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

Middle age cognition and vocational outcome of childhood brain injury

OBJECTIVES

In this almost four-decade follow-up we studied the cognitive performance of a cohort of 22 traumatic brain injury (TBI) patients in relation to vocational outcome. The patients had suffered a moderate to severe TBI in traffic accidents as preschoolers.

METHODS

The neuropsychological assessment included the Profile of Mood States questionnaire and the Neurobehavioral Rating Scale. The cognitive performance of full-time working patients was compared with that of those not working.

RESULTS

Full-time working patients had significantly better intellectual performance than the patients not at work. Memory performance was partly defective in both groups but neither group had subjective memory complaints. All patients working full time lived in a marital relationship and had less neurobehavioral problems than the patients not at work.

CONCLUSIONS

Good intellectual capacity, verbal memory, and marital status were connected with a positive outcome. We suggest that as late as in middle age in spite of moderate to severe childhood TBI, it is still possible for a subgroup of patients to live a normal productive life.

The Role of Self-Discrepancy Theory in Understanding Post–Traumatic Brain Injury Affective Disorders

This pilot study examined the utility of self-discrepancy theory (SDT) in explaining post-traumatic brain injury (TBI) depression and anxiety. The SDT model was expanded to include the discrepancy between the postinjury self and the preinjury self. Study participants were 21 individuals with mild to severe TBI residing in the community, who completed the Selves Interview, the Selves Adjective Checklist, the Beck Depression Inventory-II and the Beck Anxiety Inventory. Strong correlations were found between affective distress and self-discrepancies, as measured by the checklist. Scores on the interview were not related to affective distress. The findings suggest that further research is merited to examine the utility of the SDT in addressing issues of post-TBI depression and anxiety.

Stress and coping among families of patients with traumatic brain injury: a review of the literature

AIMS AND OBJECTIVES

This literature review aims to structure the available information on the psychological reactions of family members confronted with traumatic brain injury. The stress-coping theory and the systems theory provide the theoretical framework for this review.

METHOD

Literature review.

RESULTS

The level of stress experienced by the family members of patients who have traumatic brain injury is such that professional intervention is appropriate, even after 10-15 years. Not the severity of the injury but the nature of the injuries determines the level of stress. Partners experience more stress than parents. Children have specific difficulties. Young families with little social support, financial, psychiatric and/or medical problems are the most vulnerable. Coping with traumatic brain injury can be described in phases. The better family members can cope with the situation, the better the patient's recovery. There are functional and non-functional coping mechanisms and coping is influenced by such factors as gender, social and professional support and the possibility to have reciprocal communication or an affective relation with the patient.

RELEVANCE TO CLINICAL PRACTICE

Support from professionals reduces the stress being experienced and encourages people to cope effectively. Conflicts with professional carers should be avoided. Every attempt should be made to develop models of long-term support and care that alleviate sources of burden on relatives. Further research is necessary to develop such models.

Awareness and Distress After Traumatic Brain Injury

OBJECTIVE

To examine the relationship between relatives' distress level and their ratings of impaired awareness for persons with traumatic brain injury (TBI).

DESIGN AND OUTCOME MEASURES

Participants were 25 patients with TBI, 16 with probably dementia, and 15 with memory complaints but no dementia. Participants completed the Barrow Neurological Institute Screen for Higher Cerebral Functions. Relatives of all patients completed the Patient Competency Rating Scale (Relative Form). Relatives also rated their distress level on a scale from 0 (no distress) to 10 (severe distress) and then rated the patient's level of awareness of their difficulties, also on a scale from 0 (not aware) to 10 (completely aware).

SETTING

Clinical neuropsychology outpatient service of a neurological institute and medical center.

RESULTS

For relatives of patients with TBI, a significant correlation of -0.52 (P = .006) was found. Correlations for the dementia and memory complaint groups were -0.62 (P = .03) and -0.39 (P = .20), respectively.

CONCLUSIONS

The presence of brain dysfunction associated with neuropsychological disturbances appears to influence the magnitude of the relationship between the distress level of family members and their ratings of impaired awareness in persons with TBI.

An Interactive Web-based Intervention for Persons With TBI and Their Families

OBJECTIVE

To assess the feasibility of providing in-home adjunctive and supportive services to persons with traumatic brain injury (TBI) and their families via a Web site.

DESIGN

Nineteen families were provided with access to the Web site intervention for 6 months. Those who needed it were provided with a computer and Internet service in their homes.

PARTICIPANTS

Adult women who were the significant others of adult males with moderate-to-severe TBI.

MAIN OUTCOME MEASURE

Value and ease of use of the Web site. Each participant's usage of the Web site was automatically tracked including each page visited, time of day, and time spent on the page.

RESULTS

Female significant others found the Web site to be valuable and easy to use, and used it throughout the 6-month period. The on-line support group was the most used and valued module.

CONCLUSIONS

Family caregivers will use Web-based interventions to help meet their needs for social support, information, and guidance following the return home of persons with TBI.

Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children

OBJECTIVE

To examine the contributions of injury severity, physical and cognitive disability, child and family function to outcome 30 months after traumatic brain injury (TBI) in children.

DESIGN

A prospective, longitudinal, between group design, comparing function before and after injury across three levels of injury severity.

SUBJECTS

One hundred and fifty children, 3.0-12.11 years old, admitted to hospital with a diagnosis of TBI. The sample was divided according to injury severity: mild (n = 42), moderate (n = 70), severe (n = 38). Children with a history of neurological, developmental, and psychiatric disorders were excluded from participation.

MAIN OUTCOME MEASURES

Post injury physical function, cognitive ability (incorporating intellect, memory, and attention), behavioural and family functioning, and level of family burden.

RESULTS

A dose-response relation was identified for injury severity and physical and cognitive outcome, with significant recovery documented from acute to six months after TBI. Behavioural functioning was not related to injury severity, and where problems were identified, little recovery was noted over time. Family functioning remained unchanged from preinjury to post injury assessments. The level of family burden was high at both six and 30 months after injury, and was predicted by injury severity, functional impairment, and post injury child behavioural disturbance.

CONCLUSIONS

These results suggest ongoing problems for the child and significant family burden 30 months after TBI. The nature and severity of the physical and cognitive problems are closely related to injury severity, with child and family function predicted by psychosocial and premorbid factors.

Auto-évaluation de la gêne physique, cognitive et thymique de sujets cérébrolésés. Effet d’une prise en charge spécifique

INTRODUCTION

We studied 23 vascular or traumatic head injury subjects, five years after their injury.

METHODS

Neuropsychological testing included language tests, memory performance, frontal lobe tests and standard tests of intelligence (QI). Behavior was evaluated with the neuropsychiatric interview (NPI). Using an analogic visual scale, subjects performed a self-evaluation of their memory, language, attention, physical and thymic complaints.

RESULTS

Neuropsychological assessment was heterogeneous but seemed to show severe impairment. Mean NPI score was 31.4: 91 percent of patients showed depression or anxiety and 78 percent of them showed irritability. Mean memory and thymic complaints were scored 6 on the analogic visual scale. Thymic complaint was not correlated with neuropsychological tests but with physical complaints. Thymic complaint was correlated with NPI score. Language complaint was correlated with VIQ, attentional complaint was correlated with PIQ, memory complaint with memory tests. In a second part, we studied 21 patients again 6 months later and 14 patients 1 year later. Mean complaints were scored over 5 after 6 months and over 4 after 1 year. With neuropsychological remediation and social activities, memory complaints improved significantly after 6 months and attentional and thymic complaints after 1 year.

CONCLUSION

Using of analogical visual scales appears to be feasible: patients were able to evaluate their difficulties. This could be useful to elaborate remediation programs and evaluate outcome.

Traumatic brain injury induced hypopituitarism: the need and hope of rehabilitation

Traumatic brain injury is a leading cause of death and disability in developed countries. Damage caused by focal and diffuse lesions produces symptoms involving most major medical systems as well as symptoms of neurological and psychological origin. The severity of a traumatic brain injury is difficult to assess, and therefore, an initial accurate prognosis is difficult as well. Present treatments focus on relieving symptoms without adequately addressing the underlying cause of those symptoms. Recent studies have shown anterior pituitary deficiencies to be common amongst survivors of TBI. As many symptoms ascribed to a TBI are similar to the symptoms of hypopituitarism, it is possible that treatment of these deficiencies will improve functioning and the quality of life for survivors of traumatic brain injuries.

Psychosocial outcome following traumatic brain injury in adults: a long-term population-based follow-up

PRIMARY OBJECTIVE

On a national basis to conduct a 5, 10 and 15 year follow-up study of representative samples of survivors after traumatic brain injury (TBI) and to identify factors of importance for long-term survival and life satisfaction after TBI occurring in 1982, 1987 or 1992.

RESEARCH DESIGN

Epidemiological, register-based questionnaire survey.

MAIN OUTCOMES, RESULT AND CONCLUSIONS

Out of 389 survivors randomly chosen from a national complete hospital register, 173 had suffered a cranial fracture, 186 a cerebral lesion (brain contusion or traumatic haemorrhage) and 30 patients a chronic subdural haematoma. Out of 337 survivors found eligible for a questionnaire, 76% responded. Among the data registered according to the above mentioned areas, the main findings were that 23-31% of the cerebral lesion responders were unable to maintain earlier work/education at pre-injury level, against up to 14% of cranial fracture patients. Significantly more cerebral lesion patients than cranial fracture patients found emotional control more difficult, as well as increased difficulties with memory and concentration, maintenance of leisure time interests and general life satisfaction. In the long run, an important factor influencing survival among cerebral lesion patients seemed to be whether relations with family and friends could be maintained at the pre-injury level.

Sensory aphasia after closed head injury

A 51-year-old, right-handed male injured his head when drunk. After an initial mute state lasting for several hours, he exhibited fluent aphasia, impaired word finding, some verbal paraphasia and impaired verbal comprehension. A CT scan revealed a contusion in the left anterior temporal lobe. He was treated conservatively, and at the follow-up 6 months later, his sensory aphasia had recovered well. The relationship between closed head trauma and aphasia is reviewed with special attention to its nature and clinical course.

Change and Predictors of Change in Communication, Cognition, and Social Function Between 1 and 5 Years After Traumatic Brain Injury

OBJECTIVE

To study cognitive, communication, and social changes experienced by individuals between 1 and 5 years after traumatic brain injury (TBI).

DESIGN

Prospective cohort.

SETTING AND PARTICIPANTS

TBI Model System Database with 927 eligible subjects using a cohort with complete 1- and 5-year data (N = 292).

MAIN OUTCOME MEASURES

Change in Functional Independence Measure trade mark -Cognitive (FIM-Cog) items from Year 1 to Year 5 postinjury.

RESULTS

On the FIM-Cog Total score, 26% individuals improved, 61% stayed the same, and 14% worsened by more than 1 point from Year 1 to Year 5. On the 2 FIM Communication items, 19% individuals improved, 68% stayed the same, and 13% worsened by greater than 1 point. On the FIM Social Interaction item, 12% individuals improved, 76% stayed the same, and 11% worsened. On the FIM Memory and Problem Solving items, 34% individuals improved, 48% stayed the same, and 19% worsened. Several variables predicted this improvement and worsening, some of which were available at the time of injury and most were those available at 1 year postinjury. The Memory and Problem Solving items, taken together, showed fewer participants at ceiling at Year 1 and more change between Year 1 and Year 5 compared to the Communication and Social Interaction items.

CONCLUSIONS

Many individuals did not demonstrate meaningful change on FIM-Cog and its component items from Year 1 to Year 5. In particular, a high proportion of improvement was observed in Memory/Problem Solving, and worsening in Social Interaction. Demographic and functional indicators present at 1 year postinjury may be predictive of subsequent change.

Medical and Social Issues Related to Posttraumatic Seizures in Persons With Traumatic Brain Injury

BACKGROUND

The incidence of late posttraumatic seizures (LPTS) in individuals with traumatic brain injury (TBI) ranges anywhere from 5% to 18.9% in civilian populations up to 32% to 50% in military personnel.

OBJECTIVE

This article reviews the current knowledge about the incidence and prevalence of LPTS following a TBI, the risk factors for developing LPTS, and the options available for preventing the development of LPTS.

METHODS

The psychosocial ramifications of LPTS following a TBI have not been well explored. As a result, the psychosocial findings from the current literature on epilepsy will be reviewed with the hope that the need for future TBI outcomes research to investigate the impact of LPTS following a TBI or, at least, to include LPTS as a potential contributing factor will be recognized.

Outcome 3 to 5 years after moderate to severe traumatic brain injury

OBJECTIVE

To investigate neuropsychologic, emotional, and functional status and quality of life (QOL) 3 to 5 years after moderate to severe traumatic brain injury (TBI).

DESIGN

Observational cohort.

SETTING

Level I trauma center.

PARTICIPANTS

Consecutive adult admissions with TBI involving intracranial abnormalities, prospectively followed up for 3 to 5 years, with 80% follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Neuropsychologic functioning (Paced Auditory Serial Addition Test, California Verbal Learning Test), emotional status (Center for Epidemiologic Studies Depression Scale, Brief Symptom Inventory), functional status (Functional Status Examination, Glasgow Outcome Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, employment), and perceived QOL.

RESULTS

Significant functional limitations were observed in all areas. Recovery to preinjury levels ranged from 65% of cases in personal care to approximately 40% in cognitive competency, major activity, and leisure and recreation. Brain injury severity, measured by the modified Abbreviated Injury Scale, related to functional status and neuropsychologic functioning, but not to emotional or QOL measures. Length of impaired consciousness appeared to contribute to outcome more than did anatomic lesions.

CONCLUSIONS

The results provide representative estimates of long-term morbidity in patients with TBI involving intracranial lesions. The magnitude of morbidity was high. Although direct costs of TBI have received the most attention, the long-term consequences and their cost implications are much larger, unfold over time, and are borne by the survivors, their families, and the public subsidy system.

Traumatic brain injury brief outcome interview

There is much evidence that deficits in physical and psychological functioning persist long after traumatic brain injury occurs. This paper presents a brief outcome interview (BOI) that can be administered in person or over the telephone, with evaluation of change in functioning in three areas: (a). occupational status, (b). mobility/activities of daily living (ADL), and (c). social relationships. Forty-four traumatic brain injury participants were evaluated at an average of 6.2 years postinjury with the present BOI as well as with the Glasgow Outcome Scale and Karnofsky Performance Scale (KPS). The BOI demonstrated strong concurrent validity with both scales, as well as strong test-retest reliability. IQ and memory scores obtained at an average of 4.1 months postinjury suggested that the injury was moderately severe. The average score on the GPS suggested "good recovery" and the average score on the KPS suggested "normal activity with effort, some signs or symptoms." These descriptions matched the BOI for the mobility/ADL dimension, for which all respondents reported some form of independent mobility, and 88.6% of the respondents reported no need for any kind of assistance in daily life functioning. However, significant long-term issues were seen for social and occupational functioning. Fifty-four percent said that they did not socialize as much as before their injury, and half of the participants reported not being involved in a romantic relationship in spite of an average age of 32 years. In terms of occupational status, 40.9% reported not working at all at any kind of job. Compared to before their injury, 47.7% said this was less time, 40.9% said that it was for a lower salary, and 54.5% said that their responsibilities were less. The stability of these social and occupational changes was indicated by high test-test reliabilities for the overall BOI score and the three subscale scores (r's ranged from.97 to 1.0). These stable long-term changes are consistent with some other studies and suggest that the social and occupational needs of this population warrant more attention.

Psychosis following traumatic brain injury

Psychosis is a relatively infrequent but potentially serious and debilitating consequence of traumatic brain injury (TBI), and one about which there is considerable scientific uncertainty and disagreement. There are several substantial clinical, epidemiological, and neurobiological differences between the post-traumatic psychoses and the primary psychotic disorders. The recognition of these differences may facilitate identification and treatment of patients whose psychosis is most appropriately regarded as post-traumatic. In the service of assisting psychiatrists and other mental health clinicians in the diagnosis and treatment of persons with post-traumatic psychoses, this article will review post-traumatic psychosis, including definitions relevant to describing the clinical syndrome, as well as epidemiologic, neurobiological, and neurogenetic factors attendant to it. An approach to evaluation and treatment will then be offered, emphasizing identification of the syndrome of post-traumatic psychosis, consideration of the differential diagnosis of this condition, and careful selection and administration of treatment interventions.

Obsessive-compulsive disorder after traumatic brain injury

Traumatic brain injury ( TBI) neuropsychiatric sequelae are a significant cause of morbidity in TBI victims. Among the recognized sequelae are anxiety, obsessions, compulsions and obsessive-compulsive disorder (OCD). This review addresses the emergence of OCD and OCD symptoms after TBI with an emphasis on neural circuits that underlie OCD symptom expression that may be affected by the injury. Current studies suggest that post-TBI emergent psychopathology, including OCD, is influenced by underlying sub-clinical diathesis, brain injury lesions sites, environmental stressors and the rehabilitation process. Pre-morbid status can be obtained by structured psychiatric interviews, and TBI brain lesions can be defined with advanced neuroimaging techniques. This information along with the management of family and environmental stressors and the enhanced clinical identification of symptoms of anxiety and OCD can be used in the rehabilitation process to improve prognosis after TBI.

Depression assessment after traumatic brain injury: an empirically based classification method11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To describe the patterns of depression in patients with traumatic brain injury (TBI), to evaluate the psychometric properties of the Neurobehavioral Functioning Inventory (NFI) Depression Scale, and to classify empirically NFI Depression Scale scores.

DESIGN

Depressive symptoms were characterized by using the NFI Depression Scale, the Beck Depression Inventory (BDI), and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Depression Scale.

SETTING

An outpatient clinic within a Traumatic Brain Injury Model Systems center.

PARTICIPANTS

A demographically diverse sample of 172 outpatients with TBI, evaluated between 1996 and 2000.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The NFI, BDI, and MMPI-2 Depression Scale. The Cronbach alpha, analysis of variance, Pearson correlations, and canonical discriminant function analysis were used to examine the psychometric properties of the NFI Depression Scale.

RESULTS

Patients with TBI most frequently reported problems with frustration (81%), restlessness (73%), rumination (69%), boredom (66%), and sadness (66%) with the NFI Depression Scale. The percentages of patients classified as depressed with the BDI and the NFI Depression Scale were 37% and 30%, respectively. The Cronbach alpha for the NFI Depression Scale was.93, indicating a high degree of internal consistency. As hypothesized, NFI Depression Scale scores correlated highly with BDI (r=.765) and MMPI-2 Depression Scale T scores (r=.752). The NFI Depression Scale did not correlate significantly with the MMPI-2 Hypomania Scale, thus showing discriminant validity. Normal and clinically depressed BDI scores were most likely to be accurately predicted by the NFI Depression Scale, with 81% and 87% of grouped cases, respectively, correctly classified. Normal and depressed MMPI-2 Depression Scale scores were accurately predicted by the NFI Depression Scale, with 75% and 83% of grouped cases correctly classified, respectively. Patients' NFI Depression Scale scores were mapped to the corresponding BDI categories, and 3 NFI score classifications emerged: minimally depressed (13-28), borderline depressed (29-42), and clinically depressed (43-65).

CONCLUSIONS

Our study provided further evidence that screening for depression should be a standard component of TBI assessment protocols. Between 30% and 38% of patients with TBI were classified as depressed with the NFI Depression Scale and the BDI, respectively. Our findings also provided empirical evidence that the NFI Depression Scale is a useful tool for classifying postinjury depression.

Long-term adjustment of families following traumatic brain injury where comprehensive rehabilitation has been provided

OBJECTIVES

The present study aimed to examine long-term family and emotional adjustment in close relatives of individuals with TBI, who had access to comprehensive rehabilitation services. It also examined the relative influence thereon of factors including injury severity, handicap and cognitive and behavioural changes in the injured person, relationship with the injured person and caregiver status.

METHODS

Participants were 143 TBI individuals and their close relatives. They completed the Family Assessment Device (FAD), Leeds Scales of Anxiety and Depression, Structured Outcome Questionnaire, CHART, SIP Psychosocial Dimension and Novaco Anger Control Questionnaire 2-5 years post-injury.

RESULTS

Results showed that families were, on average, functioning in the normal range on the FAD. Anxiety and depression were more likely to be present in those responsible for care of their injured relative. There were no differences between spouses and parents. Presence of cognitive, behavioural and emotional changes was the strongest predictor of anxiety and depression in relatives and of unhealthy family functioning.

CONCLUSIONS

Every attempt should be made to develop models of long-term support and care that alleviate these sources of burden on relatives.

Rural versus urban social support seeking as a moderating variable in traumatic brain injury outcome

OBJECTIVE

To investigate personal beliefs about seeking social support following traumatic brain injury (TBI) and the relationship of these appraisals to demographic and injury variables, social integration, and quality of life ratings.

SETTING

The central region of a Midwest state.

PARTICIPANTS

Fifty-six adults with TBI who were more than 6 months postinjury and living in the community.

MAIN OUTCOME MEASURES

The Hesitation Scale, a 20-item survey that assesses reasons that people might hesitate to reach out to others in the community, and portions of the Living Life After Traumatic Brain Injury Scale.

RESULTS

Negative attitudes and beliefs about seeking social support were significantly related to lower perceptions of social support, lower ratings of quality of life, longer time since injury, being divorced or separated, and living in an urban area. Predictors of higher quality of life ratings included more positive appraisals about seeking social support, living in a rural area, and the ability to engage in productive activity.

CONCLUSIONS

Positive outcomes after TBI appear to be moderated by living in a rural area, which is associated with more openness to seeking social supports and contributes to better quality of life.

Pharmacological management for agitation and aggression in people with acquired brain injury

BACKGROUND

Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most troublesome. It is therefore important to evaluate the efficacy of psychotropic medication used in its management.

OBJECTIVES

To evaluate the effects of drugs for agitation and/or aggression following acquired brain injury (ABI).

SEARCH STRATEGY

We searched MEDLINE (1966-2002), EMBASE (1980-2002) and the Cochrane Controlled Trials Register (1996-2002), Web of Science Citation Index, reference lists of papers meeting the inclusion criteria and recent reviews. We handsearched Brain Injury and the Journal of Head Trauma Rehabilitation. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated the efficacy of drugs acting on the central nervous system for agitation and/or aggression, secondary to ABI, in participants over 10 years of age. Studies using lower levels of evidence (i.e. case series studies, single case studies and controlled group comparison studies), were collated in an appendix.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. Authors were contacted where necessary for additional information. Studies of patients within six months after brain injury and/or in a confusional state, were distinguished from those of patients more than six months post-injury, or who were not confused.

MAIN RESULTS

Six randomised controlled trials were identified. Four RCTs evaluated the beta-blockers, propranolol and pindolol, one RCT evaluated the central nervous system stimulant, methylphenidate and one RCT evaluated amantadine, a drug normally used in parkinsonism and related disorders. The best evidence of effectiveness in the management of agitation and/or aggression following ABI was for beta-blockers. Two RCTs found propranolol to be effective (one study early and one late after injury). However, these studies used relatively small numbers, have not been replicated, used large doses, and did not use a global outcome measure or long-term follow-up. Comparing early agitation to late aggression, there was no evidence for a differential drug response. Firm evidence that carbamazepine or valproate is effective in the management of agitation and/or aggression following ABI is lacking.

REVIEWER'S CONCLUSIONS

Numerous drugs have been tried in the management of aggression in ABI but without firm evidence of their efficacy. It is therefore important to choose drugs with few side effects and to monitor their effect. Beta-blockers have the best evidence for efficacy and deserve more attention. The lack of evidence highlights the need for better evaluations of drugs for this important problem.

Positive supports for people who experience behavioral and cognitive disability after brain injury: a review

BACKGROUND

Behavioral and cognitive problems are among the most common and troubling consequences of traumatic brain injury. Furthermore, behavioral and cognitive challenges typically interact in complex ways, necessitating an integrated approach to intervention and support.

OBJECTIVES

This article reviews literature on behavioral outcome in children and adults with traumatic brain injury, traditional approaches to behavioral intervention and cognitive rehabilitation, and the history, principles, and assessment and treatment procedures associated with context-sensitive, support-oriented approaches to behavioral and cognitive intervention. We propose a clinical framework that integrates cognitive and behavioral intervention themes.

The safe management of physical aggression using multi-element positive practices in community settings

BACKGROUND

Behavioral strategies often are used with people with acquired brain injury. Most involve the application of contingent reinforcement and punishment for selected behaviors or teaching important skills to overcome the challenging behaviors. However, consequential intervention and other strategies that depend on new learning may be precluded when working with individuals with significant short-term memory impairment.

MAIN OUTCOME MEASURES

The present case study reports the results of non-consequential strategies based on a positive, multi-element model to address physical aggression and other related problems for such an individual.

RESULTS

Support did not involve the use of aversive consequences for challenging behaviors nor the use of physical management/restraint. The identified problems were effectively and safely addressed and community living in close proximity to his family was maintained.

CONCLUSIONS

The implications of this approach for the support of people who face similar challenges are discussed, including the ability to address serious problems such as physical aggression without resorting to aversive procedures.

Social Attention

Abstract: Many TBI patients suffer from cognitive impairments, affecting their abilities to function on a previous level. However, some patients exhibit personality changes, manifesting themselves in inadequate or inappropriate social behavior, which are considered to have even more debilitating consequences on successful social and vocational rehabilitation. The term “impaired social attention” was put forward by Dr. van Zomeren as a description of a part of these problems: Patients' analysis of social situations seems incomplete, and they seem to lack awareness of consequences of their actions. In this paper the concept of social attention will be explored, whereby it is hypothesized that impaired social attention results from underlying emotional impairments. Two aspects of emotional behavior are considered essential prerequisites for intact social attention: The ability to perceive emotional expressions of others, and the ability to form a Theory of Mind (ToM). The literature will be reviewed in order to find out whether these aspects are impaired in TBI patients.

Chronic stress, sense of belonging, and depression among survivors of traumatic brain injury

PURPOSE

To test whether chronic stress, interpersonal relatedness, and cognitive burden could explain depression after traumatic brain injury (TBI).

DESIGN

A nonprobability sample of 75 mild-to-moderately injured TBI survivors and their significant others, were recruited from five TBI day-rehabilitation programs. All participants were within 2 years of the date of injury and were living in the community.

METHODS

During face-to-face interviews, demographic information, and estimates of brain injury severity were obtained and participants completed a cognitive battery of tests of directed attention and short-term memory, responses to the Perceived Stress Scale, Interpersonal Relatedness Inventory, Sense of Belonging Instrument, Neurobehavioral Functioning Inventory, and Center for Epidemiological Studies Depression Scale;.

FINDINGS

Chronic stress was significantly and positively related to post-TBI depression. Depression and postinjury sense of belonging were negatively related. Social support and results from the cognitive battery did not explain depression.

CONCLUSIONS

Postinjury chronic stress and sense of belonging were strong predictors of postinjury depression and are variables amenable to interventions by nurses in community health, neurological centers, or rehabilitation clinics. Future studies are needed to examine how these variables change over time during the recovery process.

Measuring unmet needs and services among persons with traumatic brain injury

OBJECTIVES

(1) To develop a comprehensive list of needs and services appropriate for persons with traumatic brain injury (TBI); (2) to determine whether these needs and services formed unidimensional hierarchies from least common to most common; (3) to describe the relationship between unmet needs and services received; and (4) to estimate the extent to which a variety of demographic, injury, and service characteristics predict unmet needs.

DESIGN

Statewide mailed survey.

SETTING

Illinois communities.

PARTICIPANTS

A total of 895 persons who had had a TBI recruited from Brain Injury Association members and rehabilitation service recipients. The median time post-TBI was 7 years; the median age was 37 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A 27-item instrument assessing service needs and utilization of services, and equal-interval measures of needs and services derived with Rasch analysis.

RESULTS

The most prevalent unmet needs were improving memory or problem-solving skills (51.9%), increasing income (50.5%), and improving job skills (46.3%). The instrument defined unidimensional and reliable constructs of needs and services. Persons with greater unmet needs tended to receive fewer services; to report lower life satisfaction and worse medical health and psychologic well-being since injury; to be younger, single, black, dependent in 1 or more daily activities; and to have more recent injuries.

CONCLUSIONS

The results show the common pattern of unmet needs and services and emphasize the importance of comprehensive, statewide assessment of services and needs in developing policies.

Predictors of caregiver and family functioning following traumatic brain injury: social support moderates caregiver distress

OBJECTIVE

This study examined predictors of family dysfunction and caregiver distress among 60 pairs of persons who sustained a traumatic brain injury and their caregivers.

DESIGN

A cross-sectional design that used hierarchical multiple regression analyses evaluated the relative influences of time since injury, awareness of deficit, and neurobehavioral and neuropsychological functioning of the person with injury, and caregiver perceived social support.

RESULTS

The predictor model accounted for 52% of the variance in family dysfunction and 39% in caregiver psychological distress. Neurobehavioral disturbance in the person with injury was the strongest predictor of caregiver distress. Social support showed a direct and linear relationship to family functioning, and it was the strongest predictor of family functioning. Social support was a powerful moderator of caregiver psychological distress. In the absence of adequate social support, caregiver distress increased with longer time after injury, cognitive dysfunction, and unawareness of deficit in care recipients, whereas these characteristics were not associated with distress among caregivers with adequate social support.

CONCLUSIONS

Rehabilitation professionals should stress the importance of caregivers and families of persons with TBI seeking and obtaining adequate social support.

A prospective study of long-term caregiver and family adaptation following brain injury in children

OBJECTIVE

We examined long-term differences in family adaptation following traumatic brain injuries (TBI) and orthopedic injuries.

DESIGN

Families of children with severe TBI (n = 53), moderate TBI (n = 56), and orthopedic injuries (n = 80) were assessed at baseline, 6 months, and 12 months post injury and at an extended follow-up an average of 4.1 years post injury. Caregiver and family outcomes were examined using mixed model analysis.

RESULTS

Patterns of adaptation over time varied across groups but indicated long-standing injury-related stress and burden in the severe TBI group.

CONCLUSIONS

Severe TBI results in persistent caregiver stress for a substantial proportion of families.

A multidimensional measure of caregiving appraisal: validation of the Caregiver Appraisal Scale in traumatic brain injury

OBJECTIVE

To investigate the factor structure and concurrent validity of the Caregiver Appraisal Scale (CAS) in a sample of caregivers of adults with traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Two sites: (1) Outpatient clinics associated with a comprehensive inpatient brain injury rehabilitation program and (2) a comprehensive residential postacute rehabilitation program in the Southern United States.

PARTICIPANTS

One hundred forty-nine caregivers of adults with TBI enrolled in the TBI Model Systems Project and 92 caregivers of adults with TBI admitted to a residential postacute rehabilitation program. Most caregivers were women and either parents or spouses of the injured person.

MAIN OUTCOME MEASURES

Caregiver Appraisal Scale (CAS); Subjective Burden Scale (SBS); Objective Burden Scale (OBS); General Health Questionnaire (GHQ).

RESULTS

Principal components analysis with varimax rotation yielded four factors: perceived burden (PB), caregiver relationship satisfaction (CRS), caregiving ideology (CI), and caregiving mastery (CM), which were found to be fairly stable across treatment settings. Adequate concurrent validity was demonstrated for the perceived burden factor, and adequate internal consistency was found for three of four scales.

CONCLUSIONS

Preliminary support for the use of the CAS in caregivers of adults with TBI was obtained. However, further scale development, particularly for the CM factor, will likely improve the stability and usefulness of this instrument.

Return to work for persons with traumatic brain injury

Individuals with traumatic brain injuries experience an array of physical, cognitive, and emotional changes that often make return to preinjury employment unlikely and locating new employment difficult. The authors review the literature related to the return to work for persons with traumatic brain injuries. This includes return to work outcomes, factors influencing return to work, and vocational programs that enhance employment, including a supported employment approach. Guidelines for professionals engaged in supported employment practices are also provided.

The neurobehavioural rating scale-revised: sensitivity and validity in closed head injury assessment

OBJECTIVES

To investigate the factor structure and psychometric properties of the neurobehavioural rating scale-revised (NRS-R) and to determine its usefulness in clinical trials.

METHODS

A consecutive series of patients sustaining severe closed head injury were evacuated to one of 11 large regional North American trauma centres and entered into a randomised, phase III, multicentre clinical trial investigating the therapeutic use of moderate hypothermia. Acute care personnel were blinded to outcome and outcome personnel were blinded to treatment condition. The Glasgow outcome scale (GOS) was the primary outcome measure. Secondary outcome measures included the disability rating scale (DRS) and the NRS-R.

RESULTS

Exploratory factor analysis of NRS-R data collected at 6 months after injury (n=210) resulted in a five factor model including: (1) executive/cognition, (2) positive symptoms, (3) negative symptoms, (4) mood/affect, and (5) oral/motor. These factors showed acceptable internal consistency (0.62 to 0.88), low to moderate interfactor correlations (0.19 to 0.61), and discriminated well between GOS defined groups. Factor validity was demonstrated by significant correlations with specific neuropsychological domains. Significant change was measured from 3 to 6 months after injury for the total score (sum of all 29 item ratings) and all factor scores except mood/affect and positive symptoms. The total score and all factor scores correlated significantly with concurrent GOS and DRS scores.

CONCLUSIONS

The NRS-R is well suited as a secondary outcome measure for clinical trials as its completion rate exceeds that of neuropsychological assessment and it provides important neurobehavioural information complementary to that provided by global outcome and neuropsychological measures.

Long-term life quality and family needs after traumatic brain injury

OBJECTIVES

This investigation assessed the life quality and long-term family needs of caregivers of persons with brain injury.

DESIGN

Respondents completed the Virginia Traumatic Brain Injury Family Needs Assessment Survey.

SETTING

Community-based sample.

PARTICIPANTS

Respondents included 57 caregivers of persons with traumatic brain injury who were at least 4 years after injury and who resided in Virginia. Respondents ranged in age from 19 to 82 years and were primarily women and Caucasian.

OUTCOME MEASURES

The Family Needs Questionnaire (FNQ) and quality of life questions.

RESULTS

Results indicate diminished life quality after injury. With regard to family needs, Health Information (51.43%) and Involvement with Care (47.93%) needs were most often rated as met. Instrumental Support (31.52%) and Professional Support (28.38%) needs were most often rated as not met.

CONCLUSIONS

Family needs and support systems for those needs change over time. This investigation provides evidence that unmet family needs extend well beyond the acute setting and that caregiver life quality diminishes over time. The importance of appreciating long-term family needs and other life quality issues should not be underestimated.

Factors associated with perceived quality of life many years after traumatic brain injury

OBJECTIVES

To explore factors associated with perceived quality of life (QOL) 8 to 24 years after traumatic brain injury (TBI).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Two hundred seventy-five individuals who sustained moderate to severe TBI who were discharged from a rehabilitation hospital participated in this study. We interviewed consenting participants up to 24 years after injury.

OUTCOME MEASURES

Self-rated Quality of Life Scale.

RESULTS

Multivariate linear regression analyses revealed that perceived mental health, self-rated health, gender (women rating QOL higher), participation in work and leisure, and the availability of emotional support were significantly associated with QOL (P <.05).

CONCLUSION

The importance of designing ongoing support programs to further reintegrate TBI survivors several years after injury is discussed.

Psychological distress in carers of head injured individuals: the provision of written information

Since the early 1970s, researchers have expressed concern about the emotional well-being of family members after traumatic brain injury (TBI), and it is now widely acknowledged that TBI has long-term effects on the patient and relatives alike. Researchers have found a substantial number of relatives caring for head injured patients to show significant levels of anxiety and depression, and have emphasized the need for information for relatives on the prognosis of head injury. There are, however, very few studies that have investigated the usefulness of giving literature to relatives. Using a longitudinal, mixed variable, within- and between-subject design, the present study investigated the effect of an information booklet on levels of distress in a group of 34 carers of individuals with TBI. These results are discussed, and the proposal made that an information booklet such as the one used in the present study should become an integral part of the discharge procedure for relatives of individuals who have sustained a head injury.

Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning

The goal of this study was to measure the very long-term mental and psychosocial outcomes of severe traumatic brain injury (TBI). Seventy-six persons with severe TBI were evaluated extensively by means of standardized scales, neuropsychological tests and evaluations by family members, at an average of 14.1 (SD = 5.5) years post-injury. Six mental and functional domains were examined: psychiatric symptomatology, cognitive abilities, vocational status, family integration, social functioning, and independence in daily routines. The findings indicate a long-term differential effect of severe TBI, with seriously affected psychiatric symptomatology, family and social domains, as compared to moderately influenced cognitive, vocational and independent functioning. Relatively high rates of depression, psychomotor slowness, loneliness and family members' sense of burden were found. In addition to their epidemiological importance, the results indicate that persons with TBI and their families may need professional assistance to maintain a reasonable psychosocial quality of life, even more than a decade post-injury.

Coping strategies and emotional outcome following traumatic brain injury: a comparison with orthopedic patients

OBJECTIVES

To investigate coping strategies in relation to emotional adjustment in individuals with traumatic brain injury (TBI) 1-5 years postinjury and to compare these with a group of 40 participants who sustained serious orthopedic injuries.

DESIGN

Participants completed measures of handicap and coping strategies, and rated their levels of depression, anxiety, and self-esteem on standardized questionnaires.

SETTING

Participants had received inpatient rehabilitation at Bethesda Hospital 1-5 years prior to completing questionnaires. They were recruited from a list of consecutive admissions.

PARTICIPANTS

88 TBI individuals were compared with 40 participants who had sustained serious orthopedic injuries without damage to the central nervous system. They had all been involved in motor vehicle or work-related accidents.

OUTCOME MEASURES

Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI).

RESULTS

Consistent with previous studies; a significant proportion of the current sample displayed high levels of emotional distress. Results showed few differences between the TBI and orthopedic groups. Coping strategies characterized by worry, wishful thinking, and self-blame were associated with higher levels of depression and anxiety in both groups. Strategies focusing on problem solving and having a positive outlook were related to lower anxiety levels, but to a lesser degree.

CONCLUSIONS

This study has provided further evidence that coping strategies are associated with emotional outcome in TBI individuals. There is now a growing empirical basis on which preliminary interventions can be based.

Preliminary outcome analysis of a long-term rehabilitation program for severe acquired brain injury

OBJECTIVES

To describe the general characteristics and functional outcomes of individuals treated in a publicly funded, long-term, acquired brain injury rehabilitation program and investigate variables affecting functional outcomes in this patient population.

DESIGN

Retrospective database review of demographic, descriptive, and functional outcome assessment data.

SETTING

Publicly funded, comprehensive, multidisciplinary, long-term, residential brain injury rehabilitation program in Alberta, Canada (64 beds).

PATIENTS

All rehabilitation patients admitted to and discharged from the brain injury program from February 1991 to March 1999 (n = 349).

INTERVENTIONS

Multidisciplinary rehabilitation program.

MAIN OUTCOME MEASURES

Demographic and descriptive information included sex, age at admission, type and severity of injury, time from injury to long-term program admission, and length of stay (LOS). Functional outcome information included level of care required at admission and discharge, admission and discharge Rappaport disability rating scale scores, and admission and discharge FIM instrument and Functional Assessment Measure scores for a subset of patients.

RESULTS

Fifty-nine percent of the subjects had severe traumatic brain injuries (TBI) and 41% had severe nontraumatic brain injuries (NTBI) of various causes. Mean age at admission was older and LOS was longer for NTBI compared with TBI; there were no other differences between the groups in demographic or descriptive measures. The TBI group had significantly lower admission motor subscale scores than the NTBI group, but the groups did not differ on cognitive scores. All functional assessment measures showed statistically significant improvement from admission to discharge, and 85.6% of patients were discharged to community living after a mean LOS of 359.5 days. Functional status at admission, age at admission, length of time between injury and admission, and LOS in the rehabilitation program significantly correlated with functional improvement.

CONCLUSIONS

Patients with severe TBI and NTBI who were not candidates for other more conventional forms of rehabilitation showed significant improvement in functional outcomes after extended program admissions. Consideration was also given to the potential insensitivity of commonly used outcome assessment measures in this population.

Slow-to-recover severe traumatic brain injury: a review of outcomes and rehabilitation effectiveness

Severe traumatic brain injury may result in very severe disability with prolonged recovery. Because of this slow recovery, survivors of severe traumatic brain injury may not be considered as good candidates for typical brain injury rehabilitation programmes and, thus, there is relatively little published information concerning the nature of this group. The recent literature regarding functional outcomes and the effectiveness of rehabilitation for this sub-population of brain-injury survivors is reviewed and suggestions for further research are discussed. The existing evidence suggests that this emerging but important group of brain-injury survivors is capable of significant functional recovery over a period of months-to-years after injury, and that rehabilitation may serve to further ameliorate disability and reduce longterm costs of care. It is suggested that further research focus on delineating the nature of recovery in the slow-to-recover brain injury population, exploring the current prevalence of slow-to-recover brain injury survivors, and assessing the effectiveness of currently existing programmes specializing in rehabilitation of this type.

Predictors and Indicators of Return to Work following Traumatic Brain Injury in South Africa: Findings from a Preliminary Experimental Database

Traumatic brain injury (TBI) affects a substantial portion of the South African population every year. However, there is little empirical evidence available regarding eventual outcome after injury in South Africa. In particular, there is little information regarding the ability of head injured individuals to return to their places of employment following injury, or what factors are most closely related to a successful return to work. This study explored the return to work of a specific group of individuals with TBI, in relation to a number of domains, including: rate and nature of return to work, pre-morbid and accident variables that appeared to be related to return to work, and the relationship between return to work and other aspects of outcome, specifically communicative, cognitive, physical and emotional outcome. The study took the form of a detailed record review of a group of subjects seeking medico-legal compensation, using a specially designed data recording form and computerised database. Results indicated a poor rate of return to work in this sample (32%), with significant changes in work status post-injury. The strongest pre-morbid predictors of outcome were found to be first language and pre-injury educational level, with African language speakers and those with an educational level of matriculation or less being at a significant disadvantage. Numerous communicative and cognitive difficulties were significantly related to a failure to RTW, including difficulties in: motor speech, comprehension, expression, attention, speed of processing, incidental visual memory, cognitive flexibility and insight. These results indicate the multi-factorial nature of outcome following head injury in the sample.

A medical/vocational case coordination system for persons with brain injury: an evaluation of employment outcomes

OBJECTIVE

To evaluate initial placement and 1-year employment outcomes of a Medical/Vocational Case Coordination System (MVCCS) for persons with brain injury (BI) that provides: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) supported employment interventions including job coaching.

PARTICIPANTS

One hundred fourteen Minnesota residents, ages 18 to 65 years, with acquired BI.

MAIN OUTCOME MEASURES

OUTCOME

Five levels of Vocational Independence Scale (VIS).

PREDICTOR

Preinjury employment status (VIS) and years of education, severity of initial injury, time since injury, current impairment/disability as measured by the Rasch-analyzed Staff Mayo-Portland Adaptability Inventory (MPAI), and impaired self-awareness measured by staff rating and the difference between Staff MPAI and Survivor MPAI.

RESULTS

At placement, 46% in independent work; 25% in transitional placements; 9% in long-term supported employment; 10% in sheltered work; and 10% not placed. At 1-year follow-up (n = 101), 53% in independent work; 19% in transitional placement; 9% in supported work; 6% in sheltered work; and 13% unemployed. Regression analyses showed time since injury and Rasch Staff MPAI predicted VIS at placement; only VIS at placement independently predicted VIS at 1-year follow-up; Rasch Staff MPAI and preinjury education level predicted time to placement.

CONCLUSIONS

The MVCCS optimized vocational outcome after BI. Time since injury and impairment/disability best predicted vocational placement. Level of initial placement best predicted employment status at follow-up. Persons with greater disability required more extended time and more extensive rehabilitation services before placement.

Psychiatric treatment outcome following traumatic brain injury

The relationship between self-reported history of traumatic brain injury (TBI) and psychiatric treatment outcome was investigated. TBI was hypothesized to be frequent, associated with cognitive deficits on neuropsychological testing, and less amenable to standard psychiatric treatment. Subjects were 42 psychiatric patients with a self-reported history of TBI and 25 psychiatric patients with no TBI history. Subjects received approximately 2 weeks of inpatient psychiatric treatment. Subjects received neuropsychological testing and completed the Brief Symptom Inventory weekly. TBI was frequent (66% of subjects); multiple injuries were common. Neuropsychological performance was generally average in both groups with few group differences. Subjects, on average, reported significantly decreased psychiatric symptoms on discharge. However, the TBI group appeared to improve less than the control group; group status was a significant predictor of treatment outcome. Implications of results for assessment and treatment of psychiatric disorders in patients with a history of TBI are discussed.

Psychological distress and family satisfaction following traumatic brain injury: injured individuals and their primary, secondary, and tertiary carers

OBJECTIVE

To assess family psychosocial outcome following traumatic brain injury (TBI) in all family members, including relatives more peripheral to the person with the injury.

DESIGN

A cross-sectional design was used to gather outcome data from individuals with TBI and primary, secondary, and tertiary carers, 19.3 months posttrauma. Multivariate analyses of variance (ANOVAs) ascertained differences in levels of psychological distress and family satisfaction within families.

SETTING AND PARTICIPANTS

Seventy-nine families (65 individuals with TBI, 72 primary carers, 43 secondary carers, and 22 tertiary carers) were drawn from a sample of outpatients of three metropolitan, acute rehabilitation hospitals over a 12-month period.

OUTCOME MEASURES

In addition to using the Family Satisfaction Scale (FSS), measures of psychological distress included the Beck Depression Inventory (BDI), State Anxiety Inventory (SAI), and Profile of Mood States (POMS).

RESULTS

Although it was noted that a significant proportion of family members were not psychologically distressed and reported good family satisfaction, people with TBI remain at greater risk of poor psychosocial outcome than do their relatives. Of other family members, primary carers-particularly wives-are at greatest risk of poor psychosocial outcome, and a number of secondary and tertiary carers also displayed high levels of psychological distress.

CONCLUSIONS

Male relatives (the majority of whom were secondary or tertiary carers) may report their distress in terms of anger and fatigue, rather than as depression and anxiety. Future research could develop TBI-specific measures of anger and fatigue as screening instruments to identify peripheral family members requiring assistance in adapting to TBI. Many families-despite their initial traumatic experience-eventually cope well, encouraging researchers and clinicians to focus future research efforts on those families who have made good adjustments to TBI.