Brain growth and cognitive improvement in children with human immunodeficiency virus-induced encephalopathy after 6 months of continuous infusion zidovudine therapy.

The ventricular area at the level of the foramen of Monro was measured from axial x-ray computed tomography (CT) scans obtained prior to and 6 months after the initiation of continuous infusion of zidovudine (ZDV) in eight children with human immunodeficiency virus-induced encephalopathy. Evidence of moderate to severe central atrophy was present on initial CT scans (p less than 0.05). Ventricular area and ventricular brain area ratio (VBR) decreased after ZDV therapy in seven of eight children (mean decrease of 21.5 and 20%, respectively, p less than 0.05). The degree of decrease in VBR correlated with reductions in cerebrospinal fluid (CSF) protein concentration (r = 0.93, p less than 0.01), but not lymphocyte T4 or T8 counts. Intelligence quotients (IQs) improved in all seven children tested (mean improvement of 17.7%, p less than 0.01) and correlated significantly with reductions in CSF protein concentration (r = -0.85, p = 0.003). The magnitude of IQ changes was not significantly correlated with the magnitude of changes in ventricular area. We conclude that the cognitive improvement of HIV encephalopathy seen after 6 months of continuous infusion of ZDV is accompanied by reduction in brain atrophy and decreased CSF protein, suggesting an ameliorating effect of ZDV on the pathogenesis of AIDS encephalopathy in children.

An interdisciplinary perspective on the agitated brain injured patient.

The Special Interest Group on Brain Injury of the American Academy of Physical Medicine and Rehabilitation is developing a practice parameter for the agitated patient following traumatic brain injury (TBI). The eventual goal of the project is to create an interdisciplinary practice guideline for classifying and treating these patients using a common nosology, based on contributions from the literatures of neurosurgery, psychology, psychiatry and rehabilitation medicine. It is envisioned that a uniform classification system would ultimately promote interdisciplinary research and serve to advance our understanding and treatment of this patient population. In the acute post-injury period, many TBI patients can be characterized by confusion, agitation, post-traumatic amnesia and delirium. In various acute care settings, psychiatrists, psychologists or rehabilitation medicine physicians (physiatrists) are asked to evaluate and treat this population of patients. Each of these disciplines employ specialty-based diagnostic criteria and rating instruments, with little or no consensus across disciplines concerning the appropriateness of these tools. This article reviews the classification and rating systems utilized within the fields of neurosurgery, rehabilitation medicine, psychology and psychiatry, to describe patients displaying agitated behaviors. The authors review the literature establishing the definitions, measurement and possible neuroanatomic and neurophysiologic substrate for delirium and brain-injury agitation, with its characteristic cognitive and behavioral manifestations. Pharmacologic treatment is briefly reviewed to emphasize the significantly different viewpoints from the fields of rehabilitation medicine and psychiatry. The authors explore support from the literature for an interdisciplinary definition for agitation following TBI which includes criteria for delirium, post-traumatic amnesia, and associated behavioral excesses such as disinhibition, aggression, or emotional lability. Wide acceptance of this definition by medical and research professionals may potentially lead to a greater understanding of this clinical state and its neuropathogenesis through promotion of intra- and inter-disciplinary research.

Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI.

OBJECTIVE: To compare the efficacy of step training with body weight support on a treadmill (BWSTT) with over-ground practice to the efficacy of a defined over-ground mobility therapy (CONT) in patients with incomplete spinal cord injury (SCI) admitted for inpatient rehabilitation. METHODS: A total of 146 subjects from six regional centers within 8 weeks of SCI were entered in a single-blinded, multicenter, randomized clinical trial (MRCT). Subjects were graded on the American Spinal Injury Association Impairment Scale (ASIA) as B, C, or D with levels from C5 to L3 and had a Functional Independence Measure for locomotion (FIM-L) score < 4. They received 12 weeks of equal time of BWSTT or CONT. Primary outcomes were FIM-L for ASIA B and C subjects and walking speed for ASIA C and D subjects 6 months after SCI. RESULTS: No significant differences were found at entry between treatment groups or at 6 months for FIM-L (n = 108) or walking speed and distance (n = 72). In the upper motor neuron (UMN) subjects, 35% of ASIA B, 92% of ASIA C, and all ASIA D subjects walked independently. Velocities for UMN ASIA C and D subjects were not significantly different for BWSTT (1.1 +/- 0.6 m/s, n = 30) and CONT (1.1 +/- 0.7, n = 25) groups. CONCLUSIONS: The physical therapy strategies of body weight support on a treadmill and defined overground mobility therapy did not produce different outcomes. This finding was partly due to the unexpectedly high percentage of American Spinal Injury Association C subjects who achieved functional walking speeds, irrespective of treatment. The results provide new insight into disability after incomplete spinal cord injury and affirm the importance of the multicenter, randomized clinical trial to test rehabilitation strategies.

Autonomic dysreflexia associated with transient aphasia.

STUDY DESIGN: Case report of autonomic dysreflexia presenting with transient aphasia in a subject with C4 tetraplegia. OBJECTIVES: To report a rare case of autonomic dysreflexia. SETTING: Rehabilitation Service, The Ohio State University, USA. CASE REPORT: A 21-year-old man with a C4 spinal cord injury (ASIA B) developed aphasia associated with autonomic dysreflexia. He was treated with an adrenergic blocking agent. CONCLUSION: Autonomic dysreflexia manifested by a transient aphasia and seizures is uncommon.

Systematic bias in outcome studies of persons with traumatic brain injury.

OBJECTIVE: (1) Examine systematic biases created by subjects lost at 1-year follow-up in samples of persons with traumatic brain injury; (2) identify potential threats to generalization of outcomes data. DESIGN: A consecutive sample of admissions to acute rehabilitation studied 1 year following discharge. SETTING: An inpatient brain injury rehabilitation unit in a large, academic medical center. SUBJECTS: Eighty-eight patients with primary diagnosis of traumatic brain injury. MAIN OUTCOME MEASURES: Subjects were considered lost to follow-up when phone calls, mail, clinic visits, and assistance from family failed to allow contact 1 year after discharge from acute rehabilitation. Potential effects of the biased follow-up sample were examined for seven suboptimal outcomes. RESULTS: A total of 38.6% of subjects were lost to follow-up. Subjects intoxicated at time of injury and those with history of substance abuse were more-likely to be lost. Among subjects followed, the likelihood of working or being in school 1 year after discharge was significantly less for those intoxicated at time of injury and those with a history of substance abuse. CONCLUSIONS: Systematic bias in longitudinal studies may result from subjects with substance use problems being lost to follow-up. Population estimates for return to work or school will be overestimated if those lost who have substance use problems resemble those followed.

Life satisfaction after traumatic brain injury.

OBJECTIVE: To investigate correlates of life satisfaction after traumatic brain injury (TBI). DESIGN: Prospective, longitudinal study of patients with TBI studied 1 and 2 years after injury. SETTING: A specialized inpatient TBI rehabilitation unit in a midwestern academic medical center. SUBJECTS: Two hundred eighteen consecutive patients admitted for rehabilitation, at least 14 years of age, with a primary diagnosis of TBI, consented to participate, and interviewed 1 and/or 2 years after injury (112 interviewed both years, 58 at year 1 only, 48 at year 2 only). MAIN OUTCOME MEASURES: Satisfaction With Life Scale. RESULTS: Stepwise multiple regressions accounted for statistically significant, but small, proportions of variance. Not having a preinjury history of substance abuse and having gainful employment at the time of follow-up were associated with higher life satisfaction both 1 and 2 years after injury. Motor independence at rehabilitation discharge was also associated at 1 year. Current social integration and the absence of depressed mood were associated at 2 years. Life satisfaction was relatively stable between years. Change that did occur was associated with marital status and depressed mood 2 years after injury. CONCLUSIONS: Life satisfaction after TBI seems to be related to attaining healthy and productive lifestyles. Future research should investigate other factors that affect life satisfaction to increase prediction and appreciate all influences on subjective well being after TBI.

Defining sleep disturbance after brain injury.

Sleep disorders are a relatively common occurrence after brain injury. Sleep disturbances often result in a poor daytime performance and a poor individual sense of well-being. Unfortunately, there has been minimal attention paid to this common and often disabling sequela of brain injury. This study attempts to define and to correlate the incidence and type of sleep disturbances that occur after brain injury. Consecutive admissions to a rehabilitation unit were used to create a longitudinal database designed to predict long-term outcomes for individuals who suffered a brain injury. Fifty percent of subjects had difficulty sleeping. Sixty-four percent described waking up too early, 25% described sleeping more than usual, and 45% described problems falling asleep. Eighty percent of subjects reporting sleep problems also reported problems with fatigue. Logistic regression analysis revealed the following: the more severe the brain injury the less likely the subject would be to have a sleep disturbance; subjects who had sleep disturbances were more likely to have problems with fatigue; females were more likely to have trouble with sleep. This study demonstrates the substantial prevalence of sleep disturbances after brain injury. It underscores the relationship between sleep disorders and perception of fatigue. It also underscores the need for clinicians to strive for interventional studies to look at the treatment of sleep and fatigue problems after brain injury.

A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury.

OBJECTIVE: To determine the relative contributions of substance abuse history and violent etiology to the prediction of outcomes for individuals who sustained a traumatic brain injury (TBI) requiring inpatient rehabilitation. DESIGN: Longitudinal study of outcomes 1 year postdischarge from rehabilitation. SETTING: Specialized TBI acute rehabilitation unit. PARTICIPANTS: Three hundred fifty-one individuals consecutively admitted for rehabilitation. INTERVENTIONS: Gathered data from patients' medical records (including etiology of injury, initial Glasgow Coma Scale scores, and FIMtrade mark instrument scores at discharge), demographic details, and history of substance abuse; phone and mail survey data from individuals (Satisfaction with Life Scale [SWLS]; Community Integration Questionnaire [CIQ]). MAIN OUTCOME MEASURES: CIQ and SWLS; relative contributions of injury etiology, demographic and injury-related dependent variables, and substance abuse history to predictive model. RESULTS: Almost 80% of persons with injuries from violence-related causes had a history of substance abuse. Substance abuse was found to contribute to the prediction of life satisfacton and productivity, while violent etiology was not a significant contributor to predictive models. CONCLUSION: Substance abuse history proved to be a strong predictor of long-term outcomes, while violent etiology of injury was less influential. The results of this study emphasize the need to include substance abuse history in all studies of outcomes after TBI, and to increase prevention efforts to limit the effects of such a history.

Role of agitation in prediction of outcomes after traumatic brain injury.

OBJECTIVE: To determine the role of agitation in the prediction of traumatic brain injury rehabilitation outcomes. DESIGN: A longitudinal study of 340 consecutive patients admitted to an acute traumatic brain injury rehabilitation unit was conducted. Outcomes under study included rehabilitation length of stay, discharge destination, functional independence at discharge (FIM instrument), productivity at 1-yr follow-up, and life satisfaction at 1-yr follow-up (Satisfaction with Life Scale). RESULTS: Univariate analyses suggested that the presence of agitation in rehabilitation is predictive of a longer length of stay and decreased functional independence in the cognitive realm at discharge. In addition, individuals who exhibit agitation at any time during rehabilitation are less likely to be discharged to a private residence. However, multivariate analyses indicated that cognitive functioning at admission to rehabilitation (FIM cognitive) mediates the relationship between the presence of agitation and length of rehabilitation, as well as between agitation and FIM cognitive at discharge. Similar results were found when discharge residence was the dependent variable; however, agitation also contributed some unique variance to the prediction. Lower cognitive functioning at admission to rehabilitation was associated with the occurrence of agitation during rehabilitation, longer length of stay, lower cognitive functioning at discharge, and a decreased likelihood that an individual would be discharged to a private residence. CONCLUSIONS: The results of the multivariate analyses support the contention that agitation and cognition are intimately related, with the long-term effects of the former being at least partially driven by the latter. These findings support the importance of systematically monitoring both agitation and cognition when applying interventions to reduce agitation.

Primary caregivers of persons with brain injury: life change 1 year after injury.

The impact of a traumatic brain injury on the family of the injured person is just beginning to be explored. In the current study, 61 primary caregivers were contacted at 1 year following injury. They completed the Relative and Friend Support Index, Social Support Index, Trauma Complaints List and the Life Change Question. The majority of caregivers indicated at least mild negative life change following the brain injury. Greater social support was correlated with less life change and greater injury severity was correlated with negative life change. Neither of these relationships was found to be significant at the 0.05 level. A significant positive correlation was found between caregivers' perception of deficits and the degree of negative life change. Perceived deficits accounted for the greatest amount of variance in life change followed by relative and friend support when all variables were entered into a stepwise regression. Further analyses indicated that the most significant factor of the Trauma Complaints List in predicting life change may be problems with cognition, which accounted for a significant amount of the variance in life change. Implications for counselling and further research regarding caregivers of persons with brain injury are discussed.

Definition of agitation following traumatic brain injury: I. A survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation.

OBJECTIVE: To determine national patterns of defining agitation after traumatic brain injury (TBI) by physiatrists with expressed interest in treating TBI survivors. DESIGN: A random sample of 70% of the members of the Brain Injury Special Interest Group (SIG) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) were surveyed by telephone. RESULTS: The 129 members who responded yielded an 82% response rate. Respondents rated 18 characteristics from established rating scales on a 5-point scale according to each characteristic's relation to its clinical definition of agitation. Physical aggression, explosive anger, increased psychomotor activity, impulsivity, verbal aggression, disorganized thinking, perceptual disturbances, and reduced ability to maintain or appropriately shift attention were rated by at least 50% of the sample as very important or essential to agitation. Delirium, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been proposed as a standard definition of agitation. The degree to which all characteristics from the 3rd revised edition of the DSM (DSM-IIIR), considered together, were perceived to relate to agitation predicted 24% of the degree to which the term "delirium" was perceived to relate to agitation (Canonical correlation r = .48, p = .0002). Physicians' ratings of individual delirium characteristics from the DSM-IIIR were examined to determine if a sufficient number were similarly ranked to fulfill the diagnostic criteria for delirium. A significant number of physicians rated diagnostic criteria for delirium in one direction, yet did not rank the term "delirium" accordingly (McNemar's p = .04). CONCLUSIONS: There is considerable variation among physiatrists in their rating of characteristics that define agitation. Many define agitation during the acute recovery phase as posttraumatic amnesia plus an excess of behavior such as aggression, disinhibition, and/or emotional lability. Less support was given to defining agitation by the DSM-IIIR or DSM-IV diagnostic criteria for delirium. Delirium appears related to, but is not sufficient for, a diagnosis of agitation.

Measurement and treatment of agitation following traumatic brain injury: II. A survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation.

OBJECTIVE: Determine national patterns of measuring and treating agitation after traumatic brain injury (TBI) by physiatrists with expressed interest in treating TBI survivors. DESIGN: A 70% random sample of members of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation was surveyed by telephone. MAIN OUTCOME MEASURE: The survey instrument was designed to determine the most common pharmacologic interventions for agitation and, where possible, match each drug with the target behavioral and cognitive characteristics for which it is prescribed. Data were also collected on the manner in which participants measured agitation and judged treatment efficacy. RESULTS: One hundred twenty-nine of 157 responded, yielding an 82% response rate. The majority of respondents were not measuring agitation in a standard fashion. The five most frequently prescribed drugs by the expert stratum were carbamazepine, tricyclic antidepressants (TCAs), trazodone, amantadine, and beta-blockers. In comparison, the nonexperts most often reported prescribing carbamazepine, beta-blockers, haloperidol, TCAs, and benzodiazepines. Desyrel (p = .06) and amantadine (p = .001) were significantly more likely to be chosen by experts than by nonexperts. Experts chose haloperidol significantly less often than nonexperts (p = .01). Prescription of sedating drugs such as haloperidol or benzodiazepines was not found to be associated with the acuity of injury of TBI patients in the respondent's practice, practice setting, or years of practice since completing residency. Choice of haloperidol to treat agitation was not significantly associated with the degree to which explosive anger, verbal aggression, or physical aggression were considered important to the respondent's definition of agitation. CONCLUSIONS: The majority of physiatrists surveyed did not formally measure agitation. Treatment strategies differ significantly between general physiatrists and those who specialize in the treatment of patients with TBI. The breadth of pharmacologic agents and strategies identified in this survey probably reflects the lack of research specific to the pathophysiology of the disorder of posttraumatic agitation.