follows the German Guidelines. It is based on a multidisciplinary team approach. Next-of kin are included in the treatment and caring.

RESULTS

The essential aspect of early neurosurgical rehabilitation is the integration of disciplines and consistent goal setting to regard individual patients' needs. Good structural organization of the team, notice of basic communication rules, conflict management and a definite decision making increase productive interdisciplinary working. The film (shown at the symposium) shows how to humanize human skills after brain damage.

DISCUSSION

Obviously the impairment of mental-cognitive and neurobehavioral functioning and not the loss of physical skills cause the patients' loss of life transactions and final outcome after brain damage. Our concept supports and fosters the individuals' neural plasticity and final social reintegration.

CONCLUSION

Functional rehabilitation is a process whereby patients regain their former abilities or, if full recovery is not possible, achieve their optimum physical, mental, social and vocational capacity. Neurosurgeons will have to work in close collaboration with the neuropsychologist and all other members of the interdisciplinary team day by day.