Recovery from severe closed head injuries: repeat testings with the Halstead-Reitan Neuropsychological Battery

Cognitive profiles in the acute phase of traumatic brain injury according to injury severity

Although several studies have documented the chronic phase of traumatic brain injury (TBI), few verified the nature and severity of cognitive impairments during the acute phase. Among the studies carried out during the acute phase, instrumental functions were rarely examined compared to attention, memory, and executive functions. This study aimed to compare the nature and intensity of cognitive problems in the acute phase according to TBI severity and age. It was hypothesized that cognitive impairments would increase in line with TBI severity and age, and that instrumental functions would be less affected in victims of mild or moderate TBI than in those with severe TBI. The Brief Cognitive Exam in Traumatology (EXACT), a new and reliable test specifically designed and validated to briefly assess global cognitive functioning during the acute phase, was administered to 319 mild to severe TBI victims (aged 16 to 96 years), within three months post-accident. The EXACT evaluates five domains: Language, Instrumental functions (other than language), Attention and working memory, Episodic memory, and Executive functions and behavioral regulation. Results confirmed the negative influence of TBI severity and age on global cognitive functioning. Also, compared to victims with a mild or moderate TBI, a higher proportion of those with a severe TBI presented impaired instrumental functions (calculation, praxis, and gnosis). Thus, during the acute phase, the nature and severity of cognitive impairments vary according to TBI severity.

Measuring recovery in new learning and memory following traumatic brain injury: A mixed-effects modeling approach

Patterns of recovery from traumatic brain injury (TBI) vary greatly across individuals. Using archival data from the Traumatic Brain Injury Model Systems, recovery of memory following TBI as measured by scores on the Rey Auditory Verbal Learning Test (RAVLT) through 5 years postinjury was examined via mixed-effects modeling. Individual-level variables of age and posttraumatic amnesia duration were significant predictors of 1-year RAVLT total score. None of the variables examined predicted the trajectory of memory recovery after 1 year. Mixed-effects analyses can be helpful in determining the effect of intervention while allowing for missing data across time points.

Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified. Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records. Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent). When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms. The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance. Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.

WAIS-III and WMS-III profiles of mildly to severely brain-injured patients

Wechsler Adult Intelligence Scale-III (WAIS-III) and Wechsler Memory Scale-III (WMS-III; The Psychological Corporation, 1997) scores of patients with mild traumatic brain injury (MTBI, n = 23) to moderate-severe traumatic brain injury (M-S TBI, n = 22) were compared to those of 45 matched normal control patients. WAIS-III results revealed that IQ and index scores of MTBI patients did not significantly differ from those of controls, whereas M-S TBI patients received significantly lower mean scores on all measures. All M-S TBI patients' WMS-III index scores also revealed significantly lower scores in comparison to those of control participants, with the exception of Delayed Auditory Recognition. MTBI patients showed significantly lower mean index scores compared to normal controls on measures of immediate and delayed auditory memory, immediate memory, visual delayed memory, and general memory. Eta-squared analyses revealed that WMS-III visual indexes and WAIS-III processing speed showed particularly large effect sizes. These results suggest that symptomatic MTBI patients obtain some low WMS-III test scores comparable to those of more severely injured patients.

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.

A meta-analysis of the relative sensitivity of neuropsychological screening tests

The National Institute of Mental Health recently formed a committee of experts which published a proposal for a lengthy neuropsychological test battery judged most apt to detect diffuse brain damage while covering a wide range of cognitive abilities. The purposes of the present study were (1) to assemble empirical evidence of the existence of statistically significantly sensitive screening tests across an equivalently wide range of functional domains, and (2) to present this evidence systematically, in such a manner as to help clinicians select subsets of screening tests manifesting greatest sensitivity to diffuse brain damage. It was found that in certain functional domains (speed of processing, problem solving, executive functions), marked differences in sensitivity occurred. Brief tests just as sensitive as time-consuming tests were also identified. The reader is cautioned about possible extraneous sources of the differences obtained (test and group selection bias, test reliability, test difficulty, procedural effects, Type I error). Nevertheless, it was concluded that a brief highly sensitive and functionally wide-ranging neuropsychological test battery for screening cases of putative diffuse brain dysfunction can be assembled.

WAIS performance during the acute recovery stage following closed-head injury

WAIS profiles of 50 acute closed head-injured patients were examined and compared with those of 40 psychiatric inpatients. Patients with moderate and severe, but not with mild, head injury differed significantly from the control group on level of subtest performance. There was no significant interaction of group by subtest. The groups also differed significantly on a measure of between-subtest scatter. Discriminant function analysis incorporating measures of within-subtest scatter correctly classified 89% of all subjects. Within the head-injured group Similarities and Block Design scores were elevated, and the Digit Symbol score depressed. These results indicate that closed head-injured patients can be discriminated from psychiatric inpatients on the basis of WAIS performance, but that they do not necessarily show a characteristic WAIS profile. Within-subtest scatter may indicate information-processing deficits.

Outcomes for traumatically brain-injured patients following post-acute rehabilitation programmes

Outcome studies from post-acute cognitive rehabilitation programmes vary widely and mostly emphasize changes in neuropsychological measures. More recently, the functional outcomes of patients following cognitive rehabilitation have been reported. This study describes the functional outcomes of 42 traumatically brain-injured patients (29 male, 13 female: average age 28.6 years, time post-injury 50.3 months) following treatment in a structured out-patient post-acute cognitive rehabilitation programme. The programme consisted of a minimum of 6 weeks of treatment and emphasized improvement of the patients' real-life functional abilities and psychological support. The treatment goals were individually established for each patient. Patient improvement was determined by the accomplishment of treatment goals and differences in pre- and post-treatment functional measures and speech pathology cognitive measures. Follow-up at 6, 12 and 18 months determined the maintenance of treatment effects. There was a significant improvement on patients' functional measures after treatment. Cognitive measures were not significantly different after treatment, but there was a trend towards improvement. Functional improvements were independent of age, neuropathological category, injury severity and time post-injury. It is concluded that post-acute traumatic brain injury treatment aimed at retraining real-life functional abilities exclusive of specific cognitive remediation can lead to long-term improvements in independence.

Neuropsychological recovery in patients with moderate to severe head injury: 2 year follow-up

Neuropsychological outcome and recovery of a group of 31 consecutive adult patients with moderate to severe head injuries were prospectively investigated over a 2-year period. A friend control group was used for comparison purposes. Based on the results we conclude: (1) there is marked impairment of a broad spectrum of neuropsychological functions at 1, 12, and 24 months postinjury; (2) coma length is significantly related to neuropsychological status at all three time periods, although the relationship is weaker at 12 and 24 months; (3) marked improvement in all functions occurs in the first year, while recovery in the second year appears more specific and may depend on the severity of the injury and type of function; (4) practice effects and variability over repeated measures cause difficulties in determining recovery and need to be addressed with larger samples.

Physiological response patterns to cognitive testing in adults with closed head injuries

Physiological measures were taken from 7 closed-head-injured patients and 7 control subjects while they took a series of cognitive tests: the finger tapping test from the Halstead Reitan battery, the Digit Symbol test from the WAIS-R, a test of logical memory, and a paced arithmetic test. Physiological reactivity was assessed relative to rest periods, which occurred at the beginning and end of each session. The tests and physiological assessment were administered twice, approximately one month apart. The patient group performed more poorly on the cognitive tests, and showed less physiological reactivity during them than did the control group. This pattern was statistically significant for heart rate, frequency of electrodermal responses, and, during the initial session, respiration rate. The control group also showed greater finger pulse amplitude during the first posttest rest period in the first session, and greater constriction during a logical memory task in the second session. No significant between-groups differences emerged for state or trait anxiety. The patients showed higher frontalis EMG and respiration rate during rest. These results suggest a pattern of poor physiological modulation for task performance in the patients with closed head injuries. The therapeutic implications are discussed.

Influence of injury severity on quality of survival after head injury

The relationship between severity of injury [as determined by the Glasgow Coma Scale (GCS)] and the quality of survival (as determined by neuropsychological measurements and work return) were investigated in 54 conscious survivors within 16 months following head injury. While severely head injured (GCS less than or equal to 8) patients had more neuropsychological impairments in areas of intelligence, attention, memory, visuomotor speed, and motor skills than those with mild injuries (GCS greater than 8), performances after both types of injury were below normative levels in areas of learning, memory, and visuomotor speed. Unemployment increased after both severe and mild injuries, while employment status changed more frequently after severe injuries. Age had a minimal effect on neuropsychological and employment outcomes after minor head injuries (GCS greater than 13). The findings suggest that regardless of acute severity, closed head injury influences long-term quality of survival.

Predicting outcome from closed head injury by early assessment of trauma severity

The relationship between severity of head injury and outcome was studied in 96 patients. Severity was assessed based on the level of coma and presence of mass lesion, hemiparesis, skull fracture, and pupil abnormality. Outcome was assessed using the Wechsler Adult Intelligence Scale, the Halstead-Reitan neuropsychological battery, and the Glasgow Outcome Scale. The relationship between assessment of severity of trauma and the outcome measurements was calculated by multiple regression analysis. Results indicate that coma grade and estimates of premorbid intelligence quotient (IQ) served best to predict IQ as assessed after the injury. The combination of coma grade, mass lesion, and skull fracture were important predictors of the Halstead Impairment Index. Coma grade and pupil abnormality predicted the Glasgow Outcome Scale. Low to moderate relationships were found between the predictor variables and the measurement of IQ and the Glasgow Outcome Scale; multiple regression coefficients were 0.63 and 0.61, respectively. The relationship between measurement of trauma severity and the Halstead Impairment Index was also low (R = 0.37).