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

The structure of head-injured patients' neurobehavioural complaints: a preliminary study

Psychological functioning in 55 severely head-injured individuals was investigated in order to extend findings on the long-term nature of psychological sequelae after closed head injury. Results showed that head-injured subjects reported numerous psychological deficits many years post-injury, were psychologically distressed by their own report (Brief Symptom Inventory) and that of care-giving relatives (Katz Adjustment Scale--Relatives Version), and also exhibited a different pattern of coping from that of a normative group. A three-factor model of residual psychological complaints that contained a 'General Complaints' factor, a 'Somatization' factor and a 'Severity' factor was identified; this showed some similarity to a model proposed by van Zomeren and van den Burg (1985). Results indicate support for the 'coping hypothesis' of post-injury psychological deficits, although effects consistent with a 'gradations of severity' hypothesis were also present.

Services for severely head-injured patients in north London and environs

There is a growing awareness of deficits in service provision for severely head-injured patients. This study identifies areas in which patients fail to receive services by investigating the admission and transfer of such patients from eleven District Health Authorities in North London and the services offered by rehabilitation professionals in hospital and community. Sixty per cent of our sample were referred to Neurosurgical Units (NSUs) and later transferred to District General Hospitals (DGHs). Of these, 20% remained in DGHs without receiving NSU care, while 20% were treated at NSUs but were not referred to a local DGH. Assessment of rehabilitation services revealed that on average physiotherapists offered the greatest amount of therapy time to head-injured patients (3-4 hours) per week compared with other professionals and that this seemed to be a reflection of referral systems. Of the patients in our sample approximately 80% received physiotherapy, 30% received occupational therapy and less than 15% received speech therapy, social work or clinical psychology. It was concluded that severely head-injured patients fail to receive available services due to haphazard admission and transfer procedures, lack of referral to rehabilitation professionals and to the paucity of appropriate community care.

Return to work (RTW) after head injury

This study explored return to work (RTW) after head injury from survey data on 177 cases of head injury. Although 45% of the sample study did engage in some work-related activity only 19% were in competitive employment positions. Factors which were related to RTW after head injury were: age when injured, sex, length of loss of consciousness and Likert ratings of learning, motor and ambulation impairment. Many of those who did return to competitive employment did so in less demanding positions than held pre-injury. Limitations of the current study and suggestions for future research are ventured.

Head injury, an empirical study: describing long-term productivity and independent living outcome

As part of larger, multivariate study to be reported later, the present research gathered data from a knowledgeable informant, via telephone, concerning productivity and independent living outcomes for 75 subjects who sustained varying degrees of head injury, 4-7 years prior to the follow-up. The severity of the injury was measured using the Glasgow Coma Scale. Eighteen subjects had a severe injury, 24 had a moderate injury and 33 had a mild injury. The outcomes researched included indices of the subjects' ability to live independently and to be productive. In general, the data indicate that the more severe the injury, as measured by the best GCS during the first 24 hours, the more dependent and less productive the subject was at follow-up. This, however, was not invariably the case. Several mildly injured subjects had poor outcomes, while several severely injured subjects had relatively good outcomes at follow-up.

Head injury, a multivariate study: predicting long-term productivity and independent living outcome

As the second of a two-part research project, this study attempted to build three clinically useful prediction equations; these equations would be used to predict three long-term functional outcomes: productivity status, living arrangement status, number of hours of assistance required per week. There were ten predictor variables used in each analysis. These ten variables belonged to four theoretical classes: pre-injury demographics, pre-injury social characteristics, severity of injury, and post-injury environmental variables. The analytical method used was the General Linear Model of multiple regression, rather than the most often used Stepwise regression procedure. The results indicate that in none of the three prediction equations was more than 28% of the criterion variance accounted for, and only a minority of the predictor variables were significant predictors. It is concluded that, while the equations are of only very limited utility, the theoretical model and the analytical technique will be useful for future investigators.

Psychosocial outcome for the survivors of severe blunt head injury: the results from a consecutive series of 100 patients

A consecutive series of 100 severely blunt head injured subjects was followed up six years after trauma and the level of psychosocial reintegration was determined for 87 subjects. Three-quarters of the series were classified as demonstrating major disability, having either a Poor Reintegration (33%) or a Substantially Limited Reintegration (43%); the remaining one-quarter of the series attained a Good Reintegration. The level of reintegration was related to the Glasgow Outcome Scale classification, although a one-to-one correspondence between the Glasgow Outcome Scale and the Psychosocial Disability Scale was not found: each of the Moderate Disability and Good Recovery groups was fairly evenly divided between a better and worse level of reintegration. Specific aspects of the subjects' psychosocial reintegration in employment, interpersonal relationships, functional independence, social contacts and leisure interests are described and the implications of the findings for the provision of extended care services to meet the long term needs are discussed.

Relationships among pre- and post-injury intelligence, length of coma and age in individuals with severe closed-head injuries

Relationships among pre-injury ability, post-injury verbal intelligence, duration of coma and age were analysed in 34 closed-head injury patients, 7-28 years of age, whose coma lengths ranged from 5 to 180 days. The results obtained suggest that moderate to severe closed-head injury uniformly impairs verbal intellectual functioning without regard to premorbid status. Premorbid ability test scores had a markedly low correlation (0.04) with Wechsler Verbal IQs, obtained after patients had plateaued in intellectual recovery. Even when the effects of coma and age were controlled, the correlation was not significant. Mean post-injury IQs for patients grouped according to pre-injury intelligence (above average, average, below average) were all in the 80s. The findings do not support the prevailing assumption that the greater the premorbid ability, the greater the potential for intellectual recovery and the better the outcome. This study instead suggests that the higher the pre-injury IQ, the greater the IQ point loss. This has important implications for rehabilitation, counselling, discharge planning and follow-up. The greater the disparity between pre- and post-injury IQs, the more profound the loss and, hence, the greater the need for patient and family adjustments, coping and modifications of future personal, educational and vocational plans.

Impact of traumatic brain damage on family dynamics and functioning: a review

The purpose of this paper is to review the dynamics and functioning of families with a severely head-injured member. In order to stress the unique problems faced by persons with brain damage and their families, a comparison with spinal cord-injured persons is presented. The review's major conclusion is that a head injury exposes the family to a complex of problems that are unique to this disability and, therefore, necessitates the delivery of special family support services focused on the family, rather than on the head-injured person.

Psychosexual consequences of traumatic brain injury: methodology and preliminary findings

A methodology to systematically assess the psychosexual consequences of traumatic brain injury was developed and applied to a group of 21 male patients. A majority of the sample reported negative changes in sexual behaviour, including decreased sex drive, erectile function and frequency of intercourse. Common personality changes included depression, reduced self-esteem and a perceived decline in personal sex appeal. However, despite these changes in sexual behaviour, there was evidence that the quality of their marital relationships was preserved. Furthermore, there was no evidence of a relationship between the level of affect and sexual behaviour.

Do young patients have worse outcomes after severe blunt head trauma?

The influence of age on very late outcome was examined in 40 patients who had received very severe blunt head trauma (post-traumatic amnesia greater than or equal to 1 month), and who were aged 15-44 years when injured. The patients were first seen on average 4.5 months after injury and then at two follow-up examinations in their homes 2.5 and 10-15 years after the trauma. There was no significant correlation between age when injured and post-traumatic amnesia. The frequency of 13 late cognitive, behavioural, social and subjective problems was examined at the second follow-up and compared with the observations made 2.5 years after injury. A statistical analysis indicated that the younger the patient the higher the risk of late behavioural and emotional sequelae. The results have been related to information and observations obtained from the home visits.

Impairment after severe blunt head injury: the results from a consecutive series of 100 patients

Three scales, assessing the degree of brain impairment after severe blunt head injury in neurophysical and neuropsychological functions as well as overall organic functioning, are described. A consecutive series of 100 severe blunt head injured patients was followed up 6 years post-trauma and the scales were used to measure the residual impairments and determine the level of recovery for 82 subjects in the series. No subject made a complete neurophysical and neuropsychological recovery, 92% of the series was classified as suffering clinically significant impairments and in half the series the moderate or severe impairments were consistent with a poor level of recovery. The impairments of a large proportion (42%) of the series, however, were classified as mild. Although most subjects demonstrated impairments in both neurophysical and neuropsychological functions, 43% of the series suffered isolated impairments in either the neurophysical or neuropsychological areas. There was strong agreement between the overall organic impairment profile and the subjects' classifications on the Glasgow Outcome Scale.

Family response in head injury: denial ... or hope for the future?

Denial is often seen as a major obstacle to successful adaptation in the family of the head-injured. In fact, it is typically inadequately understood in the rehabilitation setting. The term is frequently used in a simplistic way, with the social and cultural factors behind the denial, particularly the stigma of head injury, not examined or confronted. There is very little hard data on what constitutes successful family adaptation over the long term. Professionals have a tendency to focus exclusively on the patient's deficits and the family's difficulties, ignoring the positive ways in which people cope. This article suggests that there is a need for a paradigm shift, based on the transactional theory of stress and coping, in which denial is seen as a positive response in some situations. Instead of becoming locked into trying to dispel what is usually called denial and adopting an adversary stance to the family, it may be more beneficial for rehabilitation staff to work together with family members to understand why head injury is so difficult to deal with, develop positive models for living with the sequelae, and encourage hope for the future.

Survival of social relationships following head injury

A retrospective search through the medical records at a rehabilitation hospital in Melbourne, Australia, identified 38 subjects (within the age range 19-34 years) suffering the effect of a severe closed-head injury 2-10 years post-trauma. In regard to social relationships, availability of post-trauma close attachment figures and looser social networks were markedly reduced for the head-injured group in relation to a matched community control group. However, they did not generally perceive these social relationships as inadequate when compared to a normal control sample. Moreover, within the head-injured group the perception of inadequate social relationships was not significantly associated with minor psychiatric disturbance. The implications of these results in terms of the social bond theory of depression are discussed, and issues in long-term social support of this population are raised.

Reliability of self report among non-oriented head-injured adults

Two groups of head injury clients (oriented and non-oriented) and a group of non-disabled participants were compared on response consistency to a MMPI test. Over three testing sessions it was found that the non-oriented head injury group had the most inconsistent responses followed by the oriented head injury group and the control group. Though six of the 21 MMPI profiles from the non-oriented clients were identified as invalid, MMPI validity scales did not effectively detect unreliable responders. Results suggest that caution is needed when using self-report personal assessments with non-oriented head injury clients.

Return to work within the first seven years of severe head injury

The rate and prediction of return to work was examined in 98 severely head injured patients during the first seven years after injury. The employment rate dropped from 86% before injury to 29% after. Younger patients, and those with technical/managerial jobs before injury were more likely to return to work than those over 45 years of age, or in unskilled occupations. Physical deficits were not related to return to work, but the presence of cognitive, behavioural, and personality changes was significantly related to a failure to return to work.

Return to work after severe head injury

This paper reports attempts of a series of head-injured people to regain employment. Return to work after a severe head injury is generally considered to be a function of age, severity of injury, and nature of disability. The results showed that it was the opportunity to go back to the previous job, the provision of a work trial or easier work, and a lengthy period of support that were the more important factors. This demonstrates the importance of working to provide an environment that will help the individual learn to make adaptations and accommodate his or her disabilities.

The five year outcome of severe blunt head injury: a relative's view

A close relative of each of 42 severely head injured patients was interviewed at 5 years after injury, following initial study at 3, 6, and 12 months. Persisting severe deficits, in some cases worse than at 1 year, were primarily psychological and behavioural, although minor physical deficits, for example in vision, were also common. Relatives were under great strain; significantly more so than at 1 year. The best predictor of strain in the relative was the magnitude of behavioural and personality change in the patient.