The Barthel ADL Index: a reliability study

The Barthel Index is a valid measure of disability. In this study we investigated the reliability of four different methods of obtaining the score in 25 patients: self-report, asking a trained nurse who had worked with the patient for at least one shift, and separate testing by two skilled observers within 72 hours of admission. Analysis of total (summed) scores revealed a close correlation between all four methods: a difference of 4/20 points was likely to reflect a genuine difference. In individual items, most disagreement was minor and involved the definition of middle grades. Asking an informed nurse or relative was as reliable as testing, and is quicker.

The gross motor function measure: a means to evaluate the effects of physical therapy

This paper reports the results of a study to validate a measure of gross motor function in detecting change in the motor function of disabled children. Physiotherapists used this instrument to assess 111 patients with cerebral palsy, 25 with head injury and 34 non-disabled preschool children on two occasions, the second after an interval of four to six months. Parents and therapists independently rated the children's function within two weeks of each assessment, and a sample of paired assessments was videotaped for 'blind' evaluation by therapists. Correlations between scores for change on this measure and the judgments of change by parents, therapists and 'blind' evaluators supported the hypothesis that the instrument would be responsive to both negative and positive changes.

Disability in young people and adults one year after head injury: prospective cohort study

OBJECTIVE

To determine the frequency of disability in young people and adults admitted to hospital with a head injury and to estimate the annual incidence in the community.

DESIGN

Prospective, hospital based cohort study, with one year follow up of sample stratified by coma score.

SETTING

Five acute hospitals in Glasgow.

SUBJECTS

2962 patients (aged 14 years or more) with head injury; 549 (71%) of the 769 patients selected for follow up participated.

MAIN OUTCOME MEASURES

Glasgow outcome scale and problem orientated questionnaire.

RESULTS

Survival with moderate or severe disability was common after mild head injury (47%, 95% confidence interval 42% to 52%) and similar to that after moderate (45%, 35% to 56%) or severe injury (48%, 36% to 60%). By extrapolation from the population identified (90% of whom had mild injuries), it was estimated that annually in Glasgow (population 909 498) 1400 young people and adults are still disabled one year after head injury.

CONCLUSION

The incidence of disability in young people and adults admitted with a head injury is higher than expected. This reflects the high rate of sequelae previously unrecognised in the large number of patients admitted to hospital with an apparently mild head injury.

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.

Neuropsychological rehabilitation after closed head injury in young adults

Cognitive and personality disturbances following severe closed head injury in young adults are associated with poor rehabilitation outcome. Yet systematic programmes for dealing with these disturbances have generally not appeared. The present report briefly describes the Neuropsychological Rehabilitation Program (NRP) at Presbyterian Hospital in Oklahoma City and the initial outcome data on eighteen closed head injury patients and seventeen untreated controls. Greater improvement in neuropsychological functioning occurred in the NRP patient group on selected variables, but generally the effects were modest. Emotional distress, however, substantially decreased in treated patients. Fifty percent of the NRP patients maintained productivity 75% of the time or more following rehabilitation, compared to 36% of the controls. Treatment successes showed less personality disturbances than treatment failures and better learning and memory scores post-treatment.

Employment following traumatic head injuries

OBJECTIVE

Determine rates of, and factors predictive of, return to work in patients with civilian traumatic head injuries.

DESIGN

Inception cohort study with 1- to 2-year follow-up.

SETTING

Hospitalized patients in a level I trauma center.

PATIENTS

Three hundred sixty-six hospitalized head-injured subjects who were workers before injury and 95 comparison subjects participated in prospective, longitudinal investigations of employment following head injury. Head-injured and comparison subjects were similar on basic demographics and preinjury employment status. The comparison subjects consisted of patients who sustained traumatic injury to the body but not to the head.

MAIN OUTCOME MEASURE

Time taken to return to work following head injury.

RESULTS

Survival methodology was used for analysis. Whether patients returned to work and when related to both the characteristics of the injured patients (eg, education, preinjury work history), the severity of head injury and associated neuropsychologic problems, and severity of other system injuries. More precise predictions were possible using the multivariate model.

CONCLUSIONS

The present study provides a means of assessing employment potential predictively. This can be useful for clinical and research purposes. The results should be used cautiously and should stimulate discussions of appropriate use of services and resources to meet individual patients' needs.

Social recovery during the year following severe head injury

A group of 54 patients who had suffered severe closed head injury (PTA >24 hours) were followed from the time of their injury for a period of two years. Relatives were interviewed within the first four weeks to assess the patient's previous personality and social adjustment. Patients and relatives were then assessed personally six and 12 months later and by postal questionnaires after two years. Only six patients were still not back at work after two years but more had not resumed all their leisure activities. Family relationships appeared to have settled down again by this stage but social contacts were still less frequent. Personality changes were associated with prior family relationships, cognitive changes with diminished social contacts whilst premorbid personality and physical deficits were associated with time taken to return to work.

Thirty month outcome from early childhood head injury: a prospective analysis of neurobehavioural recovery

Traumatic brain injury (TBI) is a common cause of acquired disability during childhood. While much is now known about outcome following TBI in the school-aged population, recovery in infants and young children is less well documented. The aim of this study was to examine neurobehavioural function following TBI during early childhood, to plot recovery over the 30 months post-injury and to identify predictors of outcome. The study compared three groups of children, sustaining injuries of different severity (mild = 14, moderate = 46, severe = 24), aged 2.0-6.11 years at injury, with a healthy control group (n = 33). The groups were similar with respect to pre-injury adaptive and behavioural function, psychosocial characteristics, age and gender. Using a prospective, longitudinal design, intellectual, language and memory functions were investigated acutely post-injury and again at 12 and 30 months post-injury. Results suggested a strong association between injury severity across all neurobehavioural domains. Further, 30 month outcome was predicted by multiple factors including injury severity, socio-economic status, pre-injury adaptive abilities and age, with pre-injury child behaviour and specific lesion characteristics playing surprisingly little role. In conclusion, children with more severe injuries, lower pre-injury adaptive abilities and lower socio-economic status are at greatest risk of long-term neurobehavioural impairment, even several years post-injury.

The Sickness Impact Profile as a tool to evaluate functional outcome in trauma patients

Because the ultimate goal of trauma care is to restore injured patients to their former functional status, reliable evaluation of functional status is needed to assess fully the effectiveness of trauma care. We hypothesized that the Sickness Impact Profile (SIP), a widely used measure of general health status, would be a useful tool to evaluate the long-term functional outcome of trauma patients and that the SIP would identify unexpected problems in the recovery process and groups of patients at high risk for long-term disability. A prospective cohort of 329 patients with lower extremity fractures admitted to three level I trauma centers were interviewed using SIP at 6 and 12 months postinjury. Patients with major neurologic injuries were excluded. Overall SIP scores and each of the component subscores may range from 0 (no disability) to 100. In this series, the mean overall SIP was 9.5 at 6 months and 6.8 at 12 months, compared with a preinjury baseline of 2.5. At 12 months, 52% of patients had no disability (SIP 0 to 3), 23% mild disability (4 to 9), 16% moderate disability (10 to 19), and 9% severe disability ( > or = 20). Disability was widely distributed across the spectrum of activities of daily living, including physical functioning (mean score of 5.5), psychosocial health (mean score of 5.5), sleeping (mean score of 10.0), and work (mean score of 21.0). The SIP scores did not correlate with Injury Severity Score.(ABSTRACT TRUNCATED AT 250 WORDS)

A practical outcome scale for paediatric head injury

Traumatic brain injury (TBI) is the commonest cause of acquired disability in childhood. A major obstacle to the evaluation of acute and rehabilitative therapies after TBI is the lack of simple descriptors of outcome. We developed the King's Outcome Scale for Childhood Head Injury (KOSCHI), as a specific paediatric adaptation of the original adult Glasgow Outcome Scale (GOS). The KOSCHI expands the five category GOS to provide increased sensitivity at the milder end of the disability range. The GOS category of "persistent vegetative state" was replaced by "vegetative". "Good recovery" was allocated two categories, in acknowledgement of the long term importance of relatively minor sequelae in a developing child. The scale was quick and easy to use. Inter-rater reliability studies show that even with such an apparently simple scale, some training may be required. The KOSCHI provides a practical scale for paediatric head injury which will enable clinicians to describe rate and extent of recovery, and evaluate the effects of service and research interventions.

Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form?

BACKGROUND

Although head trauma is considered a common cause of benign paroxysmal positional vertigo (BPPV), clinical presentation and outcome of traumatic BPPV (t-BPPV) have not been systematically evaluated.

OBJECTIVES

To compare the clinical presentation, patient's response to physical treatment, and outcome of patients with t-BPPV with those with the idiopathic form (i-BBPV).

SETTING

Tertiary referral neuro-otology outpatient clinic.

METHODS

We reviewed the clinical records of 247 consecutive patients with posterior canal BPPV during the years 1997 to 2000. All patients were diagnosed using the Dix-Hallpike test and treated using the particle repositioning maneuver. Patients with an onset of positional vertigo within 3 days of well-documented head trauma were included in the t-BPPV group. The outcome was compared with the outcome of 42 patients with i-BPPV who were similarly treated and followed up.

RESULTS

Twenty-one (8.5%) of the 247 patients with BPPV fulfilled the diagnostic criteria for t-BPPV. The most common cause of head trauma was motor vehicle crash, documented in 57% of the cases; half of the patients additionally suffered from a whiplash injury. While the other causes were diverse, common falls were predominant. Only 2 of the patients involved in motor vehicle crashes experienced brief loss of consciousness. Sixty-seven percent of patients with t-BPPV required repeated physical treatments for complete resolution of signs and symptoms in comparison to 14% of patients with i-BPPV (P<.001). During a mean +/-SD follow-up of 21.7 +/- 9.7 months, 57% of t-BPPV patients and 19% of i-BPPV controls had recurrent attacks (P<.004).

CONCLUSIONS

The nature and severity of the traumas causing t-BPPV are diverse, ranging from minor head injuries to more severe head and neck trauma with brief loss of consciousness. It appears that t-BPPV is more difficult to treat than i-BPPV, and also has a greater tendency to recur.

Head injury in young adults: long-term outcome

OBJECTIVE

To describe the long-term outcome 5 years after injury of young adults who were 15 to 19 years old at the time of their head injuries.

DESIGN

A retrospective cohort. The health records of 62 consecutive eligible subjects were abstracted for baseline sociodemographic, health, and injury variables. A telephone interview was administered to assess quality of life, impairment, disability, and handicap.

SETTING

Canada's largest trauma center, Sunnybrook Health Science Centre, Toronto, Canada.

SUBJECTS

Of the 58 subjects (94%) who were traced at follow-up, 51 agreed to participate.

MAIN OUTCOME MEASURES

The Medical Outcomes Study SF-36, Head Injury Symptom Checklist, selected disability measures, Community Integration Questionnaire.

RESULTS

Of the 8 summary items of the Medical Outcomes Study SF-36, subjects scored lowest on mental health. There were no significant differences between mild and more severely injured groups in all quality of life measures. Subjects classified with mild head injury overall reported more symptoms from the Head Injury Symptom Checklist. Subjects with more severe injuries had lower community integration scores (p < .05).

CONCLUSIONS

Overall, mental health is an important area of concern at follow-up for all subjects. Adolescents with apparent mild head injury can have disabling symptoms many years after injury.

Rehabilitation interventions after mild head injury

PURPOSE OF REVIEW

This review examines current management and rehabilitation strategies for mild traumatic brain injury, with emphasis on the need to address multiple potential causative factors in order to enhance outcomes and to conduct more controlled efficacy studies.

RECENT FINDINGS

Whilst most individuals who sustain mild traumatic brain injury make a good recovery, a proportion experience significant ongoing disability. In some cases this is due to diffuse axonal injury and cognitive impairment, but in others symptoms are exacerbated by factors such as pain, stress, personality issues or litigation, or in children, previous head injury, behavioural or learning difficulties. Provision of information early after injury results in reduced symptom reporting in adults and children. There is also a need, however, to address these other factors in treatment. Psychological therapy using a cognitive behavioural approach may be helpful, but controlled evaluations of such interventions have been lacking. Recent uncontrolled studies have examined the impact of computer-mediated interventions to remediate visual and verbal processing and oculomotor problems and the impact of quantitative electroencephalography. More rigorous efficacy studies of these approaches are needed. Guidelines for management of sports-related concussion and timing of return to play also require a more solid scientific basis.

SUMMARY

The evidence base for management of mild traumatic brain injury is still very limited. There is a need to conduct more carefully controlled prospective studies and examine the influence of factors not directly related to the brain injury as a basis for formulating more uniform management guidelines.

Residual impairments and work status 15 years after penetrating head injury: report from the Vietnam Head Injury Study

We investigated the relationship of neurologic, neuropsychological, and social interaction impairments to the work status of a large sample of penetrating head-injured patients wounded some 15 years earlier during combat in Vietnam. Extensive standardized testing of neurologic, neuropsychological, and social functioning was done at follow-up on each head-injured patient (N = 520), as well as on a sample of uninjured controls (N = 85). Fifty-six percent of the head-injured patients were working at follow-up compared with 82% of the uninjured controls. Seven systematically defined impairments proved to be most correlated with work status. These were post-traumatic epilepsy, paresis, visual field loss, verbal memory loss, visual memory loss, psychological problems, and violent behavior. These disabilities had a cumulative and nearly equipotent effect upon the likelihood of work. We suggest that a simple summed score of the number of these seven disabilities can yield a residual "disability score" which may prove to be a practical tool for assessing the likelihood of return to work for patients in this population and perhaps in other brain-injured populations. These findings may also help to focus rehabilitation efforts on those disabilities most likely to affect return to work.

Prediction of behind-the-wheel driving performance in patients with cerebral brain damage: a discriminant function analysis

Rehabilitation specialists, particularly occupational therapists, are often involved in evaluating clients' fitness to resume driving after cerebral damage due to head injury or stroke. Their available methods include separate or combined administration of predriver, simulator, and behind-the-wheel evaluations. However, use of these methods without a theoretical model on which to base test selection has yielded some criticism and little research about the effectiveness of these methods in predicting driving performance. Using the authors' Cybernetic Model of Driving as the basis for assessing abilities and behaviors relevant to driving outcome, this study sought to determine the effectiveness of the evaluation methods by discriminant analysis and measurements of sensitivity in predicting behind-the-wheel failures. Comprehensive evaluations of 106 patients revealed that residual deficits in cognition per se did not render a person unfit to drive and underscored the importance of considering behaviors in determining fitness. The methods of evaluation were shown to be relatively sensitive in predicting outcome; off-road and on-road evaluation reached sensitivities of 90% and 92% with the inclusion of behavioral measures. Formulae for predicting outcome based on methods of evaluation are provided and reasons for failures in behind-the-wheel evaluations are discussed.

Short-term sequelae of minor head injury (6 years experience of minor head injury clinic)

PURPOSE

It is known that post-concussive symptoms may persist after mild head injury. However, the majority of those patients are denied follow-up or support. A minor head injury clinic was thus established in North Staffordshire Hospital in 1993 to address these problems.

METHODS

Patients 16-65 years old attending hospital with minor head injury were invited to attend the clinic two weeks after presentation. A specialized brain injury nurse and/or assistant clinical psychologist assessed them. Patients with persistent symptoms were invited to a second assessment four weeks later.

RESULTS

One thousand two hundred and fifty-five patients were invited for first assessment, the most common cause of head injury was assault (454) followed by road traffic accident (334). Six hundred and sixteen patients did not attend the first assessment; most of non-attendees were those who had been assaulted (281). Six hundred and thirty-nine patients attended, (472) were male, their mean age was 33. Forty-three per cent of them had history of recent alcohol intake. One third had had a previous head injury. Although 391 attendees were in regular employment, 219 patients were unable to return to work 2 weeks after discharge (56%), and 49 people were still off sick 6 weeks after the injury. The most common complaints at both assessments were fatigue, headache, dizziness, irritability, sleep disturbances, poor concentration and poor memory in that order.

CONCLUSION

This study shows a significant number of patients with minor head injury still complaining of post concussive symptoms, which may contribute to a delay in return to work. The high incidence of non-attendance among the assaulted victims may indicate that this group needs to be more effectively targeted. Further study to look at the longer-term consequences of minor head injury is required in view of these findings.

Physical recovery after severe closed head trauma in children and adolescents

Three hundred forty-four patients under 18 years of age with severe closed head injuries, comatose over 24 hours, were followed prospectively for a minimum of one year. Motor vehicles were involved in 82% of the injuries. Seventy-three percent of the patients regained independence in ambulation and self-care, 10% remained partially dependent in self-care and achieved only limited ambulation, 9% regained consciousness but were totally dependent, and 8% remained comatose. A favorable prognosis for recovery of motor function can be made if the duration of coma is less than three months. Complications of prolonged hypertension, ventricular enlargement, and seizures significantly decrease the probability of achieving physical independence. Although mortality following severe head injury is decreasing, neurologic sequelae in the survivors are statistically unchanged since 1970. Improved neurosurgical management in recent years has not increased the percentage of severely disabled survivors.

The effect of casting combined with stretching on passive ankle dorsiflexion in adults with traumatic head injuries

BACKGROUND AND PURPOSE

Ankle plantar-flexion contractures are a common problem following traumatic head injury. Although serial casting is used to correct and prevent ankle plantar-flexion contractures, treatment efficacy has not been evaluated using an experimental design. The aim of this research was to establish the effect of a regimen of casting combined with stretching on passive ankle dorsiflexion motion.

SUBJECTS

Nine people who had sustained traumatic closed head injuries and had limited dorsiflexion motion participated in the study.

METHODS

A crossover design was used in the study. Subjects were assigned to both experimental and control groups. Torque-controlled measurements of passive ankle dorsiflexion motion were obtained for all subjects before and after 1 week of casting combined with stretching, as well as before and after a 1-week control period. The order of the experimental and control conditions was randomized.

RESULTS

Passive ankle dorsiflexion increased by a mean of 13.5 degrees (SD = 9.3) during the experimental condition, as compared with a mean decrease of 1.9 degrees (SD = 10.2) during the control condition. The difference between the experimental and control conditions was statistically significant.

CONCLUSION AND DISCUSSION

These findings suggest that casting combined with stretching is an effective method of correcting ankle plantar-flexion contractures in patients with traumatic head injuries.

Treatment of aggression and irritability after head injury

Thirteen patients who experienced problems with irritability and aggression following closed head injury (CHI) participated in a non-blind, 8 week open trial and sertraline HCl. Significant reduction in irritability and aggressive outbursts was observed. No significant changes were observed in depressive symptomatology. Results suggest that serotonergic agents may be useful in treating aggression and irritability after head injury. Further placebo-controlled studies using serotonergic agents are indicated.

Procedural memory during posttraumatic amnesia in survivors of severe closed head injury. Implications for rehabilitation

To investigate the possibility that learning of skills (ie, procedural memory) is preserved during posttraumatic amnesia, 16 amnesic survivors of severe closed head injury and 16 control subjects were studied. Procedural learning tasks included mirror reading, mazes, and a pursuit rotor task that involved tracking a rotating target. Declarative memory was assessed by testing recognition of the words used in mirror reading and a questionnaire concerning details of the previous testing session. Learning was evaluated on 3 consecutive days and a fourth session was scheduled after resolution of posttraumatic amnesia. Despite stable impairment of declarative memory during posttraumatic amnesia, the performance of head-injured patients improved across sessions on all procedural tasks and showed transfer to testing after resolution of posttraumatic amnesia.

The value of melatonin for sleep disorders occurring post-head injury: a pilot RCT

PRIMARY OBJECTIVE

Whilst there is data to support the use of Melatonin in treating disorders of the sleep-wake cycle, so far there is little published evidence on the efficacy of Melatonin in treating the prevalent condition of post-TBI sleep disturbance.

RESEARCH DESIGN

The present work used a randomized double-blind controlled cross-over trial to compare Melatonin (5 mg) and Amitriptyline (25 mg) in a small sample of TBI patients presenting with chronic sleep disturbance.

MAIN OUTCOME AND RESULTS

No differences in sleep latency, duration, quality or daytime alertness were found for either drug compared to baseline using significance testing. However, effect sizes revealed some encouraging changes. Patients on Melatonin reported improved daytime alertness compared to baseline. On Amitriptyline, patients reported increased sleep duration compared to baseline.

CONCLUSIONS

The study provides preliminary evidence for the value of Melatonin and Amitriptyline in treating sleep disorder post-TBI. There were no adverse drug effects. Suggestions are made for ongoing investigation for the treatment of this prevalent condition.

The effectiveness of various cervical orthoses. An in vivo comparison of the mechanical stability provided by several widely used models

STUDY DESIGN

The amount of motion allowed by various cervical orthoses was compared with the amount of unrestricted neck motion in vivo.

OBJECTIVES

To determine how much mechanical stability commonly used cervical orthoses provide to the wearer.

SUMMARY OF BACKGROUND DATA

Few studies have compared quantitatively the restriction of motion from cervical orthoses that are commonly prescribed for patients. No studies have used methods allowing measurement of all three rotations throughout the range of motion in passive and active tests. Previous studies may have overstated the amount of restriction provided resulting from the methods used.

METHODS

Five subjects were tested for cervical range of motion in flexion-extension, axial, rotation, and lateral bending. Each was tested with no collar, with soft collar, with Philadelphia collar, with Philadelphia collar with thoracic extension, and with sterno-occipital mandibular immobilizer brace. Each test was conducted passively and actively. Measurements were taken with the CA-6000 Spine Motion Analyzer, a highly accurate and precise computerized linkage system that simultaneously records all three rotations in real time.

RESULTS

All orthoses restricted motion to some extent. Generally, the collars ranked (from least restrictive to most restrictive): soft, Philadelphia, Philadelphia with extension, and sterno-occipital mandibular immobilizer brace. However, the differences were not usually large, and the collars did not restrict motion as much as previously reported. No collar restricted the motion of any of the subjects to less than 19 degrees of flexion-extension, 46 degrees of axial rotation, or 45 degrees of lateral bending, and most subjects demonstrated significantly more motion.

CONCLUSIONS

Although cervical orthoses can be helpful for other reasons, they do not provide a high level of mechanical restriction of motion. Additionally, the restriction they do provide can vary widely between people. Prescribing physicians should consider the relative merits of the various orthoses before deciding whether they will meet a patient's needs. The differences between the collars tested may not be enough to justify one of the more expensive or less comfortable collars.

Some factors determining prognosis in young people with severe head injuries

Eighty-four patients under the age of 40 were rehabilitated after severe head injuries. All had been unconscious for at least 24 hours, and 35 were unconscious for more than four weeks. The mean length of treatment was 30.2 weeks. Seventy were discharged home, 13 remained in hospital, and one died. Seventy-two of the patients were followed up nine months to 15 years after the injury. Twenty-eight were working, 27 were at home but not working, 13 were in hospital, and four were dead. Prolonged unconsciousness, extensive neurological damage, and severe mental changes were found to be the main factors adversely affecting the prognosis; an inadequate family background and cerebral hypoxia were also considered to have an influence.