Measuring recovery from post traumatic amnesia

Prolonged duration of post-traumatic amnesia: A sensitive classification for predicting cognitive outcomes in children recovering from traumatic brain injury

OBJECTIVE

A paucity of data exists regarding the duration of post-traumatic amnesia (PTA) as a predictor of cognitive functioning among children after traumatic brain injury (TBI). The study aimed to assess the relationship between PTA duration and areas of neurocognitive function among the pediatric population in the sub-acute phase of recovery and rehabilitation.

METHODS

Data were collected from medical files on 103 children aged 5.5-16.5 hospitalized at a pediatric rehabilitation department with a diagnosis of moderate-severe TBI (msTBI) between the years 2004-2019. The Children Orientation and Amnesia Test was used to evaluate PTA duration. Measures of high-order cognitive abilities of attention and executive function were collected using the Test of Everyday Attention-Child version (TEA-Ch).

RESULTS

Three PTA duration groups were assembled out of a cluster analysis: "Long PTA" (M = 21 days), "Very Long PTA" (M = 47 days), and "Extremely Long PTA" (M = 94 days). Analyses revealed that the "Long PTA" group preformed significantly better than the "Very Long PTA" and "Extremely Long PTA" groups on all TEA-Ch measures, that is, Selective Attention, Attentional Control Switching, and Sustained Attention.

CONCLUSIONS

This study is the first to demonstrate that PTA duration is a useful predictor of high-order cognitive functions among children with msTBI in the sub-acute phase of recovery and rehabilitation. The findings emphasize the importance of using a more sensitive classification of prolonged PTA durations to improve outcome prediction and allocation of resources to those who can benefit most after severe brain injuries.

Aspects of Cognitive Impairment Associated with Agitated Behaviour during Post-traumatic Amnesia

OBJECTIVES

Post-traumatic amnesia (PTA) is a transient period of recovery following traumatic brain injury (TBI) characterised by disorientation, amnesia, and cognitive disturbance. Agitation is common during PTA and presents as a barrier to patient outcome. A relationship between cognitive impairment and agitation has been observed. This prospective study aimed to examine the different aspects of cognition associated with agitation.

METHODS

The sample comprised 82 participants (75.61% male) admitted to an inpatient rehabilitation hospital in PTA. All patients had sustained moderate to extremely severe brain injury as assessed using the Westmead Post-Traumatic Amnesia Scale (WPTAS) (mean duration = 42.30 days, SD = 35.10). Participants were assessed daily using the Agitated Behaviour Scale and WPTAS as part of routine clinical practice during PTA. The Confusion Assessment Protocol was administered two to three times per week until passed criterion was achieved (mean number assessments = 3.13, SD = 3.76). Multilevel mixed modelling was used to investigate the association between aspects of cognition and agitation using performance on items of mental control, orientation, memory free recall, memory recognition, vigilance, and auditory comprehension.

RESULTS

Findings showed that improvement in orientation was significantly associated with lower agitation levels. A nonsignificant trend was observed between improved recognition memory and lower agitation.

CONCLUSIONS

Current findings suggest that the presence of disorientation in PTA may interfere with a patient's ability to understand and engage with the environment, which in turn results in agitated behaviours. Interventions aimed at maximizing orientation may serve to minimize agitation during PTA.

More than amnesia: prospective cohort study of an integrated novel assessment of the cognitive and behavioural features of PTA

Background and Objective:

Post-traumatic amnesia (PTA) is an early significant stage of recovery from traumatic brain injury (TBI). Current prospective PTA scales do not assess the full range of PTA symptomatology. This study conducted a novel integrated assessment of cognition and behaviour during PTA.

Method:

Twenty-four moderate-to-severe TBI participants in PTA and 23 TBI controls emerged from PTA were matched for age, gender, and years of education. All completed PTA measures (Galveston Orientation and Amnesia Test: GOAT, Westmead Post-traumatic Amnesia Scale: WPTAS), a cognitive battery; and behaviour ratings scored by 2 independent raters (informant and staff).

Results:

Significantly poorer performance was found during PTA for attention, processing speed, delayed verbal free recall and recognition, and visual learning. A large effect size was found for category fluency only. Behaviour ratings were significantly higher during PTA. Five behaviours were rated as high frequency (>50%) by both raters: Inattention, Impulsivity, Sleep Disturbance, Daytime Arousal, and Self-Monitoring. Prospective PTA measures produced significantly different duration estimates from 2 days (GOAT vs. WPTAS 1st day) to 9 days (WPTAS 1st day vs. 3-day). The WPTAS correlated most highly with processing speed and language tasks; whilst the GOAT correlated most highly with language and executive control of verbal memory.

Conclusion:

New prospective measures are needed that integrate core cognitive and behavioural features are brief, easy to administer, and capable of measuring emergence. The term PTA is a misnomer that requires revision to better accommodate the clinical syndrome.

Comparing the Westmead Posttraumatic Amnesia Scale, Galveston Orientation and Amnesia Test, and Confusion Assessment Protocol as Measures of Acute Recovery Following Traumatic Brain Injury

BACKGROUND

The duration of the acute period of recovery following traumatic brain injury (TBI) remains a widely used criterion for injury severity and clinical management. Consensus regarding its most appropriate definition and assessment method has yet to be established.

OBJECTIVE

The present study compared the trajectory of recovery using 3 measures: the Westmead Post-Traumatic Amnesia Scale (WPTAS), the Galveston Orientation and Amnesia Test (GOAT), and the Confusion Assessment Protocol (CAP). Patterns of symptom recovery using the CAP were explored.

PARTICIPANTS

Eighty-two participants with moderate to severe TBI in posttraumatic amnesia (PTA) on admission to an inpatient rehabilitation hospital.

DESIGN

Prospective longitudinal study.

OUTCOME MEASURES

Length of PTA (days), agreement between measures (%, κ coefficient), and pattern of symptom recovery.

RESULTS

Participants emerged from PTA earliest on the CAP followed the GOAT, and last on the WPTAS. There was good agreement between the CAP and the GOAT as to PTA status, but both tests had poor agreement with the WPTAS. Of patients considered out of PTA on the CAP, the majority exhibited signs of amnesia on the WPTAS and one-third had clinical levels of agitation.

CONCLUSION

The WPTAS identifies a later stage of PTA recovery that requires specialized management due to ongoing amnesia and agitation. The CAP and the GOAT are less sensitive to this extended period of PTA.

Brain-computer interfaces in neurologic rehabilitation practice

The brain-computer interfaces (BCIs) for neurologic rehabilitation are based on the assumption that by retraining the brain to specific activities, an ultimate improvement of function can be expected. In this chapter, we review the present status, key determinants, and future directions of the clinical use of BCI in neurorehabilitation. The recent advancements in noninvasive BCIs as a therapeutic tool to promote functional motor recovery by inducing neuroplasticity are described, focusing on stroke as it represents the major cause of long-term motor disability. The relevance of recent findings on BCI use in spinal cord injury beyond the control of neuroprosthetic devices to restore motor function is briefly discussed. In a dedicated section, we examine the potential role of BCI technology in the domain of cognitive function recovery by instantiating BCIs in the long history of neurofeedback and some emerging BCI paradigms to address cognitive rehabilitation are highlighted. Despite the knowledge acquired over the last decade and the growing number of studies providing evidence for clinical efficacy of BCI in motor rehabilitation, an exhaustive deployment of this technology in clinical practice is still on its way. The pipeline to translate BCI to clinical practice in neurorehabilitation is the subject of this chapter.

Neuropsychological Characteristics of the Confusional State Following Traumatic Brain Injury

OBJECTIVES

Individuals with moderate-severe traumatic brain injury (TBI) experience a transitory state of impaired consciousness and confusion often called posttraumatic confusional state (PTCS). This study examined the neuropsychological profile of PTCS.

METHODS

Neuropsychometric profiles of 349 individuals in the TBI Model Systems National Database were examined 4 weeks post-TBI (±2 weeks). The PTCS group was subdivided into Low (n=46) and High Performing PTCS (n=45) via median split on an orientation/amnesia measure, and compared to participants who had emerged from PTCS (n=258). Neuropsychological patterns were examined using multivariate analyses of variance and mixed model analyses of covariance.

RESULTS

All groups were globally impaired, but severity differed across groups (F(40,506)=3.44; p<.001; ŋp 2 =.206). Rate of forgetting (memory consolidation) was impaired in all groups, but failed to differentiate them (F(4,684)=0.46; p=.762). In contrast, executive memory control was significantly more impaired in PTCS groups than the emerged group: Intrusion errors: F(2,343)=8.78; p<.001; ŋ p 2=.049; False positive recognition errors: F(2,343)=3.70; p<.05; ŋp 2=.021. However, non-memory executive control and other executive memory processes did not differentiate those in versus emerged from PTCS.

CONCLUSIONS

Executive memory control deficits in the context of globally impaired cognition characterize PTCS. This pattern differentiates individuals in and emerged from PTCS during the acute recovery period following TBI. (JINS, 2019, 25, 302-313).

Retrograde Personal Semantic Memory During Post-Traumatic Amnesia and Following Emergence

OBJECTIVES

Anecdotal reports suggest that following traumatic brain injury (TBI) retrograde memories are initially impaired and recover in order of remoteness. However, there has been limited empirical research investigating whether a negative gradient in retrograde amnesia-relative preservation of remote over recent memory-exists during post-traumatic amnesia (PTA) compared with the acute phase post-emergence. This study used a repeated-measures design to examine the pattern of personal semantic (PS) memory performance during PTA and within two weeks of emergence to improve understanding of the nature of the memory deficit during PTA and its relationship with recovery.

METHODS

Twenty patients with moderate-severe TBI and 20 healthy controls (HCs) were administered the Personal Semantic Schedule of the Autobiographical Memory Interview. The TBI group was assessed once during PTA and post-emergence. Analysis of variance was used to compare the gradient across lifetime periods during PTA relative to post-emergence, and between groups.

RESULTS

PS memory was significantly lower during PTA than post-emergence from PTA, with no relative preservation of remote memories. The TBI group was still impaired relative to HCs following emergence from PTA. Lower overall PS memory scores during PTA were associated with increased days to emerge from PTA post-interview.

CONCLUSIONS

These results suggest a global impairment in PS memory across lifetime periods particularly during PTA, but still present within 2 weeks of emergence from PTA. PS memory performance may be sensitive to the diffuse nature of TBI and may, therefore, function as a clinically valuable indicator of the likely time to emerge from PTA. (JINS, 2018, 24, 1064-1072).

Structural integrity of medial temporal lobes of patients with acute mild traumatic brain injury

Post-traumatic amnesia (PTA) is an acute characteristic of traumatic brain injury (TBI) and the duration of PTA is commonly used to estimate the severity of brain injury. In the context of mild traumatic brain injury (MTBI), PTA is an essential part of the routine clinical assessment. Macroscopic lesions in temporal lobes, especially hippocampal regions, are thought to be connected to memory loss. However, conventional neuroimaging has failed to reveal neuropathological correlates of PTA in MTBI. Texture analysis (TA) is an image analysis technique that quantifies the minor MRI signal changes among image pixels and, therefore, the variations in intensity patterns within the image. The objective of this work was to apply the TA technique to MR images of MTBI patients and control subjects, and to assess the microstructural damage in medial temporal lobes of patients with MTBI with definite PTA. TA was performed for fluid-attenuated inversion recovery (FLAIR) images of 50 MTBI patients and 50 age- and gender-matched controls in the regions of the amygdala, hippocampus, and thalamus. It was hypothesized that 1) there would be statistically significant differences in TA parameters between patients with MTBIs and controls, and 2) the duration of PTA would be related to TA parameters in patients with MTBI. No significant textural differences were observed between patients and controls in the regions of interest (p>0.01). No textural features were observed to correlate with the duration of PTA. Subgroup analyses were conducted on patients with PTA of>1 h, (n=33) and compared the four TA parameters to the age- and gender-matched controls (n=33). The findings were similar. This study did not reveal significant textural changes in medial temporal structures that could be related to the duration of PTA.

Development and external validation of a new PTA assessment scale

Background

Post-traumatic amnesia (PTA) is a key symptom of traumatic brain injury (TBI). Accurate assessment of PTA is imperative in guiding clinical decision making. Our aim was to develop and externally validate a short, examiner independent and practical PTA scale, by selecting the most discriminative items from existing scales and using a three-word memory test.

Methods

Mild, moderate and severe TBI patients and control subjects were assessed in two separate cohorts, one for derivation and one for validation, using a questionnaire comprised of items from existing PTA scales. We tested which individual items best discriminated between TBI patients and controls, represented by sensitivity and specificity. We then created our PTA scale based on these results. This new scale was externally evaluated for its discriminative value using Receiver Operating Characteristic (ROC) analysis and compared to existing PTA scales.

Results

The derivation cohort included 126 TBI patients and 31 control subjects; the validation cohort consisted of 132 patients and 30 controls. A set of seven items was eventually selected to comprise the new PTA scale: age, name of hospital, time, day of week, month, mode of transport and recall of three words. This scale demonstrated adequate discriminative values compared to existing PTA scales on three consecutive administrations in the validation cohort.

Conclusion

We introduce a valid, practical and examiner independent PTA scale, which is suitable for mild TBI patients at the emergency department and yet still valuable for the follow-up of more severely injured TBI patients.

Problems and Pitfalls in the Assessment of Posttraumatic Amnesia

In the early stages of recovery after a traumatic brain injury, patients usually experience a period of posttraumatic amnesia (PTA) in which they are confused, amnesic for ongoing events, and frequently behaviourally agitated. Although a variety of procedures and instruments are available to measure the duration of PTA, their applications in clinical practice are far from ideal. This review paper describes retrospective and prospective measures of PTA and critically examines variations in item content and scoring procedures. In particular, methods currently available to measure the amnesia component of PTA are especially problematic. The limitations of PTA scales give rise to a number of difficulties that impact upon clinical practice. These include determining precisely when a patient has emerged from PTA, and distinguishing between patients in PTA and those with chronic amnesia. It is concluded that there is a need to revisit basic constructs comprising PTA, and develop an instrument with greater specificity. More focus should be placed on examining the confusional component of PTA, and validity of PTA tests would be improved by measuring attention and behaviour, in addition to orientation and memory.

Objective and behavioural assessment of the emergence from post-traumatic amnesia (PTA)

PRIMARY OBJECTIVE

To determine the profile of resolution of typical PTA behaviours and describe new learning and improvements in self-care during PTA.

RESEARCH DESIGN

Prospective longitudinal study monitoring PTA status, functional learning and behaviours on a daily basis.

METHODS AND PROCEDURES

Participants were 69 inpatients with traumatic brain injury who were in PTA. PTA was assessed using the Westmead or Oxford PTA assessments. Functional learning capability was assessed using a routine set of daily tasks and behaviour was assessed using an observational checklist. Data was analysed using descriptive statistics.

MAIN OUTCOMES AND RESULTS

Challenging behaviours that are typically associated with PTA, such as agitation, aggression and wandering resolved in the early stages of PTA and incidence rates of these behaviours were less than 20%. Independence in self-care and bowel and bladder continence emerged later during resolution of PTA. New learning in functional situations was demonstrated by patients in PTA.

CONCLUSIONS

It is feasible to begin active rehabilitation focused on functional skills-based learning with patients in the later stages of PTA. Formal assessment of typically observed behaviours during PTA may complement memory-based PTA assessments in determining emergence from PTA.

Recovery of components of memory in post-traumatic amnesia

PRIMARY OBJECTIVE

Post-traumatic amnesia by definition indicates significant impairment of new learning ability, however very few studies have, examined the natural history and resolution of memory and new learning during PTA. Those studies which have, tended to examine orientation separately from the memory processes required to achieve orientation. Analysis of the order of recovery of the items of the Westmead PTA scale was used to examine recovery of memory and new learning capacity.

METHODS

The results of daily assessment of 34 patients with traumatic brain injury (TBI) on the Westmead PTA scale were analysed for order of recovery.

RESULTS

The pattern of rank order of item recovery indicated that Date of Birth recovered consistently first. There was variability in the remaining items, however items reflecting long-term memory tended to recover second and items reflecting simple new learning followed. Recall of all three pictures reflecting complex new learning recovered last.

CONCLUSION

The pattern of recovery of memory and new learning during PTA reflects a number of complex, inter-related variables including; the familiarity with the information, amount of rehearsal both before and since the accident and the number of cues available in the environment.

Applicability of neural reserve theory in mild traumatic brain injury

OBJECTIVE

The aim of the current study was to examine whether neural reserve influenced the duration of post-traumatic amnesia (PTA) following mild traumatic brain injury (MTBI).

METHOD

The relationship between duration of PTA and both IQ and education was examined in a group of 59 MTBI patients. In addition, the effects of factors that could potentially diminish neural reserve, namely pre-injury hazardous alcohol consumption, pre-injury marijuana use, previous neurological damage, age and post-injury emotional distress on PTA duration were analysed.

RESULTS

Significant, negative associations between PTA duration and both IQ and education were revealed. None of the other variables that were examined were significantly related to PTA duration.

CONCLUSION

The findings were interpreted as providing preliminary evidence to suggest that reference to neural reserve may help explain between-subject variability in acute response to MTBI.

Effect of severity of post-traumatic confusion and its constituent symptoms on outcome after traumatic brain injury

OBJECTIVE

To investigate the prognostic significance of severity of post-traumatic confusion (PTC) and its constituent symptoms for early and late outcome after traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Inpatient brain injury rehabilitation program.

PARTICIPANTS

A total of 168 patients meeting study criteria from 195 consecutive Traumatic Brain Injury Model Systems neurorehabilitation admissions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Employability at neurorehabilitation discharge and productivity status at 1 year postinjury.

RESULTS

More severely confused patients had poorer outcomes for both employability and productivity. Multivariable logistic regression revealed that after adjustment for all other predictors, time to follow commands, and confusion severity predicted employability at discharge and age and confusion severity predicted productivity status at 1 year. Each symptom showed an unadjusted effect on discharge employability. All symptoms except nighttime sleep disturbance or daytime decreased arousal had effects on productivity at 1 year. Presence of psychotic-type symptoms was associated with especially poor productivity outcomes.

CONCLUSIONS

PTC constituent symptoms and severity predict outcome after TBI. Presence or absence of psychotic-type symptoms on a single evaluation at approximately 21 days postinjury may have particular prognostic significance for productivity outcome.

[Standardization of the Children's Orientation and Amnesia Test, French version, to evaluate post-traumatic amnesia in children]

INTRODUCTION

The duration of post-traumatic amnesia (PTA), the period of altered memory that often follows traumatic brain injury (TBI), is a useful index of severity of TBI and a predictor of outcome after TBI. Yet, evaluating PTA in French-speaking brain-injured children is not standardized.

OBJECTIVE

We aimed to translate into the French language and standardize the Children's Orientation and Amnesia Test (COAT), inspired by the Galveston Orientation and Amnesia Test (GOAT), which estimates PTA duration in adults.

METHOD

Development of a French version of the COAT (COAT-VF) with 16 items: 7 of general orientation, 5 temporal orientation and 4 memory. Normative data were collected for 137 children aged 4, 6, 8 and 10 years who were attending school.

RESULTS

Performance on the COAT-VF was influenced by age and sociocultural factors but not sex.

CONCLUSION

The COAT-VF, short and simple to administer, allows for an accurate evaluation of PTA duration in French children.

The effects of post-traumatic amnesia on information processing following mild traumatic brain injury

PRIMARY OBJECTIVE

The aim of this study was to determine whether a single measurement of level of PTA could distinguish patients more severely injured from those less so, by investigating the effect of PTA on psychometric test performance.

METHODS AND PROCEDURES

Ninety patients with mTBI completed a word recall test, a spoken version of the Speed of Comprehension test and the Digit Symbol Substitution Test (Digit Symbol), within 24 hours of injury. These patients were divided into two groups, based on the presence (n=42) or absence (n=48) of PTA at the time of testing. PTA was measured with an eight-item orientation scale.

MAIN OUTCOMES AND RESULTS

An independent groups design showed that patients with mTBI in PTA recalled fewer words after two presentations and after a delay and completed fewer symbols in 90 seconds on Digit Symbol than patients with mTBI not in PTA. Discriminant function analysis was applied to explore whether classifying severity of injury in terms of number of orientation questions answered would be useful.

CONCLUSIONS

These results indicate that for individuals with mTBI in PTA, speed of information processing and verbal memory are impaired. A single brief administration of orientation questions may be sufficient to provide an index of severity of mTBI within the first 24 hours.

A multicentre, randomised trial examining the effect of test procedures measuring emergence from post-traumatic amnesia

BACKGROUND

Post-traumatic amnesia (PTA) tests that record different PTA durations in the same patient, thereby raising measurement accuracy issues, have been reported previously. A major problem lies in determining the end point of PTA.

AIMS

To delineate areas of discrepancy in PTA tests and to provide independent verification for a criterion signalling emergence from PTA.

METHODS

In a randomised design, two related PTA procedures were compared, one purportedly more difficult (Westmead PTA Scale, WPTAS) than the other (Modified Oxford PTA Scale, MOPTAS). Eighty two patients in the early stages of PTA were examined daily until emergence, by using the Galveston Orientation and Amnesia Test (GOAT) and the WPTAS/MOPTAS. A short battery of cognitive and behavioural measurements was made on three occasions: at the early stage of PTA (time 1), towards the end of PTA when the maximum score (12/12) was first obtained (time 2) and at the traditional criterion for emergence (scoring 12/12 for 3 consecutive days; time 3).

RESULTS

No significant difference was recorded in PTA duration between the MOPTAS and WPTAS. Both scales recorded longer PTA durations than the GOAT. By using Kaplan-Meier survival analyses, the WPTAS was found to show a more protracted pattern of emergence at the end stage of PTA than the MOPTAS. A time lag of > or = 1 week in the resolution of disorientation as compared with amnesia was observed in 59% cases. Significant improvements occurred on all independent measurements between time 1 and time 2, but on only 2 of 5 cognitive measurements between time 2 and time 3.

CONCLUSIONS

Although no significant differences in the duration of PTA on the MOPTAS/WPTAS were recorded, emergence from the late stages of PTA occurred more promptly with the MOPTAS. The need for inclusion of both orientation and memory items in PTA tests is highlighted by the frequency of disorientation-amnesia dissociations. The patterns of results on the independent measures suggest that patients who are in PTA for > 4 weeks have probably emerged from PTA when they first score 12/12 on the MOPTAS/WPTAS, and this criterion can replace the traditional criterion.

Memory function after resolution of post-traumatic amnesia

PRIMARY OBJECTIVES

The aims of this pilot study were (1) to examine neuropsychological, particularly memory functions immediately after post-traumatic amnesia (PTA) resolution according to the Galveston Orientation and Amnesia Test (GOAT), and (2) to provide a preliminary exploration of pattern of performance on GOAT items across PTA duration.

METHODS AND PROCEDURES

Thirty-seven head injured patients were administered the Recognition Memory Tests on the day that PTA resolved. Formal neuropsychological assessment was conducted on average 10 days after PTA resolution.

MAIN OUTCOMES AND RESULTS

All the patients in the series showed memory impairment which varied in severity but was typically characterized as global and severe. Deficits in executive and speed and attention functions were common. GOAT items relating to orientation were typically passed, while items concerning anterograde and retrograde recall were most commonly failed across all stages of PTA duration.

CONCLUSIONS

These findings suggest that reliance on memory performance as a measure of PTA is not ideal and highlight the need for further research of this issue.

Time interval of oral feeding recovery as a prognostic factor in severe traumatic brain injury

PRIMARY OBJECTIVES

To assess the outcome of severe traumatic brain injury at least 1 year after trauma, in relation to some early clinical prognostic factors occurring during coma recovery.

RESEARCH DESIGN

Retrospective study conducted at the post-coma unit of a rehabilitation hospital.

METHODS AND PROCEDURES

A total of 43 patients were included. All of the patients sustained severe traumatic brain injury and prolonged coma, i.e. coma lasting at least 15 days. Outcome was assessed by means of Glasgow Coma Scale, Barthel Index and Mini Mental State 1 year after trauma, in relation to some early clinical prognostic factors occurring during coma recovery.

MAIN OUTCOMES AND RESULTS

At the 1 year follow-up, a statistically significant correlation was found with both the Glasgow Outcome Scale and the Barthel Index for the time interval from brain injury to recovery of the following clinical variables: optical fixation, ability to obey commands, spontaneous motor activity and first safe oral feeding. Psychomotor agitation and bulimia were also favourable prognostic factors for the final outcome.

CONCLUSIONS

In the present study, first safe oral feeding during coma recovery represents the clinical feature that better predicts the final outcome of patients with severe traumatic brain injury and prolonged coma.

Measuring recovery of orientation during acute rehabilitation for traumatic brain injury: value and expectations of recovery

OBJECTIVES

To further evaluate the use of the orientation log (O-Log) in an acute rehabilitation program for adults with traumatic brain injury (TBI), specifically focusing on prediction of rehabilitation outcome, possible use of the O-Log to promote recovery, and development of templates of orientation recovery.

DESIGN

Stepwise discriminant function analysis was used in one study and ANOVA based on between-groups comparisons in another. Confidence intervals were established in the third study.

SETTING

Acute rehabilitation hospital.

PATIENTS

Samples were taken from an overall pool of 389 subjects with predominantly severe TBI based on Glasgow Coma Scale score.

RESULTS

A combination of initial O-Log performance, time since injury, and number of O-Log assessments correctly predicted resolution of disorientation for 76% of the sample. Individuals attaining orientation before discharge achieved higher discharge scores on functional measures. Administration of the O-Log 3 versus 5 times a week did not result in more rapid resolution of disorientation. A similar pattern of steady improvement in orientation was evident for mild-moderate and severe injury cases across 10 administrations.

CONCLUSIONS

Recovery of orientation provides important information about recovery following TBI and is predictive of rehabilitation outcome. More frequent administration of a formal orientation measure does not seem to expedite the recovery of orientation, which on average seems to progress at a steady pace in a rehabilitation setting regardless of the time since injury or severity of injury.