Rehabilitation after head injury

Blood-Based Biomarkers in Traumatic Brain Injury: A Narrative Review With Implications for the Legal System

Traumatic brain injury (TBI) is an increasingly recognized diagnosis with significant, and often costly, associated consequences. Yet, despite their increased recognition, TBIs remain underdiagnosed. This issue is especially prominent in the context of mild TBI (mTBI), where there often exists little to no objective evidence of brain injury. In recent years, considerable effort has been made to better define and interpret known objective markers of TBI, as well as identify and explore new ones. An area of particular interest has focused on research related to blood-based biomarkers of TBI. Advancements in our understanding of TBI-related biomarkers can make it possible to characterize the severity of TBI with greater accuracy, improve our understanding of staging within both the injury process and the recovery process, and help us develop quantifiable metrics representative of reversal and recovery from a brain injury following trauma. Proteomic and non-proteomic blood-based biomarkers are being studied extensively and have shown promise for these purposes. Developments in this realm have significant implications not only for clinical care but also for legislation, as well as civil and criminal litigation. Despite their substantial potential, most of these biomarkers are not yet ready for use within the clinical setting, and therefore, are not appropriate for use within the legal or policy-making systems at this time. Given that existing standardization for the accurate and reliable use of TBI biomarkers is currently insufficient for use within either the clinical or legal realms, such data can be vulnerable to misuse and can even result in the abuse of the legal system for unwarranted gain. Courts will need to carefully evaluate the information presented in their role as gatekeepers of the admissibility of scientific evidence within the legal process. Ultimately, the development of biomarkers should lead to improved clinical care following TBI exposure, coherent and informed laws surrounding TBI, and more accurate and just results in litigation surrounding TBI-related sequelae.

Head Injury and Mental Handicap

A clinical and pathological study of head injury and the implications in mental handicap are outlined. Non-accidental injury as a form of child abuse is suspected as contributing considerably to the cause of mental handicap in populations resident in long-stay hospital, but this is unlikely to be the best environment for such patients. A number of mentally handicapped epileptic patients who injure their heads during fits and patients who repeatedly bang their heads as a feature of self-injurious behaviour are exposed to progressive neurological deficits associated with lesions in the brain which could further impair the efficiency of brain function.

A Long Look at Head Injuries

Over the last 40 years, improved standards of early care have created a growing population of disabled survivors of severe injuries of the brain. Solutions for this growing problem exist but they can never be complete. There is understandable and justifiable concern about the deficiencies in the long-term care of the victims of severe injury of the brain, who are to some extent the price of success in the management of such injuries during the early stages and so keeping alive brains that cannot recover fully.

The association of rehabilitation and war

PURPOSE

To examine the assumed association of war and the development of rehabilitation through a review of the pertinent literature.

METHODS

Search in the Medline databases from 1942-2002 for papers that described the impact of war on rehabilitation services and their practice, and the study of the relevant identified reports. The following search terms were used: history of rehabilitation, medicine and war, rehabilitation and war, rehabilitation of war casualties.

RESULTS

In WWI physical and occupational therapy became adjuncts in the treatment of military orthopaedic casualties, artificial limb services were set-up and workshops and factories for vocational rehabilitation were created. During WWII further developments occurred, mainly in the field of amputation of limbs and spinal cord injuries. Additional advances took place in all armed conflicts after WWII, particularly in the field of brain injury.

CONCLUSION

The literature review indicates that the assumed association of rehabilitation and war is correct. Rehabilitation services have developed partly in association with war and the experience of rehabilitating war casualties supplied valuable principles and practices to rehabilitation medicine enriching the specialty and contributing to the health care systems of the involved countries.

Neuropsychological consequences of traumatic brain injury in children and adolescents

The study of the relationship between neuroscientific information and cognitive function and dysfunction is clearly a widely expanding field. In particular, there has been a growing body of research on traumatic brain injury (TBI) in children and adolescents. This article conveys recent findings concerning cognitive outcomes, with a particular focus on age differences with TBI, suggests a relationship between specific learning disorders and brain dysfunction, addresses differential hemisphere functioning with TBI, and alludes to recent developments in assessment of TBI.

Economic aspects of capacity for work after severe traumatic brain lesions

During 1981-84,310 patients with severe traumatic brain lesions were treated at the Department of Neurosurgery in Lund, Sweden. A total of 161 patients were treated after the introduction of a more aggressive management protocol in 1983. In this first part of a long-term follow-up study we concentrate on the economic aspects. Two questions were addressed: first, what was the vocational outcome after severe head injuries? and second, what were the long-term effects of the new protocol? Out of 147 patients classified as good recovery/moderate disability (GR/MD) 6-months after injury, 106 patients agreed to participate in the study. Five to 8 years after injury 70 patients were classified as capable of working: 57 of these patients were actually at work, nine were studying and four were unemployed. Twenty-two patients had received disability pension and 14 patients had retired because of old age. In the age groups up to 60 years, 70% of patients had returned to work or school. The number of patients who returned to work was significantly higher after introduction of the more aggressive management protocol: 38 of 57 patients who had returned to work were in the group treated between 1983 and 1984. Mean income for patients who had returned to work was close to the average for the corresponding age groups in Sweden. Mean sick leave 5-8 years after severe head injuries was only slightly higher than average in Sweden. Our data show that a majority of the patients classified as GR/MD 6 months after severe traumatic brain lesions have the capacity to return to work. The improvements in the primary management of patients with severe head injuries introduced in 1983 increased the number of patients who work and thus increased the number of patients who favourably contributed to the economy of the community.

Wechsler Memory Scale-Revised in closed head injury

This study was undertaken to determine the ability of the Wechsler Memory Scale-Revised (WMS-R) to differentiate a group of closed head injury patients from a group of controls and determine how injury severity and attentional deficits are associated with WMS-R performance. The relationship of WMS-R performance to everyday memory also was assessed. The head injured group performed more poorly than controls on all five WMS-R indices and exhibited greater impairments on tasks that measure retention. In the original sample only the Visual Memory Index correlated with injury severity; in a larger sample, all four memory indices correlated modestly with injury severity. Patients who performed more poorly on the WMS-R also received poorer ratings on an independent assessment of everyday memory.

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.

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.

Prediction of post-concussional sequelae by reaction time test

The aim of this study was to examine whether it was possible by a reaction time (RT) test to predict if a patient was to complain of sequelae after a cerebral concussion. 55 patients had an RT test performed 1-5 days after concussion. The test showed a significant (P less than 0.02) prolongated RT in patients having postconcussional sequelae (median 186 ms) after 1 month (27 patients, 49%) compared to the patients without sequelae (median 168 ms). Patients with sequelae after 3 months (12 patients, 22%) also had a prolongation of RT (median 183 ms) although non-significant. These results supports a structural organic etiology for postconcussional sequelae.

Neuropsychological methods in the differentiation of organic solvent intoxication from certain neurological conditions

Neuropsychological impairment and the subjective symptoms of 21 patients with organic solvent intoxication were compared with those of patients with vertebrobasilar insufficiency (n = 16), cerebral trauma (n = 16), and headache (n = 15). The aim was to study the diagnostic efficiency of psychological methods in the neuropsychological assessment of patients with suspected solvent intoxications. Our results suggest that it is possible to differentiate between the four groups at group level; however, because of the variance in each group, no specific rule for individual diagnostics can be given. At group level, a combination of three test variables and three symptom scales yielded the most effective discrimination. Instead of the raw scores, subscores for the individual tests as well as detailed use of the symptom questionnaire were informative when the groups were compared. This approach may also be applicable to individual diagnostics.

Brain contusion in minor cranial traumas

Minor cranial traumas without surgical emergency account for about 4% of admissions to our Neurological Service. We consider here 226 consecutive cases. Investigations include: clinical examination, skull X-rays, CSF, EEG, CT, isotopic cisternography. The aim of this study is to define the clinical characteristics of patients with minor head trauma and the priority of instrumental investigations. Correlation between clinical and laboratory findings suggests that: X-ray examination is not predictive of CSF hemorrhage or brain contusion; the CSF is bloody in 1/3 of asymptomatic cases and in 1/6 of cases without fracture; the EEG shows indirect signs of brain contusion even in cases without CT evidence; small subdural hematomas are best diagnosed by CT scan.

Primary brain trauma in non-accidental injury

The brains from 12 babies up to 21/2 years of age, who died after repeated non-accidental injury to the head, were subjected to detailed neuropathological examination. The nine brains from infants under 5 months showed contusional tears--slit like lesions in the white matter surrounded by astrocytes and associated with evidence of old and recent haemorrhage. The three brains from infants over 5 months showed white matter lesions similar to those seen in adults after closed head injury, including damage in the dorsolateral quadrant of the brain stem without axonal hemispheric damage, which may have been a result of whiplash injury after shaking. In addition, all the brains examined showed diffuse gliosis. This paper draws attention to contusional tears and other white matter lesions, which the authors believe are manifestations of mechanical damage produced by trauma. The long term neurological and intellectual defects observed in patients suffering non-accidental injury early in life are increasingly being recognised, although it is difficult to identify the extent to which these are due to social or neuropathological factors. We suggest that the white matter damage we describe has an important role.

Return to work after head injury: a review of post-war studies

The literature on occupational resettlement after head injury is confounded by varying standards of clinical severity and social outcome. A comparison of eleven key studies in the light of the authors' own research yielded a success rate ranging from 50 to 99 per cent, but this was based on superficial evidence. A more searching enquiry is needed, using objective methods and avoiding the technical inadequacies of most previous work. This would be unlikely to challenge the importance of age and length of post-traumatic amnesia as determinants of return to work, but should lead to a better understanding of other factors such as previous occupational status, cognitive deficits and personality changes.

Subjective impairment and social recovery after closed head injury

The level of social recovery achieved by a representative series of 50 young adults was assessed six months after a severe closed head injury (post-traumatic amnesia greater than 24 hours). Work, leisure activities, and contact with friends were the areas of life most affected, whereas family life and marital relationships appeared to withstand changes at this stage in the recovery process. Many patients were still suffering from subjective symptoms, but these appeared to have relatively minor effects on ability to resume normal activities. Physical disability was a much more important factor at this stage. A control group of patients with limb injuries suffered similar disruption of their lives, but reported few subjective complaints.

Severe head injuries in three countries

Methods for assessing early characteristics and late outcome after severe head injury have been devised and applied to 700 cases in three countries (Scotland, Netherlands, and USA). There was a close similarity between the initial features of patients in the three series; in spite of differences on organisation of care and in details of management , the mortality was exactly the same in each country. This data bank of cases (which is still being enlarged) can be used for predicting outcome in new cases, and for setting up trials of management.

Sequelae of concussion caused by minor head injuries

Of 145 patients with concussion from minor head injuries admitted to the Royal Victoria Hospital, Belfast, over one year, 49.0 per cent had no symptoms, 38.9 per cent had between 1 and 6 symptoms, and 2.1 per cent had more than 6 symptoms about six weeks after the accident. There was significant correlation between a high symptom-rate at six weeks and positive neurological signs and symptoms at twenty-four hours. Post-concussion symptoms were more frequent in women, in those injured by falls, and in those who blamed their employers or large impersonal organisations for their accidents. The results suggest that both organic and neurotic factors are involved in the pathogenesis of symptoms at six weeks.

Late recovery from head injury: case report and review

Some problems of prognosis in patients with head injury are reviewed, and a case of late and unexpected recovery from post-traumatic dementia presented. The possible mechanism of recovery is discussed with particular reference to normal pressure hydrocephalus.

The psychiatric sequelae of head injury: a review

The review deals mainly with the more chronic psychiatric sequelae of head injury. The constellation of factors—psychological, social, and organic—which may contribute to enduring disability are discussed. Principal areas of disability are then considered in detail—namely, intellectual impairments, change of personality, psychotic illness, and neurotic disorders.