Enriched, Task-Specific Therapy in the Chronic Phase After Stroke: An Exploratory Study.

BACKGROUND AND PURPOSE: There is a need to translate promising basic research about environmental enrichment to clinical stroke settings. The aim of this study was to assess the effectiveness of enriched, task-specific therapy in individuals with chronic stroke. METHODS: This is an exploratory study with a within-subject, repeated-measures design. The intervention was preceded by a baseline period to determine the stability of the outcome measures. Forty-one participants were enrolled at a mean of 36 months poststroke. The 3-week intervention combined physical therapy with social and cognitive stimulation inherent to environmental enrichment. The primary outcome was motor recovery measured by Modified Motor Assessment Scale (M-MAS). Secondary outcomes included balance, walking, distance walked in 6 minutes, grip strength, dexterity, and multiple dimensions of health. Assessments were made at baseline, immediately before and after the intervention, and at 3 and 6 months. RESULTS: The baseline measures were stable. The 39 participants (95%) who completed the intervention had increases of 2.3 points in the M-MAS UAS and 5 points on the Berg Balance Scale (both P < 0.001; SRM >0.90), an improvement of comfortable and fast gait speed of 0.13 and 0.23 m/s, respectively. (P < 0.001; SRM = 0.88), an increased distance walked over 6 minutes (24.2 m; P < 0.001; SRM = 0.64), and significant improvements in multiple dimensions of health. The improvements were sustained at 6 months. DISCUSSION AND CONCLUSIONS: Enriched, task-specific therapy may provide durable benefits across a wide spectrum of motor deficits and impairments after stroke. Although the results must be interpreted cautiously, the findings have implications for enriching strategies in stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A304).

Systematic review of the risk of Parkinson's disease after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence on the risk of Parkinson's disease (PD) after mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (1990-2012) with terms including "craniocerebral trauma" and "parkinsonian disorders." Reference lists of eligible articles and relevant systematic reviews and meta-analyses were also searched. STUDY SELECTION: Controlled clinical trials, cohort studies, and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. DATA SYNTHESIS: Evidence was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria. Sixty-five studies were eligible and reviewed, and 5 of these with a low risk of bias were accepted as scientifically admissible and form the basis of our findings. Among these admissible studies, the definitions of MTBI were highly heterogeneous. One study found a significant positive association between MTBI and PD (odds ratio, 1.5; 95% confidence interval, 1.4-1.7). The estimated odds ratio decreased with increasing latency between MTBI and PD diagnosis, which suggests reverse causality. The other 4 studies did not find a significant association. CONCLUSIONS: The best available evidence argues against an important causal association between MTBI and PD. There are few high-quality studies on this topic. Prospective studies of long duration would address the limitations of recall of head injury and the possibility of reverse causation.

Academic achievement after a CT examination toward the head in childhood: Follow up of a randomized controlled trial.

INTRODUCTION: Increasing use of CT examinations has led to concerns of possible negative cognitive effects for children. The objective of this study is to examine if the ionizing radiation dose from a CT head scan at the age of 6-16 years affects academic performance and high school eligibility at the end of compulsory school. MATERIALS AND METHODS: A total of 832 children, 535 boys and 297 girls, from a previous trial where CT head scan was randomized on patients presenting with mild traumatic brain injury, were followed. Age at inclusion was 6-16 years (mean of 12.1), age at follow up 15-18 years (mean of 16.0), and time between injury and follow up one week up to 10 years (mean of 3.9). Participants' radiation exposure status was linked with the total grade score, grades in mathematics and the Swedish language, eligibility for high school at the end of compulsory school, previously measured GOSE-score, and their mothers' education level. The Chi-Square Test, Student's t-Test and factorial logistics were used to analyze data. RESULTS: Although estimates of school grades and high school eligibility were generally higher for the unexposed, the results showed no statistically significant differences between the exposed and unexposed participants in any of the aforementioned variables. CONCLUSIONS: Any effect on high school eligibility and school grades from a CT head scan at the age of 6-16 years is too small to be detected in a study of more than 800 patients, half of whom were randomly assigned to CT head scan exposure.

Prevalence and structure of symptoms at 3 months after mild traumatic brain injury in a national cohort.

OBJECTIVES: To describe symptom prevalence and structure after mild traumatic brain injury (MTBI) in a population-based cohort. METHODS: Symptoms data were collected at 3 months post-MTBI by use of the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at follow-up of 2602 patients attending 39 Swedish hospitals. Spearmans rank correlation analysis was used to explore correlations between symptoms and structural equation modelling (SEM) was performed by use of several fit indices to explore if data were compatible with one or more factors. RESULTS: Questionnaires were received from 2523 (97%) patients with a mean age of 31 years (median 22, range 6-96). A majority of the respondents (56%) reported no remaining injury related symptoms, 24% reported three or more symptoms and 10% reported seven or more symptoms. All symptoms exhibited strong positive inter-relations and SEM provided strong support for a single or two factor solution. Fit indices were only slightly weaker for three and four factor solutions. CONCLUSIONS: A significant minority of patients reported multiple symptoms to persist at 3 months after MTBI. The observed structure of symptoms according to RPQ demonstrates a common factor for all symptoms, but also sub-groups of symptoms as previously suggested.

Management of mild traumatic brain injuries in emergency departments in Sweden: evidence of a change in clinical practice.

OBJECTIVE: A study published in 2000 on the acute clinical management of mild traumatic brain injuries in Sweden showed that these patients were routinely admitted to hospital for observation. This study aims to compare current clinical management of mild traumatic brain injury with clinical practice a decade ago. DESIGN: Questionnaire to senior residents in all emergency departments in Sweden and data from registers covering all in-hospital care in Sweden. RESULTS: The response rate to the questionnaire was 100%. In Sweden, 71 emergency departments treat patients with mild traumatic brain injuries. An estimated mean of 58% of patients with mild traumatic brain injuries receive computerized tomography scanning, which represents a 3-fold increase compared with 2000. In 2010, Swedish hospitals admitted 8821 patients for mild traumatic brain injuries (94 per 100,000 inhabitants). This figure is approximately half that of 1996, when 16,877 patients were treated as inpatients for mild traumatic brain injuries (191 per 100,000 inhabitants). However, admission rates continue to vary widely among departments. The mean hospital stay 2010 was 1.21 days, compared with 1.6 days in 1996. CONCLUSION: This study provides evidence of a change in clinical practice in the acute management of mild traumatic brain injuries in Sweden. Acute management is increasingly based on computed tomography, and in-hospital observation is used less frequently as a strategy for these patients.

Protocol for a systematic review of prognosis after mild traumatic brain injury: an update of the WHO Collaborating Centre Task Force findings.

BACKGROUND: Mild traumatic brain injury (MTBI) is a major public-health concern and represents 70-90% of all treated traumatic brain injuries. The last best-evidence synthesis, conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002, found few quality studies on prognosis. The objective of this review is to update these findings. Specifically, we aim to describe the course, identify modifiable prognostic factors, determine long-term sequelae, and identify effects of interventions for MTBI. Finally, we will identify gaps in the literature, and make recommendations for future research. METHODS: The databases MEDLINE, PsychINFO, Embase, CINAHL and SPORTDiscus were systematically searched (2001 to date). The search terms included 'traumatic brain injury', 'craniocerebral trauma', 'prognosis', and 'recovery of function'. Reference lists of eligible papers were also searched. Studies were screened according to pre-defined inclusion and exclusion criteria. Inclusion criteria included original, published peer-reviewed research reports in English, French, Swedish, Norwegian, Danish and Spanish, and human participants of all ages with an accepted definition of MTBI. Exclusion criteria included publication types other than systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies; as well as cadaveric, biomechanical, and laboratory studies. All eligible papers were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers performed independent, in-depth reviews of each eligible study, and a third reviewer was consulted for disagreements. Data from accepted papers were extracted into evidence tables, and the evidence was synthesized according to the modified SIGN criteria. CONCLUSION: The results of this study form the basis for a better understanding of recovery after MTBI, and will allow development of prediction tools and recommendation of interventions, as well as informing health policy and setting a future research agenda.

Internal construct validity of the Rivermead Post-Concussion Symptoms Questionnaire.

OBJECTIVE: To investigate the internal construct validity of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) by Rasch analysis of data from a national cohort of patients with mild traumatic brain injury. METHODS: Data collected at 3 months after mild traumatic brain injury from 2,523 patients were analysed using the partial credit model, describing rating scale structure, local dependency, age and gender differential functioning, dimensionality and model fit. RESULTS: Categories did not work in a consistent manner; however, collapsing of Categories 1 and 2 yielded ordered thresholds. Local dependency of items was present and 2 item pairs were combined. There was no differential item functioning by gender or age. The Rasch factor explained 47.7% of the variance and the first contrast explained 12.4% of the unexplained variance (eigenvalue 1.9). Further analysis indicated 3 or more dimensions. Person measure had a mean of -2.16, showing poor targeting of persons to items. Person reliability was 0.71 and person separation index was 1.56. CONCLUSION: According to this Rasch analysis of data from a representative sample of mild traumatic brain injury, the RPQ may not be optimal for this population. Even after reducing the number of categories and collapsing items with local dependency, unidimensionality was not reached, which argues against summation of a total score. However, the scale is unbiased for gender and age. :

Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial.

OBJECTIVE: To compare immediate computed tomography during triage for admission with observation in hospital in patients with mild head injury. DESIGN: Multicentre, pragmatic, non-inferiority randomised trial. SETTING: 39 acute hospitals in Sweden. PARTICIPANTS: 2602 patients (aged > or = 6) with mild head injury. INTERVENTIONS: Immediate computed tomography or admission for observation. MAIN OUTCOME MEASURE: Dichotomised extended Glasgow outcome scale (1-7 v 8). The non-inferiority margin was 5 percentage points. RESULTS: At three months, 275 patients (21.4%) in the computed tomography group had not recovered completely compared with 300 (24.2%) admitted for observation. The difference was - 2.8 percentage points, non-significantly in favour of computed tomography (95% confidence interval - 6.1% to 0.6%). The worst outcomes (mortality and more severe loss of function) were similar between the groups. In the patients admitted for observation, there was a considerable delay in time to treatment in those who required surgery. None of the patients with normal findings on immediate computed tomography had complications later. Patients' satisfaction with the two strategies was similar. CONCLUSIONS: The use of computed tomography in the management of patients with mild head injury is feasible and leads to similar clinical outcomes compared with observation in hospital. TRIAL REGISTRATION: ISRCTN81464462.

Immediate computed tomography or admission for observation after mild head injury: cost comparison in randomised controlled trial.

OBJECTIVE: To compare the costs of immediate computed tomography during triage for admission with those of observation in hospital in patients with mild head injury. DESIGN: Prospective cost effectiveness analysis within a multicentre, pragmatic randomised trial. SETTING: 39 acute hospitals in Sweden PARTICIPANTS: 2602 patients (aged > or = 6) with mild head injury. INTERVENTIONS: Immediate computed tomography or admission for observation. MAIN OUTCOME MEASURES: Direct and indirect costs related to the mild head injury during the acute and three month follow-up period. RESULTS: Outcome after three months was similar for both strategies (non-significantly in favour of computed tomography). For the acute stage and complications, the cost was 461 euros (314 pounds sterling, 582 dollars) per patient in the computed tomography group and 677 euros (462 pounds sterling, 854 dollars) in the observation group; an average of 32% less in the computed tomography group (216 euros, 95% confidence interval -272 to -164; P < 0.001). Sensitivity analysis showed that computed tomography was the most cost effective strategy under a broad range of assumptions. After three months, total costs were 718 euros and 914 euros per patient-that is, 196 euros less in the computed tomography group (- 281 to - 114; P < 0.001). The lower cost of the computed tomography strategy at the acute stage thus remained unchanged during follow-up. CONCLUSION: Patients with mild head injury attending an emergency department can be managed more cost effectively with computed tomography rather than admission for observation in hospital. TRIAL REGISTRATION: ISRCTN81464462.

Delayed intracranial complications after concussion.

BACKGROUND AND METHODS: The incidence of readmissions because of delayed intracranial complications within 3 weeks after observation for the sole diagnosis of concussion was examined in a national cohort. A nested case-control design was used to analyze the association between clinical factors as well as early computed tomography (CT) scan examination and these complications. RESULTS: Out of 100,784 patients hospitalized because of concussion during ten years, 127 (0.13%) patients were readmitted because of a delayed intracranial complication. High clinical severity grade (odds ratio [OR] 2.0, confidence interval [CI] 1.2-3.6), minor CT scan abnormalities (OR 1.7, CI 0.8-3.4) and male gender (OR 2.2, CI 1.4-3.5) were associated with an increased risk of delayed, intracranial complications. CONCLUSION: The incidence of delayed intracranial complications after primarily uncomplicated concussion was low. High clinical severity grade and male gender were risk factors. We failed to demonstrate an additional value of the acute CT scan examination to predict these complications.