Sense of coherence and disability and the relationship with life satisfaction 6-15 years after traumatic brain injury in northern Sweden.

The objective of the study was to assess sense of coherence (SOC) many years after traumatic brain injury (TBI) and explore the relationship between SOC and self-rated life satisfaction (LS) as well as measures of functioning and disability, sex, age at injury, injury severity and time post-injury. Sixty-six individuals (aged 18-65 years) who were 6-15 years post-injury were interviewed. Data on SOC (SOC-13 item scale), measures of functioning and disability (Mayo-Portland Adaptability Inventory, MPAI-4), LS (Satisfaction with Life Scale, SWLS), and sex, age at injury, injury severity and time post-injury were analysed with hierarchical multiple regression analyses. The results showed that SOC in the study group did not differ from the general population and was strongly associated with LS. Regression analyses revealed that emotional factors, social participation, SOC, and time since injury, were more influential than sex, age at injury, and injury severity in explaining LS. It was concluded that SOC in this group of individuals with TBI who were many years post-injury was similar to nondisabled individuals. SOC, together with emotional factors, social participation and injury-related factors, were determinants of LS. These results confirm that LS after TBI is a complex phenomenon dependent on several factors that are important targets for rehabilitation professionals.

Factors influencing options in primary breast cancer treatment.

Primary breast cancer treatment is determined by tumor factors and by patient preference. Breast cancer treatments that preserve the cosmetic appearance of the breast are appealing and effective for appropriately selected patients; long-term survival following tumor excision and breast irradiation appears to be comparable to that for mastectomy. Since April 1981, when a protocol was developed and treatment options were offered, factors influencing treatment selection have been analyzed in 206 consecutive primary breast cancer patients. Mastectomy was dictated by tumor-related factors in 96 patients (47%); 110 patients (53%) had the option of mastectomy or conservation--tumor excision plus radiotherapy to the breast. Among these 110 eligible patients, 54 chose conservation (49%) and 56 chose mastectomy (51%). Intraoperative findings for ten patients electing conservation necessitated mastectomy, so conservation was accomplished for 44 (21%) of those treated for breast cancer. Beginning in July 1982, breast cancer patients took a battery of psychosexual assessments before any operation (Profile of Mood States [POMS], Health Locus of Control Scale [HLCS] Locke-Wallace Marital Adjustment Test [MAT], Psychosocial Adjustment to Illness Scale [PAIS], Derogatis Sexual Function Inventory [DSFI], Millon Clinical Multiaxial Inventory [MCMI], and a Breast Cancer Information Test [BCIT]). Comparisons of psychologic and demographic variables were made between patients who chose mastectomy and those who chose conservation. No demographic variable was statistically significantly related to choice, although older women tended to select mastectomy more than younger women. Compared with those who elected conservation, women who elected mastectomy were more tense and anxious (P less than .01), more introverted (P less than .01), felt more depressed and dejected (P less than .05), and reported more sexual problems (P less than .05). Those who elected conservation valued their physical appearance more highly (P less than .01) and were generally more self-interested (P less than .05). Mastectomy was dictated by medical considerations for approximately half of patients with breast cancer. Among candidates for breast conservation, the importance of retaining the breast appeared to be determined to a significant degree by measurable psychological factors.

Mayo Medical Center Brain Injury Outpatient Program: treatment procedures and early outcome data.

The rehabilitation of persons with brain injuries has proved challenging; community reintegration is often unsuccessful. Herein we describe our intensive group-oriented outpatient treatment program for persons with brain injury and report outcome data for the graduates of the program thus far. This interdisciplinary program emphasizes the development of cognitive skills, compensation techniques, social skills, emotional adjustment, leisure skills, physical fitness, and health maintenance. Although goals are individually determined, independent living and employment are goals for most participants in the program. Before initial participation, all candidates undergo an extensive 2-day assessment. Typically, a patient remains in the program for approximately 6 months. The specific group treatment approaches used in the program are discussed. Outcome data are assessed with use of the Portland Adaptability Inventory and goal attainment scaling, as well as comparisons of preprogram and postprogram employment status and level of independent living. Our initial results support the conclusion that this comprehensive and integrated treatment program is efficacious in rehabilitating persons with mild to moderate sequelae of brain injury.

Maximizing vocational outcome after brain injury: integration of medical and vocational hospital-based services.

OBJECTIVE: To describe a medical and vocational case-management system that has been implemented at the Mayo Medical Center in Rochester, Minnesota, to decrease the time between onset of brain injury and successful community reintegration. DESIGN: Barriers to employment are identified and targeted as part of a system that integrates medical center- and community-based services. MATERIAL AND METHODS: The success of the project will be determined by several sources, including the Mayo-Portland Adaptability Inventory, a vocational rating scale, and traditional measures of vocational success (for example, level of independent living, job type and setting, rate of pay, and the type and cost of vocational supports being used). Overall study outcomes will be compared against benchmarks derived from the literature on vocational outcome after brain injury. RESULTS: Preliminary data are encouraging that project goals are attainable. The medical case-management system has decreased the amount of time between injury and initiation of vocational and other rehabilitation services. During the first year, 67 persons with brain injury began receiving vocational services through the project, and 34% are in community-based nonsheltered work or training programs. Second-year data will reveal whether the goal of 70% placement within 9 months after admission to the project can be maintained.

Age-associated memory impairment diagnoses: problems of reliability and concerns for terminology.

Objective memory criteria for diagnosing age-associated memory impairment (AAMI), age-consistent memory impairment, and late-life forgetfulness (LLF) were applied to 523 cognitively normal older persons divided into 2 groups on the basis of the clinical memory assessment battery they received. Seventy-seven percent of Group 2 and 98% of Group 1 met the Crook et al. (1986) cognitive criteria for AAMI on at least 1 test. Rates based on individual tests varied from 7% to 96%. Objective-cognitive criteria for LLF were met by no members of Group 1 but by 31% of Group 2. Results suggest that, as proposed, the criteria for age-related diagnoses lack reliability. Concerns regarding the diagnosis of normal memory in older populations are considered.

Subjective memory complaints, psychological distress, and longitudinal change in objective memory performance.

Between 1992 and 1993, the Memory Function Questionnaire General Frequency of Forgetting Scale (MFQ-GEN), the Symptom Checklist-90-Revised General Severity Index (GSI), and Mayo Cognitive Factor Scales Learning and Retention (MCFS-LRN and MCFS-RET) current and change scores were obtained for 294 of 397 (74%) participants, ages 55-97 years, originally assessed in a 1988-1990 normative study. In multiple regression modeling, the GSI and MCFS-LRN current score contributed 20% and 3%, respectively, to MFQ-GEN variance. Thus, emotional status was a better predictor of subjective memory ratings than either absolute objective memory performance or objective longitudinal memory change. Persons who developed cognitive impairment over the longitudinal interval reported greater memory problems, but memory complaints had little sensitivity in identifying these persons. In an approximate census sample of these older people, minor memory problems were reported to be frequent but not serious.

Traditional and computerized assessment procedures applied to the evaluation of memory change after temporal lobectomy.

After establishing that 40 temporal lobectomy patients (20 right, 20 left) demonstrated the same pattern of memory compromise as has been reported in prior studies, we examined the sensitivity of computerized tests of everyday memory skills to the cognitive change associated with temporal resection. Multiple cognitive deficits occur after left, but not after right, temporal lobectomies. Memory impairment after surgery is not limited to traditionally structured memory tests but is also evident on tasks designed to simulate activities of daily life.

Psychology: Current practice and training issues in treatment of cognitive dysfunction.

Psychology has a primary role in cognitive rehabilitation along with other disciplines, but may be best qualified for evaluating specific cognitive abilities directing, cognitive-behavioral intervention programs, and measuring outcomes. Several specialties within psychology provide cognitive rehabilitation services; however, current training guidelines are not specific enough to ensure adequate training. These specialties all have areas of strength and limitations, but none of them has published guidelines specific to training in cognitive rehabilitation. In this paper we critique current guidelines, and make suggestions for training to be followed for those psychologists conducting CR.

Amnesia after basal forebrain damage due to anterior communicating artery aneurysm rupture.

A 53-year-old male presented with a subarachnoid haemorrhage secondary to an anterior communicating artery aneurysm rupture. The aneurysm was successfully treated with intravascular coiling. Post-haemorrhage the patient showed a profound amnestic syndrome with deficits in anterograde (and also retrograde) memory, confabulation and personality changes consistent with the anterior communicating artery syndrome (ACAS). Magnetic resonance imaging showed basal forebrain and orbitofrontal infarction. The patient was treated with donepezil (a cholinesterase inhibitor) without symptomatic improvement or clinically meaningful change in his psychometric testing. The clinical and neuropsychological features and the pathological basis of the ACAS are reviewed.

Physical and psychological outcome after burns.

The relationship between compliance of moderately or severely burned patients with suggested plans of treatment and outcome was examined retrospectively by reviewing medical records. This review was limited to patients admitted to our facilities between 1977 and 1982 with burns in the moderate or major burn category and admitted within seven days of their injuries. The outcome measures included the following: limitation in range of motion (ROM), hypertrophic scar formation, total days of care required, quality of life, and impact of event. Noncompliance was related to the outcome as measured by limitation in ROM (P less than 0.01) and total days of care required (P less than 0.0001). A trend for diminished quality of life was related to noncompliance (P less than 0.08). Extent of injury (measured by total body surface area involved) was not related to ROM, quality of life, or impact of event but was related to total days of care required (P less than 0.01); there was also a trend toward scarring (P less than 0.06).

The Traumatic Brain Injury Model Systems: a longitudinal database, research, collaboration and knowledge translation.

In 1988, the National Institute on Disability and Rehabilitation Research (NIDRR) launched the Traumatic Brain Injury Model Systems (TBIMS) program, creating the longest and largest longitudinal database on individuals with moderate-to-severe traumatic brain injury (TBI) available today. In addition to sustaining the longitudinal database, centers that successfully compete to be part of the TBIMS centers are also expected to complete local and collaborative research projects to further scientific knowledge about TBI. The research has focused on areas of the NIDRR Long Range Plan which emphasizes employment, health and function, technology for access and function, independent living and community integration, and other associated disability research areas. Centers compete for funded participation in the TBIMS on a 5-year cycle. Dissemination of scientific knowledge gained through the TBIMS is the responsibility of both individual centers and the TBIMS as a whole. This is accomplished through multiple venues that target a broad audience of those who need to receive the information and learn how to best apply it to practice. The sites produce many useful websites, manuals, publications and other materials to accomplish this translation of knowledge to practice.

Non-declarative memory in the rehabilitation of amnesia.

The ability of amnesic patients to learn and retain non-declarative information has been consistently demonstrated in the literature. This knowledge provided by basic cognitive neuroscience studies has been widely neglected in neuropsychological rehabilitation of memory impaired patients. This study reports the case of a 43 year old man with severe amnesia following an anterior communicating artery (ACoA) aneurysm rupture. The patient integrated a comprehensive (holistic) day treatment programme for rehabilitation of brain injury. The programme explored the advantages of using preserved non-declarative memory capacities, in the context of commonly used rehabilitation approaches (i.e. compensation for lost function and domain-specific learning). The patient's ability to learn and retain new cognitive and perceptual-motor skills was found to be critical for the patient's improved independence and successful return to work.

Impact of comprehensive day treatment on societal participation for persons with acquired brain injury.

OBJECTIVES: To evaluate comprehensive day treatment (CDT) for survivors of brain injury by time since injury and to identify outcome predictors. DESIGN: Before and after. SETTING: Rehabilitation center. PARTICIPANTS: Ninety-six program graduates; 17 dropouts with acquired brain injury. INTERVENTIONS: Comprehensive Day Treatment Program: daily group sessions to build cognitive and behavioral skills through a transdisciplinary approach, supportive feedback, and a variety of therapeutic modalities. Obtained outcome measures before and after the program, and at 1-year follow-up. OUTCOME: Independent living status, vocational independence scale at program end and 1-year follow-up; and Rasch-analyzed Mayo-Portland Adaptability Inventory (MPAI-22) and goal attainment scaling (GAS) at program end. PREDICTORS: age, education, severity of initial injury, time since injury, and preadmission MPAI-22. RESULTS: Significant goal achievement on GAS and improvement on MPAI-22; increased societal participation at 1-year follow-up for those treated postacutely and many years after injury: 72% of graduates living independently; 39% working independently, 10% in transitional placements, and 18% in supported or volunteer work. Long-term outcomes were modestly related linearly to preadmission MPAI-22 and nonlinearly to time since injury. CONCLUSIONS: CDT improves societal participation even among persons with a long history of limited participation after brain injury. This de facto extended baseline analysis indicates the effectiveness of CDT and paves the way for randomized control trials of active treatment components. Relationships of predictors to outcomes are not sufficiently strong for patient selection. More effective interventions for vocational reintegration are needed for those most severely disabled after brain injury.

Ethics in brain injury rehabilitation: existential choices among western cultural beliefs.

The following issues in the practice of brain injury rehabilitation are explored: (1) validity of support for efficacy based on experience in clinical practice, (2) validity of support for efficacy based on research, (3) consumer protection, (4) qualifications and regulation of individual providers, (5) regulation of programme development and marketing. Ethical responses to these issues from each of three cultural belief systems (humanism, science and self-interest) are examined from a metaphilosophical perspective based on contemporary cognitive psychology and on philosophies of social constructionism and existentialism.

Ethical conflict resolution based on an ethics of relationships for brain injury rehabilitation.

An ethics of relationships for brain injury (BI) rehabilitation is described based on three principles; (1) human relationships are important; (2) human relationships are as important as individual survival; (3) human relationships are important enough to extend throughout the family of humankind. Within the context of this ethics of relationships, ethical conflict resolution (ECR) is offered as a process to address disagreements among those involved in BI rehabilitation. ECR provides a means to arrive at moral decisions in situations in which people disagree about the appropriate course of action because of differing values. ECR recognizes that, although disagreements in BI rehabilitation settings can be associated with multiple other factors, including disturbed self-awareness, emotions, communication, and interpersonal dynamics, such disagreements may also be value-based, either in whole or part. ECR invites the professional team to identify the value-based portion of these disagreements and provides a rational and supportive process to address disagreements. In this discussion of ECR, common and potentially universal areas of ethical concern in BI rehabilitation are identified, as well as potential risks. Specific examples of the application of ECR in cases of vegetative state, coma stimulation, and cognitive rehabilitation are described.

Postacute brain injury rehabilitation.

This review compares outcomes of adult postacute brain injury rehabilitation (PABIR) with natural recovery after brain injury. Potential outcome predictors and the effectiveness of behavioral, cognitive, pharmacologic, and vocational interventions are also appraised. The importance of standardized outcome assessment is discussed in the context of other research considerations. Although generally uncontrolled, the studies reviewed document benefits for many individuals with brain injury, including increased independence and a rate of return to independent work or training that exceeds 50% and may reach 60% to 80% for intensive comprehensive (holistic) day treatment programs. Available research is sufficiently encouraging to recommend more carefully controlled randomized studies. Future research should emphasize the development of standardized measures of patient characteristics and outcomes, and matching of patient characteristics with optimal rehabilitation approaches.

Factor analysis of the Mayo-Portland Adaptability Inventory: structure and validity.

Principal-components (PC) factor analysis of the Mayo-Portland Adaptability Inventory (MPAI) was conducted using a sample of outpatients (n = 189) with acquired brain injury (ABI) to evaluate whether outcome after ABI is multifactorial or unifactorial in nature. An eight-factor model was derived which explained 64-4% of the total variance. The eight factors were interpreted as representing Activities of Daily Living, Social Initiation, Cognition, Impaired-Self-awareness/Distress, Social Skills/ Support, Independence, Visuoperceptual, and Psychiatric, respectively. Validation of the Cognition factor was supported when factor scores were correlated with various neuropsychological measures. In addition, 117 patient self-rating total scores were used to evaluate the Impaired Self-awareness/Distress factor. An inverse relationship was observed, supporting this factor's ability to capture the two-dimensional phenomena of diminished self-awareness or enhanced emotional distress. A new subscale structure is suggested, that may allow greater clinical utility in understanding how ABI manifests in patients, and may provide clinicians with a better structure for implementing treatment strategies to address specific areas of impairment and disability for specific patients. Additionally, more precise measurement of treatment outcomes may be afforded by this reorganization.

Goal attainment scaling and outcome measurement in postacute brain injury rehabilitation.

Relationships among two-month and final goal attainment scaling (GAS) scores, preadmission and final Portland Adaptability Inventory (PAI) scores, and work outcome for 16 graduates of a comprehensive, postacute brain injury rehabilitation program were examined. Final GAS scores were higher for program graduates who obtained the most desirable work outcomes, and preadmission and final PAI scores were lower for the successful program graduates. Final GAS scores were significantly correlated with other outcome measures. Preadmission PAI scores predicted work outcome, and two-month GAS scores predicted final GAS scores. Initial PAI scores distinguished between program successes and failures, but not between program successes and dropouts. A brief look at one case illustrates the modified application of GAS in postacute brain injury rehabilitation. Results of this study and case analyses support GAS as a quantifiable, individualized measure that is useful for (1) monitoring patient progress, (2) structuring team conferences, (3) ongoing rehabilitation planning and decision-making, (4) concise, relevant communication to family, referral sources, and funding sources, and (5) overall program evaluation when used in the context of other objective outcome measures. Although our results support the clinical utility of GAS, further study is recommended to assess the psychometric characteristics of GAS in this application.

Validity of the construct of nonverbal memory: a factor-analytic study in a normal elderly sample.

One problem in evaluating the construct of nonverbal memory is finding a purely nonverbal memory measure. Encouraged by initial research with a new measure, the Visual Spatial Learning Test (VSLT), we examined nonverbal memory in a normal elderly sample. Subjects were 460 community-dwelling individuals between the ages of 55-95. All received neuropsychological batteries which included the Wechsler Adult Intelligence Scale-Revised, the Wechsler Memory Scale-Revised, the Rey Auditory Verbal Learning Test, and the VSLT. Two variable sets were created to avoid overlapping immediate and delayed recall trials for the same stimulus materials. Exploratory factor analyses using two different extraction methods were performed. Across analyses a single general memory factor was observed, no modality or time specific factors were found. If it can be assumed that we used adequate measures of nonverbal memory, our results combine with prior research to challenge the validity of the construct of nonverbal memory as distinct from verbal memory, especially in older normal adult populations.

Refining a measure of brain injury sequelae to predict postacute rehabilitation outcome: rating scale analysis of the Mayo-Portland Adaptability Inventory.

OBJECTIVE: Evaluate the psychometric properties of the Mayo-Portland Adaptability Inventory (MPAI). DESIGN: Rating scale (Rasch) analysis of MPAI and principal component analysis of residuals; the predictive validity of the MPAI measures and raw scores was assessed in a sample from a day rehabilitation program. SETTING: Outpatient brain injury rehabilitation. PARTICIPANTS: 305 persons with brain injury. RESULTS: A 22-item scale reflecting severity of sequelae of brain injury that contained a mix of indicators of impairment, activity, and participation was identified. Scores and measures for MPAI scales were strongly correlated and their predictive validities were comparable. CONCLUSIONS: Impairment, activity, and participation define a single dimension of brain injury sequelae. The MPAI shows promise as a measure of this construct.